bluuebunny/crossref_metadata_2025 huggingface dataset:
A Novel Technical Protocol for Improved Capture of the Genicular Nerves by Radiofrequency Ablation
Authors: Conger Aaron , Cushman Daniel M , Walker Kortnie , Petersen Russell , Walega David R , Kendall Richard , McCormick Zachary L
Published: April 2019

Background

Fluoroscopically guided cooled genicular nerve radiofrequency ablation (RFA) is an increasingly performed procedure for chronic, refractory knee pain due to osteoarthritis. Traditionally, partial sensory denervation has been accomplished through ablation of the superomedial, superolateral, and inferomedial genicular nerves. However, recent cadaveric studies have demonstrated additional sensory nerves and significant anatomic variation that impact current protocols.

Objective

We describe an updated cooled genicular nerve radiofrequency ablation protocol that accounts for varied nerve location of the superomedial, superolateral, and inferomedial genicular nerves, as well as capture of the terminal articular branches of the nerves to the vastus intermedius, vastus lateralis, and vastus medialis. Furthermore, we describe an adjusted technique for inferomedial genicular nerve capture that mitigates the risk of pes anserine tendon injury.

Design

Technical report and brief literature review.

Methods

Cadaveric studies relating to the sensory innervation of the anterior knee joint were reviewed, and a more accurate and comprehensive cooled genicular nerve radiofrequency ablation (CRFA) protocol is proposed.

Conclusions

Based on recent, rigorous anatomic dissections of the knee, the proposed genicular nerve CRFA protocol will provide more complete sensory denervation and potentially improve clinical outcomes. Prospective studies will be needed to confirm the hypothesis that this protocol will result in improved effectiveness and safety of genicular nerve RFA.
Epidemiology of Severe Acute Respiratory Infection (SARI) Cases at a sentinel site in Egypt, 2013–15
Authors: Elhakim Mohamed M , Kandil Sahar K , Abd Elaziz Khaled M , Anwar Wagida A
Published: April 2019

Background

Sentinel surveillance for severe acute respiratory infection (SARI) in Egypt began in 2006 and occurs at eight sites. Avian influenza is endemic, and human cases of influenza A (H5N1) have been reported annually since 2006. This study aimed to describe the epidemiology of SARI at a major sentinel site in the country.

Methods

Data included in the study were collected from a major SARI sentinel site in Egypt during three consecutive years (2013–15).

Results

A total of 1254 SARI patients conforming to the WHO case definition were admitted to the sentinel site, representing 5.6% of admitted patients for all causes and 36.6% of acute respiratory infection patients. A total of 99.7% of the patients were tested, and 21.04% tested positive; 48.7% of cases involved influenza A viruses, while 25% involved influenza B. The predominant age group was under 5 years of age, accounting for 443 cases. The seasonality of the influenza data conformed to the Northern Hemisphere pattern.

Conclusions

The present study’s results show that SARI leads to substantial morbidity in Egypt. There is a great need for high-quality data from the SARI surveillance system in Egypt, especially with endemic respiratory threats such as influenza A (H5N1) in Egypt.
Participation in local food projects is associated with better psychological well-being: evidence from the East of England
Authors: Bharucha Zareen Pervez , Weinstein Netta , Watson Dave , Boehm Steffen
Published: April 2019

Background

Studies suggest that local food may contribute to well-being, but do not use standardized measures, or control groups.

Methods

An online survey compared participants of local food initiatives (n = 302) with members of the general population (n = 157) in terms of scores on standardized measures of well-being and distress. Using hierarchical ordinary least squares regression models, we explored the relationship between participation and well-being via four mediators—nature connectedness, psychological need satisfaction, diet and physical activity.

Results

Participants scored higher than non-participants on life satisfaction (t(346) = 2.30, P = 0.02, ρr = 0.12) and the WEMWBS scale (t(335) = 2.12, P = 0.04, ρr = 0.10), but differences in psychological distress were insignificant. More actively engaged participants scored higher on positive well-being and longer duration participation was associated with higher life satisfaction and less psychological distress. Finally, we found that participation contributes to psychological need satisfaction, better diet and connection to nature, three known drivers of well-being.

Conclusions

Well-being may be a co-benefit of local food initiatives beyond the physical and psychological benefits of growing food. Further research is needed to explore the mediators driving these effects, quantify benefits, and track impacts over time and across different social groups.
Gifts of the Immigrants, Woes of the Natives: Lessons from the Age of Mass Migration
Authors: Tabellini Marco
Published: April 2019

In this article, I jointly investigate the political and the economic effects of immigration, and study the causes of anti-immigrant sentiments. I exploit exogenous variation in European immigration to U.S. cities between 1910 and 1930 induced by World War I and the Immigration Acts of the 1920s, and instrument immigrants’ location decision relying on pre-existing settlement patterns. I find that immigration triggered hostile political reactions, such as the election of more conservative legislators, higher support for anti-immigration legislation, and lower redistribution. Exploring the causes of natives’ backlash, I document that immigration increased natives’ employment, spurred industrial production, and did not generate losses even among natives working in highly exposed sectors. These findings suggest that opposition to immigration was unlikely to have economic roots. Instead, I provide evidence that natives’ political discontent was increasing in the cultural differences between immigrants and natives. Results in this article indicate that, even when diversity is economically beneficial, it may nonetheless be socially hard to manage.
Resiliency and Stock Returns
Authors: Hua Jian , Peng Lin , Schwartz Robert A , Alan Nazli Sila
Published: April 2019

We present resiliency as a measure of liquidity and assess its relationship to expected returns. We establish a covariance-based measure, RES, that captures opening period resiliency, and use it to find a significant nonresiliency premium that ranges from 33 to 57 basis points per month. The premium persists after accounting for an extensive list of other liquidity-related measures and control variables. The results are significant for both value-weighted and equal-weighted returns, when micro-cap stocks are excluded, and for a sample of large cap stocks. The premium is particularly pronounced when trading volume is high.

