bluuebunny/crossref_metadata_2025 huggingface dataset:
Approach to Acute Altered Mental Status and Seizures (DRAFT)
Authors: Manners Jody , Dharaneeswaran Kiruba , Jha Ruchira
Published: April 2018

Altered mental status (AMS) is a common presenting symptom or complication in hospitalized patients. The etiology of AMS includes potential primary neurologic entities as well as systemic disturbances such as infection, intoxication, or metabolic derangement. A systematic and rapid evaluation of potentially life threatening conditions is necessary to guide appropriate management. Seizures (particularly non-convulsive episodes) are an important cause of AMS frequently encountered in acutely ill patients with multiple medical comorbidities and need to be recognized and treated early to minimize morbidity and mortality. This chapter outlines an approach to the evaluation of acute altered mental status with an emphasis on seizure management.
Bleeding Emergencies (DRAFT)
Authors: Finn Patrick C. , Reade Michael C.
Published: April 2018

This chapter is concerned with coagulopathic and non-coagulopathic bleeding in the perioperative period, after trauma, and spontaneously, as a result of hematologic and other disease. The initial assessment and management of all potentially bleeding patients is to stop any obvious bleeding through mechanical first aid measures, then address airway or breathing compromise, and obtain intravenous (or intraosseous) access. Obvious external hemorrhage is easily identified, but most patients with bleeding emergencies who are already hospitalized will have occult blood loss. Physical examination should identify signs of shock and identify or exclude potential bleeding locations. This chapter will cover initial assessment and management, laboratory and bedside testing, as well as disease-specific therapies in the context of rapid response team (RRT) calls.
Sepsis (DRAFT)
Authors: Lapsia Munish H. , Huang David T.
Published: April 2018

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. This chapter focuses on the first 30 minutes of care for those patients with sepsis in the context of the rapid response team (RRT) activation. The definitions, etiology, incidence, and risk factors for sepsis are reviewed. Recognition of infection, sepsis, and septic shock is also reviewed while highlighting the use of sequential sepsis related organ failure assessment (SOFA) and quick SOFA (qSOFA) scores for diagnosis of sepsis. This chapter also discusses the initial fluid resuscitation, antibiotics, vasopressors, and investigations including lactate levels as a part of management of the patient in sepsis.
Pediatric Emergencies (DRAFT)
Authors: Horvat Christopher M. , Hamilton Melinda F. , Dezfulian Cameron
Published: April 2018

Pediatric rapid response teams (RRTs) respond to clinical deterioration in hospitalized children. The proportion of hospitalized children with chronic comorbidities has grown in recent decades. Common reasons for pediatric RRT activation include hypoxia, seizures, altered mentation, hypotension, and cardiac arrest. In this chapter we examine the composition of pediatric RRTs and some of the unique considerations which pertain to pediatric as opposed to adult in-hospital emergencies. We will review the composition of airway and resuscitation carts, which are generally pre-stocked to permit rapid and efficient care in pediatric emergencies, and provide clinical guidance on the most common pediatric emergency scenarios.
Pulmonary Embolism (DRAFT)
Authors: Koczo Agnes , Mahmud Reshad , Rivera-Lebron Belinda
Published: April 2018

This chapter examines the diagnosis, risk stratification, and breadth of treatment options for pulmonary embolism (PE). It reviews the decision pathways based on degree of clinical suspicion of PE and assessing pre-test probability using the Geneva and Wells’ Score. It also reviews the Pulmonary Embolism Rule-out Criteria (PERC) and D-dimer with high negative predictive values. Imaging and cardiac biomarkers, which allow classification and risk stratification of PE, are discussed in how they guide management. Options for parenteral anticoagulation including bridging to novel oral anticoagulants or vitamin K antagonists for long term therapy are discussed, as well as clinical situations where systemic or catheter based thrombolysis should be considered. Hemodynamic support involving vasopressors are reviewed. The options for surgical embolectomy, as well as special cases including clot in transit, are discussed.
Airway Management (DRAFT)
Authors: Dargin James M. , Emlet Lillian L.
Published: April 2018

Deterioration in respiratory status is the most common reason for activation of rapid response teams (RRT). Severe respiratory failure may necessitate advanced airway management interventions including endotracheal intubation (ETI) in hospital environments that may be especially challenging in clinical context, space, equipment, and personnel. Furthermore, patients undergoing ETI during the course of an RRT event are critically ill, identifying them as patients who are at increased risk for adverse events during the procedure. Many of the challenges of airway management during RRT events can be overcome with appropriate staffing, proper equipment, and careful planning prior to attempts at ETI. In this chapter, we discuss the evaluation and management of patients requiring ETI during the RRT event including recommendations on pharmacology and intubation techniques.
Critical Care Ultrasound (DRAFT)
Authors: Schott Christopher K.
Published: April 2018

