bluuebunny/crossref_metadata_2025 huggingface dataset:
Carcinoma Erysipeloides From Metastatic Cutaneous Squamous Cell Carcinoma Initially Mistaken for Intralymphatic Histiocytosis
Authors: Heath Michael S. , Slaught Christa , Ortega-Loayza Alex G. , Mengden Stephanie
Published: March 2019

Intralymphatic histiocytosis is a rare dermatologic disorder, commonly associated with inflammatory disorders and rarely malignancy. Carcinoma erysipeloides (CE) is a rare pseudoinflammatory cutaneous eruption that resembles soft -tissue infections as result of intralymphatic metastasis and subsequent lymphatic obstruction. Breast carcinoma represents most of the CE cases, but rarely other malignancies are involved. This report discusses a patient with a history of cutaneous squamous cell carcinoma (SCC) of the temple, who was initially diagnosed with intralymphatic histiocytosis located on his upper extremity, resistant to treatment. Further dermatologic and pathologic review later revealed metastatic SCC restricted to the dermal lymphatics, creating a CE reaction, initially obscured by intralymphatic histiocytes. This case highlights the difficulty in diagnosing metastatic carcinoma when the malignant cells are accompanied by a dense histiocytic infiltrate. The case demonstrates a rare presentation of CE due to metastatic cutaneous SCC and highlights the need for persistent investigation when confronted with nonconforming pathology.
Renal Cell Carcinoma Antigen Expression in Primary Cutaneous Endocrine Mucinous Carcinomas: A Case Series of 14 Patients and Review of the Literature
Authors: Ansari Ahmed N. , Bobos Mattheos , Shih Shawn , Chen Mark Chien-Chin , Ardakani Nima M. , Rosales Cecilia M. , Chen Chih-Jung , Savage Christopher , Bracey Tim , McKee Phillip H. , Cerruto Carlos A.
Published: March 2019

Endocrine mucin-producing sweat gland carcinoma (EMPSGC) and primary cutaneous mucinous carcinoma (PCMC) are both uncommon low-grade cutaneous adnexal tumors with predilection for the eyelids of elderly women. Their clinical appearance is nonspecific, typically presenting as a slowly growing poorly circumscribed papule, nodule, plaque, or swelling. Histological features of EMPSGC include a lobulated dermal neoplasm with bland cytology and an invasive mucinous component in up to half of the cases. PCMC exhibits tumor nests suspended in abundant pools of mucin with focal strands or nests of tumor cells infiltrating the dermis. Because of their rarity and banal cytological features, both entities pose a risk for misdiagnosis with other benign/malignant cutaneous adnexal neoplasms. Histomorphological features can suggest a diagnosis of EMPSGC or PCMC, but immunohistochemistry is necessary for confirmation. A review of the literature showed variable results of antigens present in EMPSGC, and many of the positive markers only show sparse or focal immunoreactivity of tumor cells. As a result, diffusely positive markers play a crucial role in identification of these tumors, particularly with initial superficial biopsies. We present 9 cases of EMPSGC and 5 cases of PCMC with strong and diffuse immunoreactivity to renal cell carcinoma antigen. This novel finding can be useful in the diagnosis of EMPSGC and PCMC in combination with other known positive markers to differentiate them from other cutaneous neoplasms. In addition, it provides further evidence that EMPSGC could be a precursor lesion to PCMC with both existing on a spectrum.
Polypoid Compound Melanocytic Proliferations: A Clinicopathological Study
Authors: Mesbah Ardakani Nima , Harvey Nathan Tobias , Wood Benjamin Andrew
Published: March 2019

Nevi can show a polypoid appearance both clinically and histologically. Anecdotally, polypoid compound melanocytic nevus may exhibit a spectrum of junctional architectural and cytologic atypia, at times creating a diagnostic challenge by mimicking the radial growth phase of melanoma. To investigate this issue, we prospectively reviewed 40 polypoid compound melanocytic proliferations without overt malignant features. The lesions frequently occurred in young female patients and were predominantly from the trunk and intertriginous areas. Commonly observed atypical features included asymmetry (30%), shouldering (47.5%), poor circumscription (37.5%), and deep extension of melanocytes along the adnexal structures (67.5%). Severe cytologic junctional atypia (22.5%), dermal mitoses (10%), and pagetoid spread of melanocytes (5%) were less commonly seen. All lesions showed a reassuring dermal component with negligible cytologic atypia and maturation with depth. Overall, 7 lesions could not be readily classified as benign nevus; 5 of these in which a benign diagnosis was strongly favored were classified as atypical polypoid compound melanocytic nevi, whereas 2 lesions with diffuse severe junctional cytologic atypia and dermal mitoses were classified as ambiguous melanocytic proliferations. Atypical/ambiguous lesions were significantly larger and predominantly located in the axilla and groin. On molecular studies, none of the lesions tested showed the molecular profile of melanoma. We confirmed that polypoid compound melanocytic nevus can exhibit a variable degree of junctional atypia, likely related to frequent episodes of trauma and regeneration resulting in melanocytic proliferation. Pathologists should be aware of this phenomenon to avoid overdiagnosis.
αEβ7 Expression Increases With the Extent of Cutaneous Involvement in Mycosis Fungoides
Authors: Barata Mariangela Crispino , Teixeira Solange Pistori , Batista Mariana Dias , Tomimori Jane , Landman Gilles , Silva Maria Regina Regis
Published: March 2019

Background:

Cell adhesion molecules are essential to lymphocyte migration in neoplastic and inflammatory skin diseases. Our aim was to investigate possible differences in cell adhesion molecule expression between mycosis fungoides (MF) and inflammatory skin diseases (drug reactions and allergic contact dermatitis).

