bluuebunny/crossref_metadata_2025 huggingface dataset:
The Relationship of Level of Education to Social Reintegration after Burn Injury: A LIBRE Study
Authors: Schulz John T , Shapiro Gabriel D , Acton Amy , Fidler Philip , Marino Molly E , Jette Allen , Schneider Jeffrey E , Kazis Lewis E , Ryan Colleen M
Published: May 2019

Social and emotional recovery from burn injury is a complex process impacted by both clinical and social factors. Because level of education (LOE) has been correlated to overall health, health outcomes, and life expectancy, we questioned whether LOE might be associated with successful social recovery after burn injury. The Life Impact Burn Recovery Evaluation (LIBRE) data set served as a novel tool to explore this question. The LIBRE project is a collaborative effort designed to provide a clinical yardstick for social reintegration among burn survivors. After institutional review board approval, 601 burn survivor respondents, aged 18 or over with >5% TBSA burn were surveyed and a six-scale, 126-item LIBRE Profile was derived from their responses. LOE was collapsed into four categories ranging from less than high school equivalency certificate to graduate degree. Impact of burn injury on subsequent LOE was examined by splitting the sample into those burned at age 30 years or less and those burned at greater than 30 years of age. Regression models were run to estimate associations between education and scale scores with adjustment for age at injury, sex, marital status, work status, TBSA, and time since burn. Regression models were run on the entire cohort and then stratified by age at burn injury (≤30 vs >30). Among all subjects, we found an association between LOE and social recovery as measured by LIBRE scale scores. This association was contributed entirely from the cohort burned at age 30 or less: for those burned at greater than age 30, there was no association between LOE and social recovery. Of particular interest, the distribution of LOE among those burned at ≤ 30 was very similar to LOE distribution in both millennials and in the U.S. population at large. LOE appears to be associated with social recovery for those burned at younger ages but not for those burned at over age 30. More importantly, burn injury during schooling may have no impact on a survivor’s educational trajectory since distribution of LOE in our ≤30 cohort mirrors that of the general population. LOE and age at burn injury may provide a quick screen for survivors at risk of difficult social reintegration, allowing providers to target those at risk with additional peer support and counseling.
Up All Night Out of Love for the Prophet: Devotion, Sanctity, and Ritual Innovation in the Ottoman Arab Lands, 1500–1620
Authors: Allen Jonathan Parkes
Published: May 2019

Devotion to the Prophet Muḥammad was a major feature of late medieval and early modern Islamic religious life across much of the Islamic world. The history of this devotion remains understudied in relation to its importance and pervasiveness. This study takes as its locus of analysis a particular instance of early modern devotion: a weekly, public all-night session of ṣalawāt upon the Prophet that would become known as the maḥyā. Developed by the peasant-turned-shaykh Nūr al-Dīn al-Shūnī in late Mamluk Egypt, performance of the maḥyā would spread over the following century throughout the Arab Ottoman world, undergoing changes, provoking controversy, and becoming embedded in the sacred spaces and ritual life of one city after another. I approach the history of the maḥyā as a discrete and legible instance of ritual change in an Islamic context, exploring this instance of communal devotion to the Prophet through such lenses as ritual studies and the spatial turn, examining the intersection of this devotional ritual with practices of subjectivity, the use and contestation of ritual space, and the meaning, regulation, and experience of the night.
Is Genetic Continuity Between Anopheles sinensis (Diptera: Culicidae) and its Sibling Species Due to Gene Introgression or Incomplete Speciation?
Authors: Wang Gang , Guo Xiaoxia , Song Fenglin , Zheng Wei , Tan Weilong , Huang Enjiong , Wu Jiahong , Wang Chongcai , Yang Qinggui , Li Chunxiao , Zhao Tongyan
Published: May 2019

The Anopheles mosquito Hyrcanus Group is widely distributed geographically across both Palearctic and Oriental regions and comprises 26 valid species. Although the species Anopheles sinensis Wiedemann (1828) is the most common in China and has a low potential vector rank, it has nevertheless long been thought to be an important natural malaria vector within the middle and lower reaches of the Yangtze River. A number of previous research studies have found evidence to support the occurrence of natural hybridization between An. sinensis and Anopheles kleini Rueda, 2005 (a competent malaria vector). We, therefore, collected a sample series of An. sinensis and morphologically similar species across China and undertook ribosomal and mitochondrial DNA analyses in order to assess genetic differentiation (Fst) and gene flow (Nm) amongst different groups. This enabled us to evaluate divergence times between morphologically similar species using the cytochrome oxidase I (COI) gene. The results of this study reveal significant genetic similarities between An. sinensis, An. kleini, and Anopheles belenrae Rueda, 2005 and therefore imply that correct molecular identifications will require additional molecular markers. As results also reveal the presence of gene flow between these three species, their taxonomic status will require further work. Data suggest that An. kleini is the most basal of the three species, while An. sinensis and An. belenrae share the closest genetic relationship.
Effect of a Responsiveness-Based Support Intervention on Smokeless Tobacco Cessation: The UCare-ChewFree Randomized Clinical Trial
Authors: Akers Laura , Andrews Judy A , Lichtenstein Edward , Severson Herbert H , Gordon Judith S
Published: May 2019

Introduction

Partner behaviors and attitudes can motivate or undermine a tobacco user’s cessation efforts. We developed a multimedia intervention, UCare (Understanding-CAring-REspect) for women who wanted their male partner to quit smokeless tobacco (ST), based on perceived partner responsiveness—the empirically based theory that support is best received when the supporter conveys respect, understanding, and caring.