Point of care ultrasonography (POCUS) is a tool that can be used at the bedside to aid in the diagnosis and treatment of critically ill patients. The ability to directly visualize physiology, pathology, and response to treatment can add valuable information in patient management particularly in time sensitive situations with acutely decompensated patients as may occur in the context of rapid response team (RRT) events. Although most of the data on POCUS to guide resuscitations has been published through emergency medicine (EM) and pre-hospital studies, the same approach can be easily adapted for in-hospital RRT events. This chapter reviews validated POCUS protocols for the assessment of hypotensive, hypoxic, or arresting patients and the ways it can be incorporated into in-hospital RRTs.
Tube Thoracostomy (DRAFT)
Authors: Rosengart Matthew R.
Published: April 2018

There are few technical skills that surpass in value the performance of tube thoracostomy. Throughout the career life span of the physician, probability dictates that at least one patient will be encountered who will require pleural drainage. And yet equal in magnitude to the perceived benefits, are the inherent risks, which for the critically ill patient may be poorly tolerated and equally lethal. Thus, it is imperative to approach each intervention with a standardized approach upon which nuanced alterations are built based upon circumstances specific and particular to each case. This chapter discusses the tube thoracostomy procedure, patient placement, and modern concepts.
Portable Monitor and Defibrillators (DRAFT)
Authors: Bauer Robert , Murugan Raghavan
Published: April 2018

Portable monitors with the capability of defibrillation, synchronized cardioversion, and transcutaneous pacing are frequently used by the rapid response teams (RRTs) in several acute care facilities to provide quick information and to treat lethal arrhythmias in critically ill and unstable patients. Portable monitors are used on lethal arrhythmias such as ventricular fibrillation (VF), monomorphic ventricular tachycardia (VT), or polymorphic ventricular tachycardia, also known as Torsades de pointes (TdP). Properly identifying lethal arrhythmias and knowing how to use the portable monitor/defibrillator is essential to positive patient outcomes. In this chapter, we review the use of portable monitors for monitoring and detection of cardiac arrhythmias as well as outline the procedure for defibrillation, synchronized cardioversion, and transcutaneous pacing in the setting of RRT activation.
Seizures and Epilepsy (DRAFT)
Authors: Kaplan Tamara , Milligan Tracey
Published: April 2018

The video in this chapter explores seizures and epilepsy, including definitions or focal or generalized seizures and epilepsy, as well as the differences between the two. It discusses risk factors for epilepsy (family history, history of febrile seizures, brain injury) and its diagnosis (by history and EEG), as well as comorbidities of epilepsy (mood and cognitive disorders, accidents, and sudden unexpected death).
Neuromuscular Junction Disease (DRAFT)
Authors: Kaplan Tamara , Milligan Tracey
Published: April 2018

The video in this chapter explores neuromuscular junction disease. It outlines the steps in neuromuscular transmission, as well as the symptoms, causes, and treatments for Myasthenia Gravis, and Lambert Eaton Syndrome
Motor Neuron Disease (DRAFT)
Authors: Kaplan Tamara , Milligan Tracey
Published: April 2018

The video in this chapter explores motor neuron disease, including amytrophic lateral sclerosis (ALS) and spinal muscular atrophy (SMA). It discusses the signs of upper motor neuron (UMN) and lower motor neuron (LMN) pathology, as well as Kennedy disease.
50 Studies Every Palliative Care Doctor Should Know
Authors: Hui David , Reddy Akhila , Bruera Eduardo
Published: April 2018

50 Palliative Care Studies Every Doctor Should Know provides a succinct summary and critical appraisal of 50 landmark studies that have defined the practice of palliative care. Carefully handpicked by the editors based on their scientific impact, these studies provide important insights into the evolution of this rapidly growing discipline. These articles cover a wide range of domains across interdisciplinary palliative care, such as pain and symptom management, psychosocial issues, spiritual care, caregiver distress, communication, advance care planning, prognostication, decision making, and end-of-life care. The principles of palliative care discussed in this book may be applicable throughout the trajectory of multiple life-limiting diseases.
Changes in the Last Months of Life (DRAFT)
Authors: Yoong Jaclyn , Runacres Fiona
Published: April 2018

This study aimed to assess symptoms and performance status of cancer patients during the last six months of life. In Ontario, Canada, Edmonton Symptom Assessment System (ESAS) scores and Palliative Performance Scale (PPS) scores of outpatients with cancer were systemically collected. This was an observational cohort study of cancer decedents’ ESAS and PPS scores between 2007 and 2009. Outcomes were the average ESAS and PPS scores per week before death. A total of 10,752 decedents with ESAS and 7,882 with PPS scores were included. General patterns of symptoms scores were observed: (1) generally stable (pain, nausea, anxiety, depression) versus (2) increased severity over time (shortness of breath, drowsiness, well-being, lack of appetite, tiredness). More than one-third reported moderate to severe symptom scores in the last month of life. Average PPS scores declined slowly for the initial five months, then more rapidly in the last month before death.
Reversibility of Delirium in Palliative Care (DRAFT)
Authors: Shaw Tiffany , Prommer Eric
Published: April 2018