Methods:

We selected 33 biopsies from patients with MF and 10 biopsies of patients with inflammatory skin diseases from Department of Pathology—Universidade Federal de São Paulo (UNIFESP) from January 1997 to December 2013. Expression of α4β1 integrin and αEβ7 integrin was assessed by immunohistochemistry in intraepidermal lymphocytes by counting 4 microscopic epidermal fields (×400) and comparing those between the 2 groups.

Results:

We observed increased expression of integrin αEβ7 in intraepidermal lymphocytes in advanced stages of MF (T3 and T4). αEβ7 expression was detected in intraepidermal dendritic cells of MF and inflammatory diseases samples. The expression of E-cadherin in epidermal cells in MF outlined Pautrier microabscesses, whereas in inflammatory diseases, spongiosis reduced its expression in keratinocytes.

Conclusions:

The findings presented here support the idea that the lymphocyte migratory mechanism observed in neoplasms is similar to that of inflammatory processes of the skin.
Secondary Congenital Glaucoma Associated With Retro-orbital Infantile Hemangioma: A Masquerade Syndrome
Authors: Ramtohul Prithvi , Beylerian Marie , Dambricourt Loic , Matonti Frédéric , Denis Danièle
Published: March 2019

Purpose:

The main purpose of this study was to describe a unique case of retro-orbital infantile hemangioma (IH) simulating a congenital glaucoma requiring prompt management with systemic propranolol.

Study Design:

This was a case report.

Results:

A 2-month-old white female was referred to our department of ophthalmology for progressive, unilateral protrusion of the left eye associated with epiphora. Clinical examination was suggestive of congenital glaucoma, as evidenced by high intraocular pressure, optic disc cup, increased corneal diameter, and axial length. The left eye proptosis was measured at 4 mm with the Hertel exophthalmometer. Cycloplegic refraction discloses high degree of astigmatism in the left eye. A cerebral and orbital magnetic resonance imaging revealed an intraconal vascular mass evocative of orbital IH.

Oral propranolol was initiated and resulted in a rapid radiologic reduction of the IH. Concomitantly, the notable finding was the reversal of congenital glaucoma parameters without the need of surgery.

Conclusions:

To the best of our knowledge, this is the first observation of a secondary congenital glaucoma reversal with oral propranolol used for orbital IH management.
The Paediatric electronic Persistent Pain Outcomes Collaboration (PaedePPOC): establishment of a binational system for benchmarking children's persistent pain services
Authors: Lord Susan M. , Tardif Hilarie P. , Kepreotes Elizabeth A. , Blanchard Megan , Eagar Kathy
Published: March 2019

Chronic or persistent pain is a growing global health problem. Effective management of pain emerging in childhood may prevent long-term health and vocational consequences. Internationally, paediatric pain services are a limited resource and, as such, must strive to improve equity, outcomes, and value for money. The Paediatric electronic Persistent Pain Outcomes Collaboration (PaedePPOC) is a binational paediatric outcome measurement centre that aims to measure, benchmark, and improve children's specialist pain services in Australasia. This study documents the establishment of PaedePPOC and presents baseline and initial outcome data. Binational consensus meetings determined the measures. Governance structures, collection protocols, information technology, site-specific logistics, and onsite training were achieved within 18 months. Children and parents complete baseline and progress questionnaires. Seven of 10 Australasian services provided data to PaedePPOC, with 1432 patients enrolled until June 2018. At baseline, patients were 12.4 ± (3.0) years, 68% female, 93% Australian-born, and 5% Aboriginal and/or Torres Strait Islander people. Most had moderate–severe functional disability and impaired quality of life, with pain affecting school attendance and employment. Opioid-containing medicines were used often or daily by 16%. Patients completing outcome measures at treatment end reported clinically significant improvement in pain intensity (49% of patients), functional ability (59%), and quality of life (69%). The PaedePPOC initiative has been successfully integrated into children's pain services, yielding timely point-of-care information to support clinicians and families, and valuable binational and service data to inform quality improvement and future sector planning.
Efficacy and safety of loxoprofen sodium topical patch for the treatment of pain in patients with minor acute traumatic limb injuries in Brazil: a randomized, double-blind, noninferiority trial
Authors: Fujiki Edison N. , Netto Nicola A. , Kraychete Durval C. , Daher Murilo T. , Tardini Ricardo , Nakamoto Allyson , Lopes Danilo G.
Published: March 2019