Methods

One thousand one hundred three women were randomized to receive either immediate access to the UCare website and printed booklet (Intervention; N = 552), or a Delayed Treatment control (N = 551). We assessed supportive behaviors and attitudes at baseline and 6-week follow-up, and the ST-using partner’s abstinence at 6 weeks and 7.5 months (surrogate report).

Results

For partners of women assigned to Intervention, 7.0% had quit all tobacco at 7.5 months, compared with 6.6% for control (χ2 (1, n = 1088) = .058, p = .810). For partners of women completing the intervention, 12.4% had quit all tobacco at 7.5 months, compared with 6.6% for Delayed Treatment (χ2 (1, n = 753) = 6.775, p = .009). A previously reported change in responsiveness-based behaviors and instrumental behaviors at 6 weeks mediated 7.5-month cessation, and change in responsiveness-based attitudes mediated the change in responsiveness-based behaviors, indirectly increasing cessation.

Conclusions

A responsiveness-based intervention with female partners of male ST users improved supportive attitudes and behaviors, leading to higher cessation rates among tobacco users not actively seeking to quit. The study demonstrates the potential for responsiveness as a basis for effective intervention with supporters. This approach may reach tobacco users who would not directly seek help.

Implications

This study demonstrates the value of a responsiveness-based intervention (showing respect, understanding, and caring) in training partners to provide support for a loved one to quit ST. In a randomized clinical trial, 1,103 women married to or living with a ST user were randomized to receive the UCare-ChewFree intervention (website + booklet) or a Delayed Treatment control. Women completing the intervention were more likely to improve their behaviors and attitudes, and change in behaviors and attitudes mediated cessation outcomes for their partners, who had not enrolled in the study and may not have been seeking to quit.

Trial Registration

ClinicalTrials.gov NCT01885221
Risk Factors for Failure of Primary (Val)ganciclovir Prophylaxis Against Cytomegalovirus Infection and Disease in Solid Organ Transplant Recipients
Authors: Khurana Mark P , Lodding Isabelle P , Mocroft Amanda , Sørensen Søren S , Perch Michael , Rasmussen Allan , Gustafsson Finn , Lundgren Jens D
Published: May 2019

Background

Rates and risk factors for cytomegalovirus (CMV) prophylaxis breakthrough and discontinuation were investigated, given uncertainty regarding optimal dosing for CMV primary (val)ganciclovir prophylaxis after solid organ transplantation (SOT).

Methods

Recipients transplanted from 2012 to 2016 and initiated on primary prophylaxis were followed until 90 days post-transplantation. A (val)ganciclovir prophylaxis score for each patient per day was calculated during the follow-up time (FUT; score of 100 corresponding to manufacturers’ recommended dose for a given estimated glomerular filtration rate [eGFR]). Cox models were used to estimate hazard ratios (HRs), adjusted for relevant risk factors.

Results

Of 585 SOTs (311 kidney, 117 liver, 106 lung, 51 heart) included, 38/585 (6.5%) experienced prophylaxis breakthrough and 35/585 (6.0%) discontinued prophylaxis for other reasons. CMV IgG donor+/receipient- mismatch (adjusted HR [aHR], 5.37; 95% confidence interval [CI], 2.63 to 10.98; P < 0.001) and increasing % FUT with a prophylaxis score <90 (aHR, 1.16; 95% CI, 1.04 to 1.29; P = .01 per 10% longer FUT w/ score <90) were associated with an increased risk of breakthrough. Lung recipients were at a significantly increased risk of premature prophylaxis discontinuation (aHR, 20.2 vs kidney; 95% CI, 3.34 to 121.9; P = .001), mainly due to liver or myelotoxicity.

Conclusions

Recipients of eGFR-adjusted prophylaxis doses below those recommended by manufacturers were at an increased risk of prophylaxis breakthrough, emphasizing the importance of accurate dose adjustment according to the latest eGFR and the need for novel, less toxic agents.
Giant Choroid Plexus Papilloma Resection Utilizing a Transcollation System
Authors: Asmaro Karam , Pawloski Jacob , Skoch Jesse
Published: May 2019

BACKGROUND

Large vascular brain tumors pose an exceptional challenge in young children. Choroid plexus papilloma (CPP) is an example of a rare, often large and especially vascular neuroepithelial tumor that most commonly arises in children under 5 yr old. Although patients may be cured by total resection, this tumor poses significant surgical risks and challenges related to intraoperative hemostasis.

OBJECTIVE

To describe our experience using a transcollation system during brain tumor surgery in a child to achieve hemostasis and minimize blood loss while preserving normal brain tissue.

METHODS

A 3-yr-old girl presented following a fall and was found to have a giant CPP growing from the right lateral ventricle. Given the vascularity of the tumor and the low intravascular reserve in a small child, a transcollation device was used to reduce blood loss intraoperatively.

RESULTS

Gross total resection was achieved with approximately 300 mL of blood loss without complications. The patient did well postoperatively. Imaging performed at 3 mo after resection revealed return of normal brain architecture.