Delirium is a frequent event in patients with advanced cancer. Untreated delirium affects assessment of symptoms, impairs communication including participation in clinical decision-making. This study used specific diagnostic criteria for delirium and prospectively identified precipitating causes of delirium. The study identified factors associated with reversible and irreversible delirium. Impact of delirium on prognosis was evaluated. This chapter describes the basics of the study, including funding, year study began, year study was published, study location, who was studied, who was excluded, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case. Topics covered include delirium, neoplasms, palliative care, polypharmacy, risk factors, and therapeutics.
Decompressive Surgery for Malignant Spinal Cord Compression (DRAFT)
Authors: Finlay Esmé , Osman Diaa
Published: April 2018

Metastatic epidural spinal cord compression (MESCC) is a potentially disabling complication associated with advanced cancer. To address whether decompressive surgery followed by radiation therapy is superior to radiation therapy alone, this multi-institutional randomized trial compared outcomes among 101 patients with MESCCC. The study assessed functional outcomes such as ability to ambulate posttreatment, length of ambulation and maintained continence posttreatment, survival time after intervention, and additional functional, quality of life, and medication use outcomes. The practice-changing results of this study indicate that patients who received decompressive surgery and radiation had a longer length of posttreatment ambulation (122 days vs. 13 days, P = 0.03), better overall survival (126 days vs. 100 days, Relative risk 0.60, P = 0.033), lower doses of palliative medications, as well as better performance on several other secondary outcomes. From this landmark study, in appropriately selected patients with MESCC, surgery followed by radiation has become the standard of care.
Parenteral Hydration in Patients with Advanced Cancer (DRAFT)
Authors: Paiva Carlos Eduardo , Paiva Bianca Sakamoto Ribeiro
Published: April 2018

There has been much debate about the role of parenteral hydration in the last weeks and days of life. In this important study, 129 patients with advanced cancer receiving hospice care with mild to moderate dehydration who were no longer able to maintain adequate fluid intake were randomized to receive parenteral hydration of either 1 L or 100 ml of normal saline per day subcutaneously. Parenteral hydration did not significantly improve the symptoms related to dehydration, the occurrence of delirium, fatigue, quality of life, and overall survival. At the end of the chapter, a clinical case leads readers to consider the common practice of parenteral hydration.
Docusate and Sennosides for Constipation (DRAFT)
Authors: Dalal Shalini
Published: April 2018

This chapter describes a prospective study that ran from December 2005 to November 2010 using three hospital inpatient units of adding a stool softener, docusate versus placebo, to sennosides alone for the treatment of constipation among hospice patients. Patients were adults admitted to an inpatient hospice program with a Palliative Performance Status 20% or greater. The chapter describes the basics of the study, including funding, year study began, year study was published, study location, who was studied, who was excluded, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case.
Dignity Therapy for Patients Near the End of Life (DRAFT)
Authors: Delgado-Guay Marvin Omar
Published: April 2018

The objective of this study was to establish the feasibility of dignity therapy and determine its impact on psychosocial and existential distress in 100 patients near the end of life. Dignity therapy helped patients to discuss issues that matter most or that they would mostly want to be remembered. Sessions were transcribed and edited, with a returned final version to the patient. This psychological therapy was well accepted, and it did help patients at the end-of-life in many psychosocial and existential issues and increased will to live. This chapter describes the basics of the study, briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case
Association between Spirituality/Religiosity and Quality of End-of-Life Care (DRAFT)
Authors: Delgado-Guay Marvin Omar
Published: April 2018

The Coping with Cancer Study is a multicenter, prospective, longitudinal observational study that examines the association between religious coping strategies and end-of-life care outcomes in patients with advanced cancer. Baseline interviews were performed to assess religious coping and other related variables. Patients were followed until death, a median of 122 days after baseline assessment. Logistic regression analyses showed a significant association between higher positive religious coping with increased preference of aggressive care at the end-of-life. Subsequent analyses from the same study showed that patients who expressed high spiritual support only from religious communities were less likely to receive hospice and more likely to receive aggressive end-of-life measures including dying in an intensive care unit. This effect was reverse in spiritual/religious care and was provided by the medical team.
Physician Message and Patient’s Perception of Compassion (DRAFT)
Authors: Flint Lynn A. , Widera Eric
Published: April 2018

This randomized, crossover study examined advanced cancer patients’ perceptions of physician compassion when delivering a less optimistic versus more optimistic message. Patients with advanced cancer viewed two videos, each depicting actors portraying a physician and a patient discussing cancer treatment options. In one video, the physician delivers a less optimistic message and in the other, the physician delivers a more optimistic message. Participants rated their perceptions of physician compassion after viewing each video. They perceived the physician with the more optimistic message as more compassionate than the physician with the less optimistic message. The chapter describes the basics of the study, briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case.
Family Perspectives on Aggressive End-of-Life Care (DRAFT)
Authors: Parikh Ravi B. , Odejide Oreofe
Published: April 2018

The chapter describes the study by Wright and colleagues examining the impact of aggressive cancer care on bereaved family members’ perceptions of end-of-life care. Family members of patients with advanced-stage lung or colorectal cancer were interviewed after their loved ones died to elicit perceptions of care. This chapter presents family-member reported rating of quality of end-of-life care and the association of such rating with aggressive cancer care, including intensive care unit admission within 30 days of death, and no hospice or late hospice admission. It also reviews family members’ perception of whether patients received end-of-life care that was concordant with their wishes. This chapter highlights the downstream impact of aggressive cancer care on family members and the resulting implications for end-of-life care.
Constraint Management in a Bottleneck Environment (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

