bluuebunny/crossref_metadata_2025 huggingface dataset:
The need to know: experiences of critically ill patients
Authors: Hupcey JE , Zimmerman HE
Published: November 2019

BACKGROUND: Critically ill patients vary in their memories of their experience in the intensive care unit. Some have little recall and need to learn about their critical illness. Others have more vivid memories of their experiences, some of which were extremely unpleasant. Patients' not knowing what was happening may have exacerbated the unpleasant experiences. OBJECTIVES: To elicit the experience of knowing for critically ill patients and to explore the differences in perceptions between patients who were intubated and those who were not intubated during the illness. METHODS: Grounded theory was used to explore the meaning of knowing and not knowing and the process by which knowing occurs. Unstructured interviews were done with 14 patients. RESULTS: Knowing had 2 phases: the need to know (1) during and (2) after the critical illness. The first phase had 3 facets: needing information, needing to be oriented, and having confusing perceptions. The second phase had 2 facets: needing information about what had happened and piecing together events. Many experiences with knowing during and after a critical illness were similar for both intubated and nonintubated patients. The main difference was the intensity of the experience in some categories. CONCLUSIONS: Critically ill patients have a strong need to know throughout and after their time in the intensive care unit. Nurses must address this need for constant reorientation to the past and present in these patients. In addition, adequate nursing staff must be available for these patients.
Management of patients with multiple rib fractures
Authors: Easter A
Published: November 2019

Multiple rib fractures in trauma patients are associated with significant morbidity and mortality. Delayed morbidity for patients with rib fractures is often a result of hypoventilation leading to atelectasis, pneumonia, and respiratory failure. Pain management was first recognized as an important factor in preventing complications in these patients. Later, management of the respiratory system became more widely recognized as a major factor in patients' care. It is now known that patients with multiple rib fractures benefit most from adequate pain control, rapid mobilization, and meticulous respiratory care to prevent complications. A protocol based on a synthesis of the existing literature is developed. Development of such a protocol for decisions about rapid mobilization, respiratory support, and pain management is the first step in testing the hypothesis that these interventions will decrease the length of patients' stay in intensive care units.
Brugada
Authors: Futterman LG , Lemberg L
Published: November 2019

The Brugada syndrome was first described in 1992. Palpitations and/or syncope are usually experienced during rest and increased vagal activity. [table: see text] However, in 15% of patients with Brugada syndrome, symptoms occur during physical activity. The syndrome is further characterized by a pattern of RBBB and ST-segment elevation in V1 to V2/V3 (see Table). One major and one minor criterion from the Table can serve to establish a diagnosis of Brugada syndrome. The patient presented in this report described symptoms only during physical activity. EPS confirmed the diagnosis of the Brugada syndrome, and an ICD was implanted. The clinical importance of the Brugada syndrome is that it calls attention to patients at risk for SCD. The syndrome is genetically determined and caused by mutations in the cardiac ion channels. Signal averaging that reveals late potentials can help identify persons who may be at high risk for SCD and who would thus be candidates for EPS, which can identify those at risk of SCD. The ICD is the only therapy known to help prevent SCD in patients with Brugada syndrome.
Effect of Tracheal Gas Insufflation During Weaning From Prolonged Mechanical Ventilation: A Preliminary Study
Authors: Hoffman Leslie A. , Tasota Frederick J. , Delgado Edgar , Zullo Thomas G. , Pinsky Michael R.
Published: November 2019

• Background Tracheal gas insufflation reduces inspired tidal volume and minute ventilation in spontaneously breathing patients and may facilitate weaning from mechanical ventilation.

• Objective To determine if tracheal gas insufflation can reduce ventilatory demand during weaning trials in patients who require prolonged mechanical ventilation.

• Methods A reduction in ventilatory demand was defined as a relative decrease in tidal volume, minute ventilation, and mean inspiratory flow during trials with tracheal gas insufflation compared with the values during trials without this therapy. A total of 14 subjects underwent T-piece trials with and without insufflation (flow rate 6 L/min) on 2 consecutive days; the order of insufflation was randomized. Tidal volume, minute ventilation, and mean inspiratory flow were measured at baseline (without insufflation) and 2 hours later.

• Results Differences in ventilatory demand were not significant when comparisons were made for condition (tracheal gas insufflation vs no flow) or time (baseline vs 2 hours) for the total group (P = .48). Subjects were classified post hoc as responders (n = 9) or nonresponders (n = 5). Comparisons between responders and nonresponders indicated a significant (P = .02) 3-way multivariate interaction for group (responder vs nonresponder), condition (tracheal gas insufflation vs no flow), and time (baseline vs 2 hours) for ventilatory demand variables.

• Conclusion Tracheal gas insufflation can reduce ventilatory demand during weaning trials in some patients who require mechanical ventilation.
Early Predictors of Long-Term Disability After Injury
Authors: Richmond Therese S. , Kauder Donald , Hinkle Janice , Shults Justine
Published: November 2019

• Background Improving outcomes after serious injury is important to patients, patients’ families, and healthcare providers. Identifying early risk factors for long-term disability after injury will help critical care providers recognize patients at risk.

