bluuebunny/crossref_metadata_2025 huggingface dataset:
The Mucosal Innate Immune Response in Primary Human Papillomavirus Infection: A Pilot Study
Authors: Gardella Barbara , Iacobone Anna Daniela , Musacchi Valentina , Calvino Isabel Giacoma , De Amici Mara , Torre Cristina , Bogliolo Stefano , Spinillo Arsenio
Published: August 2016

Objectives

The purpose of the study was to evaluate the mucosal immune response in women affected by primary human papillomavirus (HPV) infection, in comparison with HPV-negative women with no previous history of HPV.

Methods

A case–control study comparing the activity of myeloperoxidase (MPO) and lactoferrin (LF) between 19 HPV-positive and 19 HPV-negative women matched for age. Plasmatic and cervicovaginal levels of polymorphonuclear neutrophils (PMN) exhibiting MPO and LF receptors were measured using cytofluorimetric analysis and expressed as mean of percentages.

Results

Cervicovaginal levels of MPO-/LF- PMN were lower among HPV-negative women, with a mean rate of 18.81% (SD, 21.38), as opposed to a mean rate of 35.56% (SD, 21.02) (P = 0.020) in HPV-positive women. A similar significant difference was not proven in plasma. The mean rates of plasmatic levels of MPO-/LF- PMN were 36.21% (SD, 16.87) and 36.93% (SD, 10.54) (P = 0.875) in cases and controls, respectively. All patients were evaluated 1 year later, and only 6 cases became negative.

Conclusions

The presence of MPO-/LF- PMN has been considered as a marker of lower rate of apoptosis of HPV-infected cells. This could explain why HPV-positive women are less capable to deal with a primary infection.
Current Status of Immunotherapy Treatments for Pancreatic Cancer
Authors: Jimenez-Luna Cristina , Prados Jose , Ortiz Raul , Melguizo Consolacion , Torres Carolina , Caba Octavio
Published: August 2016

Pancreatic cancer (PC) is a lethal disease representing the seventh most frequent cause of death from cancer worldwide. Resistance of pancreatic tumors to current treatments leads to disappointing survival rates, and more specific and effective therapies are urgently needed. In recent years, immunotherapy has been proposed as a promising approach to the treatment of PC, and encouraging results have been published by various preclinical and clinical studies. This review provides an overview of the latest developments in the immunotherapeutic treatment of PC and summarizes the most recent and important clinical trials.
A 1-year prospective study of the effect of infliximab on bone metabolism in inflammatory bowel disease patients
Authors: Veerappan Sundaram G. , Healy Martin , Walsh Bernard , O’Morain Colm A. , Daly Jacqueline S. , Ryan Barbara M.
Published: August 2016

Objectives

Infliximab (IFX) treatment has shown potentially beneficial effects on bone metabolism in inflammatory bowel disease (IBD) patients. We aimed to prospectively evaluate the impact of IFX treatment on bone metabolism in antitumour necrosis factor (TNF)-α-naive IBD patients using established bone metabolism markers and an in-vitro osteoblast model.

Materials and methods

A total of 37 anti-TNFα-naive IBD patients and 20 healthy controls were included. All measurements were performed at baseline and repeated in IBD patients following IFX therapy. Bone mineral density was measured by dual-energy X-ray absorptiometry. Parathyroid hormone, vitamin D, osteoprotegerin, soluble receptor activator of nuclear factor B ligand and proinflammatory and anti-inflammatory cytokines were measured. Bone formation was measured using osteocalcin (OC) and procollagen type 1N propeptide, and bone resorption was measured using serum type 1 collage c-telopeptide. The effect of control and IBD patient sera on human osteoblast viability and differentiation was analysed.

Results

OC level was higher in controls than IBD patients (P=0.018). After IFX, OC and procollagen type 1N propeptide increased significantly (P=0.002 and 0.011) and (P<0.001 and P=0.016) at weeks 6 and 30 after treatment, respectively. There was a nonsignificant decrease in serum type 1 collage c-telopeptide. After IFX therapy, proinflammatory cytokines TNF-α, interleukin-6 and interleukin-13 decreased significantly (P=0.016, week 54; P=0.005, week 6 and P=0.025, week 6), respectively. Sera from IBD patients before IFX showed increased osteoblast viability compared with the controls (P=0.003 to P<0.005), but induced reduced osteoblast differentiation. After IFX, viability reduced to control levels, but osteoblast differentiation increased (P=0.041).

Conclusion

IFX treatment induced beneficial effects on bone metabolism. Osteoblast culture results suggest that IBD patients may have increased osteoblast viability, but reduced differentiation, which has implications for bone strength.
Effectiveness of Pay-for-Performance Incentive Designs on Diabetes Care
Authors: Hsieh Hui-Min , Shin Shyi-Jang , Tsai Shu-Ling , Chiu Herng-Chia
Published: August 2016

Background:

Taiwan’s National Health Insurance program implemented a pay-for-performance (P4P) program based on process measures in 2001. In late 2006, the P4P was revised to also include achievement of outcome measures.

Objectives:

This study examined whether a change in P4P incentive design structure affected diabetes outcomes.