This chapter introduces steps 4 through 7 of the theory of constraints—that, respectively, decide how to exploit and utilize the constraint, subordinate the system to the constraint, elevate and break the constraint, and do not let inertia become the system constraint. The chapter shows how to achieve more using the existing resources by focusing on the bottleneck. For example, reducing waste (“garbage time”) of the bottleneck can quite quickly increase the system’s throughput. The subordination of the rest of the system to the bottleneck is then discussed. For this purpose, the scheduling mechanism of drum–buffer–rope can be implemented in some areas of healthcare systems, like operating rooms, leading to increased throughput and reduction of waiting times as well as improved clinical quality.
Focused Current Reality Tree (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

The focused current reality tree (fCRT) is a simple tool for identifying the core or root problems of an organization or a system. This tool provides the organization with a small number of core problems that, when solved, will increase its value significantly. It also serves as a visual communication tool within the organization. Since the fCRT is a subjective tool, we recommend creating it by interdisciplinary teams. This chapter provides an easy recipe for constructing fCRTs. In a similar manner, the core competences tree (CCT) is a simple yet potent tool for identifying and focusing on the organization’s strengths. A detailed recipe for constructing core competence trees is provided.
Pancreatic surgery (DRAFT)
Authors: Ritchie Judith , Al-Mukhtar Ahmed
Published: April 2018

Pancreatic surgery is a fascinating subspecialty of general surgery. It is considered a superspecialty, with pancreatic surgery limited to a number of tertiary centres around the country taking referrals from regional hospitals. However, surgical trainees will encounter pancreatic pathology on a day-to-day basis through the acute take, with emergency presentations arising from patients presenting with complications from acute and chronic pancreatitis and from locally advanced pancreatic cancers. In addition this chapter includes a case based discussion of pancreatic trauma to educate on its variable and often insidious nature. These cases aim to outline relevant information regarding each of the clinical cases, with a sensible and appropriate approach to investigation and management.
Emergency surgery (DRAFT)
Authors: Wild Jonathan , Nofal Emma , Wijetunga Imeshi , Hall Antonia Durham
Published: April 2018

Emergency general surgery comprises patients with surgical problems requiring surgical intervention or post-operative surgical patients who require further surgical intervention or symptom palliation at any time of the day or night. Beyond the cases discussed below, this will include also emergency presentations from all of the sub-specialty chapters covered so far. Over 600,000 emergency hospital admissions are made to general surgery. Of these patients, they comprise the sickest patient cohort relative to the majority of elective patients, which results from sepsis, shock, or organ dysfunction from the underlying causative pathology, as well as the impact of any pre-existant comorbid states. This often has a significant impact on patient outcome, with high rates of morbidity and mortality relative to elective surgery. With this in mind, a lot of work has been channelled into improving outcomes for these patients. Furthermore, emergency and trauma surgery is beginning to establish itself as a subspecialty in itself. This chapter starts by making applied discussion of the assessment and initial investigation of acute abdominal pain, a complaint that comprises half of the annual 600,000 emergency general surgical admissions. It covers the pertinent features of diagnosis, investigation, and management of a range of common or serious emergency surgical and trauma cases that will be encountered on the acute surgical take. Kidney transplantation is not in itself an emergency operation when you consider the degree of pre-operative preparation of recipient donors, but is included in this chapter as it is commonly encountered by junior trainees on the emergency theatre list when donors are found at short notice.
The course and prognosis of adjustment disorders (DRAFT)
Authors: Casey Patricia
Published: April 2018

The diagnostic stability of AD is questionable since there are no specific diagnostic criteria and many clinicians are not familiar with AD, mistaking it for some overlapping disorder. Case-register and inpatient records all identify poor stability, although this was not unique to AD and includes other non-psychotic disorders. The duration of hospitalization is shorter for those with AD than for those with other diagnoses, and a similar pattern has been observed for outpatient follow up. The prognosis for AD is described as good. Long-term follow-up studies show that a large proportion of patients are well and do not require readmission. Among adolescents, a diagnosis of AD may augur more serious underlying psychopathology, and they have higher readmission rates than adults with the diagnosis. AD is the most common diagnosis in those dying by suicide in some countries and it occurs earlier in the course of AD than in other diagnostic groups.
Effects of a dietary supplement on gastric ulcer number and severity in exercising horses1
Authors: Conner Alysia L , Davis Amanda J , Porr Cheryl A
Published: April 2018

