bluuebunny/crossref_metadata_2025 huggingface dataset:
Cognitive Characteristics Associated With Device Adoption, Skill Retention, and Early Withdrawal From a Study of an Advanced Upper Limb Prosthesis
Authors: Lafo Jacob , Correia Stephen , Borgia Matthew , Acluche Frantzy , Resnik Linda
Published: May 2019

Objective

The aim of the study was to examine the role of cognition in device adoption, skill retention, and withdrawal from a study of an advanced upper limb prosthesis (the DEKA Arm).

Design

T tests and Wilcoxon rank-sum tests were used to compare test performance among study completers and noncompleters. Multivariable regression analyses were used to predict study withdrawal and DEKA Arm skill retention.

Results

Compared with self-withdrawn participants, those who were withdrawn by study staff performed significantly worse on tests indexing processing speed, set-shifting, and memory encoding. The DEKA Arm configuration (transradial, transhumeral, shoulder—based on amputation level) was a stronger predictor of skill retention than neuropsychological test performance.

Conclusions

Frontally-mediated cognitive skills may influence the successful adoption of the DEKA Arm. The DEKA Arm configurations at higher amputation levels (e.g., shoulder) appear to be more strongly associated with prosthetic skill retention than users’ cognitive status. This may be due to noncognitive user demands (e.g., device weight) statistically masking the discrete influence of cognitive status on skill retention at higher configuration levels. Neuropsychological assessment warrants consideration as a valuable tool in rehabilitation settings to assist in functional device candidacy evaluations.
Management of T-Cell Engaging Immunotherapy Complications
Authors: Varadarajan Indumathy , Lee Daniel W.
Published: May 2019

The advent of T-cell–mediated immunotherapy has led to a new era in the treatment of relapsed, refractory B-cell lymphomas and leukemias. Chimeric antigen receptor T-cell and engineered T-cell receptor therapies have demonstrated impressive efficacy in treating refractory disease. The principal toxicities of these therapies include cytokine release syndrome and immune effector cell–associated neurotoxicity syndrome (ICANS), but others exist as well. Cytokine release syndrome and ICANS are typically acute events occurring within 30 days of therapy, but other on-target/off-tissue toxicities may persist for years. There is no currently accepted single approach to managing all aspects of cytokine release syndrome and ICANS. However, there are clear trends in many areas and a clear need for further consensus surrounding others. This article will discuss T-cell–mediated immunotherapy complications and their suggested management. It is not intended to be comprehensive or applicable to every patient, so practitioners should exercise sound clinical judgment. Rather, this may serve as a starting point for further management discussions in the community.
Urethral Catheterization Is Not Necessary During Nononcological Laparoscopic Pelvic Surgery
Authors: Nevins Edward J. , Nevins Elizabeth G. , Moori Parisa L. , Strong Catherine , Al-Zubaidi Samim , Wayman John , Karat Dayalan
Published: May 2019

Objectives

Expert opinion remains divided regarding whether routine urethral catheterization is required before nononcological laparoscopic pelvic surgery. Catheterization is thought to reduce the incidence of bladder injury when inserting a suprapubic laparoscopic port and prevent obstruction of the view of the pelvis because of bladder filling. However, catheterization comes with a risk of nosocomial infection and harbors financial cost. Moreover, indwelling catheters inhibit early mobilization and increase postoperative discomfort.

Methods

A systematic review was undertaken using the Meta-Analysis of Observational Studies guidelines to identify eligible publications. End points included bladder injury, positive postoperative urinary microbiology, and postoperative urinary symptoms.

Results

The reported incidence rates of laparoscopic bladder injury in included publications ranges from 0% to 1.3%. Importantly, bladder injury has occurred during both catheterized and noncatheterized operations. Our meta-analysis also shows that patients who are catheterized have a 2.33 times relative risk of developing postoperative positive microbiology in their urine (P = 0.01) and a 2.41 times relative risk of postoperative urinary symptoms (P = 0.005), when compared with noncatheterized patients.

Conclusions

This meta-analysis indicates that omitting a catheter in emergency and elective nononcological laparoscopic pelvic surgery may be a safe option. Catheterization does not remove the risk of bladder injury but results in more urinary tract infections and symptoms. It may be reasonable to ask a patient to void immediately before anesthesia, after which an on-table bladder scan should be performed. If there is minimal residual volume, a urinary catheter may not be necessary, unless operative time is estimated to be greater than 90 minutes.
Sharing Lessons Learned to Prevent Adverse Events in Anesthesiology Nationwide
Authors: Soncrant Christina , Neily Julia , Sum-Ping Sam John T. , Wallace Arthur W. , Mariano Edward R. , Leissner Kay B. , Mills Peter D. , Mazzia Lisa , Paull Douglas E.
Published: May 2019

Objectives

The Veterans Health Administration (VHA) lessons learned process for Anesthesia adverse events was developed to alert the field to the occurrences and prevention of actual adverse events. This article details this quality improvement project and perceived impact.

Methods

As part of ongoing quality improvement, root cause analysis related to anesthesiology care are routinely reported to the VHA National Center for Patient Safety. Since May 2012, the National Anesthesia Service subject matter experts, in collaboration with National Center for Patient Safety, review actual adverse events in anesthesiology and detailed lessons learned are developed. A survey of anesthesiology chiefs to determine perceived usefulness and accessibility of the project was conducted in April 2018.

