bluuebunny/crossref_metadata_2025 huggingface dataset:
Optimization of therapy against Pseudomonas aeruginosa with ceftazidime and meropenem using chemostats as model for infections
Authors: Feng Yanfang , Bakker Roosmarijn T , van Hest Reinier M , Hodiamont Caspar J , Brul Stanley , Schultsz Constance , ter Kuile Benno H
Published: June 2017

Pseudomonas aeruginosa is an opportunistic pathogen that can cause life-threatening infections in patients admitted to intensive care units. Resistance rapidly develops against two drugs of choice: ceftazidime and meropenem. Several therapeutic protocols were compared for reduction in viable cells and limiting development of resistance. Chemostat cultures were exposed to antibiotic concentrations measured in the blood of patients at low (5th percentile), medium (50th percentile) or high (95th percentile) levels in several therapy protocols to simulate therapy. Cultures exposed to ceftazidime recovered after 1 day at low, 2 days at medium and 3 days at high concentrations and developed corresponding levels of resistance. Patterns were very similar for meropenem except that recovery was delayed. Fluctuating levels and intermittent treatment achieved similar reduction of cell numbers at lower resistance costs. Treatment alternating ceftazidime and meropenem reduced cell numbers more than monotherapy, while strongly limiting resistance. Combination therapy was even more effective in both respects. Therapeutic goals are best reached with least risk of resistance when ceftazidime and meropenem are used in combination or alternating, at the highest concentrations the patient can endure. Monotherapy should also apply the highest concentration that is safe for the shortest time that achieves treatment objectives.
GAVCA Study: Randomized, Multicenter Trial to Evaluate the Quality of Ventricular Catheter Placement with a Mobile Health Assisted Guidance Technique
Authors: Thomale Ulrich-Wilhelm , Schaumann Andreas , Stockhammer Florian , Giese Henrik , Schuster Dhani , Kästner Stefanie , Ahmadi Alexander Sebastian , Polemikos Manolis , Bock Hans-Christoph , Gölz Leonie , Lemcke Johannes , Hermann Elvis , Schuhmann Martin U , Beez Thomas , Fritsch Michael , Orakcioglu Berk , Vajkoczy Peter , Rohde Veit , Bohner Georg
Published: June 2017

BACKGROUND

Freehand ventricular catheter placement may represent limited accuracy for the surgeon's intent to achieve primary optimal catheter position.

OBJECTIVE

To investigate the accuracy of a ventricular catheter guide assisted by a simple mobile health application (mhealth app) in a multicenter, randomized, controlled, simple blinded study (GAVCA study).

METHODS

In total, 139 eligible patients were enrolled in 9 centers. Catheter placement was evaluated by 3 different components: number of ventricular cannulation attempts, a grading scale, and the anatomical position of the catheter tip. The primary endpoint was the rate of primary cannulation of grade I catheter position in the ipsilateral ventricle. The secondary endpoints were rate of intraventricular position of the catheter's perforations, early ventricular catheter failure, and complications.

RESULTS

The primary endpoint was reached in 70% of the guided group vs 56.5% (freehand group; odds ratio 1.79, 95% confidence interval 0.89-3.61). The primary successful puncture rate was 100% vs 91.3% (P = .012). Catheter perforations were located completely inside the ventricle in 81.4% (guided group) and 65.2% (freehand group; odds ratio 2.34, 95% confidence interval 1.07-5.1). No differences occurred in early ventricular catheter failure, complication rate, duration of surgery, or hospital stay.

CONCLUSION

The guided ventricular catheter application proved to be a safe and simple method. The primary endpoint revealed a nonsignificant improvement of optimal catheter placement among the groups. Long-term follow-up is necessary in order to evaluate differences in catheter survival among shunted patients.
Impact of Characteristics of Different Wheat Flours on the Quality of Frozen Cooked Noodles
Authors: Yue Feng‐Ling , Guo Xiao‐Na , Zhu Ke‐Xue
Published: June 2017

In this study, the impact of characteristics (physicochemical, rheological, and pasting properties) of different wheat flours on the quality of frozen cooked noodles was investigated. In this sample set, results showed the cooking loss of noodles related negatively to flour swelling power. The water absorption of noodles related negatively to the dough stability time, the area, and the resistance to extension. The wheat flour with higher dough development time resulted in frozen cooked noodles with higher hardness, chewiness, and adhesiveness. Springiness of noodles correlated negatively to degree of softening. The tensile properties of frozen cooked noodles were influenced by rheological and pasting properties of wheat flours. The present study indicated high quality of frozen cooked noodles demanded wheat flours with high dough gluten strength, peak viscosity, and final viscosity and with low pasting temperature.
A Free-Market Approach to the Match: A Proposal Whose Time Has Not Yet Come
Authors: Arnold Louise , Sullivan Christine , Okah Felix A.
Published: June 2017

The authors respond to a proposal in this issue of Academic Medicine by Ray, Bishop, and Dow, who recommend adopting a free-market approach to the Match in which applicants and programs negotiate directly with each other to find and fill residency positions year-round. This Invited Commentary examines and responds to the reasons Ray and colleagues give for changing the Match and explores their proposal’s implications and likelihood of success.