Authors have furnished an Internet Appendix, which is available on the Oxford University Press Web site next to the link to the final published paper online.
Biomarkers identified by serum metabolomic analysis to predict biologic treatment response in rheumatoid arthritis patients
Authors: Takahashi Soshi , Saegusa Jun , Onishi Akira , Morinobu Akio
Published: April 2019

Objectives

Biologic treatment has recently revolutionized the management of RA. Despite this success, ∼30–40% of the patients undergoing biologic treatment respond insufficiently. The aim of this study was to identify several specific reliable metabolites for predicting the response of RA patients to TNF-α inhibitors (TNFi) and abatacept (ABT), using capillary electrophoresis-time-of-flight mass spectrometry (CE-TOFMS).

Methods

We collected serum from RA patients with moderate or high disease activity prior to biologic treatment, and obtained the serum metabolomic profiles of these samples using CE-TOFMS. The patients' response was determined 12 weeks after starting biologic treatment, according to the EULAR response criteria. We compared the metabolites between the response and non-response patient groups and analysed their discriminative ability.

Results

Among 43 total patients, 14 of 26 patients in the TNFi group and 6 of 17 patients in the ABT group responded to the biologic treatment. Of the metabolites separated by CE-TOFMS, 196 were identified as known substances. Using an orthogonal partial least-squares discriminant analysis, we identified five metabolites as potential predictors of TNFi responders and three as predictors of ABT responders. Receiver operating characteristic analyses for multiple biomarkers revealed an area under the curve (AUC) of 0.941, with a sensitivity of 85.7% and specificity of 100% for TNFi, and an AUC of 0.985, with a sensitivity of 100% and specificity of 90.9% for ABT.

Conclusion

By metabolomic analysis, we identified serum biomarkers that have a high ability to predict the response of RA patients to TNFi or ABT treatment.
Involvement of CesA4, CesA7-A/B and CesA8-A/B in secondary wall formation in Populus trichocarpa wood
Authors: Abbas Manzar , Peszlen Ilona , Shi Rui , Kim Hoon , Katahira Rui , Kafle Kabindra , Xiang Zhouyang , Huang Xiong , Min Douyong , Mohamadamin Makarem , Yang Chenmin , Dai Xinren , Yan Xiaojing , Park Sunkyu , Li Yun , Kim Seong H , Davis Mark , Ralph John , Sederoff Ronald R , Chiang Vincent L , Li Quanzi
Published: April 2019

Cellulose synthase A genes (CesAs) are responsible for cellulose biosynthesis in plant cell walls. In this study, functions of secondary wall cellulose synthases PtrCesA4, PtrCesA7-A/B and PtrCesA8-A/B were characterized during wood formation in Populus trichocarpa (Torr. & Gray). CesA RNAi knockdown transgenic plants exhibited stunted growth, narrow leaves, early necrosis, reduced stature, collapsed vessels, thinner fiber cell walls and extended fiber lumen diameters. In the RNAi knockdown transgenics, stems exhibited reduced mechanical strength, with reduced modulus of rupture (MOR) and modulus of elasticity (MOE). The reduced mechanical strength may be due to thinner fiber cell walls. Vessels in the xylem of the transgenics were collapsed, indicating that water transport in xylem may be affected and thus causing early necrosis in leaves. A dramatic decrease in cellulose content was observed in the RNAi knockdown transgenics. Compared with wildtype, the cellulose content was significantly decreased in the PtrCesA4, PtrCesA7 and PtrCesA8 RNAi knockdown transgenics. As a result, lignin and xylem contents were proportionally increased. The wood composition changes were confirmed by solid-state NMR, two-dimensional solution-state NMR and sum-frequency-generation vibration (SFG) analyses. Both solid-state nuclear magnetic resonance (NMR) and SFG analyses demonstrated that knockdown of PtrCesAs did not affect cellulose crystallinity index. Our results provided the evidence for the involvement of PtrCesA4, PtrCesA7-A/B and PtrCesA8-A/B in secondary cell wall formation in wood and demonstrated the pleiotropic effects of their perturbations on wood formation.
Left ventricular assist devices in the treatment of advanced heart failure
Authors: Becnel Miriam , Krim Selim R.
Published: April 2019

The left ventricular assist device (LVAD) is becoming the standard of care in treating patients with advanced heart failure. This article describes available LVADs, their clinical indications, and important caveats when caring for this complex patient population.
Exploring the effect of PAs on physician trainee learning
Authors: Polansky Maura N. , Govaerts Marjan J.B. , Stalmeijer Renée E. , Eid Ahmed , Bodurka Diane C. , Dolmans Diana H.J.M.
Published: April 2019

Background:

Physician assistants (PAs) often have been embedded in academic medical centers to help ensure an adequate patient care workforce while supporting compliance with work-hour restrictions for residents and fellows (also called trainees). Limited studies have explored the effect of PAs on trainee learning. This qualitative study explored, from the perspective of physician faculty and PAs, how PAs working in the clinical learning environment can enhance or hinder trainee learning.