Results

The distributed survey yielded a response rate of 69% (84/122). Most of those who have seen the lessons learned (85%, 71/84) found them valuable. Ninety percent of those aware of the lessons learned (64/71) shared them with staff and 75% (53/71) reported a changed or reinforced patient safety behavior in their facility. The lessons learned provided 72% (51/71) of chiefs with new knowledge about patient safety and 75% (53/71) gained new knowledge for preventing adverse events.

Conclusions

This nationwide VHA anesthesiology lessons learned project illustrates the tenets of a learning organization. implementing team and systems-based safeguards to mitigate risk of harm from inevitable human error. Sharing lessons learned provides opportunities for clinician peer-to-peer learning, communication, and proactive approaches to prevent future similar errors.
Comparison of Functional Deficit Zone Defined by FDG PET to the Epileptogenic Zones Described in Stereo-Electroencephalograph in Drug-Resistant Epileptic Patients Treated by Surgery
Authors: Montaz-Rosset Marie-Soline , Scholly Julia , Voulleminot Paul , Severac François , Hirsch Edouard , Valenti-Hirsch Maria Paola , Namer Izzie Jacques
Published: May 2019

Introduction

The purpose of presurgical assessment is to delimit the epileptogenic zone and the functional deficit zone with a brain MRI, an electroencephalograph or even a stereo-electroencephalograph (SEEG), neuropsychological evaluation, and a cerebral FDG PET. Several studies concur that the hypometabolism of FDG PET seems to be consistent with epileptogenic zones. We compared the functional deficit zone defined by FDG PET with the results of the SEEG, for each cluster electrode contact (CEC) located in the gray matter.

Methods

The electrode diagram of the 15 patients (486 CECs) operated on for drug-resistant epilepsy was merged with MRI and FDG PET. The metabolisms of FDG PET and SEEG were compared using a logistic regression test.

Results

The presence of hypometabolism resulted in a significantly higher risk of being in the seizure onset zone and the irritative zone, particularly when it was intense. Of the deeply hypometabolic CECs, 47% were in the seizure onset zone and 76% in the irritative zone. Normal metabolism resulted in a significantly higher probability of being in the healthy zone.

Conclusions

This study demonstrated an association between the presence of normal metabolism and the location of CECs in the healthy zone, and between the presence of pathological metabolism and the location of CECs in the seizure onset zone and the irritative zone, with metabolism abnormalities progressively more present and more intense near the seizure onset zone.
FDG-Avid Hürthle Cell Thyroid Adenoma
Authors: Yu Run , Auerbach Martin S.
Published: May 2019

Incidental thyroid uptake is found in approximately 2.5% of patients who undergo FDG PET for nonthyroid malignancy; approximately a third of the FDG PET thyroid incidentalomas are malignant, including primary thyroid malignancies and metastasis. We describe a 50-year-old woman, a potential heart transplant candidate with history of breast cancer, who was found by FDG PET/CT to harbor a large thyroid mass with intense FDG uptake. Biopsy and molecular study demonstrated that the thyroid mass was a Hürthle cell adenoma. This case highlights that Hürthle cell neoplasm should be included in the differential diagnosis of a thyroid nodule with very high FDG avidity.
Utility of 18F-FDG PET/CT in Infantile Myofibromatosis
Authors: Tang Elizabeth R. , Khalatbari Hedieh , Parisi Marguerite T.
Published: May 2019

Infantile myofibromatosis, a rare, nonmalignant disease seen almost exclusively in the pediatric population, can involve skin, muscle, soft tissues, bone, or viscera in either solitary or multicentric pattern. Although nonmalignant, visceral involvement in infantile myofibromatosis is a key prognostic indicator, which is associated with mortality in 75% of patients. Those with pulmonary involvement have a particularly poor outcome. This case illustrates the diagnostic utility of 18F-FDG PET/CT in defining disease extent in this unusual entity and compares it to other commonly used imaging modalities.
Keystone Flaps
Authors: Riccio Charles Alexander , Chang Jeremy , Henderson Joshua Thomas , Hassouba Mahmoud , Ashfaq Faisal , Kostopoulos Epameinondas , Konofaos Petros
Published: May 2019

The keystone perforator flap (KPF) was first introduced in 2003 by Behan et al for use in reconstruction after skin cancer excision. Since its initial description, KPF use has been expanded to complex defects of various etiologies and disorders throughout the body. At its most basic, the KPF is a perforator-type flap designed with a 1:1 flap-to-defect width ratio. Keystone perforator flaps are specifically raised on pedicles arising from musculocutaneous or fasciocutaneous perforator vessels. Major advantages of the KPF derive from the maintenance of perforator vascular territories, perforosomes, permitting increased flap viability. In turn, this allows for more aggressive undermining in sites away from perforators when greater skin mobilization is necessary. Furthermore, the KPF is relatively easy to perform leading to shorter operative times and no postoperative monitoring period. There are basically 4 different types of keystone flaps in order of increasing undermining and disturbance of underlying fascia. These different classifications of KPFs may be used in different anatomical locations over the entire body based on skin laxity and defect size/depth. Numerous advancements and modifications have been documented adapting the KPF to specific conditions, including myelomeningoceles, and scrotal and lower eyelid defects. The purpose of this article is to provide an organized review of the KPF with emphasis on different classifications, applications, and limitations as well as an overview of the surgical technique. We have additionally included a discussion on KPF physiology and review of current literature.
Soft Tissue Reconstruction and Facial Reanimation With Bilateral Latissimus Dorsi Flaps After Extensive Resection of Head and Neck Arteriovenous Malformation
Authors: Wong Manzhi , Ozaki Mine , Kurita Masakazu , Ihara Aki , Iwashina Yuki , Takushima Akihiko
Published: May 2019