The authors question Ray and colleagues’ argument that assumptions underlying the National Resident Matching Program algorithm have been violated. The authors suggest there is insufficient evidence for the “July effect” and that the possibility for improvement in physician supply due to the year-round entry of graduates into the workforce ultimately faces the rate-limiting step of caps on residency positions allocated to programs. Most important, competency-based medical education, on which the free-market proposal depends, is not yet sufficiently developed.

Nonetheless, the imbalanced ratio of applicants to positions in the Match is contributing to a rise in the numbers of student applications and program interviews. Although the proposed free-market approach might, as Ray and colleagues envision, curtail applications as well as reduce time and financial resources currently expended on the process, it would require significant changes on the part of applicants, residency programs, medical schools, and other stakeholders.

Because the proposed free-market approach could reduce some negative effects of the imbalance of applicants and positions, it merits ongoing discussion along with other more immediate practical solutions to issues with the Match.
Musculoskeletal manifestations of systemic lupus erythmatosus
Authors: Mahmoud Khaled , Zayat Ahmed , Vital Edward M.
Published: June 2017

Purpose of review

Imaging studies suggest potential changes to the classification and assessment of inflammatory musculoskeletal lupus. This is important because of the burden of disease but the potential for new targeted therapies.

Recent findings

Using our current classification and treatment, musculoskeletal symptoms continue to impact significantly on quality of life and work disability. Ultrasound and MRI studies suggested that new approaches to the diagnosis, classification, and evaluation of these symptoms are needed. Many patients with pain but no synovitis have ultrasound-proven joint and tendon inflammation but would not qualify for clinical trials or score highly on disease activity instruments. MRI studies show that erosions are more common than previously thought and may have a different pathogenesis than RA. Immunology studies suggest differences from other autoimmune synovitis, with a complex role for type I interferons. A wide range of biologic therapies appear more consistently effective for arthritis than some other manifestations.

Changes to the selection of patients for therapy and stratification using musculoskeletal imaging may offer new approaches to clinical trials and the routine care of systemic lupus erythematosus patients with inflammatory musculoskeletal symptoms. Outcomes may thereby be improved using existing therapies. There are significant knowledge gaps that must be addressed to achieve these potential improved outcomes.
Do Occupational Risks for Low Back Pain Differ From Risks for Specific Lumbar Disc Diseases?
Authors: Bergmann Annekatrin , Bolm-Audorff Ulrich , Ditchen Dirk , Ellegast Rolf , Grifka Joachim , Haerting Johannes , Hofmann Friedrich , Jäger Matthias , Linhardt Oliver , Luttmann Alwin , Meisel Hans Jörg , Michaelis Martina , Petereit-Haack Gabriela , Schumann Barbara , Seidler Andreas
Published: June 2017

Study Design.

A multicenter, population based, case-control study.

Objective.

The aim of the present analysis is to clarify potential differences in the “occupational risk profiles” of structural lumbar disc diseases on the one hand, and low back pain (LBP) on the other hand.

Summary of Background Data.

Physical workplace factors seem to play an important etiological role.

Methods.

We recruited 901 patients with structural lumbar disc diseases (disc herniation or severe disc space narrowing) and 233 control subjects with “low-back-pain.” Both groups were compared with 422 “low-back pain free” control subjects. Case history, pain data, neurological deficits, and movement restrictions were documented. LBP was recorded by the Nordic questionnaire on musculoskeletal symptoms. All magnetic resonance imaging, computed tomography, and X-rays were inspected by an independent study radiologist. The calculation of cumulative physical workload was based on a computer-assisted interview and a biomechanical analysis by 3-D-dynamic simulation tool. Occupational exposures were documented for the whole working life.

Results.

We found a positive dose-response relationship between cumulative lumbar load and LBP among men, but not among women. Physical occupational risks for structural lumbar disc diseases [odds ratio (OR) 3.7; 95% confidence interval (95% CI) 2.3–6.0] are higher than for LBP (OR 1.9; 95% CI 1.0–3.5).

Conclusion.

Our finding points to potentially different etiological pathways in the heterogeneous disease group of LBP. Results suggest that not all of the structural disc damage arising from physical workload leads to LBP.

Level of Evidence: 4
Radiographic Analysis of Psoas Morphology and its Association With Neurovascular Structures at L4-5 With Reference to Lateral Approaches
Authors: Louie Philip K. , Narain Ankur S. , Hijji Fady Y. , Yacob Alem , Yom Kelly H. , Phillips Frank M. , Singh Kern
Published: June 2017

Study Design.

Retrospective imaging review.

Objective.

Utilize magnetic resonance imaging (MRI) to expand the anatomical description of psoas morphology and its association with neurovascular structures at L4-5.

Summary of Background Data.

Anatomical psoas muscle variants may present a greater risk of neurovascular injury at the L4-5 level during lateral transpsoas approaches.

Methods.

Axial L4-5 sections of consecutive patients who obtained lumbar MRIs were analyzed. Teardrop psoas morphology was assessed qualitatively. MRI described psoas morphology and proximity of neurovascular structures, whereas plain radiographs were evaluated for lumbosacral transitional vertebrae (LSTV). Teardrop morphology was tested for associations with radiographic measurements using t tests and χ

2
analysis.

Results.