Methods:

Using purposive sampling, 12 PAs and 12 physician faculty members in one US teaching hospital were selected for semistructured interviews. Data collection and analysis were characterized by an iterative process. Data analysis was informed by principles of conventional content analysis.

Results:

Participants identified various ways in which PAs may affect trainee learning, intrinsically linked to the roles PAs assume in the clinical learning environment: clinician, teammate, and clinical teacher. Trainee learning may be enhanced because learning time can be optimized by having PAs in the clinical learning environment. Trainees can learn about PAs and how to collaborate with them, and PAs can enculturate and provide clinical instruction to trainees. Trainee learning may be hindered if learning opportunities for trainees go to PAs, trainees feel intimidated by experienced PAs, or trainees become too dependent on PAs.

Conclusions:

Our findings demonstrate enhancements and hindrances to trainees' learning linked to three key roles PAs perform in the clinical learning environment. These findings can inform how PAs are integrated into teaching services. Further investigation is needed to understand how PAs can balance their professional roles to foster effective collaborative practice and learning.
When Is It Time to Leave Nursing?
Authors: Blake Janet
Published: April 2019

A nurse perceives a possible decline in her own cognitive abilities.
Intervention Reduces Racial Disparity in Care of Lung Cancer Patients
Authors: Potera Carol
Published: April 2019

Nurse navigators are key players.
Subacromial Decompression Surgery Is No Longer Advised
Authors: Potera Carol
Published: April 2019

Patients are urged to avoid this ineffective shoulder treatment.
Allowing Organs from Donors with Hepatitis C May Reduce the Transplant Wait List
Authors: Zolot Joan
Published: April 2019

Direct-acting antivirals can effectively treat recipients who become HCV positive.
What Would You Do If You Weren't a Nurse?
Authors: Paradisi Julianna
Published: April 2019

Updated several times a week with posts by a wide variety of authors, AJN's blog Off the Charts allows us to provide more timely—and often more personal—perspectives on professional, policy, and clinical issues. Best of the Blog will be a regular column to draw the attention of AJN readers to posts we think deserve a wider audience. To read more, please visit: www.ajnoffthecharts.com.
Inappropriate Prescribing of Antibiotics Remains Widespread
Authors: Rosenberg Karen
Published: April 2019

According to this study:

Almost a quarter of outpatient antibiotic prescriptions filled for privately insured adults and children were classified as inappropriate, according to a classification scheme based on the most recent diagnosis codes.
Statins Reduce Major Vascular Events in All Age Groups
Authors: Rosenberg Karen
Published: April 2019

According to this study:

Statin therapy significantly reduces the risk of major vascular events in all age groups, but the proportional reductions in risk decreased slightly with increasing age.
The Other Side
Authors: Lower Amy D.
Published: April 2019

As her father's hospital stay is prolonged, a nurse struggles with a newfound sense of helplessness.
Validating a Quick Spectral Modulation Detection Task
Authors: Landsberger David M. , Dwyer Robert T. , Stupak Natalia , Gifford René H.
Published: April 2019

Objectives:

The Quick Spectral Modulation Detection (QSMD) test provides a quick and clinically implementable spectral resolution estimate for cochlear implant (CI) users. However, the original QSMD software (QSMD(MySound)) has technical and usability limitations that prevent widespread distribution and implementation. In this article, we introduce a new software package EasyQSMD, which is freely available software with the goal of both simplifying and standardizing spectral resolution measurements.

Design:

QSMD was measured for 20 CI users using both software packages.

Results:

No differences between the two software packages were detected, and based on the 95% confidence interval of the difference between tests, the difference between the tests is expected to be <2% points. The average test duration was under 4 minutes.

Conclusions:

EasyQSMD is considered functionally equivalent to QSMD(MySound) providing a clinically feasible and quick estimate of spectral resolution for CI users.
Impact of Lexical Parameters and Audibility on the Recognition of the Freiburg Monosyllabic Speech Test
Authors: Winkler Alexandra , Carroll Rebecca , Holube Inga
Published: April 2019

Objective:

Correct word recognition is generally determined by audibility, but lexical parameters also play a role. The focus of this study was to examine both the impact of audibility and lexical parameters on speech recognition of test words of the clinical German Freiburg monosyllabic speech test, and subsequently on the perceptual imbalance of test lists observed in the literature.

Design:

For 160 participants with normal hearing that were divided into three groups with different simulated hearing thresholds, monaural speech recognition for the Freiburg monosyllabic speech test was obtained via headphones in quiet at different presentation levels. A software manipulated the original speech material to simulate two different hearing thresholds. All monosyllables were classified according to their frequency of occurrence in contemporary language and the number of lexical neighbors using the Cross-Linguistic Easy-Access Resource for Phonological and Orthographic Neighborhood Density database. Generalized linear mixed-effects regression models were used to evaluate the influences of audibility in terms of the Speech Intelligibility Index and lexical properties of the monosyllables in terms of word frequency (WF) and neighborhood density (ND) on the observed speech recognition per word and per test list, respectively.