CONCLUSION

Transcollation devices appear to be an effective and safe addition to the armamentarium of neurosurgical hemostatic options in intracranial tumor resection in which there is a high risk of intraoperative hemorrhage.
Resection of Massive “Tarry” Intra/Extra-ventricular Prepontine Colloid Cyst: 2-Dimensional Operative Video
Authors: Sorenson Thomas J , Graffeo Christopher S , Marcellino Christopher R , Raghunathan Aditya , Van Gompel Jamie J
Published: May 2019

Colloid cysts are typically slow-growing lesions that account for approximately 1% of primary intracranial neoplasms and predominantly exist intraventricularly. These benign lesions typically can exist symptom-free for years and do not require surgical intervention. However, if the location of the colloid cyst is symptomatic, surgical debulking may be indicated. In this intraoperative video, we illustrate the case of an 8 cm, intra/extra-ventricular colloid cyst that appeared as a craniopharyngioma on preoperative imaging, but upon resection via a trans-middle temporal gyrus approach, was found to be very atypically filled with a thick, “tarry” substance, which we hypothesize is due to serial, subacute lesional hemorrhages. After debulking and piecemeal resection of the majority of the mass with ultrasonic aspiration and microsurgical tools, a hard, calcified nodule was left tenaciously adherent to the superior cerebellar artery to prevent damage to this vascular structure.
Influence of commissioned provider type and deprivation score on uptake of the childhood flu immunization
Authors: Christensen Hannah , Reynolds Rosy , Kwiatkowska Rachel , Brooks-Pollock Ellen , Dominey Matthew , Finn Adam , Gjini Ardiana , Hickman Matthew , Roderick Marion , Yates Julie
Published: May 2019

Background

Since 2015/16 the UK seasonal influenza immunization programme has included children aged 5 and 6 years. In the South West of England school-based providers, GPs or community pharmacies were commissioned to deliver the vaccine depending on the locality. We aimed to assess variation in vaccine uptake in relation to the type of commissioned provider, and levels of socioeconomic deprivation.

Methods

Data from the South West of England (2015–16 season) were analysed using multilevel logistic regression to assess variation in vaccine uptake by type of commissioned provider, allowing for clustering of children within delivery sites.

Results

Overall uptake in 5 and 6 year olds was 34.3% (37 555/109 404). Vaccine uptake was highest when commissioned through school-based programmes 50.2% (9983/19 867) and lowest when commissioned through pharmacies, 23.1% (4269/18 479). Delivery through schools resulted in less variation by site and equal uptake across age groups, in contrast to GP and pharmacy delivery for which uptake was lower among 6 year olds. Vaccine uptake decreased with increasing levels of deprivation across all types of commissioned provider.

Conclusion

School-based programmes achieve the highest and most consistent rates of childhood influenza vaccination. Interventions are still needed to promote more equitable uptake of the childhood influenza vaccine.
Genetic Structure and Subclonal Variation of Extant and Recent U.S. Lineages of Phytophthora infestans
Authors: Saville Amanda , Ristaino Jean Beagle
Published: May 2019

The oomycete Phytophthora infestans is an important plant pathogen on potato and tomato crops. We examined the genetic structure of extant 20th and 21st century U.S. lineages of P. infestans and compared them with populations from South America and Mexico to examine genetic relationships and potential sources of lineages. US-23, currently the most prevalent lineage detected in the United States, shared genetic similarity primarily with the BR-1 lineage identified in the 1990s from Bolivia and Brazil. Lineages US-8, US-14, and US-24, predominantly virulent on potato, formed a cluster distinct from other U.S. lineages. Many of the other U.S. lineages shared significant genetic similarity with Mexican populations. The US-1 lineage, dominant in the mid-20th century, clustered with US-1 lineages from Peru. A survey of the presence of RXLR effector PiAVR2 revealed that some lineages carried PiAVR2, its resistance-breaking variant PiAVR2-like, or both. Minimum spanning networks developed from simple sequence repeat genotype datasets from USABlight outbreaks clearly showed the expansion of US-23 over a 6-year time period and geographic substructuring of some lineages in the western United States. Many clonal lineages of P. infestans in the United States have come from introductions from Mexico, but the US-23 and US-1 lineages were most likely introduced from other sources.
Identification and Functional Characterization of an Effector Secreted by Cronartium ribicola
Authors: Ma Zhenguo , Liu Jun-Jun , Zamany Arezoo
Published: May 2019

Cri-9402 was identified as a protein effector from Cronartium ribicola, based on the effect of its expression on growth of Pseudomonas syringae Psm ES4326 introduced into transiently transformed tobacco leaves and stably transformed Arabidopsis seedlings. In tobacco leaves transiently expressing its coding sequence, growth of P. syringae Psm ES4326 was inhibited. Expression of pathogenesis-related (PR) protein 2 (PR2), PR4a, endochitinase B, hypersensitive-related 201 (HSR201), HSR203J, and proteinase inhibitor 1 was upregulated but expression of PR1, coronatine insensitive 1, and abscisic acid 1 was significantly suppressed. In transformed Arabidopsis seedlings, the effector stimulated growth of P. syringae Psm ES4326; significantly suppressed expression of PR1, PR2, nonexpresser of pathogenesis-related genes 1 (NPR1), NPR3, NPR4, phytoalexin deficient 4, and salicylic acid induction deficient 2; and enhanced expression of plant defensin 1.2 (PDF1.2). The above results showed that the majority of responses to this effector in tobacco leaves were converse to those in transformed Arabidopsis. We could conclude that Cri-9402 promoted disease resistance in tobacco leaves and disease susceptibility in Arabidopsis seedlings. Its transcript was mainly expressed in aeciospores of C. ribicola and was probably involved in production or germination of aeciospores, and it was an effector potentially functioning in white pine–blister rust interactions.
Enhanced Recovery After Surgery Pathway for Cesarean Delivery: Effect on Opioid Use and Pain Scores [5K]
Authors: Fay Emily E. , Delgado Carlos C. , Hitti Jane , Savitsky Leah , Mills Elizabeth , Bollag Laurent
Published: May 2019

INTRODUCTION:

One in 300 opioid-naïve women develop opioid addiction following cesarean delivery (CD). Enhanced recovery after surgery (ERAS) pathways provide a multidisciplinary, evidence-based approach to postoperative care and have been shown to decrease postoperative opioid consumption. We implemented an ERAS CD pathway and evaluated the impact on postoperative opioid use and pain scores.