Fifty teardrop and 476 nonteardrop psoas muscles were identified. Teardrop morphology was associated with greater longitudinal length (53.1 vs. 49.3 mm, P = 0.012), and shorter transverse length (34.9 vs. 44.8 mm, P < 0.001) compared with nonteardrop. Teardrop morphology was associated with anterior and lateral migration of the psoas with greater distance between the anterior borders of the psoas and disc (13.5 vs. 6.3 mm, P < 0.001), and greater distance between the medial border of the psoas to the lateral disc border (1.6 vs. 0.5 mm, P < 0.001). Teardrop morphology was associated with a higher incidence of the lumbar plexus migrating anteriorly adjacent to the middle-third of the disc (43.4% vs. 17.6%, P < 0.001) and the iliac vasculature being more laterally and posteriorly located, adjacent to the anterior-third of the disc (43.4% vs. 30.0%, P = 0.047). Teardrop morphology was not associated with presence of LSTV (3.8% vs. 7.6%, P = 0.306).

Conclusion.

The current study provides detailed metrics of teardrop psoas muscles and surrounding structures. The study confirms that the presence of teardrop anatomy on L4-5 axial imaging is associated with anterior migration of the lumbar plexus and posterolateral migration of the iliac vasculature which may increase the risk of neurovascular injury during direct and oblique-lateral lumbar spine procedures.

Level of Evidence: 3
The Impact of Mortality on Total Costs Within the ICU
Authors: Kramer Andrew A. , Dasta Joseph F. , Kane-Gill Sandra L.
Published: June 2017

Objectives:

The high cost of critical care has engendered research into identifying influential factors. However, existing studies have not considered patient vital status at ICU discharge. This study sought to determine the effect of mortality upon the total cost of an ICU stay.

Design:

Retrospective cohort study.

Setting:

Twenty-six ICUs at 13 hospitals in the United States.

Patients:

58,344 admissions from January 1, 2012, to June 30, 2016, obtained from a commercial ICU database.

Interventions:

None.

Measurements and Main Results:

The median observed cost of a unit stay was $9,619 (mean = $16,353). A multivariable regression model was developed on the log of total costs for a unit stay, using severity of illness, unit admitting diagnosis, mortality in the unit, daily unit occupancy (occupying a bed at midnight), and length of mechanical ventilation. This model had an r
2 of 0.67 and a median difference between observed and expected costs of $437. The first few days of care and the first day receiving mechanical ventilation had the largest effect on total costs. Patients dying before unit discharge had 12.4% greater costs than survivors (p < 0.01; 99% CI = 9.3–15.5%) after multivariable adjustment. This effect was most pronounced for patients with an extended ICU stay who were receiving mechanical ventilation.

Conclusions:

While the largest drivers of ICU costs at the patient level are day 1 room occupancy and day 1 mechanical ventilation, mortality before unit discharge is associated with substantially higher costs. The increase was most evident for patients with an extended ICU stay who were receiving mechanical ventilation. Studies evaluating costs among ICUs need to take mortality into account.
Emergent Literacy in Thai Preschoolers: A Preliminary Study
Authors: Yampratoom Ramorn , Aroonyadech Nawarat , Ruangdaraganon Nichara , Roongpraiwan Rawiwan , Kositprapa Jariya
Published: June 2017

Objective:

To investigate emergent literacy skills, including phonological awareness when presented with an initial phoneme-matching task and letter knowledge when presented with a letter-naming task in Thai preschoolers, and to identify key factors associated with those skills.

Methods:

Four hundred twelve typically developing children in their final kindergarten year were enrolled in this study. Their emergent reading skills were measured by initial phoneme-matching and letter-naming tasks. Determinant variables, such as parents' education and teachers' perception, were collected by self-report questionnaires.

Results:

The mean score of the initial phoneme-matching task was 4.5 (45% of a total of 10 scores). The mean score of the letter-naming task without a picture representing the target letter name was 30.2 (68.6% of a total of 44 scores), which increased to 38.8 (88.2% of a total of 44 scores) in the letter-naming task when a picture representing the target letter name was provided. Both initial phoneme-matching and letter-naming abilities were associated with the mother's education and household income. Letter-naming ability was also influenced by home reading activities and gender.

Conclusion:

This was a preliminary study into emergent literacy skills of Thai preschoolers. The findings supported the importance of focusing on phonological awareness and phonics, especially in the socioeconomic disadvantaged group.
Urrets-Zavalia Syndrome After Diode Laser Transscleral Cyclophotocoagulation
Authors: Vieira Geraldo M. , Vieira Fernando J. , Ritch Robert
Published: June 2017

Objective:

To report the occurrence of 5 cases of Urrets-Zavalia syndrome after transscleral diode laser cyclophotocoagulation (TSCPC).

Design:

Retrospective cases series.

Methods:

A review of the charts of 5 patients treated with TSCPC as primary glaucoma surgery who developed Urrets-Zavalia syndrome.

Results:

A total of 8 eyes of 5 patients developed a fixed and dilated pupil after TSCPC, unresponsive to light. A mydriatic pupil could still be observed at least 6 months after treatment in 7 of 8 eyes; however, it was asymptomatic.