This study evaluated the effect of a dietary supplement on the treatment of equine gastric ulcer syndrome (EGUS). Gastroscopy was performed on university riding horses of mixed breeds at two locations and only horses exhibiting gastric ulcers were selected to participate in this study (location A, n = 13; location B, n = 15). Gastric ulcer severity was assessed using two different methods depending on location before treatment (Pre). After gastroscopy, horses were fed the supplement in addition to their regular diet for 44 d (14-d adaptation period followed by 30-d feeding period). All horses were subjected to gastroscopy again at the end of the feeding period (Post) to evaluate changes in gastric lesions. Statistical analysis was performed using SAS. Individual horses were the experimental unit with dependent variables including severity and number of gastric ulcers. At location A, dependent variable included severity of gastric lesions with fixed effects of time (Pre and Post) and location (stall or pasture). For location B, dependent variables included severity and number of gastric lesions with fixed effects of time. Severity of gastric ulcers decreased at both locations in horses following the feeding period. Gastric lesion scores decreased from 2.2990 to 1.3760 (P = 0.0015) at location A and gastric lesion severity from 3.8000 to 2.5667 (P = 0.0322) at location B. No differences were found in gastric lesion scores at location A between horses housed in stalls or pastures (1.8750 and 1.8000; P = 0.7783). The number of gastric ulcers observed at location B were similar Pre and Post treatment (3.4667 and 3.5333; P = 0.8363). There were no changes in body condition score (P ≥ 0.2607), BW (P ≥ 0.4551), or behavior at either location. Results suggest that oral supplementation may decrease severity of gastric ulcers in horses participating in university riding programs.
Accessories Make the Outfit: Accessory Chromosomes and Other Dispensable DNA Regions in Plant-Pathogenic Fungi
Authors: Bertazzoni Stefania , Williams Angela H. , Jones Darcy A. , Syme Robert A. , Tan Kar-Chun , Hane James K.
Published: April 2018

Fungal pathogen genomes can often be divided into core and accessory regions. Accessory regions ARs) may be comprised of either ARs (within core chromosomes (CCs) or wholly dispensable (accessory) chromosomes (ACs). Fungal ACs and ARs typically accumulate mutations and structural rearrangements more rapidly over time than CCs and many harbor genes relevant to host-pathogen interactions. These regions are of particular interest in plant pathology and include host-specific virulence factors and secondary metabolite synthesis gene clusters. This review outlines known ACs and ARs in fungal genomes, methods used for their detection, their common properties that differentiate them from the core genome, and what is currently known of their various roles in pathogenicity. Reports on the evolutionary processes generating and shaping AC and AR compartments are discussed, including repeat induced point mutation and breakage fusion bridge cycles. Previously ACs have been studied extensively within key genera, including Fusarium, Zymoseptoria, and Alternaria, but are growing in frequency of observation and perceived importance across a wider range of fungal species. Recent advances in sequencing technologies permit affordable genome assembly and resequencing of populations that will facilitate further discovery and routine screening of ACs.
The Art (and Artifice) of Seeking Feedback: Clerkship Students’ Approaches to Asking for Feedback
Authors: Bing-You Robert , Hayes Victoria , Palka Tamara , Ford Marybeth , Trowbridge Robert
Published: April 2018

Purpose

As attention has shifted to learners as significant partners in feedback interactions, it is important to explore what feedback-seeking behaviors medical students use and how the faculty–student relationship affects feedback-seeking behaviors.

Method

This qualitative study was inspired by the organizational psychology literature. Third-year medical students were interviewed at Maine Medical Center in April–May 2017 after completing a traditional block rotation clerkship or a nine-month longitudinal integrated clerkship (LIC). A constructivist grounded theory approach was used to analyze transcripts and develop themes.

Results

Fourteen students participated (eight LIC, six block rotation). Themes associated with why students sought feedback included goal orientations, perceived benefits and costs, and student and feedback provider characteristics. Factors influencing the way students sought feedback included busy environments, timing, and cues students were attuned to. Students described more inquiry than monitoring approaches and used various indirect and noninquiry techniques (artifice) in asking for feedback. Students did not find summative feedback as helpful as seeking feedback themselves, and they suggested training in seeking feedback would be beneficial. Faculty–student relationship dynamics included several aspects affecting feedback-seeking behaviors, and relationship differences in the LIC and block models affected feedback-seeking behaviors.

Conclusions

Medical students have many motives to seek feedback and adapt their feedback-seeking behaviors to actively participate in an intricate dialogic interaction with feedback providers. Students gradually refine the art (and artifice) of obtaining the specific feedback information that meets their needs. The authors offer a prototype curriculum that may facilitate students’ development of feedback-seeking skills.
What Factors Influence Union and Refracture of Congenital Pseudarthrosis of the Tibia? A Multicenter Long-term Study
Authors: Shah Hitesh , Joseph Benjamin , Nair Binu V.S. , Kotian Devaki B. , Choi In Ho , Richards Benjamin Stephens , Johnston Charles , Madhuri Vrisha , Dobbs Matthew B. , Dahl Mark
Published: April 2018

Objective:

To identify factors influencing union of congenital pseudarthrosis of the tibia (CPT), refractures, and integrity of the tibia at maturity.

Methods:

Data of 119 children operated for Crawford-type IV CPT and followed-up till skeletal maturity were analyzed. Logistic regression and recursive partitioning analyses were used to test associations between several variables and the outcome.