We report a rare case of a 37-year-old man who presented with a huge arteriovenous malformation in the head and neck region. After resection, the 30 × 25 cm defect was reconstructed with a preexpanded musculocutaneous latissimus dorsi flap. The facial nerve had to be sacrificed during the resection, and smile reanimation was restored in a second operation with the contralateral latissimus muscle flap. A 15-cm length of thoracodorsal nerve was dissected and was anastomosed to the contralateral zygomatic branch in a single stage. He recovered well without any significant complications. At 6 years follow-up, there was no further growth of the arteriovenous malformation, and he had a spontaneous smile.
A Comparison of Outcomes and Resource Utilization Between Plastic Surgeons and General Surgeons in Implant-Based Breast Reconstruction
Authors: Chattha Anmol , Muste Justin , Chen Austin D. , Patel Ashit
Published: May 2019

Background

Because of lack of patient education on the importance of surgeon certification and barriers to access a plastic surgeon (PS), non–PSs are becoming more involved in providing implant-based breast reconstruction procedures. We aim to clarify differences in outcomes and resource utilization by surgical specialty for implant-based breast reconstruction.

Methods

Data were obtained from the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2014. Patients undergoing immediate implant-based reconstruction or immediate/delayed tissue expander–based reconstruction were identified (Current Procedural Terminology codes 19340 and 19357, respectively). Outcomes studied were major and wound-based 30-day complications, operation time, unplanned readmission or reoperation, and length of hospital stay.

Results

We identified 9264 patients who underwent prosthesis or tissue expander–based breast reconstruction, 8362 (90.3%) by PSs and 902 (9.7%) by general surgeons (GSs). There were significant differences in major complications between specialty (1.2% PS vs 2.8% GS; P < 0.001). There were no significant differences in unplanned reoperation (5.3% PS vs 4.9% GS; P = 0.592), unplanned readmissions (4.3% PS vs 3.8% GS; P = 0.555), wound dehiscence (0.7% PS vs 0.6% GS; P = 0.602), or wound-based infection rates (2.9% PS vs 2.8% GS; P = 0.866). As it pertains to resource utilization, the GS patients had a significantly longer length of stay (1.02 ± 4.41 days PS vs 1.62 ± 4.07 days GS; P < 0.001) and operative time (164.3 ± 97.6 minutes PS vs 185.4 ± 126.5 minutes; P = 0.001) than PS patients.

Conclusions

This current assessment demonstrates that patients who undergo breast implant reconstruction by a GS have significantly more major complications. It is beneficial for the health care system for PSs to be the primary providers of breast reconstruction services. Measures should be taken to ensure that PSs are available and encouraged to provide this service.
Treating Intimal Injury to the Graft Hepatic Artery by Intraoperative Fluorescence Vascular Stenting
Authors: Hsieh Chia-En , Chen Yao-Lin , Lin Kuo-Hua , Chou Chen-Te , Hsu Ya-Lan , Chen Chia-Bang , Lin Ping-Yi , Lin Shin-Lung
Published: May 2019

Background

Early hepatic artery (HA) thrombosis and primary graft failure contribute greatly to the mortality of patients after liver transplantation. Herein, we present the treatment of intimal injury of HA by intraoperative fluorescence vascular stenting.

Methods

A sample of 471 patients receiving liver transplantations underwent arterial anastomosis. Six patients (1.3%) were found to have early HA thrombosis. Two patients had thrombi that were impenetrable with a guide wire. Intimal injury on both the graft and the donor sides of the HA was found after thrombectomy. We performed anastomosis between unhealthy graft vessels and healthy recipient vessels. Intraoperative angiography was done immediately because of the guide wire being easier to insert through a fresh thrombus, and a long endovascular stent was inserted to bypass the injured vessels.

Results

The proper HA was reconstructed under microscopy. Three days after reconstruction, an angioplasty showed no dissection, stenosis, or pseudoaneurysm of the HA. Unexpectedly, these 2 patients survived well with acceptable graft functionality, one based on a 32-month follow-up and the other based on a 2-month follow-up.

Conclusion

Anastomosis of the intimally injured graft artery followed by immediate endovascular angioplasty with stenting to bypass the injury zone is an efficacious and tolerable procedure.
Adding Depth to Cephalometric Analysis: Comparing Two- and Three-Dimensional Angular Cephalometric Measurements
Authors: Jodeh Diana S. , Kuykendall Lauren V. , Ford Jonathan M. , Ruso Stephen , Decker Summer J. , Rottgers S. Alex
Published: May 2019

Introduction:

Lateral cephalometric radiographs (LCR) have been the standard tool used for cephalometric analysis in craniofacial surgery. Over the past decade, a three-dimensional (3D) revolution in cephalometric analysis and surgical planning has been underway. To date, research has not validated whether cephalometric measurements taken from two-dimensional (2D) and 3D data sources are equivalent and interchangeable. The authors sought to compare angular cephalometric measurements taken with 2D and 3D modalities.