Conclusions:

Urrets-Zavalia syndrome is a possible complication of TSCPC, as well as of other 360-degree thermal laser procedures.
Testing a Holistic Meditation Intervention to Address Psychosocial Distress in Patients With Heart Failure
Authors: Heo Seongkum , McSweeney Jean , Ounpraseuth Songthip , Shaw-Devine Allison , Fier Audrey , Moser Debra K.
Published: June 2017

Background:

Many patients with heart failure (HF) experience persistent symptoms and poor health-related quality of life (HRQOL). Psychosocial distress is common and adversely affects HF symptoms and HRQOL. A holistic meditation (HOME) intervention that combines mindfulness, compassionate meditation, and self-management may reduce psychosocial distress.

Purpose:

The aims of this study were to examine the feasibility and acceptability of the HOME intervention in patients with HF and to obtain preliminary data about its effects on psychosocial factors (depressive symptoms, perceived control, and social support), HF symptoms, and HRQOL.

Methods:

Weekly 90-minute intervention sessions were delivered to 11 patients with HF for 12 weeks. Data on feasibility and acceptability were collected for 12 weeks, and data on psychosocial factors, HF symptoms, and HRQOL were collected at baseline and after the intervention.

Results:

Eleven of 13 enrolled patients completed all intervention sessions; 2 withdrew because of family health issues. Mean acceptability scores for all sessions ranged from 98% to 100%. In paired t test analyses, perceived control (P = .02, Cohen d = 0.82) and social support (P = .008, Cohen d = 1.00) increased, severity of depressive symptoms (P < .001, Cohen d = 1.54) and HF symptoms (P < .001, Cohen d = 1.91) decreased, and HRQOL was improved (P < .001, Cohen d = 1.82).

Conclusions:

The HOME intervention was feasible and acceptable and had positive effects on psychosocial variables, HF symptoms, and HRQOL for patients with HF. Our results indicate that treatment effects should be tested in a larger, controlled clinical trial.
Validation of a Questionnaire to Delineate the Clinical Trial Nursing Roles in Korea
Authors: Choi In Jung , Park Hye-Ja
Published: June 2017

Background:

In clinical trials, research nurses play a particularly important role in promoting cancer care best practices. However, no Korean questionnaire has been developed to define the clinical trial nursing roles based on Good Clinical Practice standards.

Objective:

The aim of this study was to cross-culturally evaluate the reliability and validity of a Korean version of the Clinical Trials Nursing Questionnaire (CTNQ) among Korean clinical research nurses.

Methods:

Cross-cultural adaptation was performed, with forward and backward translation, a pilot test (linguistic validation), and a field test. Validation was performed by questioning 53 clinical research nurses who were working in clinical cancer centers at 5 tertiary university hospitals. The distribution of the item responses and internal consistency reliability were assessed using the ceiling and floor effects, Cronbach’s α, and the item-total correlation. Construct validity was assessed using Spearman correlation analysis and principal-component factor analysis.

Results:

The distributions of the item responses and the item-total correlation were generally appropriate. The Cronbach’s α values for the frequency scale and the importance scale were 0.852 and 0.899, respectively. Eight sections of the Korean CTNQ were generally correlated with each other. The frequency subscale loaded on 1 factor, and the importance subscale loaded on 2 factors, with broadly similar factor loadings.

Conclusion:

The Korean version of the CTNQ is reliable, valid, and interchangeable with the original CTNQ.

Implications for Practice:

The Korean version of the CTNQ can be used to validly and reliably assess the clinical trial nursing roles in Korea.
Noise Reduction in Progressive Care Units
Authors: McGough Nancy N. H. , Keane Trevor , Uppal Avneesh , Dumlao Maritoni , Rutherford Wendy , Kellogg Kristen , Ward Erin , Kendal Courtney , Fields Willa
Published: June 2017

Uncontrolled noise in the hospital setting can have a negative physiological and psychological impact on patients and nurses. To reduce unit noise levels and create a quiet patient and nurse experience, an evidence-based practice project was conducted in 4 progressive care units in a community hospital. The Quiet Time Bundle implementation improved patient satisfaction and patient and nurse perceptions of noise even though the decrease in noise levels may not be discernible.
Nurse-Led Patient-Centered Advance Care Planning in Primary Care
Authors: Holland Diane E. , Vanderboom Catherine E. , Dose Ann Marie , Ingram Cory J. , Delgado Adriana , Austin Christine M. , Green Michael J. , Levi Benjamin
Published: June 2017

Advance care planning rates remain low, indicating a need to identify an approach that promotes acceptance of, and participation in, high-quality advance care planning by clinicians, patients, and families. A pilot study was conducted to evaluate the feasibility and acceptability of a nurse-led advance care planning intervention in primary care, comparing 4 advance care planning decision aids to help patients consider options; a 4-arm, prospective, comparative design was used with scripted discussions between 4 nurses and 40 patients in a large Midwestern clinic. The study procedures were determined to be feasible and acceptable. Most invited patients agreed to participate (40 of 66, 60%); 38 of 40 completed the intervention. Overall, patients and nurses were satisfied with the intervention. Changes in scores on the engagement survey were positive, indicating improvement across all groups. According to these preliminary data, 124 patients would be required in each group for a fully powered study. In addition, 34 of 40 patients (85%) completed an advance directive; all 40 patients identified a healthcare agent. The use of nurses to facilitate advance care planning with patients may be an opportunity to improve healthcare and patient outcomes and support full-scope nursing practice in primary care settings.
Measuring Provider Performance for Physicians Participating in the Merit-Based Incentive Payment System
Authors: Squitieri Lee , Chung Kevin C.
Published: June 2017