Results:

Audibility and interactions of audibility with WF and ND correctly predicted identification of the individual monosyllables. Test list recognition was predicted by test list choice, audibility, and ND, as well as by interactions of WF and test list, audibility and ND, ND and test list, and audibility per test list.

Conclusions:

Observed differences in speech recognition of the Freiburg monosyllabic speech test, which are well reported in the literature, depend not only on audibility but also on WF, neighborhood density, and test list choice and their interactions. The authors conclude that future creations of speech test material should take these lexical parameters into account.
Surgical treatment of pediatric forearm fractures with intramedullary nails: is it a disadvantage to leave the tip exposed?
Authors: Dinçer Recep , Köse Ahmet , Topal Murat , Öztürk İbrahim A. , Engin Muhammed Ç.
Published: April 2019

Elastic intramedullary nailing is the main treatment method in the surgical treatment of pediatric forearm fractures. In this study, we compared the clinical outcomes of intramedullary nailing of forearm fractures with leaving the tips exposed and with placing the tip of the nails under the skin. We aimed to present the clinical outcomes of intramedullary nailing and determine the advantages and disadvantages of leaving the tips of the nails exposed. One hundred and ninety-two children with both-bone forearm fracture who were treated with titanium elastic nailing (TEN) in the Department of Orthopedics at Erzurum Regional Training and Research Hospital between January 2009 and December 2016 were included in the study. All cases had been followed up for at least 1 year. The tips of the TENs were left exposed in 74 and buried subcutaneously in 118 children. Union was achieved in all cases. Delayed union was observed in just one case. Skin irritation was observed in 11 (5.7%) of the exposed TEN cases. Superficial infection developed in two (1%) cases with exposed TEN tips. Migration developed during the follow-up of 11 (5.7%) cases with buried tips. The mean time to removal of TEN was 7.9 weeks in cases with exposed and 26.2 weeks in cases with buried cases. Refracture was observed in six buried (3.1%) cases and four exposed TEN (2.1%) cases in the first year after the removal of the nails. Perfect outcomes were achieved in 146 (76%) cases and good outcomes in 36 (19%) cases in our study. On comparing the rate of complications and clinicaloutcomes, leaving the TEN exposed seems to be safe.
Fracture obliquity is a predictor for loss of reduction in supracondylar humeral fractures in older children
Authors: Segal David , Cobb Leah , Little Kevin J
Published: April 2019

Supracondylar humeral fractures in older children have different biomechanical characteristics and surgical outcomes when compared to the same fractures in younger children. We aimed to analyze the fracture’s architecture in a large group of older children and investigate the correlation between patients’ variables, fracture patterns, fixation techniques and the rate of loss of reduction (LOR). A retrospective review study was conducted. We collected the records of 240 consecutive patients aged 8–14 years that sustained Gartland type 2/3 supracondylar humeral fractures between 2004 and 2014 and were operated at our hospital. We excluded patients with intra-articular or pathological fractures. Following the radiographical analysis and chart review, we conducted a multivariable regression analysis. Fracture obliquity on the sagittal plane ( > 20°) occurred in 33% of the cases and was found to be the only factor related to LOR (P = 0.01). Gartland type 3 fractures and more than two lateral pin configuration did not correlate to fixation failure (P = 0.69 and 0.14, respectively). The incidence of flexion-type fractures (5.8%) was found to be higher than in the total pediatric population. The sagittal oblique supracondylar humeral fracture is common and is related to fixation instability and LOR. This pattern needs to be considered when investigating different pin configurations, complication rates, and biomechanical properties. Subclassifying Gartland type 2/3 supracondylar humeral fractures as ‘oblique’ or ‘transverse’ might offer more comprehensive information about the anticipated operative results, lead to applying more stable pin constructs to these fractures and allow improved outcomes following surgical fixation.
Intracranial remission with brigatinib rechallenge as fifth-line ALK inhibition therapy in a lung cancer patient
Authors: Hochmair Maximilian , Weinlinger Christoph , Prosch Helmut
Published: April 2019

Several anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors have been developed for the treatment of EML4-ALK-rearranged non-small-cell lung cancer, with the newer generation agents brigatinib, alectinib and lorlatinib showing pronounced central nervous system activities. Intracranial efficacy is an important feature for these agents, as metastatic lesions frequently occur in the central nervous system in the ALK-positive setting. Here, we report on an updated case of a patient who received her diagnosis in 2005 and has had disease progression with new lesions on six occasions over the last 8 years. During the first two progressions, only local recurrence was observed. After that, the lungs stayed clear and the patient progressed exclusively in the brain and spinal cord. Initial treatments consisted of chemotherapy and radiotherapy. In 2012, ALK-directed targeted therapy became available, and crizotinib was administered. The treatment was switched to brigatinib 3 years later because of spinal cord lesions. Brigatinib induced partial remission and was followed by lorlatinib and, later on, alectinib, when new metastases arose in the spinal cord and brain. Each of these drugs promoted complete remission of the recent lesions. In November 2018, imaging showed multiple cerebral metastases. As radiotherapy was not an option because of previous irradiation, and as chemotherapy cannot be expected to be active in the brain, the patient underwent brigatinib rechallenge, which led to partial remission. All of the central nervous system relapses were symptomatic, with symptoms resolved rapidly during treatment. This case of a patient with EML4-ALK-rearranged non-small-cell lung cancer shows that sequential treatment with next-generation ALK tyrosine kinase inhibitors, including rechallenge, can induce profound remission even in heavily pretreated patients, especially if the central nervous system is the site of progression.
Low-Dose Versus Therapeutic Anticoagulation in Patients on Extracorporeal Membrane Oxygenation: A Pilot Randomized Trial
Authors: Aubron Cécile , McQuilten Zoe , Bailey Michael , Board Jasmin , Buhr Heidi , Cartwright Bruce , Dennis Mark , Hodgson Carol , Forrest Paul , McIlroy David , Murphy Deirdre , Murray Lynne , Pellegrino Vincent , Pilcher David , Sheldrake Jayne , Tran Huyen , Vallance Shirley , Cooper D. James ,   endorsed by the International ECMO Network (ECMONet)
Published: April 2019