METHODS:

We conducted an IRB approved, retrospective cohort study comparing postoperative opioid use and pain scores among women on the ERAS CD pathway in the first year of implementation (4/2017-3/2018, n=531) compared to historical controls (3/2016-2/2017, n=661). Women with pregestational diabetes on insulin preconception, preeclampsia with severe features, and/or complex pain needs were excluded. Analysis was stratified for women undergoing planned (no labor, n=530) and unplanned (labor, n=662) CD. Postoperative opioid use and pain scores were compared using chi-squared and t-tests.

RESULTS:

During implementation, 531 (83%) of 640 eligible women were included in the ERAS CD pathway. Compared to baseline, the ERAS CD pathway resulted in an overall decrease of 13.7% (p=0.001) in postoperative opioid use with a 23.2% reduction in patients with unplanned CD (p<0.001). There was no difference in postoperative opioid use in patients with planned CD (p=0.456). ERAS patients with planned CD had a 9.5% reduction in pain scores on postoperative day 0 (p<0.05). There were no other significant differences in pain scores.

CONCLUSION:

The ERAS CD pathway was associated with decreased postoperative opioid use overall. Interestingly, the decrease in opioid use was driven by the unplanned CD subset. Further research should explore these differences.
Lifestyle Factors Do Not Meaningfully Impact Age-Based AMH Levels in Non-Infertile Women [30O]
Authors: Maslow Bat-Sheva L. , Mancinelli Kristen , Guarnaccia Michael , Klein Joshua U.
Published: May 2019

INTRODUCTION:

Increasing age has a well-established negative association on ovarian reserve, reflected in decreasing AMH levels. The role of lifestyle on physiologic AMH levels is unknown. The aim of the study was to identify whether lifestyle factors impact AMH levels in a cohort of non-infertile women.

METHODS:

This retrospective cohort study includes all initial oocyte cryopreservation consultations from 3/1/2016 to 9/30/2018 at Extend Fertility Medical Practice. The study was granted IRB exempt status. Subjects were asked about smoking, drug use, caffeine intake, and exercise frequency. AMH levels were measured at an independent laboratory on the Gen-II ELISA platform. Lifestyle and BMI data were categorized. AMH levels were log transformed to approximate normal distribution. Linear regression analyses were performed controlling for age.

RESULTS:

2623 subjects were included in the study. Mean age 35.9Â±3.5 years. Median AMH 1.93 ng/mL [IQR 0.99-3.52]. Smoking, drug use, or caffeine intake were not significantly associated with age-controlled AMH levels. There was a trend towards an association with lower AMH levels for underweight (BMI<18.5kg/m2) and obese (BMI>30kg/m2) subjects (P=.03, P=.05 when controlled for age). Exercising more than two times per week was weakly associated with higher AMH levels (P=.03).

CONCLUSION:

This data supports that physiologic AMH levels are not meaningfully impacted by lifestyle factors such as exposure to caffeine, smoking, or drug use. The incidence of current smokers in our population was small and therefore the impact may be underestimated. A healthy body weight and exercise regimen may be associated with higher AMH levels, even when controlling for age.
Predictive Modeling of Spontaneous Preterm Birth Using Machine Learning [36C]
Authors: Guang Stephanie , Sarkar Indra N. , Werner Erika F.
Published: May 2019

INTRODUCTION:

Spontaneous preterm birth (sPTB) is the clinical manifestation of many overlapping pathologies, making its prediction challenging. This study explored the potential of machine learning techniques to identify risk of sPTB using complex, non-linear associations between variables.

METHODS:

Data for this study came from the Healthcare Cost and Utilization Project National Inpatient Sample database, which included 835,704 obstetric patients. Subjects were divided into three cohorts for training (60%), validation (20%), and testing (20%). Thirty-one features, relating to clinical diagnoses and demographic data, were selected for developing predictive models. The goal of classification was the binary discrimination between spontaneous onset of delivery before 37 completed weeks of gestation versus full-term birth. Classification was performed using logistic regression (LR), random forest classifier (RFC), C and nu support vector machine classifiers (C/nu-SVC), and a multi-layer perceptron artificial neural network (ANN). Data processing, training, and testing of classifiers were done using the Julia programming language.

RESULTS:

Of the 835,704 obstetric patients, 49,563 resulted in sPTB (5.9%). Classifier models were constructed and assessed relative to the training dataset. The areas under the receiver operating characteristic curves (AUROC) were 0.50, 0.86, 0.79, 0.92, and 0.75 for LR, RFC, C-SVC, nu-SVC, and the ANN respectively. The nu-SVC performed best, with the highest AUROC and a sensitivity and specificity of 78.8% and 94.9%.