In 2017, the Centers for Medicare and Medicaid Services began requiring all eligible providers to participate in the Quality Payment Program or face financial reimbursement penalty. The Quality Payment Program outlines two paths for provider participation: the Merit-Based Incentive Payment System and Advanced Alternative Payment Models. For the first performance period beginning in January of 2017, the Centers for Medicare and Medicaid Services estimates that approximately 83 to 90 percent of eligible providers will not qualify for participation in an Advanced Alternative Payment Model and therefore must participate in the Merit-Based Incentive Payment System program. The Merit-Based Incentive Payment System path replaces existing quality-reporting programs and adds several new measures to evaluate providers using four categories of data: (1) quality, (2) cost/resource use, (3) improvement activities, and (4) advancing care information. These categories will be combined to calculate a weighted composite score for each provider or provider group. Composite Merit-Based Incentive Payment System scores based on 2017 performance data will be used to adjust reimbursed payment in 2019. In this article, the authors provide relevant background for understanding value-based provider performance measurement. The authors also discuss Merit-Based Incentive Payment System reporting requirements and scoring methodology to provide plastic surgeons with the necessary information to critically evaluate their own practice capabilities in the context of current performance metrics under the Quality Payment Program.
Assessment of the Efficacy of Cryolipolysis on Saddlebags: A Prospective Study of 53 Patients
Authors: Adjadj Lucille , SidAhmed-Mezi Mounia , Mondoloni Marine , Meningaud Jean Paul , Hersant Barbara
Published: June 2017

Background:

Cryolipolysis is a noninvasive subcutaneous fat removal technique. Its efficacy has been demonstrated on various fatty areas but not yet on saddlebags. The main objective of this study was to demonstrate the efficacy, patient tolerance, and safety of cryolipolysis on the saddlebags.

Methods:

This prospective study enrolled 53 patients with saddlebags. Patients with a history of liposuction or other surgical procedure on the saddlebag area and those on diet pills were excluded. The primary endpoint was a decrease in fat thickness at 3 and 6 months, as assessed by thigh circumference measurement and by ultrasound evaluation of subcutaneous fat. Pain associated with cryolipolysis was assessed using a visual analogue scale. Body mass index at the different time points and adverse events were recorded. All patients completed a satisfaction questionnaire at the end of the study.

Results:

At 6 months, there was a mean decrease of 5.63 cm in thigh circumference; the mean decrease in fat layer thickness measured by ultrasound was 1.31 cm. The satisfaction questionnaire showed that 93.75 percent of patients were satisfied with the results. The mean visual analogue scale score was 1.66 of 10 after the session. Reversible skin changes such as postprocedure postinflammatory hyperpigmentation were observed in 8.33 percent of patients.

Conclusions:

Cryolipolysis is an effective technique for reducing saddlebag fat and is well tolerated by patients. A substantial risk of skin lesions, including postinflammatory hyperpigmentation that resolved after a few months, was observed. Cryolipolysis is a good alternative to liposuction in women with moderate, well-localized saddlebags.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Predictors, Classification, and Management of Umbilical Complications in DIEP Flap Breast Reconstruction
Authors: Cho Min-Jeong , Teotia Sumeet S. , Haddock Nicholas T.
Published: June 2017

Background:

In recent years, the deep inferior epigastric perforator (DIEP) flap has become the workhorse flap for autologous breast reconstruction. Despite increased reports on DIEP flaps, umbilical complications have not been previously studied. The aesthetics of the umbilicus dictates the beauty of the abdomen, and it is critical for plastic surgeons to minimize the scarring of the umbilicus. In this study, we retrospectively reviewed patients who underwent DIEP flaps to determine the predictors of umbilical complications, and created a classification system of these wounds.

Methods:

Retrospective review of 323 patients who underwent DIEP flap surgery from 2009 to 2016 was performed. Umbilical stalk heights, widths of fascial diastasis, and abdominal wall thicknesses were measured from computed tomographic scans. Data regarding demographic and patient characteristics were collected.

Results:

Of the 323 patients, there were 58 patients that had umbilical complications (18 percent). These patients had statistically higher body mass indexes, heavier flaps, and thicker abdominal walls (p < 0.05). Also, they had statistically higher umbilical stalk heights (29.3 mm versus 18.7 mm), and analysis showed that the likelihood ratio of having umbilical complications was 2.05 at 20.1 mm, 3.05 at 25.4 mm, and 6.43 at 30 mm. Logistic regression analysis revealed that umbilical stalk height, fascial diastasis, age, procedure time, and flap weight were significant predictors (p < 0.05).