Objectives:

To determine whether randomization of patients undergoing extracorporeal membrane oxygenation to either therapeutic or a low-dose anticoagulation protocol results in a difference in activated partial thromboplastin time and anti-Xa.

Design:

Randomized, controlled, unblinded study.

Setting:

Two ICUs of two university hospitals.

Patients:

Patients admitted to the ICU, who required extracorporeal membrane oxygenation (venovenous or venoarterial) and who did not have a preexisting indication for therapeutic anticoagulation.

Interventions:

Therapeutic anticoagulation with heparin (target activated partial thromboplastin time between 50 and 70 s) or lower dose heparin (up to 12,000 U/24 hr aiming for activated partial thromboplastin time < 45 s).

Measurements and Main Results:

Thirty-two patients were randomized into two study groups that were not significantly different in demographics and extracorporeal membrane oxygenation characteristics. There was a significant difference in the daily geometric mean heparin dose (11,742 U [95% CI, 8,601–16,031 U] vs 20,710 U [95% CI, 15,343–27,954 U]; p = 0.004), daily geometric mean activated partial thromboplastin time (48.1 s [95% CI, 43.5–53.2 s] vs 55.5 s [95% CI, 50.4–61.2 s]; p = 0.04), and daily geometric mean anti-Xa (0.11 international units/mL [95% CI, 0.07–0.18] vs 0.27 [95% CI, 0.17–0.42]; p = 0.01). We found similar results when considering only venovenous extracorporeal membrane oxygenation episodes; however, no difference in daily geometric mean activated partial thromboplastin time between groups when considering only venoarterial extracorporeal membrane oxygenation episodes.

Conclusions:

Allocating patients on extracorporeal membrane oxygenation to two different anticoagulation protocols led to a significant difference in mean daily activated partial thromboplastin time and anti-Xa levels between groups. When considering subgroups analyses, these results were consistent in patients on venovenous extracorporeal membrane oxygenation. Our results support the feasibility of a larger trial in patients undergoing venovenous extracorporeal membrane oxygenation to compare different anticoagulation protocols; however, this study does not provide evidence on the optimal anticoagulation protocol for patients undergoing extracorporeal membrane oxygenation.
The Effectiveness of α2 Agonists As Sedatives in Pediatric Critical Care: A Propensity Score-Matched Cohort Study
Authors: Hayden John C. , Doherty Dermot R. , Dawkins Ian , Leacy Finbarr P. , Healy Martina , Breatnach Cormac V. , Cousins Gráinne , Gallagher Paul J.
Published: April 2019

Objectives:

There is limited evidence supporting the widespread use of α2 agonists (clonidine and dexmedetomidine) in pediatric critical care sedation. This study sought to test the association between the use of α2 agonists and enhanced sedation.

Design:

A retrospective observational cohort study was conducted. Noninferiority of time adequately sedated (COMFORT Behavior Score 11–16) while mechanically ventilated was assessed. Secondarily, dosing of opioids and benzodiazepines was examined.

Setting:

Two tertiary PICUs.

Patients:

Children were classified into an exposed group, who received an α2 agonist as part of their sedation regimen, and an unexposed group. Groups were matched using propensity score analysis.

Interventions:

None.

Measurements and Main Results:

One-thousand eighty-five patients were included. The exposed group were adequately sedated 74% (95% CI, 72–75%) of the study time compared with the unexposed group at 70% (95% CI, 67–72%) giving a ratio of 1.06 (95% CI, 1.02–1.10) and a noninferior time adequately sedated. A decrease in time oversedated was observed with 8.1% (95% CI, 4.3–11.9%) less time classified as oversedated in the exposed group. Reduction in morphine use of 0.25 μg/kg/hr (95% CI, –0.68 to 1.18 μg/kg/hr) was not statistically significant. Midazolam use did not decrease and was statistically higher.

Conclusions:

Use of α2 agonists was associated with similar time adequately sedated as a matched unexposed group although no reduction in morphine or benzodiazepine coadministration was observed. There was a shift toward lighter sedation with α2 agonist use.
Adjuvant treatment of pancreatic cancer
Authors: Conroy Thierry , Ducreux Michel
Published: April 2019

Purpose of review

Pancreatic cancer will soon become one of the most common causes of cancer death. Early detection of pancreatic cancer remains impossible and only 20% of patients are suitable for surgery once diagnosed. Even in this specific subgroup of patients, and despite improvements in surgery, overall survival remains poor, with an 80% recurrence rate. Consequently, many attempts have been made to prevent recurrence by adding chemotherapy, radiotherapy, or both.