Posttraumatic injury pain is commonly treated with oral nonsteroidal anti-inflammatory drugs. However, oral nonsteroidal anti-inflammatory drugs cause several adverse events, with topical formulations arising as an important alternative. Therefore, we aimed at evaluating the efficacy and safety of loxoprofen patch (LX-P) in the treatment of patients with posttraumatic pain. This phase III, randomized, double-blind, noninferiority study enrolled Brazilian patients aged 18 to 65 years diagnosed with lower and upper limb posttraumatic injury who were experiencing moderate or severe pain. Patients were assigned to active LX-P or to loxoprofen tablet (LX-T), and pain intensity was measured based on a visual analog scale score variation after 7 days of treatment. Data on clinical symptoms, rescue medication use, and adverse events were also collected. Visual analog scale score variation was compared using a 10% noninferiority margin. Two hundred forty-two patients were randomly assigned to LX-P (n = 123) or to LX-T (n = 119). The results showed a reduction in pain after 7 days of treatment: −49.96 (n = 118; SE 1.7) in the LX-P and −47.71 (n = 117; SE 1.6) in the LX-T groups (difference of −2.25; 95% CI: −5.97 to 1.47; P = 0.23). On the safety analysis, the LX-T group presented twice as many patients with treatment-emergent adverse events as the LX-P group (30.8% and 14.2%, respectively). A sensitivity analysis demonstrated that rescue medication use has not affected the primary end point. This study showed that LX-P has a comparable efficacy to LX-T, but with a better safety profile, being a therapeutic option for the treatment of posttraumatic injury pain.
Muscle Damage, Soreness, and Stress During Preseason Training in Collegiate Swimmers
Authors: Rusnak Mario , VanderMeulen Melissa , Byrd Brigid , Byrd Gregory , Rusnak Raychel , Martin Jeffrey , Hew-Butler Tamara
Published: March 2019

Background:

In 2014, 6 collegiate swimmers were hospitalized for symptomatic exertional rhabdomyolysis.

Objective:

To serially monitor and assess relationships between skeletal muscle membrane disruption, upper body soreness (UBS) and lower body soreness (LBS), and stress during the first 6 weeks (timepoints) of preseason training in collegiate male and female swimmers.

Design:

Prospective observational study.

Setting:

College/university.

Participants:

Forty swimmers.

Independent Variables:

Upper and lower body soreness rating (0-10); testosterone (T), cortisol (C), and T/C ratio.

Main Outcome Measures:

Creatine kinase (CK) and myoglobin (over time) versus independent variables.

Results:

Weekly training load consisted of ∼87% swimming, ∼5% running, and ∼8% weight training, which increased from 15.8 hours to 20.5 total training hours per week over the first 6 weeks of training. Muscle damage in collegiate swimmers was modest and peaked after the first week of training (week 2) for men (CK = 438 ± 259 U/L; P < 0.0001; r2 = 0.28; myoglobin = 47 ± 18 ng/mL; P = 0.001; r2 = 0.22) and women (CK = 446 ± 723 U/L; P < 0.01; r2 = 0.13; myoglobin = 63 ± 140 ng/mL, not significant) with high variability. Data were presented as peak mean ± SD, significant P value, and r2 from repeated-measures analysis of variance. A temporal disconnect was noted between muscle damage and UBS, which peaked at week 5 in both men (5 ± 2; P < 0.0001; r2 = 0.44) and women (6 ± 2; P < 0.0001; r2 = 0.57). The serum cortisol level decreased over time, which peaked at week 1 (baseline) in men (15 ± 6 μg/dL; P = 0.0004; r2 = 0.38) and women (19 ± 10 μg/dL; P < 0.0001; r2 = 0.49). The testosterone level remained unchanged, which promoted an anabolic hormonal environment that peaked at week 6 (increasing T/C ratio) in men (58 ± 32; P = 0.0003; r2 = 0.31) and women (4 ± 3; P = 0.04; r2 = 0.18) despite gradual increases in training and soreness.

Conclusions:

Muscle soreness does not parallel muscle membrane disruption. A 1-week “transition” period is required for muscles to adapt to intense/novel training.
Trends in probabilities of death owing to cancer and owing to other causes in patients with colon cancer
Authors: Jooste Valérie , Bouvier Anne-Marie , Bossard Nadine , Uhry Zoé , Coureau Gaëlle , Remontet Laurent , Dantony Emmanuelle
Published: March 2019

Background

It is of interest to both the clinicians and patients to estimate the probability of death owing to cancer in the presence of other causes as time elapses since diagnosis. The objective of this study was to depict for patients diagnosed with colon cancer between 1990 and 2010 in France, the probability of surviving up to 10 years after diagnosis and to disentangle the probability of death owing to cancer from that of death owing to other causes.

Patients and methods

Individuals with cancer were described, up to 10 years after diagnosis, as belonging to one of three categories: those who died owing to a cause related to cancer, those who died owing to another cause and those who survived. Net survival, crude probabilities of death related to colon cancer, death related to another cause and survival were estimated by modeling excess mortality hazard.

Results

In women of all ages, 5 and 10-year net survival improved over calendar time. The 10-year probability of survival decreased when age increased in both sexes. It was higher in women than in men, and this difference increased with age. Crude probabilities of death related to colon cancer decreased between 1990 and 2010 for men and women, although this was not observed in the eldest men.

Conclusion

Crude probability of death related to colon cancer is an important indicator for patients and health policy makers. Results of cancer screening should be faced to trends in probability of death related to colorectal cancer.
Therapeutic Advances in Emergency Cardiology: Acute Pulmonary Embolism
Authors: Petriş Antoniu Octavian , Konstantinides Stavros , Tint Diana , Cimpoeşu Diana , Pop Călin
Published: March 2019

Background:

Acute pulmonary embolism (PE) requires rapid diagnosis and early and appropriate treatment, often under conditions of hemodynamic instability. The therapeutic strategy should optimally integrate the therapeutic arsenal in a multidisciplinary but unitary approach.