Conclusions:

Umbilical complications in patients undergoing DIEP flap surgery for breast reconstruction have not been previously studied. Our study shows that the umbilical stalk height plays a significant role, and umbilical wounds can be classified into five types: no wound, minor wound, wound dehiscence, partial necrosis, and total necrosis.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
The Efficacy of Perforator Flaps in the Treatment of Chronic Osteomyelitis
Authors: Hong Joon Pio (Jp) , Goh Terence L. H. , Choi Dong Hoon , Kim Jung Jae , Suh Hyun Suk
Published: June 2017

Background:

Treatment of chronic osteomyelitis involves aggressive débridement followed by soft-tissue coverage. The dictum of muscle coverage being superior has been challenged by successful reports of coverage with skin flaps. The objective of this article is to evaluate the efficacy of perforator flaps for reconstruction of chronic osteomyelitis defects.

Methods:

A retrospective review of 120 patients with chronic osteomyelitis who underwent débridement and reconstruction using perforator flaps from April of 2000 to November of 2015 was conducted. Inclusion criteria were cases with chronic osteomyelitis for a minimum of 6 weeks and with a follow-up of at least 2 years after surgery. Correlation between recurrence and the following factors was analyzed: comorbidities, frequency of débridement, duration of chronic osteomyelitis, limb vascular status, and method of dead space obliteration. The outcomes analyzed were flap loss, recurrence rate, primary remission rate, secondary remission rate, and amputation rate.

Results:

The flap loss rate was 4.2 percent flap, the recurrence rate was 8.3 percent, the primary remission rate was 91.6 percent, the secondary remission rate was 98.3 percent, and the amputation rate was 1 percent. Significant predictors of recurrence were peripheral vascular disease and major vessel compromise, which had 5.1 times higher odds of recurrence (p < 0.05).

Conclusions:

Used with adequate débridement, bone reconstruction, and obliteration of dead space, a primary remission rate of 91.6 percent and a secondary remission rate of 98.3 percent were achieved using perforator flap. The predictors of chronic osteomyelitis recurrence were peripheral vascular disease and major vascular compromise.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Evidence-Based Medicine: Management of Metacarpal Fractures
Authors: Wong Victor W. , Higgins James P.
Published: June 2017

Learning Objectives:

After reading this article, the participant should be able to: 1. Understand metacarpal anatomy and its role in fracture pathology. 2. Determine when surgical intervention is needed for metacarpal fractures. 3. Understand the various treatment options for surgical fixation of metacarpal fractures. 4. Describe the role for external fixation in managing difficult metacarpal fractures.

Background:

Metacarpal fractures are common injuries that plastic surgeons should be able to evaluate and treat. The goal of this review is to highlight current evidence for managing metacarpal fractures. This Continuing Medical Education article consists of a literature review, illustrations, videos, and an online Continuing Medical Education examination.

Methods:

The authors reviewed the scientific literature from 2000 to 2015 regarding treatment of metacarpal fractures. Cadaver models were used for instructional videography demonstrating common surgical techniques. Multiple-choice questions were created to review pertinent topics. A discussion and references are provided.

Results:

Numerous treatment options have been described for metacarpal fractures, including splinting, percutaneous fixation, open reduction with internal fixation, and external fixation. All modalities are acceptable strategies for treating metacarpal fractures. The ultimate goal is to maximize hand function with minimal morbidity.

Conclusions:

A thorough understanding of treatment modalities is helpful in evaluating and managing metacarpal fractures. Although the current literature supports a wide array of treatment strategies, high-level evidence to guide fracture management remains lacking.
The Classification and Prognosis of Periocular Complications Related to Blindness following Cosmetic Filler Injection
Authors: Myung Yujin , Yim Sangjun , Jeong Jae Hoon , Kim Baek-Kyu , Heo Chan-Yeong , Baek Rong-Min , Pak Chang-Sik
Published: June 2017

Common side effects during hyaluronic acid filler injections are typically mild and reversible, but several reports of blindness have received attention. The present study focused on orbital symptoms combined with blindness, aiming to classify affected patients and predict their disease course and prognosis. From September of 2012 to August of 2015, nine patients with vision loss after filler injection were retrospectively reviewed. Ptosis, ophthalmoplegia, and enophthalmos were recorded over a 6-month follow-up, and patients were classified into four types according to periocular symptom manifestation. Two patients were categorized as type I (blindness without ptosis or ophthalmoplegia), two patients as type II (blindness and ptosis without ophthalmoplegia), two patients as type III (blindness and ophthalmoplegia without ptosis), and three patients as type IV (blindness with ptosis and ophthalmoplegia). The present study includes previously unpublished information about orbital symptom manifestations and prognosis combined with blindness caused by retinal artery occlusion after cosmetic filler injection.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, V.
Evidence-Based Medicine: Alloplastic Breast Reconstruction
Authors: Lennox Peter A. , Bovill Esta S. , Macadam Sheina A.
Published: June 2017

Learning Objectives:

After studying this article, the participant should be able to: 1. Understand the different advances that have resulted in improved outcomes in implant-based reconstruction. 2. Gain knowledge about specific techniques that have evolved rapidly in recent years and how to implement these. 3. Gain an understanding of controversies associated with alloplastic reconstruction. 4. Recognize undesirable outcomes in implant-based breast reconstruction and understand strategies for correction.