Recent findings

Here, we will focus on results of randomized trials evaluating the role of different postoperative treatments. Over 15 years ago, a trial demonstrated that chemoradiotherapy has a deleterious effect on survival. The same trial recommended adjuvant chemotherapy with fluorouracil as standard of care. Subsequent trials sought to identify better chemotherapy regimens. Two recently published trials evaluated the role of combination therapies for resected pancreatic cancer and demonstrated better outcomes with a gemcitabine and capecitabine combination and a fluorouracil, oxaliplatin, and irinotecan combination (FOLFIRINOX) versus gemcitabine alone.

Results from recent trials suggest that FOLFIRINOX should be considered standard of care for fit patients.
Immunotherapy of heterogenous sarcomas: questions and strategies
Authors: Dufresne Armelle , Meurgey Alexandra , Brahmi Mehdi
Published: April 2019

Purpose of review

Development of immune therapy in sarcoma faces the rarity and heterogeneity of the disease. This review analyses the data available from published clinical trials, and the new clinical strategies under assessment, developed in parallel to the exploration of biological mechanisms underlying the efficacy of immune therapy.

Recent findings

Published data of four clinical trials assessing the efficacy of immune therapy in metastatic bone and soft-tissue sarcoma and associated translational programs are available. Response rate and progression-free survival with single-agent immune check point blockade in unselected sarcoma are low. No biomarkers of efficacy have been identified so far. To increase the efficacy of such treatments, combination of immune check point blockade with chemotherapy, radiotherapy or targeted therapy is currently assessed. Signal of specific sensibility of some histological subtypes is explored. Adoptive cell therapy or vaccine seems particularly promising in translocation-associated sarcoma.

Characterization of immune environment, mechanism of action of combined regimen and identification of biomarkers will be key steps to build the next clinical trials to improve the efficacy of such strategy.
Sequential Two-Stage Network and Thematic Analysis for Exploring an Interdisciplinary Care Approach in Nursing Homes
Authors: Park Min Sun , Kim Gyu-Tae , Lee Su Jung , Kim Mi So , Jeong Eun-Hye , Chang Sung Ok
Published: April 2019

Since various groups of older adults with different conditions and levels of function coexist in nursing homes, it is necessary to develop integrated care strategies through collaboration among experts across related fields. The purposes of this study are to identify the regularity of information sharing in managing daily function for older adults, with a special focus on interdisciplinary cooperation, and to explore a practical care strategy for nursing home residents. The collaborative methods of network and thematic analysis were done by conducting in-depth interviews with 33 interdisciplinary experts working at seven nursing homes. This study proposed three relationships and three themes as interrelated key factors for providing interdisciplinary care to the elderly at various levels of function based on the experiences accumulated by the practitioners. First, independent sharing is required to make professional judgments about how daily function in older adults changes from reported baselines. Second, practitioners accurately judge clinical situations and supplement experts' judgments through partial sharing. Finally, all interdisciplinary consensus through complete sharing achieves the ultimate goal of maintaining remaining function in older adults. These findings can be the first step in developing practical care guidelines for interdisciplinary use, and the results can be used to develop integrated assessment and intervention strategies.
Usability of a Disease Management Mobile Application as Perceived by Patients With Diabetes
Authors: Janatkhah Roqaieh , Tabari-Khomeiran Rasoul , Asadi-Louyeh Attaolah , Kazemnejad Ehsan
Published: April 2019

The use of mobile applications in chronic disease management has grown significantly over the past decade. When properly designed, these apps provide a convenient, safe, high-quality service to patients. In this study, a health management app was developed, and its usability among patients with diabetes mellitus was examined. A convenience sample of 136 patients, referred to two academic centers from December 2016 to July 2017, was enrolled. Upon completion of informed consent, the participants were asked to install the app on their smartphone. Two weeks later, they were required to complete a postapplication usability questionnaire, comprising 21 questions classified into six domains. The response rate was 89%. The highest scores were given for “ease of use and learnability”; the lowest-scored domains were “interaction quality” and “reliability.” Urban residents, participants with lower educational qualifications, and retirees were significantly more satisfied with the app. Overall, patients with diabetes mellitus perceived the app as useful for disease management. However, the overall usability of health apps is expected to improve when a multidisciplinary team (health professionals, computer engineers, art designers) is involved in the development process.
Intraoperative SPY Reduces Post-mastectomy Skin Flap Complications: A Systematic Review and Meta-Analysis
Authors: Liu Edward H. , Zhu Sarah L. , Hu Jiayi , Wong Nathan , Farrokhyar Forough , Thoma Achilles
Published: April 2019

Background:

Indocyanine-green and laser-assisted fluorescence angiography, known as the SPY system, is a recently developed tool that has shown promise in assessing tissue perfusion. Its intraoperative use is becoming more common particularly in breast surgery. This systematic review aims to determine whether SPY technology can reduce postoperative complications related to tissue ischemia, specifically skin necrosis of the mastectomy native breast skin flaps.