Areas of Uncertainty:

The short list of the major uncertainties associated with acute PE should include limited general public awareness on venous thromboembolism, acute hemodynamic support not based on evidence from randomized clinical trials, with few updates lately, mainly linked to extracorporeal membrane oxygenation, thrombolytic therapy having firm indications only in high-risk PE, without clear strategies for particular clinical situations (ie, stroke, tumors, thrombi in transit, and cardiac arrest), using old therapeutic agents with old administration regimens, lack of evidence from large-volume trials on the optimal interventional approach, and relatively imprecise indications for surgical treatment.

Data Sources:

We reviewed current data on the diagnosis and therapeutic approach of acute PE.

Therapeutic Advances:

A collaborative idea has been reached: apply the multidisciplinary expertise of a rapid response heart team to patients with PE in Pulmonary Embolism Response Teams. Optimization of acute hemodynamic support involves the cautious use of volume expansion; diuretic treatment may provide early improvement in normotensive patients with acute PE and RV failure, and during massive PE, we may use the venoarterial extracorporeal membrane. Until new data accumulate, rescue reperfusion should be performed only if hemodynamic decompensation develops despite adequate anticoagulation. Only EkoSonic catheter is approved by the FDA in the interventional treatment of acute PE, without the routine use of retrievable inferior vena cava filters. Outcomes of pulmonary embolectomy after an early triage of patients with hemodynamically unstable PE are acceptable. In selected low-risk patients, an ambulatory treatment of PE with DOAC is effective and safe.

Conclusions:

Nowadays, evidence and ideas have been gathered that can significantly improve the outcome of patients with PE with varying degrees of severity, remaining to demonstrate the cost-effectiveness of this advanced therapeutic approach.
Novel Therapeutic Options in the Management of Reflex Syncope
Authors: Podoleanu Cristian , Deharo Jean-Claude
Published: March 2019

Background:

Syncope is a symptom associated with a wide range of pathological conditions, ranging from benign to life threatening. The most frequent is the reflex syncope that may be challenging to treat because of the complex and partially unknown pathophysiological mechanism that has to be addressed by the chosen therapy.

Areas of Uncertainty:

Head-up tilt testing is so far the only clinical test able to reproduce reflex syncope, but its diagnostic yield has been recently redefined. A new mechanism such as adenosine-sensitive syncope and idiopathic atrioventricular block have been recently described, and the appropriate therapy is not yet established. There is uncertainty on the efficacy of theophylline and on the use of cardiac pacing in these patients.

Data Sources:

Clinical trial published data and position paper from the main expert groups on fludrocortisone, midodrine, etilefrine, beta-blockers, and cardiac pacing as useful therapies for patients affected by reflex syncope.

Therapeutic Advances:

Theophylline proved in observational trials to be efficient in preventing reflex syncope recurrences in patients with documented spontaneous paroxysmal conduction disorders comparable to cardiac pacing in a subgroup of patients. Reboxetine and sibutramine may elicit a significant pressor and tachycardic effect able to delay the onset of symptoms during head-up tilt testing. Droxidopa has short-term effects on improving the symptoms because of orthostatic hypotension. Cardiac pacing is effective in preventing reflex syncope recurrences with best results when the indication for pacemaker implantation was based on the documentation of bradycardia or asystole during the spontaneous event by a cardiac monitor. External compression using elastic bandage or compressive stockings is able to prevent the decrease in blood pressure in patients with orthostatic hypotension.

Conclusions:

The optimal management of the complex diagnostic and therapeutic options can be achieved following a standardized and evidence-based approach to the patient with syncope.
Therapeutic Challenges in Patients With Noncardioembolic Acute Ischemic Stroke in Need of Double Antiplatelet Therapy for Coronary Artery Disease
Authors: Oana Darabont Roxana , Stoicescu Claudiu , Tiu Cristina
Published: March 2019

Background:

The risk of ischemic stroke (IS) is significant within 6–12 months from the myocardial revascularization for an acute cardiac event. Consequently, we can expect to have patients with an acute IS occurring right in the time frame of dual antiplatelet therapy (DAPT) imposed by the coronary heart disease (CHD).

Areas of Uncertainty:

Until present, there are no evidence-based guidelines for the management of patients with acute IS in need of DAPT for ischemic heart disease. The aim of this article was to go through the available data and to depict the appropriate therapeutic strategy for this category of patients.

Data Sources:

We have performed a systematic review of the literature through June 2018, using Medline/PubMed database.

Therapeutic Advances:

DAPT (aspirin and only clopidogrel among all P2Y12 inhibitors) might be maintained or initiated for CHD in patients with minor acute stroke and high-risk transient ischemic attack patient with IS attributable to an important intracranial stenosis, as long as this drug combination proved to be safe for them in the prevention of stroke recurrence. In patients with IS receiving thrombolysis, with increased size of infarction or high National Institute of Health Stroke Score (NIHSS), the risk of hemorrhagic transformation under DAPT must be weighed against the risk of stent thrombosis in the coronary arteries, which, on its turn, depends on the clinical form for which myocardial revascularization was performed, the time interval from the complexity of a certain interventional procedure.