There have been multiple advances in implant-based breast reconstruction. Many of these have resulted in improvements in patient outcomes and care. Understanding new techniques and technologies ensures competence in providing care for the alloplastic breast reconstruction patient. This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.
Evidence-Based Medicine: The Bilateral Cleft Lip Repair
Authors: Zhang Jacques X. , Arneja Jugpal S.
Published: June 2017

Learning Objectives:

After reading this article, the participant should be able to: 1. Understand the epidemiology, abnormal embryology, anatomy, and etiopathogenesis of cleft lip. 2. Be able to classify and describe bilateral cleft lip. 3. Recognize the importance of preoperative management of bilateral cleft lip. 4. Recognize the large breadth of differing management options. 5. Describe key steps and tenets of the surgical repair.

This fourth Maintenance of Certification/Continuing Medical Education article on cleft lip focuses on the topic of bilateral cleft lip. Previous articles placed an emphasis on the unilateral cleft lip, velopharyngeal insufficiency, or cleft lip and palate management. The authors focus on summarizing key points from previous articles and describing the importance of preoperative management and surgical repair of the bilateral cleft lip.
Evidence-Based Medicine: Surgical Management of Flexor Tendon Lacerations
Authors: Kamal Robin N. , Yao Jeffrey
Published: June 2017

Learning Objectives:

After reading this article, the participant should be able to: 1. Accurately diagnose a flexor tendon injury. 2. Develop a surgical approach with regard to timing, tendon repair technique, and rehabilitation protocol. 3. List the potential complications following tendon repair.

Flexor tendon lacerations are complex injuries that require a thorough history and physical examination for accurate diagnosis and management. Knowledge of operative approaches and potential concomitant injuries allows the surgeon to be prepared for various findings during exploration. Understanding the biomechanical principles behind tendon lacerations and repair techniques aids the surgeon in selecting the optimal repair technique and postoperative rehabilitation.
Evidence-Based Medicine: Current Evidence in the Diagnosis and Management of Carpal Tunnel Syndrome
Authors: Hermiz Steven J. , Kalliainen Loree K.
Published: June 2017

Learning Objectives:

After studying this article, the participant should be able to: 1. Create a safe and effective plan for management of carpal tunnel syndrome. 2. Support his or her rationale for the use of diagnostic tests. 3. Discuss elements of management that have been controversial, including anesthesia, the use of a tourniquet, postoperative pain control, and cost of care.

This is the fourth MOC-PS CME article on carpal tunnel syndrome. Each of the prior three has had a slightly different focus, and the reader is invited to review all to generate a comprehensive view of the management of this common, and often controversial, topic. The operative goal—to release the transverse carpal ligament—is straightforward: diagnosis, cause, and technique have generated more vibrant discussions.
Evidence-Based Medicine: Breast Augmentation
Authors: Schwartz Michael R.
Published: June 2017

Learning Objectives:

After reading this article, the participant should be able to: 1. Understand the key decisions in patient evaluation for cosmetic breast augmentation. 2. Cite key decisions in preoperative planning. 3. Discuss the risks and complications, and key patient education points in breast augmentation.

Breast augmentation remains one of the most popular procedures in plastic surgery. The integral information necessary for proper patient selection, preoperative assessment, and surgical approaches are discussed. Current data regarding long term safety and complications are presented to guide the plastic surgeon to an evidence-based approach to the patient seeking breast enhancement to obtain optimal results.
Vaginal Uterosacral Ligament Suspension: A Retrospective Cohort of Absorbable and Permanent Suture Groups
Authors: Bradley Megan S. , Bickhaus Jennifer A. , Amundsen Cindy L. , Newcomb Laura K. , Truong Tracy , Weidner Alison C. , Siddiqui Nazema Y.
Published: June 2017

Objective

The aim of this study was to compare anatomic results after vaginal uterosacral ligament suspension with absorbable versus permanent suture.

Methods

We performed a retrospective cohort study of women who underwent vaginal uterosacral ligament suspension, from 2006 to 2015. We compared 2 groups: (1) absorbable suspension suture and (2) permanent suspension suture (even if accompanied by absorbable suture). Our primary outcome was composite anatomic failure defined as (1) recurrent prolapse in any compartment past the hymen or (2) retreatment for prolapse. Continuous variables were analyzed using the Student t test or Mann-Whitney U test, and categorical variables were analyzed using χ2 or Fisher exact test. Multivariable logistic regression analysis was performed to control for confounders. P < 0.05 was considered significant.

Results

Of the 242 patients with medium-term follow-up (3 months to 2 years after surgery), 188 underwent vaginal uterosacral ligament suspension with only absorbable suture, and 54 underwent suspension with permanent suture. Compared with the absorbable suture cohort, the permanent suture cohort was more likely to have had advanced preoperative prolapse (P = 0.01), less likely to have had a prior hysterectomy (P = 0.01), and less likely to have undergone a concomitant posterior colporrhaphy/perineoplasty (P < 0.01). Overall, there were no differences in composite anatomic failure between the absorbable and permanent suture groups (17.0% vs 20.4%, P = 0.41). In multivariable logistic regression analyses, when controlling for covariates, there remained no difference in composite anatomic failure between permanent and absorbable suture groups.