Research Design and Method:

We used a longitudinal cohort study design using 2 population-based databases. Newly enrolled P4P patients with diabetes in 2002–2003 (phase 1) and 2007–2008 (phase 2) made up the study cohorts. Propensity score matching was used to match comparable cohorts in each phase. In total, 46,286 matched cohorts in phase 1 and 2 were analyzed. Process measures were defined as the provision of tests of glycosylated hemoglobin A1c (HbA1c), low-density lipoprotein cholesterol, and blood pressure, and outcome measures as changes in those values between baseline and last follow-up within 3 years. Patient-level generalized linear regression models were used and patient characteristics, physician characteristics, and health care facility characteristics were adjusted for.

Results:

Our results indicated that the process measures of HbA1c and low-density lipoprotein cholesterol tests did not differ significantly between the 2 phases. In addition, better improvements were noted in outcome measures for the phase 2 patients (ie, HbA1c level and lipid profiles), whereas nonincentivized intermediate measures (eg, blood pressure) showed no negative unintended consequences.

Conclusions:

Quality of care tended to be better when both process and targeted outcome measures were combined as quality metrics in the P4P program in Taiwan.
Allogeneic stem cell transplantation for sickle cell disease
Authors: Robinson Tara M. , Fuchs Ephraim J.
Published: August 2016

Purpose of review

As the safety and availability of allogeneic hematopoietic stem cell transplantation (HSCT) have improved, this procedure is becoming a viable option for nonmalignant conditions such as sickle cell disease (SCD). There are very few treatment options available for SCD, and even with optimal care SCD patients still suffer from a myriad of comorbidities to multiple organ systems and have a decreased life span. In this review, we will summarize results from trials of HSCT for children or adults with SCD using a variety of graft sources as well as conditioning and graft-versus-host disease prophylaxis regimens, and discuss the unique challenges that arise in these patients.

Recent findings

AlloHSCT for SCD has been performed on small numbers of patients at multiple centers around the world using several different transplant platforms, and early outcomes are encouraging. Overall survival is excellent, although graft failure remains a challenge.

As alloHSCT becomes safer and more widely available, the procedure should be considered for patients with severe disease phenotypes in whom the potential benefits of transplantation outweigh the complications from the disease. AlloHSCT has been shown to reverse or at least halt the progression of end-organ damage secondary to SCD. More research is needed to understand the mechanisms underlying graft failure in SCD recipients, as well as to understand the biopsychosocial underpinnings of persistent pain in the posttransplant period to maximize the benefit from the transplant procedure.
Reading disorders and dyslexia
Authors: Hulme Charles , Snowling Margaret J.
Published: August 2016

Purpose of review

We review current knowledge about the nature of reading development and disorders, distinguishing between the processes involved in learning to decode print, and the processes involved in reading comprehension.

Recent findings

Children with decoding difficulties/dyslexia experience deficits in phoneme awareness, letter-sound knowledge and rapid automatized naming in the preschool years and beyond. These phonological/language difficulties appear to be proximal causes of the problems in learning to decode print in dyslexia. We review data from a prospective study of children at high risk of dyslexia to show that being at family risk of dyslexia is a primary risk factor for poor reading and children with persistent language difficulties at school entry are more likely to develop reading problems. Early oral language difficulties are strong predictors of later difficulties in reading comprehension.

There are two distinct forms of reading disorder in children: dyslexia (a difficulty in learning to translate print into speech) and reading comprehension impairment. Both forms of reading problem appear to be predominantly caused by deficits in underlying oral language skills. Implications for screening and for the delivery of robust interventions for language and reading are discussed.
Use of Daily Interruption of Sedation and Early Mobility in US Hospitals
Authors: Manojlovich Milisa , Ratz David , Miller Melissa A. , Krein Sarah L.
Published: August 2016

Although the Awakening and Breathing Coordination, Delirium assessment, and Early exercise/mobility (ABCDE) bundle may be effective, individual components of ABCDE may not be implemented as intended. We examined the use of daily interruption of sedation (DIS) and early mobility, looking for an association between these bundle elements. Despite the growing use of DIS and early mobility, the two do not seem to be adopted together, with serious implications for the effectiveness of the ABCDE bundle.
Alarm Fatigue
Authors: Turmell Jacob W. , Coke Lola , Catinella Rachel , Hosford Tracy , Majeski Amy
Published: August 2016

The purpose of this article is to describe the impact of an evidence-based alarm management strategy on patient safety. An alarm management program reduced alarms up to 30%. Evaluation of patients on continuous cardiac monitoring showed a 3.5% decrease in census. This alarm management strategy has the potential to save $136 500 and 841 hours of registered nurses' time per year. No patient harm occurred during the 2-year project.
Empathic Communication in Virtual Education for Nursing Students
Authors: Strekalova Yulia A. , Krieger Janice L. , Kleinheksel A.J. , Kotranza Aaron
Published: August 2016

The current study examined the communication strategies used by undergraduate nursing students (N = 343) to express empathy during simulated health history interviews. Interacting with a virtual patient, students encountered up to 9 information disclosures that warranted the expression of empathy but recognized few (33.54%). Sophistication of language to express empathy varied depending on the disclosure topic. These findings suggest that empathy as a learned skill can be incorporated into a variety of nursing contexts.
From Hospital to Ambulatory Care
Authors: Negley Kristin D. , Cordes Mary E. , Evenson Laura K. , Schad Shauna P.
Published: August 2016

Purpose/Objectives:

This article describes how a large healthcare organization expanded the practice of clinical nurse specialists from the hospital to the ambulatory setting.