Results:

Primary union occurred in 86% of children. At maturity, 69% remained soundly united. The odds ratio for failure of primary union was 3.89 (95% confidence interval, 1.05-14.40; P=0.042) when bone morphogenetic protein was used, and children who had a combination of the Ilizarov technique and intramedullary nailing were at risk for unsound union at maturity (odds ratio, 6.19; 95% confidence interval, 1.24-30.83; P=0.026). No other association reached statistical significance. On recursive partitioning, use of the Ilizarov technique, transfixing the ankle and subtalar joints, use of cortical graft and not operating on the fibula were associated with a better outcome; use of bone morphogenetic protein and combining intramedullary nailing with the Ilizarov technique were associated with poor results.

Conclusions:

A larger sample is needed to confirm which factors truly influence the outcome of CPT. This may be feasible if data are collected prospectively through a multicenter registry.
Spinal Sagittal Alignment in Patients With Dropped Head Syndrome
Authors: Murata Kazuma , Kenji Endo , Suzuki Hidekazu , Takamatsu Taichiro , Nishimura Hirosuke , Matsuoka Yuji , Sawaji Yasunobu , Tanaka Hidetoshi , Yamamoto Kengo
Published: April 2018

Study Design.

This is a retrospective radiographic study of a consecutive case series of dropped head syndrome (DHS) at a single tertiary referral center.

Objective.

The aim was to clarify the spinal sagittal alignment of DHS.

Summary of Background Data.

DHS is characterized by chin-on-chest deformity and devastatingly impedes activities of daily living in affected individuals. Among various forms of DHS, isolated neck extensor myopathy (INEM) is considered to cause the chin-on-chest symptom in the absence of specific abnormality. There is a paucity of literature about spinal sagittal alignment, of this condition however.

Methods.

Thirty-seven patients diagnosed with INEM DHS were enrolled. Radiographic measurements were made, including the following parameters: C2 slope (C2S), C2-C7 A, C2-C7 sagittal vertical axis (SVA), T1 slope (T1S), C7-S1 SVA, T1-T4 thoracic kyphosis (TK), T4-T12 TK, lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI). Sixty-one patients with cervical spondylosis were enrolled as a control group.

Results.

C2-C7 SVA was greater in INEM DHS (52.0 ± 2.9 vs. 18.6 ± 1.9 mm). C2S and T1S were larger to the control (C2S: 52.6° ± 2.0° vs. 13.0° ± 1.4°, T1S: 37.3° ± 2.2° vs. 22.7° ± 1.4°). C2-C7 A was smaller in INEM DHS (−7.8° ± 2.6° vs. 15.2° ± 2.7°). Among sagittal parameters, C2S, T1S, and T1-T4 TK positively correlated with C2-C7 SVA (r = 0.63, r = 0.54, and r = 0.58). For these correlations with C2-C7 SVA, both logistic and linear regression models predicted threshold of 40° for C2S, 40° for T1S, and 15° for T1-T4 TK responsible for C2-C7 SVA > 40 mm, respectively.

Conclusion.

Increased offset of the gravity axis of the head represented by C2-C7 SVA was observed in INEM DHS. Magnified offset of the gravity axis of the head was affected by enlarged C2S, T1S, and T1-T4 TK for the strong correlation with C2-C7 SVA, respectively. Cervical kyphosis was considered as some of the anthropometric characteristics due to regressive changes in affected individuals; a correlation between C2-C7 A and C2-C7 SVA was exhibited.

Level of Evidence: 4
Comparing Conventional and Navigation-assisted Techniques for Lateral Opening-wedge Femoral Varus Osteotomy
Authors: da Costa Sergio R. , da Mota e Albuquerque Roberto F.
Published: April 2018

Objective:

The aim of this study was to assess short-term clinical and radiographic results of opening-wedge distal femoral varus osteotomy performed using either the conventional technique or a navigation (NAV)-assisted technique.

Materials and Methods:

This study included 25 patients; 12 patients underwent femoral osteotomy with NAV, and 13 patients underwent the conventional procedure.

Results:

In the NAV osteotomy group, the mean duration of surgery was 73.69 minutes (SD, 12.53 min), and the mean tourniquet time was 59 minutes. Mean preoperative mechanical alignments were 13.84 degrees in the conventional osteotomy group and 14.4 degrees in the NAV osteotomy group (P=0.7432; 95% confidence interval=12.8-15.4 degrees), and the final postoperative mechanical alignment varied between −2 and 3 degrees in both groups, with no significant difference between the results obtained using the 2 techniques (P=0.1316; 95% confidence interval=0.08-1.24 degrees). However, the correlation between initial alignment and postoperative result was strong (P=−0.68) in the NAV osteotomy group and weak (P=−0.07) in the conventional osteotomy group.