Methods:

Sixty-two head CT scans (36 females, 26 males) with an average age of 63 ± 20 years were studied. Twelve cephalometric angular measurements were taken from 3D reconstructed skulls using the software package Mimics 19.0 (Materialize; Leuven, Belgium). These same facial angles were measured from 2D lateral cephalograms reconstructed from the original CT scans using Dolphin 11.9. Measurements taken with both techniques were compared for agreement using a paired t test. Intra-class correlation coefficient assessment was used to determine inter-rater reliability. Statistical significance was set at P < 0.05.

Results:

Five of the 12 angular measurements (SNA, SNB, MP-FH, U1-SN, and U1-L1) demonstrated statistically significant differences (P < 0.05) between the 2D and 3D analyses. All of these differences were less than the standard deviations for the respective measure.

Conclusion:

The differences between angular cephalometric values obtained from 2D LCRs and 3D CT reconstructions are small. This supports the practices of using 2D and 3D cephalometric data interchangeably in most applications. Clinicians must be selective in which measures they employ to maximize accuracy and care must be taken when measuring dental inclination with lateral cephalograms.
Transnasal Endoscopic Retrieval of a Metallic Intraorbital Intraconal Foreign Body Facilitated by an Intraoperative Magnetic Stick
Authors: Zhao Yu , Liu Jianfeng , Wang Zhijun , Yan Yujie , Han Jun , Yang Dazhang
Published: May 2019

Here, we report the case of an intraorbital intraconal foreign body that was successfully retrieved by a transnasal endoscopic approach facilitated intraoperatively by a magnetic stick. A 36-year-old man was admitted to our unit with a left-sided intraorbital intraconal metallic foreign body. Following 2 failed attempts via a transconjunctiva approach, we finally recovered the foreign body using transnasal endoscopic surgery. During this procedure, a magnetic stick was used to help us locate and successfully remove the foreign body, grapeshot measuring approximately 0.5 cm in diameter. Visual acuity in the injured eye increased from 0.01 preoperatively to 0.04 6 days after surgical intervention. There were no complications. We therefore propose that in selected patients, the endoscopic transnasal approach is an effective, safe and minimally invasive approach for the removal of intraorbital intraconal foreign bodies. The intraoperative use of a magnet can facilitate the successful location and removal of magnetic metallic foreign bodies.
Coexistence of Antrochoanal Polyp and Fibrous Dysplasia in the Maxilla
Authors: Lee Dong Hoon , Yoon Tae Mi , Lee Joon Kyoo , Lim Sang Chul
Published: May 2019

The authors report an unusual case of coexistence of antrochoanal polyp (ACP) and fibrous dysplasia (FD) in the maxilla. To the best of our knowledge, this condition has never been reported in the literature. The complete removal of the ACP through endoscopic sinus surgery was attained and FD was ultimately diagnosed by histopathological examination. It is hypothesized that chronic inflammation or irritation due to FD has an effect on the occurrence of ACP.
Early Positive Fluid Balance is Associated with Mortality in Patients Treated with Veno-Arterial Extra Corporeal Membrane Oxygenation For Cardiogenic Shock: a Retrospective Cohort Study
Authors: Besnier Emmanuel , Boubèche Samia , Clavier Thomas , Popoff Benjamin , Dureuil Bertrand , Doguet Fabien , Gay Arnaud , Veber Benoit , Tamion Fabienne , Compère Vincent
Published: May 2019

Purpose:

Veno-arterial Extracoporeal Membrane Oxygenation (VA-ECMO) provides circulatory assistance for patients in cardiogenic shock. Large quantities of fluids are often required, especially during the early stages, but can result in a potentially harmful fluid-overload. The objective was to determine the association of early fluid-balance and mortality.

Methods:

Retrospective single-center study in 101 VA-ECMO patients between 2013 and 2016. Daily fluid-balance and weight changes over the 5 first days were observed. Analyses between survivors and non-survivors were conducted using Mann–Whitney tests and logistic regression multivariable and Cox hazard-proportional analyses to determine any association with 28-days mortality.

Results:

Mortality was 47.5%. The fluid-balance was higher in non-survivors at day-1 (47.3[18.1–71.9] vs. 19.3[1.5–36.2] mL/kg, P < 0.0001) and day-2 (30.6[14.8–71.0] vs. 10.1[−9.8 to 34.7] mL/kg, P = 0.025), as was the cumulative fluid-balance over the first 5 days (107.3[40.5–146.2] vs. 53.0[7.5–74.3] mL/kg, P = 0.04). The administration of unintentional fluids (used for preparation and infusion of drugs) represented an important part of the administrated fluids (15 mL/kg/d–23 mL/kg/d). A significant but moderate correlation was observed between fluid-balance and weight variations over the 5 days (r values ranging from 0.36 to 0.54). Among other parameters, day-1 fluid-balance was independently associated with mortality (OR = 14.34 [1.58–129.79], P = 0.02) and day-1 and day-2 with time to death (HR = 8.26 [1.12–60.98], P = 0.04 and 2.89 [1.26–6.65], P = 0.01). A threshold of 38.8 mL/kg predicted mortality with a sensitivity of 60% and specificity of 83% (area under the curve: 0.749).