Conclusions:

In the acute phase of an IS, maintenance or initiation of DAPT therapy imposed by CHD relies, on one hand, on the risk of hemorrhagic transformation of the brain injury and, on the other hand, on the risk of stent thrombosis in the coronary arteries. The management of these patients must be carried on by a vascular team, on an individualized basis.
Intraoperative anesthetic management of the liver transplant recipient with portopulmonary hypertension
Authors: Kandil Sherif
Published: March 2019

Purpose of review

Liver transplantation in patients with portopulmonary hypertension (POPH) is associated with increased perioperative risk. Important recent advances in the management of liver transplantation recipients with POPH are discussed.

Recent findings

The presence of POPH at the time of liver transplantation should not be a contraindication for liver transplantation, as POPH is common and may be related to volume overload and/or high cardiac output (CO). Available data suggest that patients with mild POPH (25–35 mmHg) can safely undergo liver transplantation surgery. In more severe cases, treatment of POPH with a combination of vasoactive drugs may lead to successful liver transplantation with normalization of POPH. The key to successful intraoperative anesthetic management is maintaining the right ventricular preload and avoiding right ventricular dysfunction. Techniques include diuresis, intraoperative hemodialysis, venovenous bypass, or extracorporeal membrane oxygenation. Apart from the surgical and anesthetic techniques used, factors that contribute to increased pulmonary vascular resistance have to be avoided and the continuation of the vasodilators into the intraoperative and postoperative periods is crucial.

The current article provides a review of the current challenges and advances in the management of liver transplantation recipients with POPH from the anesthetic point of view.
Why Nurse Leaders Derail
Authors: Bellack Janis P. , Dickow Mary
Published: March 2019

To be successful, nurse leaders must be able to develop and articulate a vision for their areas of responsibility, build strong relationships with those they lead, and execute strategies and actions to achieve shared goals. Emotional intelligence and mastering self, interpersonal, and team relationships, while understanding organizational culture and systems, are critical components of successful leadership. Nurse leaders must be aware of their own strengths and weaknesses, be able to manage their emotions, exhibit social awareness of others' emotions, and successfully manage their relationships with others within their sphere of influence. Leaders who fail to manage themselves and their relationships with others fail to lead with clear direction and purpose, or fail to deliver results for their organizations, and risk derailing their careers. This article focuses on common behaviors and characteristics that cause leaders to derail as well as the risks for leadership failure (self-imposed, boss-imposed, situation-imposed), including common traps leaders can fall into in the first months of assuming a new leadership role. Risks for career derailment and opportunities for preventing or rebounding from leadership failure are reviewed.
Rapid Response Team-Quality Champion Registered Nurse
Authors: McNeill Margaret M. , Archer Susan , Remsburg Dana , Storer Jill , Rudman Heather
Published: March 2019

Background:

Operationalization of the rapid response team (RRT) and its quality champion (QC) nurses at a community hospital is unique and provides benefits not entirely captured by analysis of mortality data.

Purpose:

The purpose was to determine the perceived benefits of the RRT at the facility and behaviors and activities observed during actual RRT responses. Also examined was the timeliness of the RRT calls.

Methods:

This was a mixed-method study including qualitative (interviews, focus groups, and surveys) and quantitative (retrospective chart reviews) data collection.

Results:

Themes included teaching/education, foster development of critical thinking skills, expertise/resource, communication/facilitation/go-between, safety net/security, validation, and advocate/foster collaboration. RRT calls were made quickly after clinical deterioration.

Conclusions:

Benefits of the RRT-QC registered nurse were extensive. Observations showed support, education, and teamwork in an effort to improve outcomes and support clinicians.
Reshaping Nursing Workforce Development by Strengthening the Leadership Skills of Advanced Practice Nurses
Authors: Tran Anh N. , Nevidjon Brenda , Derouin Anne , Weaver Sarah , Bzdak Michael
Published: March 2019

A nurse leadership program provides advanced practice nurses, many of whom have nursing professional development roles within their agencies, with a year of education, mentoring, and guidance to create and implement innovative models of care designed to improve population health. This article highlights program participants’ leadership development outcomes, along with strategies to educate and mentor rising nurse leaders.
How to Flip the Classroom to Improve Learner Engagement
Authors: Puppe Jacqueline M. , Nelson Dawn M.
Published: March 2019

Providing effective nursing professional development that meets the needs of a variety of learners, promotes critical thinking skills, and results in application in clinical practice is challenging. The flipped classroom was successfully implemented at a large Midwestern teaching hospital to address these challenges. This article explores flipped classroom exemplars including descriptions of prework, active learning strategies, and recommendations for successful implementation of the flipped classroom.
Comparison of Minimally Invasive Loop Drainage and Standard Incision and Drainage of Cutaneous Abscesses in Children Presenting to a Pediatric Emergency Department
Authors: Rencher Logan , Whitaker Winnie , Schechter-Perkins Elissa , Wilkinson Matthew
Published: March 2019

Objective

This study aimed to determine whether the treatment of skin abscesses with vessel loop drainage is noninferior to standard incision and drainage (I&D) regarding treatment failure in pediatric patients in the emergency department (ED).