CONCLUSION:

Machine learning methodologies show promise in characterizing sPTB versus full term births using comorbidity information from administrative health data. Machine learning techniques, such as nu-SVC, might be considered as a supplement for clinical assessment of sPTB risk.
Medical Student Perceptions of Parenthood Timing [37A]
Authors: Berroth Margeaux , Miura Lisa , Robertson Katie , Feryn Alicia , Hui Jia , Lapidus Jodi
Published: May 2019

INTRODUCTION:

The practice of delaying parenthood in lieu of professional pursuits is common in medicine. Scant literature exists on medical students' postponement of parenthood. We aimed to assess medical students' self-perceived fertility and preservation, attitudes toward delaying parenthood, and if the desire to have children affects specialty choice.

METHODS:

A 23-item survey of yes/no and multiple-choice questions was distributed to students at two west coast medical schools. Responses were voluntary and anonymous. 658 total surveys were collected and analyzed between October 2017 and March 2018. Nonparent and parent responses were analyzed separately using univariate logistic regression. All analyses were conducted in R software using the generalized linear model function.

RESULTS:

Among all those surveyed, 59.8% were female, 59.3% MD students, 85.1% age 30 or younger, and 88.5% were nonparents. Among nonparents who desire children: 55% want their first child between ages 31-35, 82.6% have concerns about the timing of when to start a family, 72% feel pressure to delay parenthood given career circumstances, and males more than females would consider cryopreservation in the face of subfertility.

CONCLUSION:

Many medical students have concerns about the timing of when to have children, feel the pressure to delay having children, and/or desire starting families when professional demands peak and fertility declines. Given the increasing age of matriculating medical students and the intensive time investment in education and training, our research suggests that medical education institutions consider how they can better aid students in balancing the challenges of pursuing medicine with the desire to have children.
Cesarean Prevalence Rates for Different Races by Maternal Characteristics [20B]
Authors: Thompson Jennifer Anne , Olyaei Amy , Skeith Ashley , Caughey Aaron B.
Published: May 2019

INTRODUCTION:

Cesarean delivery rates reached a peak in 2009 and most recently have decreased to their lowest rate since 2007. Our goal was to examine if there were differences in rates of decline for each race (White, Black, Hispanic, Asian and American Indian/Alaska Native.

METHODS:

We conducted a retrospective cohort study of 1,868,948 singleton, non-anomalous, term gestations from 2010 through 2016 who underwent cesarean section. From there, the rates for each race (White, Black, Hispanic, Asian, American Indian and AI/AN) were stratified based on parity and prior cesarean section. Multivariate regression analyses and chi-square tests were employed for statistical comparisons and a p-value of less than 0.05 was used to indicate statistical significance.

RESULTS:

White, Hispanic, Asian and AI/AN all have statistically significant decreasing cesarean prevalence rates overtime for nulliparous, multiparous and prior cesarean section gestations. The rates of cesarean section in nulliparous black women however, did not decline (Table 1). Black and Asian gestations overall had higher prevalence rates for cesarean delivery among nulliparous women. AI/AN had the lowest prevalence rates of cesarean delivery in nulliparous gestations of all races (25.3, 24.5, 22.7, 22.9).

CONCLUSION:

Overall, there is a race disparity in cesarean section rates among nulliparous black women as compared to all other races, which have all shown a decline over time in cesarean section rates. Nulliparous Black and Asian women have an elevated prevalence rate while nulliparous AI/AN had the lowest cesarean delivery rates of all races. Resources should be targeted to reduce the cesarean section rate among nulliparous black women.
Trends in Radiation Dose and Technique For Anal Canal Squamous Cell Carcinoma
Authors: Wegner Rodney E. , Abel Stephen , Hasan Shaakir , White Richard J. , Raj Moses , Monga Dulabh , Finley Gene , McCormick James , Kirichenko Alexander V.
Published: May 2019

Background:

Anal canal squamous cell carcinoma (SCC) is managed definitively with chemoradiation, reserving surgery for salvage. The dosage of radiation has varied from 30 Gy to in excess of 60 Gy. RTOG 0529 established intensity modulated radiation therapy (IMRT) as standard of care for anal canal SCC with doses of 50.4 to 54 Gy. We sought to use the National Cancer Database to examine trends in dose selection and radiation technique over time.

Methods:

We queried the National Cancer Database from 2004 to 2015 for cases of anal cancer stage groups 1 to 3, treated with definitive doses of radiation with chemotherapy. Dose escalation was defined as >54 Gy. Univariable and multivariable analyses were performed to identify factors predictive of dose, IMRT, and overall survival. Propensity-adjusted Cox proportional hazard ratios for survival were used to account for indication bias.

Results:

We identified 7792 patients meeting the eligibility criteria, with 4269 treated to doses of 45 to 54 Gy and 3163 treated to doses >54 Gy. Patients who were older, had government or private insurance, IMRT treatment, treatment at an academic center, or more recent years were less likely to get dose escalation. The use of dose escalation decreased over time, from 50% in 2005 to 30% in 2015. IMRT use increased over time from 2% to 63%. On multivariable analysis with propensity score included it was found that increased age, higher comorbidity score, lower income, shorter distance to facility, and male sex were predictive of decreased overall survival. In addition, escalated dose was associated with a lower survival (hazard ratio: 1.10, 95% confidence interval: 1.01-1.20,P=0.03).