Background:

Clinical nurse specialist practice traditionally focused on actualizing the 3 spheres of influence (patient, nurse, and organization) in the hospital setting.

Rationale:

Changes in the healthcare system shifting patient care to the ambulatory setting created opportunities for clinical nurse specialists to improve patient outcomes in this setting.

Description:

An innovation framework from the Mayo Clinic Center for Innovation based on inspiration, generation of ideas, experimenting, and diffusion was used to assess and prioritize the work of clinical nurse specialists in the ambulatory setting.

Outcomes:

Clinical nurse specialists became integral members of hospital and ambulatory nursing leadership. In the ambulatory setting, they are partnering to standardize patient care, providing tools for nurses to practice to full scope, and identifying and providing solutions for patient safety issues.

Conclusion:

Aligning clinical nurse specialists in the hospital and ambulatory care settings allows partnership with multidisciplinary teams to ensure that evidence-based practices and standardized care are infused across the continuum of care.

Implications:

Evidence-based practices and standardized care encourage nurses to practice to full scope and focus on improved patient outcomes.
Two Hours of Teamwork Training Improves Teamwork in Simulated Cardiopulmonary Arrest Events
Authors: Mahramus Tara L. , Penoyer Daleen A. , Waterval Eugene M.E. , Sole Mary L. , Bowe Eileen M.
Published: August 2016

Purpose/Aim:

Teamwork during cardiopulmonary arrest events is important for resuscitation. Teamwork improvement programs are usually lengthy. This study assessed the effectiveness of a 2-hour teamwork training program.

Design:

A prospective, pretest/posttest, quasi-experimental design assessed the teamwork training program targeted to resident physicians, nurses, and respiratory therapists.

Methods:

Participants took part in a simulated cardiac arrest. After the simulation, participants and trained observers assessed perceptions of teamwork using the Team Emergency Assessment Measure (TEAM) tool (ratings of 0 [low] to 4 [high]). A debriefing and 45 minutes of teamwork education followed. Participants then took part in a second simulated cardiac arrest scenario. Afterward, participants and observers assessed teamwork.

Results:

Seventy-three team members participated—resident physicians (25%), registered nurses (32%), and respiratory therapists (41%). The physicians had significantly less experience on code teams (P < .001). Baseline teamwork scores were 2.57 to 2.72. Participants’ mean (SD) scores on the TEAM tool for the first and second simulations were 3.2 (0.5) and 3.7 (0.4), respectively (P < .001). Observers’ mean (SD) TEAM scores for the first and second simulations were 3.0 (0.5) and 3.7 (0.3), respectively (P < .001). Program evaluations by participants were positive.

Conclusions:

A 2-hour simulation-based teamwork educational intervention resulted in improved perceptions of teamwork behaviors. Participants reported interactions with other disciplines, teamwork behavior education, and debriefing sessions were beneficial for enhancing the program.
Effects of Lipid Supplements on Tear Biochemistry in Contact Lens Wearers
Authors: Rohit Athira , Willcox Mark D. P. , Stapleton Fiona
Published: August 2016

Purpose

To establish the effect of lipid supplements on tear lipid biochemistry and their influence on lens wear comfort in habitual lens wearers.

Methods

Forty habitual soft contact lens wearers were recruited to a double-masked, randomized crossover trial. An emulsion drop containing phosphatidylglycerol (Systane Balance; Alcon) and a liposomal spray containing phosphatidylcholine (Tears again; BioRevive) along with saline placebos were used three times a day for 14 days with 48 hours of washout between each intervention. The Contact Lens Dry Eye Questionnaire categorized participants into symptomatic and asymptomatic wearers. Ocular comfort was measured using the Ocular Comfort Index. Basal tears (15 μl from each eye) were collected with lenses in situ and assayed for the concentration and activity of phospholipase (sPLA2) and the concentration of a malondialdehyde (MDA). Electrospray ionization mass spectrometry characterized the tear lipidome.

Results

Neither of the lipid supplements improved lens wear comfort compared to baseline. The spray treatment did not affect the concentration of the majority of lipid classes either at day 1 or at day 14. Both the lipid and placebo drops resulted in increased concentration of several lipid classes after day 1 of use, but by day 14, the concentration of most of the lipid classes had returned to baseline levels. With the lipid spray, sPLA2 activity (0.38 ± 0.2 vs. 0.73 ± 0.6 mmol/min/ml, p = 0.03) and lysophosphatidylethanolamine (LPE) (1.3 ± 0.5 vs. 2.7 ± 0.07 pmol/μl, p = 0.02) were higher in the symptomatic group compared to asymptomatic group at day 1 but not at day 14. The lipid drop resulted in increased LPE concentration in symptomatic wearers at day 1 (1.7 ± 0.3 vs. 2.4 ± 0.3 pmol/μl, p = 0.01) and at day 14 (1.7 ± 0.4 vs. 2.5 ± 0.5 pmol/μl, p = 0.04). Ocular comfort was inversely proportional to the level (r = -0.21, p = 0.007) and activity of sPLA2 (r = -0.20, p = 0.01). There was an association between sPLA2 and LPC (r = 0.41, p < 0.001) and LPE (r = 0.40, p = 0.001), and a negative association with (O-acyl)-ω-hydroxy fatty acids (OAHFAs) (r = -0.30, p = 0.03) in tears.