Methods

This study was a prospective, randomized controlled trial in a pediatric ED of an urban tertiary pediatric hospital. Patients with a skin abscess were enrolled. Subjects were assigned to the control arm of I&D or the study arm of vessel loop drainage. Study end points (failure rates, satisfaction scores, wound appearance, visit frequency) were assessed before discharge from the ED, at 24- to 48-hour follow-up, and at 14-day follow-up. Treatment failure was declared if the abscess required reinstrumentation or admission for intravenous antibiotics for systemic illness within 14 days.

Results

From August 2014 to October 2015, 81 patients completed this study. Treatment failure was observed in 3 subjects of each arm (7.3% loop vs 7.5% standard; risk difference, 0.2%; 95% confidence interval, −11.2% to 11.6%). Parent satisfaction rates with wound appearance at day 14 were similar (86.1% loop vs 88.2% standard were at least satisfied). Median cosmetic scores were similar at day 14 (6 [interquartile range {IQR}, 5–6] loop vs 6 [IQR, 5–6] standard, where 6 was optimal). Follow-up visit frequency was similar (2 [IQR, 2–3] loop vs 2 [IQR, 2–2.5] standard).

Conclusions

Abscess drainage with a vessel loop in the pediatric ED results in failure rates noninferior to those of the standard I&D. Satisfaction and cosmetic scores are favorable in both groups.
Diaphragmatic Pathology in Children
Authors: Moreno-Galarraga Laura , Bardaji Carlos , Herranz Aguirre Mercedes , Viguria Natividad
Published: March 2019

We present a rare case of a 10-year-old boy with a right diaphragmatic eventration (DE), an uncommon pathology in children. The case highlights the importance of making a correct differential diagnosis between an acquired diaphragmatic hernia and a DE, two uncommon diaphragmatic pathologies. Differential diagnosis of these two entities can usually be made based on radiological findings, by identifying the continuity or the lack of continuity of the diaphragm, but sometimes, especially when on the right side, like in our case, they can be very difficult to differentiate by imaging. Diaphragmatic eventration is an abnormal elevation of an intact diaphragm that maintains its continuity and its attachments to the costal wall. Diaphragmatic hernia occurs when abdominal organs move into the chest through a defect in the diaphragm. Diaphragmatic hernia is generally symptomatic and always a medical emergency and requires urgent surgery, whereas DE is generally asymptomatic, has a better prognosis, and can be treated conservatively.

As the treatment, the surgical approach, and the prognosis of these two entities are very different, a correct differential diagnosis is very important.
Artificial Intelligence and Applications in PM&R
Authors: Anderson Dustin
Published: March 2019

Artificial intelligence methods are being applied broadly in society and increasingly in health care and research. Machine learning, a subset of artificial intelligence, represents the study of algorithms that improve automatically with experience. This article provides a basic overview of artificial intelligence, machine learning categories, common applications in the business sphere, advantages and disadvantages of using this technology, and example applications in rehabilitation and other fields for contextual purposes. The study and implementation of machine learning and artificial intelligence can function to improve patient care and represents a burgeoning area of research.
HIV Diagnoses and the HIV Care Continuum Among Women and Girls Aged ≥13 Years–39 States and the District of Columbia, 2015–2016
Authors: Hoover Karen W. , Hu Xiaohong , Porter Sarah E. , Buchacz Kate , Bond Martha D. , Siddiqi Azfar-E-Alam , Haynes Suzanne G.
Published: March 2019

Background:

In 2017, 19% of new HIV diagnoses in the United States were in women. HIV acquisition can be prevented with pre-exposure prophylaxis, and HIV transmission with viral suppression. HIV viral suppression is achieved by linking women to care and supporting adherence to antiretroviral medications. The national HIV prevention goal for viral suppression is 80%.

Setting:

United States.

Methods:

We analyzed data reported by 40 US jurisdictions to the Centers for Disease Control and Prevention's National HIV Surveillance System to determine the number and rate of HIV diagnoses per 100,000 women in 2016. We also determined the percentages of women with diagnosed HIV who were linked to care within 1 and 3 months, received HIV care, were retained in HIV care, and were virally suppressed in 2015. Findings were stratified by demographic characteristics and HIV transmission category.

Results:

In 2016, 6407 women were diagnosed with HIV. Black women had a rate of 783.7 per 100,000, Hispanic/Latino women 182.7, and white women 43.6. In 2015, 190,735 women were living with diagnosed HIV. Viral suppression increased with age, ranging from 46.5% among women aged 13–24 years to 62.3% among women aged ≥45 years. Black women had the lowest rate of viral suppression (55.5%). No age group of women achieved 80% viral suppression.

Conclusions:

Pre-exposure prophylaxis implementation for women at high risk for HIV infection can help to decrease new infections. Women living with HIV would benefit from interventions that support linkage to HIV care and antiretroviral medication adherence to increase viral suppression.
Correlation Between Soft Tissue Injury and the Type of Nasal Fracture Based on Stranc–Robertson Classification
Authors: Jeon Minseok , Kim Youngjun , Choi Youngwoong
Published: March 2019

Nasal fractures are the most common facial bone fractures, and soft tissue injuries are frequently accompanied. This study intends to make a deep analysis on the relationship between the 2.