Methods:

A systematic review of the literature was performed based on the PRISMA guideline. All studies that involved use of the SPY system to assess perfusion of postmastectomy skin flaps from January 1, 1960, to March 1, 2018 were included. Postoperative complications, including mastectomy skin flap necrosis were extracted from the selected studies. The perfusion-related complication rates and unexpected reoperation rates across multiple studies were then reviewed.

Results:

Five relevant articles were identified including 902 patients undergoing mastectomy and native breast flap reconstructive procedures. Groups that used indocyanine-green angiography had statistically less incidence of native breast skin flap necrosis and unexpected reoperations due to perfusion-related complications compared with groups that monitored flaps with only clinical observation (odds ratio 0.54 for skin necrosis, and 0.36 for reoperation).

Conclusions:

In this systematic review, the incidence of native breast skin flap necrosis and unexpected reoperations were found to be statistically lower in cases where SPY was used. However, more prospective studies are required to establish SPY angiography as an accurate and cost-effective tool for assessment of tissue perfusion.
Quality of Life after Flap Reconstruction of the Distal Lower Extremity: Is There a Difference Between a Pedicled Suralis Flap and a Free Anterior Lateral Thigh Flap?
Authors: Schmidt Karsten , Jakubietz Michael Gregor , Gilbert Fabian , Hausknecht Franca , Meffert Rainer Heribert , Jakubietz Rafael Gregor
Published: April 2019

Background:

Flap reconstruction of the distal lower extremity is challenging. Especially, the concept of perforator surgery has increased available surgical options. Although results are generally judged in terms of objective facts, patients-perceived quality of life has largely remained unexamined. The aim of the study was to compare quality of life after lower extremity reconstruction with pedicled and free flaps.

Methods:

Patients were evaluated retrospectively after reconstruction of defects of the distal lower extremity either with distally based adipofascial sural flap (pedicled reverse sural flap) or an anterior lateral thigh (ALT) flap. A specific questionnaire was developed to measure the patient’s quality of life, based on short form health survey-12, Dresden Body Image Score-35, Patient Health Questionnaire-4, and X-SMFA questionnaires with additional specific questions. Furthermore, results, secondary surgeries, and complications were analyzed.

Results:

Thirty-seven patients with reconstruction of lower limb defects treated with a pedicled reverse sural flap and 34 patients treated with an ALT flap were included in the study. There was no statistical significant difference in the overall satisfaction with the procedure in the long-term follow-up between both groups, but patients with ALT showed a higher satisfaction with the treatment in the initial postoperative period. Both groups demonstrated approximately similar results in the long term for self-acceptance and vitality.

Conclusions:

Although anatomic situation may dictate flap choice coverage with free flaps, a less-complicated flap is by no means regarded as an inferior treatment option in patient’s estimation. Despite the intuitive speculation that patients with more advanced reconstruction methods should have better function and subsequently higher quality of life, this assumption was clearly not supported by data in this study.
Unusual “Dumbbell”-Shaped Hibernoma
Authors: Tsapralis Nikolaos , Pham Hien , Vlachogiorgos Apostolos , Sangar Vijay , Mowatt David
Published: April 2019

Hibernoma is considered as a rare soft tissue benign tumor originating from brown fat. Few cases have been described so far in the literature; hibernoma was first described by Merkel in 1906, but it was named by Gery in 1914. We present the case of 33-year-old woman who presented with a palpable lump over superior aspect of her thigh associated with pain. Magnetic resonance imaging examination reported a “dumbbell”-shaped soft tissue tumor involving the right side of the pelvis and adductor compartment passing through the obturator foramen into the adductor compartment infiltrating the hip joint. Clinical and imaging features initially suggested liposarcoma, but ultrasound-guided biopsy and final surgical resection yielded the diagnosis of hibernoma. This rare soft tissue tumor can imitate malignancy, but magnetic resonance imaging and possibly guided biopsy are essential for preoperative planning as surgical resection remains the best management pathway.
Alternative Approach for Occipital Headache Surgery: The Use of a Transverse Incision and “W” Flaps
Authors: Afifi Ahmed M. , Carbullido Mary K. , Israel Jacqueline S. , Sanchez Ruston J. , Albano Nicholas J.
Published: April 2019

The most commonly used approach for a greater occipital nerve decompression is through a vertical midline incision, with multiple authors reporting favorable long-term outcomes. A transverse approach to the occipital nerves has been described, yet it does not include the use of fat flaps to insulate the decompressed nerves. In this study, we describe the use of a single transverse incision with modified “W” fat flaps to decompress both the greater and lesser occipital nerves. This allows for wider exposure of the nerves without the need for an additional incision to access the lesser occipital nerve. The described technique provides increased reach and versatility of the fat flap, allowing for coverage over a longer course of the nerve and further cephalad, close to the bony skull base. In addition, the fat flaps cover the greater occipital nerve closer to its native position, as opposed to bringing the nerve into a subcutaneous position. This, theoretically, keeps the nerve in a more protected deep position and technically makes it easier to avoid any tendency for kinking the nerves while wrapping them with the fat flap. Our experience has demonstrated that this modified technique is not only safe but also efficacious in affecting a statistically significant reduction (70% improvement, P = 0.004) in migraine headache index and HIT-6 scores. This study provides further evidence that nerve decompression for headache following the principles described by Guyuron is an efficacious and reproducible procedure and that a proper nerve decompression is effective in reducing headache.
Synchronous Breast Implant–associated Anaplastic Large Cell Lymphoma and Invasive Carcinoma: Genomic Profiling and Management Implications
Authors: Mukhtar Rita A. , Holland Michael , Sieber David A. , Wen Kwun Wah , Rugo Hope S. , Kadin Marshall E. , Bean Gregory R.
Published: April 2019