Conclusions:

The results of this analysis show a steady increase in the use of IMRT, with corresponding decrease in dose escalation. These findings correlate with the results of RTOG 0529 establishing IMRT as standard of care for anal SCC, using doses of 50.4 to 54 Gy.
Cost Implications of Varying the Surgical Setting and Anesthesia Type for Trigger Finger Release Surgery
Authors: Kazmers Nikolas H. , Stephens Andrew R. , Presson Angela P. , Yu Ziji , Tyser Andrew R.
Published: May 2019

Background:

Trigger finger release (TFR) is a common surgical procedure, representing a financial burden to the healthcare system. Our null hypothesis is that the choice surgical setting [operating room (OR) versus procedure room (PR)] and anesthetic type [local-only or monitored anesthesia care (MAC)] do not affect surgical encounter costs for TFR.

Methods:

Adult patients undergoing isolated unilateral TFR between May 2014 and December 2017 by 5 fellowship-trained hand surgeons at a single academic medical center were identified by Current Procedural Terminology (CPT) code (26055). We excluded patients undergoing revision surgery, tenosynovectomy, or additional procedures. Using our institution’s information technology value tools, we calculated total direct costs for each surgical encounter, which were compared between groups. Univariate and multivariable gamma regression were used to model costs.

Results:

Of 210 included patients, 54% (113/210) of cases were performed in the PR and 46% (97/210) in the OR. No significant differences in demographics were observed between PR and OR groups. Compared to local-only in the PR, the OR with local-only, and OR with MAC, demonstrated 2.2- and 3.2-fold greater median costs. Multivariable models suggested that use of the OR independently led to 221% [95% Confidence interval: 137%–345%; P < 0.01] greater mean costs than the PR, and use of MAC was associated with 30% (95% confidence interval: 13%–49%; P < 0.01) greater mean costs for OR cases than local-only, while controlling for other confounders.

Conclusion:

Performing TFR in the PR setting under local-only anesthesia minimizes surgical encounter direct costs for this common procedure.
Subtenon Bupivacaine for Postoperative Pain in Patients Undergoing Pterygium Excision: A Double-Blinded Randomized Control Trial
Authors: Bhikoo Riyaz , Hughes Karen , Vather Ryash , Murphy Chris
Published: May 2019

Purpose:

Patients undergoing primary pterygium excision with autologous conjunctival autograft and human tissue adhesive in New Zealand, currently receive subconjunctival anesthesia with oral postoperative analgesia for pain. Our aim was to investigate the potential added benefit of intraoperative subtenon bupivacaine to this regimen.

Methods:

A double-blinded, placebo-controlled, randomized trial was conducted at 2 centers. All patients received topical and subconjunctival anesthesia intraoperatively, with standardized oral analgesia as required postoperatively. Participants were allocated to receive subtenon bupivacaine 0.5% or placebo at the conclusion of surgery. Corneal epithelial defect and conjunctival graft size were recorded. Pain and ocular surface irritation were assessed (Likert scale) immediately postoperatively at 3, 6, 12, 24, and 36 hours. Cumulative oral analgesia consumption (doses) was reported at 24 and 36 hours.

Results:

Forty-two patients were randomized with participants evenly matched at baseline. Postoperative pain at all time points ≤24 hours was significantly less (2.4 vs. 1.2; P < 0.04) in the bupivacaine arm with no difference at 36 hours (P = 0.27). Ocular surface irritation was also significantly less at all time points ≤12 hours (4.8 vs. 1.3; P < 0.01) with no difference at 24 hours (P = 0.10). Analgesia consumption was less in the bupivacaine arm at 24 (6.5 vs. 2.5; P < 0.01) and 36 hours (7.6 vs. 3.4; P < 0.01). No complications were observed.

Conclusions:

Intraoperative subtenon bupivacaine improves patient comfort after pterygium excision by reducing pain, irritation, and requirement for oral analgesia after surgery.
Conflict Experienced by Nurses Providing End-of-life Care in Emergency Departments in Japan
Authors: Satake Yoko , Arao Harue
Published: May 2019

Saving lives is the first priority in emergency departments. However, it is important to provide end-of-life care (EOLC) for patients and their families in these departments when the patient's life cannot be saved. Existing work reporting the obstacles and difficulties of nursing practice has found that the perceptions of nurses who provide EOLC include distress and conflict. The primary aims of this study were (i) to clarify the structure of the conflict experienced by nurses providing EOLC in emergency departments and (ii) to explore factors influencing this experience of conflict. A questionnaire survey was conducted among nurses working in emergency departments in Japan. The participants were sampled using a random sampling design. In total, 290 (55.3%) nurses responded to the survey and 288 (55.0%) responses were usable for the analysis. Seven components comprising 31 items were identified: (1) conflict about ability to practice EOLC; (2) conflict about relationships with the medical team; (3) conflict about the environment for EOLC; (4) conflict about decision making; (5) conflict about family nursing; (6) conflict about patients' pain; and (7) conflict about medical limitations. The nurses' individual backgrounds and support systems were found to influence their experience of conflict. To support nurses providing EOLC in emergency departments, we need to understand the conflict they experience, including how their backgrounds affect this experience, and construct a system that incorporates support from the specialized field of EOLC.
Oxylipins and Free Fatty Acids in Parenteral Lipid Emulsions Currently Used in Preterm Infant Care
Authors: Suganuma Hiroki , Collins Carmel T. , McPhee Andrew J. , Liu Ge , Gibson Robert A.
Published: May 2019