Conclusion:

Early positive fluid-balance is associated with mortality in VA-ECMO patients.
PEARLS for Systems Integration
Authors: Dubé Mirette M. , Reid Jennifer , Kaba Alyshah , Cheng Adam , Eppich Walter , Grant Vincent , Stone Kimberly
Published: May 2019

Summary Statement

Modern healthcare organizations strive for continuous improvement in systems and processes to ensure safe, effective, and cost-conscious patient care. However, systems failures and inefficiencies lurk in every organization, often emerging only after patients have experienced harm or delays. Simulation and debriefing, focused on identifying systems gaps, can proactively lead to improvements in safety and quality. Systems-focused debriefing requires a different approach than traditional, learner-focused debriefing. We describe PEARLS for Systems Integration, a conceptual framework, debriefing structure and script that facilitators can use for systems-focused debriefing. The framework builds on Promoting Excellence And Reflective Learning in Simulation, using common debriefing strategies (plus/delta, focused facilitation, and directive feedback) in a modified format, with new debriefing scripts. Promoting Excellence And Reflective Learning in Simulation for System Integration offers a structured framework, adaptable for debriefing systems-focused simulations, to identify systems issues and maximize improvements in patient safety and quality.
Effect of Visual Aids During Surgical Consents on Patient Understanding and Satisfaction
Authors: Wang Rui , Haviland Miriam J. , Hacker Michele R. , Lefevre Roger
Published: May 2019

Objective

This study aimed to assess whether the use of visual aids to augment the consent process for pelvic floor surgeries affects patient understanding and satisfaction.

Methods

We conducted a single-blind, randomized controlled trial. Adults planning robotic sacrocolpopexy or suburethral sling surgeries were eligible. All participants received standard preoperative consent counseling. Participants randomized to the intervention also viewed slides with visual aids that paralleled standard counseling; participants randomized to the control group received only standard counseling. All participants completed surveys after their preoperative visit, the day of surgery, and at their postoperative visit. Each survey contained 12 true-false questions about risks, benefits, and alternatives of surgery, and expectations during recovery. The primary outcome was the percentage of correct true-false questions. We conducted an intention-to-treat analysis.

Results

We randomized 32 participants undergoing robotic sacrocolpopexy and 32 undergoing suburethral sling surgeries, yielding 16 in the intervention group and 16 in the control group for each procedure. The intervention and control groups for both surgeries were similar in age, body mass index, race, education, and previous surgery for similar symptoms.

Among participants undergoing robotic sacrocolpopexies, median knowledge scores at the preoperative visit were similar between the intervention (92% [interquartile range {IQR}, 86%–100%]) and control (86% [IQR, 75%–94%]) groups (P = 0.21). Similar results were seen for participants undergoing suburethral sling procedures in the intervention (83.3% [IQR, 71%–92%]) and control (83% [IQR, 75%–88%]) groups (P = 0.64).

Conclusions

We found that using visual aids during the consent process for patients undergoing robotic sacrocolpopexy or suburethral sling surgeries did not improve knowledge.
Opportunistic Salpingectomy at the Time of Urogynecologic Surgery: Why, in Whom, and How?
Authors: Catanzarite Tatiana , Eskander Ramez N.
Published: May 2019

Objectives

This review aims to (1) describe evidence supporting the fallopian tube as a site of high-grade serous carcinoma, (2) review literature regarding salpingectomy in high- and average-risk women, and (3) discuss feasibility and safety of salpingectomy in urogynecologic surgery.

Methods

PubMed and university library resources were used to retrieve relevant English-language publications via keyword search, including “ovarian cancer,” “salpingectomy,” “risk,” “safety,” “hysterectomy,” “trends,” “technique,” and “urogynecology.” Each publication was reviewed in detail and references incorporated, where relevant.

Results

Evidence supports the fimbriated portion of the fallopian tube as a site of high-grade serous carcinoma in both hereditary and sporadic cases. Routine opportunistic salpingectomy in average-risk women may reduce ovarian cancer risk by 42% to 65% and prevent future surgery for benign tubal disease. Opportunistic salpingectomy is cost-effective for sterilization and cost-saving during hysterectomy. For genetically predisposed women, salpingo-oophorectomy remains the recommended strategy for ovarian cancer risk reduction. Despite being feasible, safe, and cost-effective, concomitant salpingectomy is least commonly performed during vaginal hysterectomy compared with other hysterectomy routes. Salpingectomy rates during vaginal hysterectomy are influenced by geographic factors, surgeon experience, and adhesive disease.

Conclusions

Opportunistic salpingectomy holds promise as a risk-reducing intervention for ovarian cancer. The American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncology recommend that physicians counsel average-risk women regarding opportunistic salpingectomy when planning pelvic surgery. Randomized controlled trials are needed to evaluate long-term implications of salpingectomy. Urogynecologic surgeons should discuss salpingectomy as part of surgical informed consent. Vaginal salpingectomy should be incorporated into residency and fellowship training programs.
Point-of-care resuscitation research: From extreme to mainstream: Trauma Association of Canada Fraser Gurd Lecture 2019
Authors: Kirkpatrick Andrew W.
Published: May 2019