A 59-year-old woman with a history of cosmetic implants developed ipsilateral synchronous breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) and invasive ductal carcinoma in the left breast. Each tumor was subjected to next-generation sequencing, and separate analyses revealed mutually exclusive aberrations: an activating STAT3 mutation in the lymphoma and a PIK3CA in-frame deletion in the carcinoma. The patient was treated with removal of implants, capsulectomy, partial mastectomy, sentinel node biopsy, radiotherapy, and endocrine therapy with no evidence of recurrence for 1 year. This case illustrates the importance of obtaining thorough evaluation for concomitant malignancies in the breast at the time of diagnosis of BIA-ALCL. Herein, we review the current recommendations for evaluation and management of BIA-ALCL.
Reconstructive Surgery for Mycetoma: Is There a Need to Establish an Algorithm?
Authors: Abdelrahman Mohamed , Saad Eltaib A. , Abdulla Gamal M. , Mohamed Abdelsamie
Published: April 2019

Background:

Mycetoma is a chronic, progressive, disfiguring, and destructive disease. It caused by a variety of microorganisms including fungi and higher bacteria. It is primarily an infection of the skin and soft tissue, most frequently affecting the lower extremity and the hand and spread through fascial planes and lymphatics.

Methods:

Current medical and surgical management are still inadequate and the recurrence rate is high with severe disabilities.

Results:

This review describes some reconstructive techniques that were performed to address essential aspects with regard to mycetoma surgical management that include coverage of large skin and soft-tissue defects left after local excisions, enhancing the rate of chronic mycetoma wound healing, and preservation or restoration of functional status of the affected limbs.

Conclusion:

These applied techniques—which had acceptable preliminary outcome—have to be considered by the surgeons dealing with mycetoma to improve the functional and cosmetic outcomes and to minimize tremendous morbidities and disabilities that are associated with this neglected disease.
Consensus Opinions on Facial Beauty and Implications for Aesthetic Treatment in Middle Eastern Women
Authors: Kashmar Mohamad , Alsufyani Mohammed A. , Ghalamkarpour Fariba , Chalouhi Micheline , Alomer Ghanima , Ghannam Sahar , El Minawi Hisham , Saedi Babek , Hunter Nahla , Alkobaisi Abeer , Rafla Karim , Zari Shadi , Abdel Razzak Elsayed Mohamed , Hamdan Firas , Santangelo Samantha , Khater Mohamed , Rogers John D.
Published: April 2019

Background:

Middle Eastern women worldwide increasingly seek aesthetic treatment to enhance their beauty and improve self-esteem, but literature describing standards of beauty across the Middle East are scarce. Knowledge of facial anthropometry and Middle Eastern subregional beauty preferences and aesthetic weaknesses are key to develop an effective facial enhancement strategy that does not jeopardize ethnic identity or facial harmony.

Methods:

Dermatologists and plastic surgeons from 8 Middle Eastern countries who had 7.5–25 (mean 13.5) years of experience in aesthetic medicine examined female Middle Eastern beauty in 4 geographic subregions: the Gulf (comprising Bahrain, Kuwait, Saudi Arabia, and the United Arab Emirates), Iran, Lebanon, and Egypt. They developed consensus opinions regarding facial beauty, aesthetic deficiencies, and injectable treatment solutions.

Results:

Facial anthropometry differs between Middle Eastern and Western women, and also within the region. Although subregional differences are seen, beauty is generally recognized by an oval or round face; temple fullness; pronounced, elevated, arched eyebrows; large almond-shaped eyes; well-defined, laterally full cheeks; a small, straight nose; full lips; a well-defined jawline; and a prominent, pointed chin. The relative prominence of the nose necessitates attention to the lips and the shape and projection of the chin. Aging is often accompanied by midface sagging that leads to increased heaviness in the lower facial third.

Conclusions:

Middle Eastern beauty is characterized by striking eyes, defined cheeks, and full lips. These consensus opinions inform aesthetic practitioners who treat Middle Eastern women worldwide about their aesthetic ideals and the implications for treatment.
3-DIEPrinting: 3D-printed Models to Assist the Intramuscular Dissection in Abdominally Based Microsurgical Breast Reconstruction
Authors: Jablonka Eric M. , Wu Robin T. , Mittermiller Paul A. , Gifford Kyle , Momeni Arash
Published: April 2019

Harvest of the deep inferior epigastric vessels for microsurgical breast reconstruction can be complicated by an intricate and lengthy subfascial dissection. Although multiple preoperative imaging modalities exist to help visualize the vascular anatomy and assist in perforator selection, few can help clearly define the intramuscular course of these vessels. The authors introduce their early experience with 3D-printed anatomical modeling (to-scale) of the infraumbilical course of the deep inferior epigastric subfascial vascular tree to better assist in executing the intramuscular dissection.