Lipid emulsions used to support nutrition in preterm infants contain long‐chain polyunsaturated fatty acids (LCPUFAs) as a source of essential fatty acids; these LCPUFAs and their parent polyunsaturated fatty acid (PUFA) can be oxidized by a variety of mechanisms to bioactive molecules called oxylipins, which are signaling molecules that initiate and/or resolve inflammation. The aim of this study was to explore levels of free LCPUFA and their related oxylipins in 3 commercially available lipid emulsions (Intralipid, SMOFlipid, and ClinOleic) using ultra high‐performance liquid chromatography mass spectroscopy. Free LCPUFA were detected in all lipid emulsions tested. Seven, 8, and 9 different oxylipin compounds were detected in the 3 emulsions, respectively. The oxylipins detected were mainly derived from omega‐6 PUFAs; these included 13‐hydroxyoctadecadienoic acid from linoleic acid and 5‐hydroxyeicosatetraenoic acid derived from arachidonic acid. It may be clinically important to know that oxylipins exist in lipid emulsions and to evaluate their potential effects on preterm infants.
Intrinsic Molecular Subclassification of Urothelial Carcinoma of the Bladder: Are We Finally there?
Authors: Akhtar Mohammed , Al-Bozom Issam A. , Ben Gashir Mohamed , Taha Noheir M.
Published: May 2019

Bladder cancer is a highly prevalent disease throughout the world usually encountered in older patients, and associated with substantial morbidity, mortality, and cost. The treatment of bladder cancer has remained unchanged for the last several decades. However, in recent years the availability of comprehensive genomic data from The Cancer Genome Atlas and other large projects have considerably improved our understanding of the pathogenesis of these tumors. These studies demonstrated that bladder cancers can be grouped into 2 broad categories namely basal and luminal molecular subtypes with recognizable subgroups in each of these categories. Clinical data suggest that invasive basal cancers are more sensitive to neoadjuvant chemotherapy (NAC), such that most patients with basal cancers who are aggressively managed with NAC have excellent outcomes. Patients with luminal cancers do not appear to derive much clinical benefit from NAC, but some may appear to be sensitive to anti-programmed death-ligand 1 (PDL1) antibodies and possibly other immune checkpoint inhibitors. It is hoped that future studies will also identify biomarkers such as immunohistochemical markers which may be used to predict therapeutic response of these tumors. This will contribute substantially toward efficient and cost-effective diagnosis and management of these neoplasms.
A Prospective Look at Career Aspirations Among Pediatric Emergency Medicine Trainees
Authors: Morrison Sephora , Jones Nathaniel , Koutroulis Ioannis , Chamberlain James
Published: May 2019

Objectives

Before delivering a contract negotiation workshop to pediatric emergency medicine fellows in training, we wanted to understand the group's career aspirations. We hypothesized that fellows would be interested in nonclinical skill building in addition to the clinical training.

Methods

A 9-question survey was anonymously administered to fellows registered for the national conference using SurveyMonkey before the conference date. Six questions were quantitative, 2 were qualitative and open ended, and 1 required ranking of elements.

Results

Seventy-seven (47%) of the conference attendees responded to the survey, and approximately 80 (48%) attended the workshop session.

Of the 77 fellows responding when asked about desired percentage of time per week devoted to the 4 categories of clinical, research, education, and administrative work within a 40-hour week, 76 (99%) chose the clinical category with an average of 58% of total hours devoted, 71 (92%) chose education with an average of 14% of total hours, 69 (90%) chose administration with an average of 8% of total hours, and 62 (81%) chose research with an average of 11% of total hours.

Seventy attendees provided 1 sentence with the description of their ideal job. Thematic analysis of these responses revealed the following 5 main themes: academic potential, clinical environment, remuneration, job location, and work-life balance.

Conclusions

Diversification in pediatric emergency medicine training is becoming a growing area of importance. Our study highlights a discrepancy in the expected time dedicated for nonclinical activities from those seen in previous workforce studies.
Surgery for Recurrent Hepatocellular Carcinoma
Authors: Yoh Tomoaki , Seo Satoru , Taura Kojiro , Iguchi Kohta , Ogiso Satoshi , Fukumitsu Ken , Ishii Takamichi , Kaido Toshimi , Uemoto Shinji
Published: May 2019

Objective:

To evaluate the long-term outcomes of surgery for recurrent hepatocellular carcinoma (HCC).

Background:

HCC recurs with high incidence after liver resection. Little is known about long-term outcomes of patients undergoing surgery for recurrent HCC.

Methods:

Among 989 patients who underwent R0/R1 liver resection for HCC between 1995 and 2014, 676 patients who exhibited recurrence were included. Repeat surgery was performed in 128 patients (RS group), and not in the remaining 548 patients (NS group). Prognostic value after repeat surgery was evaluated by comparing survival after recurrence (SAR) between the RS and NS groups. Subgroup analyses according to the 3 recurrence patterns [intrahepatic recurrence (IHR), extrahepatic recurrence (EHR), and intra plus extrahepatic recurrence (IHR + EHR)] were performed.

Results:

Seventy-three of 430 patients (17.0%) with IHR, 17 of 57 patients (29.8%) with EHR, and 38 of 189 patients (20.1%) with IH + EHR underwent repeat surgery. Compared with the NS group, the RS group had better liver function and their time to recurrence was significantly longer (16.5 vs 11.4 months; P < 0.001). In the overall and 3 recurrence patterns, the 5-year SAR rate was better in the RS group compared with the NS group (RS vs NS group; overall, 53.0% vs 25.7%; IHR, 73.8% vs 37.2%; EHR, 30.0% vs 0%; IHR + EHR, 34.1% vs 10.6%; all P < 0.001, respectively). On multivariate analysis, repeat surgery was identified as an independent factor for better SAR (P < 0.001).