The Gurd Family surgical legacy was deeply intertwined with National service in both World Wars. My own personal research mission has attempted to emulate such service, by enhancing the tools and techniques available to facilitate point-of-care diagnosis and resuscitation in extreme and adverse environments. Our efforts involving point-of-care diagnosis/resuscitation and the telementored guidance of those remotely responding to catastrophic injury have included collaborations with National Aeronautics and Space Administration (NASA) the Canadian Space Agency, the Canadian Forces, its democratic allies, and non-governmental surgical organizations. Research has been conducted in resuscitative suites and operating theaters, research laboratories, parabolic flight aircraft, on humanitarian surgical missions, and from ski-hills and firehalls. The initial phases of these efforts involved inaugural studies in resuscitative sonography including defining the Extended Focused Assessment with Sonography for Trauma (EFAST) examination. Although the original work was commissioned for Space Medicine, generalization to mainstream practice further justifies space medicine research. Iterative steps in advancing telementored resuscitation have subsequently involved the maturation of space-mandated telementored ultrasound support (TMUS), exploration of TMUS in terrestrial clinical practice, and the creation of increasingly mobile (hand-held) TMUS solutions. Subsequently it was recognized that teleultrasound is simply one informatic dimension of remote telemedicine, and current efforts are focused in a Program known as TeleMentored Ultrasound Supported Medical Interactions (TMUSMI) of remote responders required to intervene with catastrophic trauma. While this research program has yielded many techniques and findings that have benefited mainstream terrestrial practice, these investigations are currently ongoing, and we hope to demonstrate that TMUSMI may benefit all Canadians especially those in remote areas, as well as potentially every global inhabitant without immediate access to care. Further, we propose that to fully utilize these techniques, a new specialty, that of the remote medical mentor will be required, a new specialty that will require the creation and scientific validation of its principles and techniques.
Promotility agents for the treatment of ileus in adult surgical patients: A practice management guideline from the Eastern Association for the Surgery of Trauma
Authors: Bugaev Nikolay , Bhattacharya Bishwajit , Chiu William C. , Como John J. , Cripps Michael W. , Ferrada Paula , Gelbard Rondi B. , Gondek Stephen , Kasotakis George , Kim Dennis , Mentzer Caleb , Robinson Bryce R. H. , Salcedo Edgardo S. , Yeh D. Dante
Published: May 2019

BACKGROUND

Ileus is a common challenge in adult surgical patients with estimated incidence to be 17% to 80%. The main mechanisms of the postoperative ileus pathophysiology are fluid overload, exogenous opioids, neurohormonal dysfunction, gastrointestinal stretch, and inflammation. Management includes addressing the underlying cause and supportive care. Multiple medical interventions have been proposed, but effectiveness is uncertain. A working group of the Eastern Association for the Surgery of Trauma aimed to evaluate the effectiveness of metoclopramide, erythromycin, and early enteral nutrition (EEN) on ileus in adult surgical patients and to develop recommendations applicable in a daily clinical practice.

METHODS

Literature search identified 45 articles appropriate for inclusion. The Grading of Recommendations Assessment, Development and Evaluation methodology was applied to evaluate the effect of metoclopramide, erythromycin, and EEN on the resolution of ileus in adult surgical patients based on selected outcomes: return of normal bowel function, attainment of enteral feeding goal, and hospital length of stay. The recommendations were made based on the results of a systematic review, a meta-analysis, and evaluation of levels of evidence.

RESULTS

The level of evidence for all PICOs was assessed as low. Neither metoclopramide nor erythromycin were effective in expediting the resolution of ileus. Analyses of 32 randomized controlled trials showed that EEN facilitates return of normal bowel function, achieving enteral nutrition goals, and reducing hospital length of stay.

CONCLUSION

In patients who have undergone abdominal surgery, we strongly recommend EEN to expedite resolution of Ileus, but we cannot recommend for or against the use of either metoclopramide or erythromycin to hasten the resolution of ileus in these patients.

LEVEL OF EVIDENCE

Type of Study Therapeutic, level II.
Preinjury Palliative Performance Scale predicts functional outcomes at 6 months in older trauma patients
Authors: Hwang Franchesca , Pentakota Sri Ram , McGreevy Christopher M. , Glass Nina E. , Livingston David H. , Mosenthal Anne C.
Published: May 2019

BACKGROUND

Older trauma patients have increased risk of adverse in-hospital outcomes. We previously demonstrated that low preinjury Palliative Performance Scale (PPS) independently predicted poor discharge outcomes. We hypothesized that low PPS would predict long-term outcomes in older trauma patients.

METHODS

Prospective observational study of trauma patients aged ≥55 years admitted between July 2016 and April 2018. Preinjury PPS was assessed at admission; low PPS was defined as 70 or less. Primary outcomes were mortality and functional outcomes, measured by Extended Glasgow Outcome Scale (GOSE), at discharge and 6 months. Poor functional outcomes were defined as GOSE score of 4 or less. Secondary outcomes were patient-reported outcomes at 6 months: EuroQol-5D and 36-Item Short Form Survey. Adjusted relative risks (aRRs) were obtained for each primary outcome using multivariable modified Poisson regression, adjusting for PPS, age, race/ethnicity, sex, and injury severity.

RESULTS

In-hospital data were available for 516 patients; mean age was 70 years and median Injury Severity Score was 13. Thirty percent had low PPS. Six percent (n = 32) died in the hospital, and half of the survivors (n = 248) had severe disability at discharge. Low PPS predicted hospital mortality (aRR, 2.6; 95% confidence interval [CI], 1.2–5.3) and poor outcomes at discharge (aRR, 2.0; 95% CI, 1.7–2.3). Six-month data were available for 176 (87%) of 203 patients who were due for follow-up. Functional outcomes improved in 64% at 6 months. However, 63% had moderate to severe pain, and 42% moderate to severe anxiety/depression. Mean GOSE improved less over time in low PPS patients (7% vs. 24%; p < 0.01). Low PPS predicted poor functional outcomes at 6 months (aRR, 3.1; 95% CI, 1.8–5.3) while age and Injury Severity Score did not.