Conclusions

Contact lens wear comfort was associated with sPLA2 concentration and activity in tears. Lipid biochemistry was transiently influenced by exogenous supplements. Although the specific supplement formulations tested did not differ from placebo in this study, the results do suggest a potential role for lysophospholipids and OAHFAs in modulating symptoms during contact lens wear.
Another Form of Focal Choroidal Excavation Based on Multimodality Imaging
Authors: Wang Shiyuan , Zhao Peiquan
Published: August 2016

Purpose

To describe a peculiar choroidal entity using multimodality imaging and to further understand the relationship between focal choroidal excavation and central serous chorioretinopathy.

Case Report

A peculiar entity was detected in both eyes of a 20-year-old male patient who was followed for more than 4 years; one perifoveal focal choroidal excavation and two extrafoveal focal choroidal excavations were noted in each eye. The bilateral perifoveal focal choroidal excavations exhibited progressive development with repeated interconversion between the nonconforming and conforming types. Dilated choroid blood vessels were detected by en face spectral-domain optical coherence tomography (SD-OCT). Although the ellipsoid zone and retinal pigment epithelium layer defect also involved the fovea, a visual acuity of 20/20 was maintained in both eyes, with neither metamorphopsia by Amsler grid nor abnormalities noted by multifocal electroretinogram. However, pigment epithelium detachment finally appeared in the right eye. The microperimetry test revealed reduced threshold sensitivity corresponding to the lesions, and near-infrared autofluorescence revealed increased hyperfluorescence at the latest visit.

Conclusions

Idiopathic focal choroidal excavation may convert to the structure of central serous chorioretinopathy alike, which likely indicates another rare condition of focal choroidal excavation or central serous chorioretinopathy. Wide- and deep-scanning modes should be routinely applied in OCT imaging to detect choroidal disorders.
Genetic Analysis of Mismatch Repair Genes Alterations in Extramammary Paget Disease
Authors: Kang Zhihua , Xu Feng , Zhu Yingfeng , Fu Pan , Zhang Qiao-an , Hu Tingting , Li Xiangyu , Zhang Qunfeng , Wu Zhiyuan , Zhang Xinju , Wang Hua , Xu Jinhua , Fang Zujun , Guan Ming
Published: August 2016

Extramammary Paget disease (EMPD) is a rare cutaneous malignant neoplasm. The familial occurrence of EMPD and the high risk of concomitant secondary tumors in EMPD patients have gained much attention. These findings highlight the importance of genetic alterations in the tumorigenesis of this skin cancer. Genetic tests and functional analysis of mismatch repair (MMR) genes were performed in EMPD. The results showed that 8 of 20 cases with germline MMR genes mutations and 5 of them exhibited microsatellite instability (MSI). Immunohistochemical staining showed that the tumor tissues from 20 patients had the normal expression of MLH1 but 5 cases had the reduced expression of MSH2. There is a nearly significant correlation between MSI and germline mutations. In 172 cases, rates of germline and somatic mutations were 34.3% and 13.4%, respectively. The mutations of MLH1 V384D (15.7%), R217C (4.1%), and I219V (5.2%) were common in this cancer. In addition, the yeast 2-hybrid and immunoprecipitation assays exhibited reduced interaction between MLH1 and PMS2 in MLH1 V384D and R217C but not I219V. Moreover, MLH1 V384D and R217C had impaired MMR activity compared with the wild-type and I219V mutation by an in vitro MMR assay. The germline mutations in MMR genes are involved in the pathogenesis of EMPD and partially explain the genetic abnormalities for this disease.
MDM2 and CDK4 Immunohistochemistry: Should It Be Used in Problematic Differentiated Lipomatous Tumors?
Authors: Clay Michael R. , Martinez Anthony P. , Weiss Sharon W. , Edgar Mark A.
Published: August 2016

Although most cases of atypical lipomatous tumor/well-differentiated liposarcoma (ALT/WDL) can be diagnosed solely on the basis of histologic features, those lacking diagnostic histologic features require ancillary studies for accurate classification. Fluorescent in situ hybridization (FISH) for amplification of MDM2 has been considered the gold standard for diagnosis in these situations. Immunostaining for MDM2 and/or CDK4 has been adopted as a surrogate method because of its high concordance rate with FISH and lower cost. However, studies examining the concordance of the 2 methods have been based preferentially on cases in which the diagnosis could be established histologically. No study has explored the concordance between the 2 methods in histologically ambiguous cases or in cases in which the diagnosis of ALT/WDL is not apparent after a review of all slides. To address this, we performed immunostaining for MDM2 and CDK4 on 183 well-differentiated lipomatous tumors that could not be diagnosed on purely histologic grounds and that were, therefore, subjected to FISH analysis. These included ALT/WDLs (n=56), lipomas (n=96), and lipoma variants (n=31). Staining for MDM2 and CDK4 was noted in 25/56 and 23/56 ALT/WDL, respectively, giving a sensitivity of 45% and 41% and a specificity of 98% and 92%. Staining was noted exclusively in the nuclei of atypical cells and not in the nuclei of adipocytes. Staining for MDM2 and CDK4 occurred in 2/125 and 10/117 benign lipomatous lesions, respectively. False-positive staining was equivalent in intensity to ALT/WDL. We conclude that MDM2 and CDK4 staining is a relatively insensitive method for diagnosing ALT/WDL in cases that are histologically ambiguous, as staining is restricted to neoplastic cells with atypia that are underrepresented in these cases. Therefore, in cases like ours that closely simulate clinical practice, FISH is the more reliable and cost-effective option.
Extracorporeal Membrane Oxygenation for Cardiac Indications in Children
Authors: Thiagarajan Ravi R.
Published: August 2016