Patients diagnosed with nasal fracture between 2015 and 2017 were included. Patients younger than 17 years and those with previous facial fractures or aesthetic surgeries were excluded. Nasal fractures were classified according to the Stranc–Robertson (S–R) classification, and the severity of soft tissue injury was evaluated by length and depth. The authors compared the frequency of soft tissue injury between frontal and lateral groups. Second, the authors investigated whether the incidence of soft tissue injuries increases as a function of the increase in the S–R classification both in frontal and lateral group (from plane I to III). The authors also analyzed the difference in severity of soft tissue injuries in each group. Pearson chi-square analysis, linear by linear and Jonckheere–Terpstra tests were used for statistical analysis.

Of 621 patients, 296 were frontal plane and 325 were lateral plane. The frontal group had a higher incidence of soft tissue injury than the lateral group (P = 0.004). The incidence of soft tissue injury and severity by depth increased as a function of the increase in the S–R classification only in the frontal group (P = 0.046, 0.019).

In nasal fractures, frontal impact is more associated with frequency and severity of soft tissue injury than lateral impact. This seems to be related to the anatomical characteristics of nasal area and mechanism of injuries in each group.
Does Piezosurgery Influence the Severity of Neurosensory Disturbance Following Bilateral Sagittal Split Osteotomy?
Authors: D’Agostino Antonio , Favero Vittorio , Lanaro Luca , Zanini Matteo , Nocini Pier Francesco , Trevisiol Lorenzo
Published: March 2019

The present paper aims to evaluate the long-term incidence and severity of the neurosensory disturbance (NSD) of the inferior alveolar nerve following bilateral sagittal split osteotomy (BSSO) of the mandibular ramus performed with piezosurgery. A retrospective study on patients referred to the Maxillofacial Surgery and Dentistry Clinic of the University of Verona for orthognathic surgery between March 2013 and October 2015 was performed. Inclusion criteria were having undergone BSSO with piezosurgery and follow-up lasting at least 24 months. Exclusion criteria were history of surgical infection, osteosynthesis failure or re-do surgery. The extent of mandibular repositioning movements was retrieved and patients underwent 4 clinical neurosensory tests. Descriptive statistical analysis was performed. 52 patients met the inclusion criteria. Average follow-up was 40 months (range 24–75). 83% of the nerves examined have no or slightly altered sensitivity. Seventy-one percent of patients perceive a moderate to none discomfort and none describes the discomfort as serious (Visual Analogue Scale [VAS] >7). The extent of mandibular repositioning did not have significant influence on the development and severity of the NSD. Resulting data led the Authors to infer that using piezosurgery in BSSO, the severity of the NSD of inferior alveolar nerve is reduced, but the incidence of permanent nerve lesions remains unchanged, compared to historical controls.
The Effective Fixation Level for Cosmetic Lateral Canthoplasty
Authors: Cho Young Kyoo , Suh Bo Ik , Park Kwang Min
Published: March 2019

Background:

In previous reports of lateral canthoplasty, the components of the inferior retinaculum were mostly secured to the lateral orbital rim at a level around the pupil or superior limbus. However, that level is not adjustable in young patients who want to lengthen the short palpebral fissure for cosmetic purposes. Moreover, the anchoring method based on the palpebral portion can also be inconvenient and ineffective. Thus, the authors report an effective fixation level of the lateral orbital rim to lengthen and widen the lateral palpebral fissure.

Methods:

From June 2015 to August 2017, 202 women and 44 men underwent cosmetic lateral canthoplasty (mean age 28.4 ± 2.8 years old). The lower lid component of the lateral retinaculum was identified and selectively released through a small incision at the lateral commissure. Then, the released retinaculum was secured to the periosteum of the inner aspect of the lateral orbital wall. The fixation level corresponded to the most concave portion or immediately below the most concave point (1 to 2 mm below).

Results:

Cosmetic lateral canthoplasty was successfully performed in all cases. No severe complications were observed. There were some minor complications. In most cases, the lateral palpebral fissure was naturally reshaped into a wider and brighter contour. Almost all of the patients were satisfied with the results of the treatment.

Conclusions:

The anchoring procedure at the most concave portion of the lateral orbital rim, which corresponds to the level of the inferior edge of the limbus or medial epicanthus, consistently resulted in a brighter and wider shape of the lateral palpebral fissure. Fixation based on the bony portion, compared to palpebral portion, offers several advantages as follows: effective lengthening and widening the lateral palpebral fissure; ease of application; symmetry with consistent final results; and minimal occurrences of overcorrection and undercorrection.
Effect of Septoplasty On Voice Performance: Nasalance and Acoustic Study
Authors: Hernández-García Estefanía , Moro-Velazquez Laureano , González-Herranz Ramón , Lara Antonio , Godino-Llorente Juan Ignacio , Plaza Guillermo
Published: March 2019

Background:

Septoplasty is a surgical technique for the correction of the nasal septum that may alter the vocal tract. The aim of our study is to assess whether this technique modifies nasalance and acoustic parameters, and their clinical implications in voice perception.

Methodology:

A prospective study was performed between January 2017 and June 2017 including 2 groups of patients: those undergoing septoplasty, and a control group. Subjective nasality questionnaire, objective nasalance with nasometer, and GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) assessment were statistically analysed. In addition, a recording of patients’ voices was made with a subsequent acoustic analysis. Samples were taken: pre-surgically, 2 weeks after surgery and after 3 months.