CONCLUSION

Preinjury PPS predicts mortality and poor outcomes at discharge and 6 months. Despite improvement in function, persistent pain and anxiety/depression were common. Low PPS patients fail to improve over time compared to high PPS patients. Preinjury PPS can be used on admission for prognostication of short- and long-term outcomes and is a potential trigger for palliative care in older trauma patients.

LEVEL OF EVIDENCE

Prognostic study, Therapeutic level IV.
Predictors of Discontinuance of Oral Feeding in Patients With Advanced Alzheimer Dementia and Aspiration Pneumonia in Japan
Authors: Akuzawa Nobuhiro , Yoshii Akihiro , Ono Akihiro , Kuwako Tomohito , Osaki Takashi , Osawa Sho , Jingu Asuka , Watanabe Satoru , Saito Ryusei
Published: May 2019

Background:

Difficulty with oral feeding, the most commonly observed complication of Alzheimer disease (AD) in its final stages, occurs in 86% of AD patients and may prevent achievement of oral feeding after aspiration pneumonia. However, no reliable indicators of discontinuance of oral feeding have yet been identified. We therefore aimed to identify predictors of discontinuance of oral feeding in postaspiration pneumonia patients with AD.

Materials and Methods:

Relevant clinical and laboratory data of 60 patients with AD admitted to our hospital in Japan for aspiration pneumonia were retrospectively compared between oral feeding and discontinuance groups.

Results:

The study groups differed in interval since diagnosis of AD, CURB-65 score, pneumonia severity index score, and proportion of patients who died (higher in the discontinuance group) and body mass index (BMI), Mini Mental State Examination (MMSE) score, and functional independence measure score (lower in the discontinuance group). According to multivariate logistic regression analysis of all identified independent variables, only CURB-65 and MMSE scores and BMI are significant predictors of discontinuance of oral feeding after aspiration pneumonia in patients with advanced AD.

Conclusions:

In patients with advanced AD, discontinuance of oral feeding after aspiration pneumonia may be predicted by CURB-65 and MMSE scores and BMI.
Automated Volumetry of Medial Temporal Lobe Subregions in Mild Cognitive Impairment and Alzheimer Disease
Authors: Hata Kaori , Nakamoto Kazunori , Nunomura Akihiko , Sone Daichi , Maikusa Norihide , Ogawa Masayo , Sato Noriko , Matsuda Hiroshi
Published: May 2019

Purpose:

Hippocampal subfield volumetry should be more useful than whole hippocampal (WH) volumetry for diagnosing Alzheimer disease (AD). This study sought to confirm this.

Methods:

We investigated cognitively normal (CN) participants and patients with mild cognitive impairment (MCI) or AD using high-resolution T2-weighted and 3-dimensional T1-weighted magnetic resonance imaging. Using medial temporal subregion volumetry, we investigated discriminative power for MCI and AD versus CN.

Patients:

We recruited 30 CN participants, 30 amnestic MCI patients, and 49 AD patients between April 2015 and October 2016.

Results:

For AD, discriminative power of the combined volumes of the subiculum, entorhinal cortex, and cornu ammonis 1 was highest [area under the curve (AUC)=0.915; 85.7% sensitivity, 86.7% specificity, 86.1% accuracy], and was significantly higher than that of the WH volume (AUC=0.887; 90.0% sensitivity, 75.5% specificity, 84.5% accuracy) (P=0.019). For MCI, discriminative power of the subiculum volume was highest (AUC=0.747; 80.0% sensitivity, 73.3% specificity, 76.7% accuracy), but was only slightly higher than that of the WH volume (AUC=0.730; 56.7% sensitivity, 90.0% specificity, 73.3% accuracy).

Conclusions:

Using the combined volumes of the subiculum, entorhinal cortex, and cornu ammonis 1 may enable greater diagnostic accuracy compared with the WH volume or any single subfield in AD patients.
The Diagnostic Pathway From Cognitive Impairment to Dementia in Japan
Authors: Black Christopher M. , Ambegaonkar Baishali M. , Pike James , Jones Eddie , Husbands Joseph , Khandker Rezaul K.
Published: May 2019

Objective:

This study aimed to quantify the diagnostic pathway from cognitive impairment (CI) to dementia in Japan.

Methods:

This was a real-world, cross-sectional survey of patients with CI and their physicians.

Results:

Data for 1107 patients were provided by 106 physicians. Mean time from initial symptoms to the first consultation was 7.4±6.9 months; 42% of patients had moderate/severe CI at first consultation. Mean time from the first consultation to formal diagnosis was 2.9±11.0 months (1.9±8.8 mo if not referred to a secondary physician, and 5.1±14.6 mo if referred). Time from the first consultation to diagnosis was shorter with more severe CI at first consultation (P=0.0072). The highest proportion of patients were diagnosed by neurologists (45.8%). Tests or scales were used to aid diagnosis in 81.2% of patients. There was no association of disease severity and referral to a secondary physician; 30.9% of patients were referred, the majority (57.7%) to a neurologist.

Conclusions:

A substantial proportion of patients with dementia in Japan experience CI for some time before consulting a physician. Government policy to increase public understanding and awareness of dementia, and a proposed dementia screening system, should increase the proportion of individuals consulting physicians before disease progression.
Health-related Quality of Life, Cognitive Performance, and Incident Dementia in a Community-based Elderly Cohort
Authors: Ezzati Ali , Zammit Andrea R. , Katz Mindy J. , Derby Carol A. , Zimmerman Molly E. , Lipton Richard B.
Published: May 2019

Background:

We hypothesized that higher quality of life would be associated with better cognitive function and a reduced risk of incident all cause dementia and Alzheimer disease (AD) in older adults.