Objectives:

The objectives of this review are to discuss the use of extracorporeal membrane oxygenation following surgery for congenital heart disease, myocarditis and as a bridge to cardiac transplantation. In addition, the latest in circuit equipment, the management of anticoagulation and blood transfusions, and short- and long-term outcomes are reviewed.

Data Source:

MEDLINE, PubMed.

Conclusions:

The use of extracorporeal membrane oxygenation to support children with heart disease is increasing. There is wide variability in the use and management of extracorporeal membrane oxygenation between centers. Many areas of extracorporeal membrane oxygenation management warrant additional research to inform clinical practice and improve patient outcomes, including the use of extracorporeal membrane oxygenation in patients undergoing single ventricle palliation, optimizing strategies for monitoring and titrating anticoagulation therapies, and efforts directed at minimizing the risk of neurologic injury.
Ventricular Assist Devices in Pediatric Cardiac Intensive Care
Authors: Byrnes Jonathan , Villa Chet , Lorts Angela
Published: August 2016

Objectives:

The objectives of this review are to discuss the process of patient and mechanical device selection, operative management, and postoperative care with a focus on the management of right ventricular failure, anticoagulation strategies, device-related infections and neurologic sequelae.

Data Sources:

MEDLINE, PubMed.

Conclusion:

The number of patients with advanced heart failure due to either acquired or congenital heart disease continues to increase, necessitating in some mechanical circulatory support and in others cardiac transplantation. With a limited cardiac donor pool, mechanical circulatory support is playing a greater role in the management of this population. The perioperative morbidity associated with mechanical circulatory support has lessened with improved postoperative management strategies.
Hypoplastic Left Heart Syndrome and Other Shunt-Dependent Single Ventricles
Authors: Tabbutt Sarah , Tweddell James S. , Ghanayem Nancy
Published: August 2016

Objectives:

In this review, we discuss the pathophysiology, treatment, and outcomes of patients with the hypoplastic left heart syndrome and other single ventricle variants prior to and following surgery.

Data Source:

MEDLINE and PubMed.

Conclusions:

Patients with shunted single ventricle physiology are at increased risk for acute hemodynamic decompensation owing to the increased myocardial workload, the dynamic balance between systemic and pulmonary circulations, and the potential for shunt obstruction. Understanding of the physiology and anticipatory management are critical to prevent hemodynamic compromise and cardiac arrest.
Outcomes Analysis and Quality Improvement in Children With Congenital and Acquired Cardiovascular Disease
Authors: Jeffries Howard E. , Gaies Michael G.
Published: August 2016

Objectives:

In this review, the current state of outcomes analysis and quality improvement in children with acquired and congenital cardiovascular disease will be discussed, with an emphasis on defining and measuring outcomes and quality in pediatric cardiac critical care medicine and risk stratification systems.

Data Source:

MEDLINE and PubMed

Conclusion:

Measuring quality and outcomes in the pediatric cardiac critical care environment is challenging owing to many inherent obstacles, including a diverse patient mix, difficulty in determining how the care of the ICU team contributes to outcomes, and the lack of an adequate risk-adjustment method for pediatric cardiac critical care patients. Despite these barriers, new solutions are emerging that capitalize on lessons learned from other quality improvement initiatives, providing opportunities to build upon previous successes.
Cardiopulmonary Resuscitation in Congenital and Acquired Heart Disease
Authors: Tabbutt Sarah , Marino Bradley S.
Published: August 2016

Objectives:

The Pediatric Advanced Life Support recommendations were developed for otherwise healthy infants and children with normal cardiac anatomy. Patients with acquired and congenital heart disease require specific considerations that may differ from the Pediatric Advanced Life Support recommendations. Our aim is to present prearrest, arrest, and postarrest considerations that are unique to children with congenital and acquired heart disease.

Data Source:

MEDLINE and PubMed.

Conclusion:

A clear understanding of the underlying anatomy and physiology of congenital and acquired heart disease is imperative in order to employ the appropriate modifications to the current Pediatric Advanced Life Support recommendations and to optimize outcomes.
Neurodevelopmental Outcomes in Children With Congenital Heart Disease—What Can We Impact?
Authors: Wernovsky Gil , Licht Daniel J.
Published: August 2016

Objectives:

The objectives of this review are to discuss the scope of neurologic injuries in newborns with congenital heart disease, the mechanisms of injury, including prenatal, pre-, intra-, and postoperative factors, neurodevelopmental outcomes, and therapeutic strategies for the timely intervention and prevention of neurologic injury.

Data Source:

MEDLINE and PubMed.