Results:

After septoplasty, a significant difference was observed in GRBAS, nasality questionnaire and nasometer nasalance, when compared with the control group. As for the acoustic analysis, no differences were observed in most parameters (F0, Jitter, Shimmer, HNR, NHR, Formants F1-F3), except for the antiF3 antiformant, which showed significant changes in all the vowels studied.

Conclusions:

Septoplasty can produce changes in the vocal tract, with an increase in initial nasalance but with subsequent normalization. Besides, minor changes were found in the acoustic analysis but with no clinical relevance.
Impact of Sleep Deprivation on Surgical Laparoscopic Performance in Novices: A Computer-based Crossover Study
Authors: Leu Svenja , Staerkle Ralph F. , Gaukel Stefan , Fink Lukas , Soll Christopher , Aasen Davis M. , Liechty Kenneth , Vitz Martina , Ramseier Leonhard E. , Vuille-dit-Bille Raphael N.
Published: March 2019

Objective:

The 24-hour work shifts are newly permitted to first-year surgical residents in the United States. Whether surgery novices’ motor activity is affected by sleep deprivation is controversial.

Materials and Methods:

This study assesses sleep deprivation effects in computer-simulated laparoscopy in 20 surgical novices following 24 hours of sleep deprivation and after resting using a virtual-reality trainer. Participants were randomly assigned to perform simulator tests either well rested or sleep deprived first.

Results:

Of 3 different tasks performed, no significant differences in total time to complete the procedure and average speed of instruments were found. Instrument path length was longer following sleep deprivation (P=0.0435) in 1 of 3 tasks. Error rates (ie, noncauterized bleedings, perforations, etc.), as well as precision, and accuracy rates showed no difference. None of the assessed participants’ characteristics affected simulator performance.

Conclusions:

Twenty-four hours of sleep deprivation does not affect laparoscopic performance of surgical novices as assessed by computer-simulation.
SimRVSequences: an R package to simulate genetic sequence data for pedigrees
Authors: Nieuwoudt Christina , Brooks-Wilson Angela , Graham Jinko
Published: March 2019

1

Family-based studies have several advantages over case-control studies for finding causal rare variants for a disease; these include increased power, smaller sample size requirements, and improved detection of sequencing errors. However, collecting suitable families and compiling their data is time-consuming and expensive. To evaluate methodology to identify causal rare variants in family-based studies, one can use simulated data. For this purpose we present the R package SimRVSequences. Users supply a sample of pedigrees and single-nucleotide variant data from a sample of unrelated individuals representing the pedigree founders. Users may also model genetic heterogeneity among families. For ease of use, SimRVSequences offers methods to import and format single-nucleotide variant data and pedigrees from existing software.

Availability and Implementation

SimRVSequences is available as a library for R≥ 3.5.0 on the comprehensive R archive network.
Chronic unpredictable stress promotes cell-specific plasticity in prefrontal cortex D1 and D2 pyramidal neurons
Authors: Anderson EM , Gomez D , Caccamise A , McPhail D , Hearing M
Published: March 2019

Exposure to unpredictable environmental stress is widely recognized as a major determinant for risk and severity in neuropsychiatric disorders such as major depressive disorder, anxiety, schizophrenia, and PTSD. The ability of ostensibly unrelated disorders to give rise to seemingly similar psychiatric phenotypes highlights a need to identify circuit-level concepts that could unify diverse factors under a common pathophysiology. Although difficult to disentangle a causative effect of stress from other factors on medial prefrontal cortex (PFC) dysfunction, a wealth of data from humans and rodents demonstrates that the PFC is a key target of stress. The present study sought to identify a model of chronic unpredictable stress (CUS) which induces affective behaviors in C57BL6J mice and once established, measure spike firing and the ability to evoke an action potential in mPFC layer 5/6 pyramidal neurons. Adult male mice received 2 weeks of ‘less intense’ stress or 2 or 4 weeks of ‘more intense’ CUS followed by sucrose preference for assessment of anhedonia, elevated plus maze for assessment of anxiety and forced swim test for assessment of depressive-like behaviors. Our findings indicate that more intense CUS exposure results in increased anhedonia, anxiety, and depressive behaviors, while the less intense stress results in no measured behavioral phenotypes. Once a behavioral model was established, mice were euthanized approximately 21 days post-stress for whole-cell patch clamp recordings from layer 5/6 pyramidal neurons in the prelimbic (PrL) and infralimbic (IL) cortices. No significant differences were initially observed in intrinsic cell excitability in either region. However, post-hoc analysis and subsequent confirmation using transgenic mice expressing tdtomato or eGFP under control of dopamine D1- or D2-type receptor showed that D1-expressing pyramidal neurons (D1-PYR) in the PrL exhibit reduced thresholds to fire an action potential (increased excitability) but impaired firing capacity at more depolarized potentials, whereas D2-expressing pyramidal neurons showed an overall reduction in excitability and spike firing frequency. Examination of synaptic transmission showed that D1- and D2-PYR in exhibit differences in basal excitatory and inhibitory signaling under naïve conditions. In CUS mice, D1-PYR showed increased frequency of both miniature excitatory and inhibitory postsynaptic currents, whereas D2-PYR only showed a reduction in excitatory currents. These findings demonstrate that the intrinsic physiology and synaptic regulation of D1- and D2-PYR subpopulations differentially undergo stress-induced plasticity that may have functional implications for stress-related pathology, and that these adaptations may reflect unique differences in basal properties regulating output of these cells.