Conclusion:

Surgery for recurrent HCC may yield long-term survival for not only IHR but also for EHR in selected patients.
Carbon stocks of coastal seagrass in Southeast Asia may be far lower than anticipated when accounting for black carbon
Authors: Gallagher John B. , Chuan Chee Hoe , Yap Tzuen-Kiat , Fredelina Dona Wydia Farhain
Published: May 2019

Valuing sedimentary ‘blue carbon’ stocks of seagrass meadows requires exclusion of allochthonous recalcitrant forms of carbon, such as black carbon (BC). Regression models constructed across a Southeast Asian tropical estuary predicted that carbon stocks within the sandy meadows of coastal embayments would support a modest but not insignificant amount of BC. We tested the prediction across three coastal meadows of the same region: one patchy meadow located close to a major urban centre and two continuous meadows contained in separate open embayments of a rural marine park; all differed in fetch and species. The BC/total organic carbon (TOC) fractions in the urban and rural meadows with small canopies were more than double the predicted amounts, 28 ± 1.6% and 36 ± 1.5% (±95% confidence intervals), respectively. The fraction in the rural large-canopy meadow remained comparable to the other two meadows, 26 ± 4.9% (±95% confidence intervals) but was half the amount predicted, likely owing to confounding of the model. The relatively high BC/TOC fractions were explained by variability across sites of BC atmospheric supply, an increase in loss of seagrass litter close to the exposed edges of meadows and sediment resuspension across the dispersed patchy meadow.
Oldest record of monk seals from the North Pacific and biogeographic implications
Authors: Velez-Juarbe Jorge , Valenzuela-Toro Ana M.
Published: May 2019

True seals (crown Phocidae) originated during the late Oligocene–early Miocene (approx. 27–20 Ma) in the North Atlantic/Mediterranean region, with later (middle Miocene, approx. 16–11 Ma) dispersal events to the South Atlantic and South Pacific. Contrasting with other pinnipeds, the fossil record of phocids from the North Pacific region is scarce and restricted to the Pleistocene. Here we present the oldest fossil record of crown phocids, monachines (monk seals), from the North Pacific region. The specimens were collected from the upper Monterey Formation in Southern California and are dated to 8.5–7.1 Ma, predating the previously oldest known record by at least 7 Ma. This record provides new insights into the early biogeographic history of phocids in the North Pacific and is consistent with a northward dispersal of monk seals (monachines), which has been recognized for other groups of marine mammals. Alternatively, this finding may correspond with a westward dispersal through the Central American Seaway of some ancestor of the Hawaiian monk seal. This record increases the taxonomic richness of the Monterey pinniped assemblage to five taxa, making it a fairly diverse fossil assemblage, but also constitutes the oldest record of sympatry among all three extant pinniped crown clades.
Resilin in the flight apparatus of Odonata (Insecta)—cap tendons and their biomechanical importance for flight
Authors: Bäumler Fabian , Büsse Sebastian
Published: May 2019

In Odonata, a direct flight mechanism with specialized tendons evolved. One particular adaptation, the implementation of the rubber-like protein resilin in these cap tendons, might be of major importance. Although resilin was first described in one tendon of Odonata, to our knowledge no comprehensive study about the presence of resilin in the thorax exists yet. We investigated various species of Odonata, using µCT, dissection and fluorescence microscopy. Here we show a complete mapping of the odonatan pterothorax, regarding the presence of tendons and their properties. Thus, 20–21 cap tendons in the pterothorax of Odonata show the presence of resilin. While performing outstanding and often-aggressive flight manoeuvres, resilin can provide shock absorption against mechanical damage from strong impacts. It may further improve the wear and fatigue resistance owing to resilin's damping behaviour. Additionally, resilin in tendons can absorb and return kinetic energy to restore muscles to their original shape after contracting and help in maintaining self-oscillation of the flight muscles. Here, the material distribution within the direct flight system of Odonata and the biomechanical importance and possible function of resilin are discussed. These results are an important step towards the understanding of the complex form–material–function interplay of the insect cuticle.
Time-dependent latent inhibition of predator-recognition learning
Authors: Crane Adam L. , Chivers Douglas P. , Ferrari Maud C. O.
Published: May 2019

To optimally manage an environment with predators, prey must correctly distinguish between cues that are risky and cues that are safe. Even a specific cue that is safe in one area or at a certain time may be dangerous in other situations, and vice versa. Latent inhibition is a cognitive mechanism by which animals fail to learn that a stimulus as risky because they have already learned it as non-threatening via previous encounters with the stimulus in the absence of negative consequences. Here, we demonstrate that latent inhibition of predator-recognition learning in wood frog tadpoles,Lithobates sylvaticus, depends on the timing of their learning opportunities. For 6 days, tadpoles were exposed daily to an initially novel stimulus (salamander odour), either in the morning (11.00–13.00 h) or evening (16.00–18.00 h). The following day, we conditioned tadpoles to recognize the salamander odour as a predator by pairing it with injured tadpole cues, either at the same time as their previous experience or at the opposite time. When tested the following day, latent inhibition occurred under each scenario where the timing of conditioning matched the timing of the pre-exposure. However, tadpoles tested in the morning showed learned fright responses when conditioned in the morning if their pre-exposure had occurred in the evening, whereas individuals tested in the evening showed learned fright responses when conditioned in the evening if their pre-exposure had occurred in the morning. This is the first report of time-dependent latent inhibition of predator-recognition learning, which is likely an important mechanism for correctly managing predation risk and safety.