Conclusion:

At the current time, important research is underway to 1) better understand the developing brain in the fetus with complex congenital heart disease, 2) to identify modifiable risk factors in the operating room and ICU to maximize long-term neurodevelopmental outcomes, and 3) develop strategies to improve family psychosocial health, childhood development, and health-related quality of life following hospital discharge. Crucial in this effort is the identification of an early postoperative surrogate variable with good predictive validity for long-term outcomes. If an appropriate surrogate variable for long-term outcomes can be identified, and measured relatively early after surgical intervention for complex congenital heart disease, reliable clinical trials can be undertaken to improve upon current outcomes.
Transposition of the Great Arteries and Common Variants
Authors: Wernovsky Gil
Published: August 2016

Objectives:

The objectives of this review are to discuss the physiology, perioperative management, surgical correction, and outcomes of infants with transposition of the great arteries and common variants undergoing the arterial switch operation.

Data Source:

MEDLINE and PubMed.

Conclusion:

The widespread adoption of the arterial switch operation for transposition of great arteries has been one of the more gratifying advances in pediatric cardiovascular care, and represents the simultaneous improvements in diagnostics, surgical and bypass techniques, anesthesia in the neonate, improvements in intensive care technology, nursing strategies, and system-wide care delivery. Many of the strategies adopted for the neonate with transposition of the great arteries have been translated to neonatal care for other congenital heart lesions. Continued work is necessary to investigate the effects of perioperative care on long-term neurodevelopmental outcomes, as well as collaboration between centers to spread “best practices” for outcome, cost, and morbidity reduction.
Tetralogy of Fallot and Its Variants
Authors: Karl Tom R. , Stocker Christian
Published: August 2016

Objectives:

The objectives of this review are to discuss the anatomy, pathophysiology, surgical repair, and perioperative management strategies for tetralogy of Fallot and its variants.

Data Source:

MEDLINE and PubMed.

Conclusions:

Significant refinements have been made in the repair strategy for tetralogy of Fallot, based on improved understanding of postrepair physiology. Important considerations for timing and technique of surgery and perioperative management have been presented, and continued evolution is expected. Expanded use of the pulmonary valve reconstruction technique outlined herein, whatever the age of repair, may improve long-term outcome.
Pharmacodynamics and Pharmacokinetics of Morphine After Cardiac Surgery in Children With and Without Down Syndrome
Authors: Valkenburg Abraham J. , Calvier Elisa A. M. , van Dijk Monique , Krekels Elke H. J. , O’Hare Brendan P. , Casey William F. , Mathôt Ron A. A. , Knibbe Catherijne A. J. , Tibboel Dick , Breatnach Cormac V.
Published: August 2016

Objective:

To compare the pharmacodynamics and pharmacokinetics of IV morphine after cardiac surgery in two groups of children—those with and without Down syndrome.

Design:

Prospective, single-center observational trial.

Setting:

PICU in a university-affiliated pediatric teaching hospital.

Patients:

Twenty-one children with Down syndrome and 17 without, 3–36 months old, scheduled for cardiac surgery with cardiopulmonary bypass.

Interventions:

A loading dose of morphine (100 μg/kg) was administered after coming off bypass; thereafter, morphine infusion was commenced at 40 μg/kg/hr. During intensive care, nurses regularly assessed pain and discomfort with validated observational instruments (COMFORT-Behavior scale and Numeric Rating Scale—for pain). These scores guided analgesic and sedative treatment. Plasma samples were obtained for pharmacokinetic analysis.

Measurements and Main Results:

Median COMFORT-Behavior and Numeric Rating Scale scores were not statistically significantly different between the two groups. The median morphine infusion rate during the first 24 hours after surgery was 31.3 μg/kg/hr (interquartile range, 23.4–36.4) in the Down syndrome group versus 31.7 μg/kg/hr (interquartile range, 25.1–36.1) in the control group (p = 1.00). Population pharmacokinetic analysis revealed no statistically significant differences in any of the pharmacokinetic variables of morphine between the children with and without Down syndrome.

Conclusions:

This prospective trial showed that there are no differences in pharmacokinetics or pharmacodynamics between children with and without Down syndrome if pain and distress management is titrated to effect based on outcomes of validated assessment instruments. We have no evidence to adjust morphine dosing after cardiac surgery in children with Down syndrome.
Bedside Ultrasound for Tracheal Tube Verification in Pediatric Emergency Department and ICU Patients: A Systematic Review*
Authors: Lin Margaret J. , Gurley Kiersten , Hoffmann Beatrice
Published: August 2016

Objectives:

Improper placement of the tracheal tube during intubation can lead to dangerous complications, and bedside ultrasound has been proposed as a method of quickly and accurately identifying tube placement. Recent studies in adults have found it to be accurate, but its applicability in pediatric patients is unclear. This systematic review aims to describe the current available data on the accuracy and feasibility of bedside ultrasound for tracheal tube placement in children.

Data Sources:

OVID MEDLINE and EMBASE.

Study Selection:

Available articles on bedside neck or lung/diaphragm ultrasound for confirmation of tracheal tube placement in children through December 2015.

Data Extraction:

Two reviewers screened studies for eligibility and abstracted data independently. The quality of selected articles was evaluated using Quality Assessment of Diagnostic Accuracy Studies statement.