Conclusions:

Duration of surgery and tourniquet time were longer in the NAV osteotomy group. The use of NAV for femoral varus osteotomy did not result in any significant difference in final alignment.
Evaluating for Pseudoprogression in Colorectal and Pancreatic Tumors Treated With Immunotherapy
Authors: Parseghian Christine M. , Patnana Madhavi , Bhosale Priya , Hess Kenneth R. , Shih Ya-Chen Tina , Kim Bumyang , Kopetz Scott , Overman Michael J. , Varadhachary Gauri R. , Javle Milind , Naing Aung , Piha-Paul Sarina , Hong David , Le Hung , Subbiah Vivek , Pant Shubham
Published: April 2018

Pseudoprogression has been observed in patients with various tumor types treated with immunotherapy. However, the frequency of pseudoprogression is unknown in gastrointestinal malignancies. Metastatic colorectal cancer (mCRC) and advanced pancreatic ductal adenocarcinoma (PDAC) patients who progressed on treatment with immunotherapy beyond RECIST version 1.1 criteria were analyzed. Degree of progression, tumor markers, time to progression, overall survival, Eastern Cooperative Oncology Group Performance Status (ECOG PS), and costs were analyzed for patients treated beyond progression (TBP) and not treated beyond progression. Fifty-nine of 159 (37%) patients with mCRC or PDAC were TBP (31 mCRC, 28 PDAC). Fifty-four of 59 (92%) patients were microsatellite stable. Zero of these 59 patients with initial treatment beyond progression demonstrated subsequent radiographic tumor shrinkage at a median 42 days from first scan documenting progression. A pseudoprogression rate of >6% could be excluded with 95% confidence. Compared with baseline, median growth on the first and second scan that showed progression was 29.8% and 43%, respectively. In those not treated beyond progression, median growth at first restaging was 31.2%. The trend in change in tumor size positively correlated with the trend in tumor markers in all patients TBP. Fifteen patients (25%) experienced grade 3/4 adverse events by continuing treatment beyond progression, whereas 19 (32%) experienced deterioration in ECOG PS. Pseudoprogression was not seen in microsatellite stable patients with mCRC or PDAC treated with immunotherapy. Changes in tumor markers correlated with changes in tumor volume. This data may help inform future treatment decisions and/or trial design in patients with mCRC or advanced PDAC treated with immunotherapy.
The Role of Provider Characteristics in the Selection of Surgery or Radiation for Localized Prostate Cancer and Association With Quality of Care Indicators
Authors: Satkunasivam Raj , Lo Mary , Stern Mariana , Gill Inderbir S. , Fleming Steven , Wu Xiao-Cheng , Anderson Roger T. , Thompson Trevor D. , Hamilton Ann S.
Published: April 2018

Introduction:

We sought to identify the role of provider and facility characteristics in receipt of radical prostatectomy (RP) or external beam radiation therapy (EBRT) and adherence to quality of care measures in men with localized prostate cancer (PCa).

Materials and Methods:

Subjects included 2861 and 1630 men treated with RP or EBRT, respectively, for localized PCa whose records were reabstracted as part of the Centers for Disease Control and Prevention Breast and Prostate Patterns of Care Study. We utilized multivariable generalized estimating equation regression analysis to assess patient, clinical, and provider (year of graduation, urologist density) and facility (group vs. solo, academic/teaching status, for-profit status, distance to treatment facility) characteristics that predicted use of RP versus EBRT as well as quality of care outcomes.

Results:

Multivariable analysis revealed that group (vs. solo) practice was associated with a decreased risk of RP (odds ratio, 0.47; 95% confidence interval, 0.25-0.91). Among RP patients with low-risk disease, receipt of a bone scan that was not recommended was significantly predicted by race and insurance status. Surgical quality of care measures were associated with physician’s year of graduation and receiving care at a teaching facility.

Conclusions:

In addition to demographic factors, we found that provider and facility characteristics were associated with treatment choice and specific quality of care measures. Long-term follow-up is required to determine whether quality of care indicators are related to PCa outcomes.
Impact of Right-sided Primary Tumor Location Among Patients With Oligometastatic Colorectal Cancer Treated With Stereotactic Body Radiotherapy
Authors: Bates James E. , Choi Gyujae , Usuki Kenneth Y. , Katz Alan W. , Milano Michael T.
Published: April 2018

Introduction:

Among patients with colorectal cancer, those with right-sided primary tumors have worse outcomes in both the primary and metastatic setting. Patients with oligometastatic colorectal cancer (OMCC) have improved prognosis relative to those with diffusely metastatic disease. We aimed to assess if the trend toward worse outcomes with right-sided tumors remained in the oligometastatic setting.

Patients and Methods:

We analyzed 31 patients treated at a single institution with stereotactic body radiotherapy for OMCC from 2011 to 2014 to assess the impact that primary tumor location had on overall survival (OS) and progression-free survival (PFS).

Results:

Overall, patient local control was fair (66% at 2 y); however, distant control was only 37.4% at 2 years. The median OS was 2.4 years; the median PFS was 6.5 months. Patients with right-sided primary tumors had numerically worse median OS than those with left-sided or rectal primary tumors (1.4 vs. 3.7 y, P=0.09). Median PFS was significantly worse among those with right-sided primaries (2.9 vs. 10.8 mo, P=0.05). This held on multivariate analysis.