Materials and Methods:

Participants included 1183 older adults with an average age of 78.2 (SD=5.3) from Einstein Aging Study. The 36-Item Short-Form Health Survey was used to measure health-related quality of life (HRQoL). We investigated baseline associations between the cognitive domains of memory, executive function, and general fluid ability with 8 subscales of the 36-Item Short-Form Health Survey (physical functioning, role limitations due to physical problems, bodily pain, general health perceptions, social functioning, role limitations due to emotional problems, vitality, and general mental health) and the 2 component summary scores of physical component summary (PCS) and mental component summary (MCS). Next, we used Cox proportional hazard models to assess the predictive validity of HRQoL subscales for the onset of incident dementia and incident AD.

Results:

At baseline, higher scores (better HRQoL) on MCS and its 4 subscales (social functioning, role limitations due to emotional problems, vitality, and general mental health) were associated with higher performance on both memory and executive function domains. Higher scores in role limitation due to physical problems, role limitation due to emotional problems, and general mental health subscales were associated with reduced risk of incident dementia. Higher MCS, but not PCS, predicted a reduced incident of all-cause dementia and AD.

Conclusions:

These findings suggest that diminution of HRQoL precedes the onset of diagnosable dementia and may be useful in the prediction of dementia onset.
Recent genetic and functional insights in autism spectrum disorder
Authors: Nakanishi Moe , Anderson Matthew P. , Takumi Toru
Published: May 2019

Purpose of review

Recent advances in genetic technologies allowed researchers to identify large numbers of candidate risk genes associated with autism spectrum disorder (ASD). Both strongly penetrant rare variants and the accumulation of common variants with much weaker penetrance contribute to the cause of ASD. To identify the highly confident candidate genes, software and resources have been applied, and functional evaluation of the variants has provided further insights for ASD pathophysiology. These studies ultimately identify the molecular and circuit alteration underlying the behavioral abnormalities in ASD. In this review, we introduce the recent genetic and genomic findings and functional approaches for ASD variants providing a deeper understanding of the etiology of ASD.

Recent findings

Integrated meta-analysis that recruited a larger number of ASD cases has helped to prioritize ASD candidate genes or genetic loci into highly confidence candidate genes for further investigation. Not only coding but also noncoding variants have been recently implicated to confer the risk of ASD. Functional approaches of genes or variants revealed the disruption of specific molecular pathways. Further studies combining ASD genetics and genomics with recent techniques in engineered mouse models show molecular and circuit mechanisms underlying the behavioral deficits in ASD.

Advances in ASD genetics and the following functional studies provide significant insights into ASD pathophysiology at molecular and circuit levels.
Optimizing colour for camouflage and visibility using deep learning: the effects of the environment and the observer's visual system
Authors: Fennell J. G. , Talas L. , Baddeley R. J. , Cuthill I. C. , Scott-Samuel N. E.
Published: May 2019

Avoiding detection can provide significant survival advantages for prey, predators, or the military; conversely, maximizing visibility would be useful for signalling. One simple determinant of detectability is an animal's colour relative to its environment. But identifying the optimal colour to minimize (or maximize) detectability in a given natural environment is complex, partly because of the nature of the perceptual space. Here for the first time, using image processing techniques to embed targets into realistic environments together with psychophysics to estimate detectability and deep neural networks to interpolate between sampled colours, we propose a method to identify the optimal colour that either minimizes or maximizes visibility. We apply our approach in two natural environments (temperate forest and semi-arid desert) and show how a comparatively small number of samples can be used to predict robustly the most and least effective colours for camouflage. To illustrate how our approach can be generalized to other non-human visual systems, we also identify the optimum colours for concealment and visibility when viewed by simulated red–green colour-blind dichromats, typical for non-human mammals. Contrasting the results from these visual systems sheds light on why some predators seem, at least to humans, to have colouring that would appear detrimental to ambush hunting. We found that for simulated dichromatic observers, colour strongly affected detection time for both environments. In contrast, trichromatic observers were more effective at breaking camouflage.
Advantages of social skills for contest resolution
Authors: Camerlink Irene , Turner Simon P. , Farish Marianne , Arnott Gareth
Published: May 2019

Animal contests are natural interactions that occur to obtain or defend resources such as food and territory. Selection should favour individuals that can win contests with minimal costs in terms of energy expenditure or injuries. We hypothesized that social skills contribute to animals' assessment abilities in a contest situation and thereby will shorten contest duration. Animals were either raised in early life conditions stimulating the development of social skills, termed socialization or not (control). Contests between 342 pigs at eight weeks old (171 dyads) were studied for opponent assessment ability (using a game theoretical approach), examining duration and escalation, social behaviours performed, injuries and outcome. Contesting dyads were from the same treatment group and varied in body weight, a validated measure of resource holding potential (RHP). Socialized animals had shorter contests that were resolved with fewer injuries and they showed more ritualized display behaviour, consistent with mutual assessment. Furthermore, there was evidence of a novel form of opponent assessment in the socialized group revealed by a positive relationship between winner RHP and fight duration. In conclusion, social skills enabled more rapid establishment of dominance relationships at lower cost. Besides its evolutionary relevance, these findings may also contribute towards improving animal welfare.