Data Synthesis:

A total of nine articles were identified: one study using neck ultrasound, two using lung/diaphragmatic ultrasound, one with both, and five studies looking at direct visualization of the tracheal tube tip met our inclusion criteria. There were 81 intubations evaluated using neck ultrasound, 214 intubations evaluated using diaphragmatic or pleural sliding, and 165 intubations evaluated for feasibility of bedside ultrasound in visualizing tracheal tube tip placement. The sensitivities of transtracheal ultrasound for intubation were overall high ranging from 0.92 to 1.00 with excellent specificities at 1.00. For lung ultrasound, the sensitivities for tracheal placement versus esophageal placement were high at 1.00, but only one study reported esophageal intubations and had a specificity of 1.00. When assessing the appropriate tracheal tube depth for tracheal intubations using lung ultrasound, the sensitivities ranged from 0.91 to 1.00 with specificities ranging from 0.5 to 1.0. Regarding feasibility of direct visualization of tracheal tube tip, visualization ranged from 83% to 100%.

Conclusion:

Bedside ultrasound has been described to be feasible in determining tracheal tube placement in several small single center studies and could be a useful adjunct tool in confirming tracheal tube placement in critically ill pediatric patients, but further studies are needed to assess its accuracy in a randomized multicenter setting.
Deep Vein Thrombus Occurring Immediately After Blunt Abdominal Trauma
Authors: Oshima Kiyohiro , Hagiwara Shuichi , Murata Masato , Aoki Makoto , Kaneko Minoru , Niwamae Nogiku , Kurabayashi Masahiko
Published: August 2016

Case

A 13-year-old adolescent girl with blunt abdominal injury was transferred to our hospital. Enhanced computed tomography (CT) showed not only retroperitoneal hematoma around the inferior vena cava and left common iliac vein but also thrombus extending from the left common iliac vein to the femoral vein.

Outcome

Enhanced CT performed on the second day revealed no increase in retroperitoneal hematoma and a new small thrombus in the popliteal vein. Anticoagulant therapy was therefore started with administration of unfractionated heparin. Administration of warfarin was started on the 12th day and heparin administration was stopped on the 14th day. The patient was discharged on the 19th day with continuation of warfarin administration. Enhanced CT performed 10 months after injury showed no thrombus, and the administration of warfarin was then stopped.

Conclusions

She was successfully treated with the appropriate start time and control of anticoagulation therapy based on careful evaluation of her general condition.
Essentials of Pediatric Emergency Medicine Fellowship
Authors: Wolff Margaret , Carney Michele , Eldridge Charles , Zaveri Pavan , Kou Maybelle
Published: August 2016

This article is the third in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article focuses on the skills beyond clinical training required of pediatric emergency medicine physicians including teaching, leadership, teamwork, and communication.
PEMNetwork
Authors: Lumba-Brown Angela , Tat Sonny , Auerbach Marc A. , Kessler David O. , Alletag Michelle , Grover Purva , Schnadower David , Macias Charles G. , Chang Todd P.
Published: August 2016

In January 2005, PEMFellows.com was created to unify fellows in pediatric emergency medicine. Since then, the website has expanded, contracted, and focused to adapt to the interests of the pediatric emergency medicine practitioner during the internet boom. This review details the innovation of the PEMNetwork, from the inception of the initial website and its evolution into a needs-based, user-directed educational hub. Barriers and enablers to success are detailed with unique examples from descriptive analysis and metrics of PEMNetwork web traffic as well as examples from other online medical communities and digital education websites.
Behavioral Adjustment of School-Age Children with and without Single-Suture Craniosynostosis
Authors: Speltz Matthew L. , Collett Brent R. , Wallace Erin R. , Kapp-Simon Kathleen
Published: August 2016

Background:

Previous research has observed higher than average rates of behavior problems in school-age children with single-suture craniosynostosis. However, most studies used a single informant (mothers) and did not include comparison groups to control for sociodemographic factors.

Methods:

The authors gave standardized behavior checklists to the mothers, fathers, and teachers of 179 elementary school children with single-suture craniosynostosis and 183 controls. We used linear regression to compare children with and without single-suture craniosynostosis on continuous measures of adjustment, and logistic regression to compare the proportions of children who scored above a well-established clinical threshold based on the report of one or more informants. All analyses were adjusted for demographic confounds (age, sex, socioeconomic status, maternal intelligence quotient).

Results:

Cases received higher average behavior problem scores than controls from all informants. However, differences were small in magnitude (0.01 to 0.2 SD; p = 0.12 to p = 0.96). Thirty-three percent of children with single-suture craniosynostosis were rated above a clinical threshold by one or more informants, compared with 21 percent of controls (adjusted odds ratio, 1.67; p = 0.04). Among cases, children with metopic synostosis had the highest level of observed behavior problems (41 percent greater than threshold); those with sagittal synostosis had the lowest level (29 percent).

Conclusions:

The authors observed little difference in average ratings of behavior problems between children with and without single-suture craniosynostosis. However, children with single-suture craniosynostosis were more likely to score above a clinical threshold than unaffected controls. No specific areas of maladjustment were associated with case status or location of suture fusion.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, II.
Improved Short-Term Outcomes following Orthognathic Surgery Are Associated with High-Volume Centers
Authors: Berlin Nicholas L. , Tuggle Charles T. , Steinbacher Derek M.
Published: August 2016

Background:

Previous studies assessing outcomes following orthognathic surgery rely primarily on single-center/surgeon experience. In addition to issues of generalizability, these studies are limited in evaluating the effect of operative volume on patient outcomes.