Conclusions:

These results affirm that patients with OMCC have extended OS periods and that stereotactic body radiotherapy offers strong local control in these settings. We show that even in the oligometastatic setting those with right-sided primary tumors have worse outcomes relative to those with left-sided or rectal primary tumors. This suggests more aggressive treatment may be needed for those with oligometastatic right-sided colorectal cancer.
Pouch Volvulus in Patients Having Undergone Restorative Proctocolectomy for Ulcerative Colitis: A Case Series
Authors: Landisch Rachel M. , Knechtges Paul M. , Otterson Mary F. , Ludwig Kirk A. , Ridolfi Timothy J.
Published: April 2018

BACKGROUND:

Restorative proctocolectomy with IPAA improves quality of life in patients with medically refractory ulcerative colitis. Although bowel obstruction is common, pouch volvulus is rare and described only in case reports. Diagnosis can be challenging, resulting in delayed care and heightened morbidity.

OBJECTIVE:

The purpose of this study was to delineate the symptoms and successful management strategies used in patients with IPAA volvulus that result in pouch salvage.

DESIGN:

This study was a case series.

SETTINGS:

The study was conducted at a tertiary referral center for ulcerative colitis in Milwaukee, Wisconsin.

PATIENTS:

Patients included those with volvulus of the IPAA.

MAIN OUTCOME MEASURES:

Over the study period (2010–2015), 6 patients were diagnosed with IPAA volvulus. The primary outcomes were symptom manifestation, diagnostic practices, and treatment of pouch volvulus.

RESULTS:

Six patients with ulcerative colitis were identified with pouch volvulus. The majority (n = 4) underwent a laparoscopic pouch creation and had early symptom manifestation after surgery. Complications preceding volvulus included pouch ulceration (n = 5) and pouchitis (n = 4). The most common presenting symptoms of volvulus were abdominal pain (n = 4) and obstipation (n = 4). Multiple imaging modalities were used, but volvulus was most frequently identified by CT scan. Management was primarily operative (n = 5), composed of excision of the pouch (n = 3), pouch-pexy (n = 1), and detorsion with defect closure (n = 1). Both operative and nonoperative treatment with endoscopic detorsion resulted in low morbidity and improved patient symptoms.

LIMITATIONS:

This single-institution study is limited by its retrospective design and small number of patients.

CONCLUSIONS:

IPAA volvulus is a rare and challenging cause of bowel obstruction in ulcerative colitis. Heralding signs and symptoms, such as pouch ulceration and acute obstipation, should initiate a workup for a twisting pouch. Diagnosis, which is multimodal, must occur early to avert necrosis and allow for preservation of a well-functioning pouch. See Video Abstract at http://links.lww.com/DCR/A561.
Should we consider telomere length and telomerase activity in male factor infertility?
Authors: Balmori Carlos , Varela Elisa
Published: April 2018

Purpose of review

The purpose of this review is to analyze what is known to date about the relation between telomeres and male fertility, and if it is possible for telomeres, or elements related to them, to be used as new prognostic biomarkers in fertility treatment.

Recent findings

Cells in germ series, including spermatozoids, have longer telomeres (10–20 kb), and do not seem to undergo the shortening that takes place in somatic cells with age as they present telomerase activity. Longer telomere length found in the sperm of older fathers, influences their offspring possessing cells with longer telomere length. Infertile patients have spermatozoids with shorter telomere length than fertile people, but telomere length does neither correlate with the sperm concentration, mobility or morphology, nor with the DNA fragmentation indices (DFI) of spermatozoids. Embryo quality rate and transplantable embryo rate are related with the telomere length of spermatozoids (STL), but pregnancy rates are not affected.

Telomere length and telomerase levels can be used as biomarkers of male fertility. Higher STL can have beneficial effects on fertility, thus the use of spermatozoids with longer telomere length in an assisted reproduction technique (ART) could be one way of solving some infertility cases.
Extracellular vesicles: a promising tool for assessment of embryonic competence
Authors: Marin Diego , Scott Richard T.
Published: April 2018

Purpose of review

Extracellular vesicles have recently emerged as a promising field of research due to their pivotal roles in intercellular communication and potential to serve as biomarkers. This review focuses on extracellular vesicles secreted by the human preimplantation embryo. The most recent findings on embryo-derived extracellular vesicles are described and discussed, as well as current technical challenges to study them.

Recent findings

So far, only a few studies have addressed extracellular vesicles of embryonic origin and explored their potential as biomarkers for embryo selection. Two main hypotheses have driven interest in studying extracellular vesicles in IVF embryo-conditioned culture media. On the one hand, the potential roles of extracellular vesicles in mediating the embryo-endometrial crosstalk for proper implantation. On the other hand, the profile of secreted extracellular vesicles as an indicator of embryonic fitness irrespective of any involvement or communication with the endometrium. Embryo-derived extracellular vesicles have already been investigated to design diagnostic tests for embryo viability, however with small sample sizes or without extensive technology validation.

Extracellular vesicles offer indeed a novel means to assess embryonic fitness. Further validation studies, technology development and more complex study designs are certainly required to implement the profiling of embryonic extracellular vesicles as a diagnostic test for embryo selection.