Conclusions

Completion of vaginal uterosacral ligament suspension using only absorbable suture affords similar anatomic outcomes in the medium term as compared with suspension with additional permanent suture.
Hippocampal Gray Volumes Increase in Treatment-Resistant Depression Responding to Vagus Nerve Stimulation
Authors: Perini Giulia Ida , Toffanin Tommaso , Pigato Giorgio , Ferri Giovanni , Follador Halima , Zonta Filippo , Pastorelli Carlo , Piazzon Giulia , Denaro Luca , Rolma Giuseppe , Ermani Mario , D'Avella Domenico
Published: June 2017

Background

Changes in hippocampal gray matter volumes are proposed to be involved in pathogenesis, course, and treatment response of major depressive disorder. Converging evidence suggests that reduced neurogenesis may occur in treatment-resistant depression (TRD). Vagus nerve stimulation (VNS) is a well-defined, long-term brain stimulation treatment for TRD. However, its in vivo positive effect on hippocampal modulation as mechanism of action has never been investigated before in clinical studies. In this study, we intended to explore hippocampal volumetric changes and clinical antidepressant responses in patients with TRD after 6 and 12 months of treatment with VNS.

Methods

The TRD outpatients were evaluated for VNS implantation. Right and left hippocampal volumes in 6 TRD patients, who met the criteria for VNS treatment, were measured at baseline before the implantation and after 6 and 12 months. The patients were assessed using Beck Depression Inventory and Hamilton Depression Rating Scale at baseline and at follow-up visits.

Results

There was a statistically significant and progressive increase in right and left hippocampal volumes during the follow up (P < 0.05). Furthermore, patients showed a significant improvement on Hamilton Depression Rating Scale and Beck Depression Inventory scores (P < 0.05).

Conclusions

Our data suggest a VNS modulatory effect on hippocampal plasticity as measured by hippocampal gray volume increase in TRD patients. These preliminary findings indicate the fundamental role of hippocampal remodeling as a marker of response to VNS in TRD.
Deubiquitylation of deubiquitylases
Authors: Haq Saba , Ramakrishna Suresh
Published: June 2017

Deubiquitylating enzymes (DUBs) reverse the ubiquitylation of target proteins, thereby regulating diverse cellular functions. In contrast to the plethora of research being conducted on the ability of DUBs to counter the degradation of cellular proteins or auto-ubiquitylated E3 ligases, very little is known about the mechanisms of DUB regulation. In this review paper, we summarize a novel possible mechanism of DUB deubiquitylation by other DUBs. The available data suggest the need for further experiments to validate and characterize this notion of ‘Dubbing DUBs’. The current studies indicate that the idea of deubiquitylation of DUBs by other DUBs is still in its infancy. Nevertheless, future research holds the promise of validation of this concept.
Cell signalling pathway regulation by RanBPM: molecular insights and disease implications
Authors: Salemi Louisa M. , Maitland Matthew E. R. , McTavish Christina J. , Schild-Poulter Caroline
Published: June 2017

RanBPM (Ran-binding protein M, also called RanBP9) is an evolutionarily conserved, ubiquitous protein which localizes to both nucleus and cytoplasm. RanBPM has been implicated in the regulation of a number of signalling pathways to regulate several cellular processes such as apoptosis, cell adhesion, migration as well as transcription, and plays a critical role during development. In addition, RanBPM has been shown to regulate pathways implicated in cancer and Alzheimer's disease, implying that RanBPM has important functions in both normal and pathological development. While its functions in these processes are still poorly understood, RanBPM has been identified as a component of a large complex, termed the CTLH (C-terminal to LisH) complex. The yeast homologue of this complex functions as an E3 ubiquitin ligase that targets enzymes of the gluconeogenesis pathway. While the CTLH complex E3 ubiquitin ligase activity and substrates still remain to be characterized, the high level of conservation between the complexes in yeast and mammals infers that the CTLH complex could also serve to promote the degradation of specific substrates through ubiquitination, therefore suggesting the possibility that RanBPM's various functions may be mediated through the activity of the CTLH complex.
Fate predetermination of cardiac myocytes during zebrafish heart regeneration
Authors: Tekeli Isil , Garcia-Puig Anna , Notari Mario , García-Pastor Cristina , Aujard Isabelle , Jullien Ludovic , Raya Angel
Published: June 2017

Adult zebrafish have the remarkable ability to regenerate their heart upon injury, a process that involves limited dedifferentiation and proliferation of spared cardiomyocytes (CMs), and migration of their progeny. During regeneration, proliferating CMs are detected throughout the myocardium, including areas distant to the injury site, but whether all of them are able to contribute to the regenerated tissue remains unknown. Here, we developed a CM-specific, photoinducible genetic labelling system, and show that CMs labelled in embryonic hearts survive and contribute to all three (primordial, trabecular and cortical) layers of the adult zebrafish heart. Next, using this system to investigate the fate of CMs from different parts of the myocardium during regeneration, we show that only CMs immediately adjacent to the injury site contributed to the regenerated tissue. Finally, our results show an extensive predetermination of CM fate during adult heart regeneration, with cells from each myocardial layer giving rise to cells that retain their layer identity in the regenerated myocardium. Overall, our results indicate that adult heart regeneration in the zebrafish is a rather static process governed by short-range signals, in contrast to the highly dynamic plasticity of CM fates that takes place during embryonic heart regeneration.