Methods:

Orthognathic procedures were identified in the 1999 to 2011 Healthcare Cost and Utilization Project Nationwide Inpatient Sample. Outcomes included occurrence of any in-hospital complication, extended length of stay (>2 days), and increased costs (>$10,784). High-volume hospitals were defined as the 90th percentile of case volume or higher (>31 cases/year). Univariate and multivariate analyses were conducted to identify independent predictors of outcomes. Trend analyses were performed to assess changes in the annual rate of patients treated at high-volume hospitals over the study period.

Results:

Among 101,692 orthognathic surgery patients, 19.6 percent underwent concurrent ancillary procedures (i.e., genioplasty, rhinoplasty, or septoplasty), and 37.6 percent underwent double-jaw surgery. Fifty-three percent were treated at high-volume hospitals. High-volume hospitals more often performed ancillary procedures (21.4 percent versus 17.4 percent; p < 0.001) and double-jaw surgery (41.3 percent versus 33.4 percent; p < 0.001). After adjustments for clinical and hospital characteristics, patients treated at high-volume hospitals were less likely to experience any complication (OR, 0.75; 95 percent CI, 0.70 to 0.81; p < 0.001) and extended length of stay (OR, 0.71; 95 percent CI, 0.68 to 0.75; p < 0.001). There was a 2 percent annual increase in the rate of patients treated at high-volume hospitals over the study period (incidence rate ratio, 1.02; 95 percent CI, 1.01 to 1.03; p < 0.001).

Conclusions:

The majority of orthognathic cases nationwide are performed at a small number of high-volume hospitals. These hospitals discharge patients earlier, perform more complex procedures, and have fewer complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, III.
A Treatment Protocol for Velopharyngeal Insufficiency and the Outcome
Authors: Yamaguchi Kazuaki , Lonic Daniel , Lee Che-Hsiung , Wang Shu-Hui , Yun Claudia , Lo Lun-Jou
Published: August 2016

Background:

A simple algorithm is applied to treat velopharyngeal insufficiency. The purpose of this study was to assess its success rate and complications.

Methods:

The diagnosis includes speech perceptual assessment and nasopharyngoscopy, focusing on velopharyngeal closure ratio. The treatment is composed of a double-opposing Z-plasty for marginal velopharyngeal insufficiency or a pharyngeal flap for moderate to severe velopharyngeal insufficiency. A retrospective chart review was conducted for 84 consecutive nonsyndromic postpalatoplasty patients undergoing velopharyngeal insufficiency surgery from August of 2007 to December of 2014. The demographic, perioperative, and follow-up data were collected. Statistical analyses were performed.

Results:

Mean age at velopharyngeal insufficiency surgery was 7.0 years. The overall improvement rate for patients was 86.9 percent. Nine patients in the double-opposing Z-plasty group and two patients in the pharyngeal flap group were refractory to velopharyngeal insufficiency surgery. The improvement rates for each surgical group were 80.4 percent for the double-opposing Z-plasty group and 94.7 percent for the pharyngeal flap group. There were no significant differences in postoperative velopharyngeal function between the coronal and noncoronal groups. Airway-associated complications were observed in nine patients (10.7 percent). The complications in the double-opposing Z-plasty group were observed in two patients (4.3 percent), and none of the patients presented obstructive sleep apnea. Seven patients (18.4 percent) in the pharyngeal flap group showed postoperative snoring, and one (2.6 percent) of them presented with obstructive sleep apnea.

Conclusion:

The authors’ algorithm is a simple patient- and surgeon-friendly strategy to obtain satisfactory improvement of velopharyngeal function for velopharyngeal insufficiency patients, with a low risk of airway complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Performance on a Surgical In-Training Examination Varies by Training Year and Pathway
Authors: Silvestre Jason , Levin L. Scott , Serletti Joseph M. , Chang Benjamin
Published: August 2016

Background:

Few studies in surgery have addressed medical knowledge competency training as defined by the Accreditation Council for Graduate Medical Education. As in-training examinations are ubiquitous educational tools for surgical residents in the United States, insights into examination performance may help fill this void. The purpose of this study was to determine the relationship between In-Service Examination performance and training characteristics in plastic surgery.

Methods:

This retrospective cohort study reviewed performance data for the Plastic Surgery In-Service Training Examination for the years 2012 to 2015. Comparisons were made both within and between training pathways by means of Kruskal-Wallis and Mann-Whitney U tests.

Results:

Data were available for 1367 independent (37.9 percent) and 2240 integrated residents (62.1 percent). Among integrated residents, performance increased with additional years of training (p < 0.001), but no difference existed between postgraduate year–5 and postgraduate year–6 residents (p > 0.05). Similarly, independent resident examination performance increased by year of training (p < 0.001), with no difference between postgraduate year–2 and postgraduate year–3 residents (p > 0.05). At each level of training (postgraduate years 4 to 6), integrated residents outperformed their independent resident colleagues (postgraduate years 1 to 3) (p < 0.001).

Conclusions:

Performance on the Plastic Surgery In-Service Training Examination increases during residency, with integrated residents outperforming independent residents. These findings may have implications for medical knowledge competency training as defined by the Accreditation Council for Graduate Medical Education.