• Objectives To identify early predictors of long-term disability after injury and to ascertain if age, level of disability before injury, posttraumatic psychological distress, and social network factors during hospitalization and recovery significantly contribute to long-term disability after injury.

• Methods A prospective, correlational design was used. Injury-specific information on 63 patients with serious, non–central nervous system injury was obtained from medical records; all other data were obtained from interviews (3 per patient) during a 2½-year period. A model was developed to test the theoretical propositions of the disabling process. Predictors of long-term disability were evaluated using path analysis in the context of structural equation modeling.

• Results Injuries were predominately due to motor vehicle crashes (37%) or violent assaults (21%). Mean Injury Severity Score was 13.46, and mean length of stay was 12 days. With structural equation modeling, 36% of the variance in long-term disability was explained by predictors present at the time of injury (age, disability before injury), during hospitalization (psychological distress), or soon after discharge (psychological distress, short-term disability after injury).

• Conclusions Disability after injury is due partly to an interplay between physical and psychological factors that can be identified soon after injury. By identifying these early predictors, patients at risk for suboptimal outcomes can be detected.
A Multisite Survey of Suctioning Techniques and Airway Management Practices
Authors: Sole Mary Lou , Byers Jacqueline F. , Ludy Jeffery E. , Zhang Ying , Banta Christine M. , Brummel Kathy
Published: November 2019

• Background Ventilator-associated pneumonia, common in critically ill patients, is associated with microaspiration of oropharyngeal secretions and may be related to suctioning and airway management practices.

• Objectives To describe institutional policies and procedures related to closed-system suctioning and airway management of intubated patients, and to compare practices of registered nurses and respiratory therapists.

• Methods A descriptive, comparative, multisite study of facilities that use closed-system suctioning devices on most intubated adults was conducted. Nurses and respiratory therapists who worked at the sites completed surveys related to their practices.

• Results A total of 1665 nurses and respiratory therapists at 27 sites throughout the United States responded. The typical respondent had at least 6 years’ experience with patients receiving mechanical ventilation (61%) and a baccalaureate degree or higher (54%). Most sites had policies for management of endotracheal tube cuffs (93%), hyperoxygenation (89%) and use of gloves (70%) with closed-system suctioning, and instillation of isotonic sodium chloride solution for thick secretions (74%). Only 48% of policies addressed oral care and 37% addressed oral suctioning. Nurses did more oral suctioning and oral care than respiratory therapists did, and respiratory therapists instilled sodium chloride solution more and rinsed the suctioning device more often than nurses did.

• Conclusions Policies vary widely and do not always reflect current research. Consistent performance of practices such as wearing gloves for airway management and maintaining endotracheal cuff pressures must be evaluated. Collaborative, research-based policies and procedures must be developed and implemented to ensure best practices for intubated patients.
Comparison of 2 Methods for Postpyloric Placement of Enteral Feeding Tubes
Authors: Lenart Sylvia , Polissar Nayak L.
Published: November 2019

• Background Multiple techniques are available for postpyloric placement of feeding tubes. Administration of metoclopramide and air insufflation are easily accomplished at the bedside. Variable success rates have been reported for both procedures.

• Objectives To determine which method, administration of 10 mg of metoclopramide or gastric insufflation of 350 mL of air, is superior for successful postpyloric placement of feeding tubes at the bedside.

• Methods A prospective trial consisting of 60 adult patients randomized to have a feeding tube placed by 1 of 2 methods, either after intravenous administration of 10 mg of metoclopramide or via gastric insufflation of 350 mL of air. Placement results were confirmed by radiography.

• Results Among patients receiving narcotics, the 72% successful placement rate with insufflation was significantly better than the 11% success rate achieved with metoclopramide (P < .001). Among the narcotic-free patients, the 83% success rate with metoclopramide was not significantly better than the 58% success rate with insufflation (P = .37). The difference in treatment effect between narcotic and narcotic-free groups was significant (P < .001).

• Conclusion Patients receiving narcotics should have feeding tubes placed via the air insufflation technique. The use of continuous or regularly scheduled administration of narcotics significantly decreases the effectiveness of metoclopramide in successful placement of feeding tubes.
Gastric Feeding in Critically Ill Children: A Randomized Controlled Trial
Authors: Horn Desley , Chaboyer Wendy
Published: November 2019

• Background Provision of enteral nutrition via the gastric route is a common nursing procedure in pediatric intensive care units. Little research, however, has focused on children’s tolerance of different types of gastric feeding regimens.

• Objectives To examine the relationship between 2 gastric feeding regimens, continuous and intermittent, and children’s tolerance as measured by the number of stools and prevalences of diarrhea and vomiting.

• Methods A randomized controlled trial was conducted in an Australian pediatric intensive care unit; 45 children were randomly assigned to either the continuous or the intermittent gastric feeding groups. Participants remained in the assigned feeding group for the duration of the study, and values of variables used to monitor patients’ tolerance were recorded.

• Results Both feeding groups were similar with respect to Pediatric Index Mortality score, age, weight, sex, diagnosis, and use of pharmacological agents known to affect the gastrointestinal tract. Additionally, the 2 groups did not differ in study duration or the daily volume of administered enteral formula per kilogram of body weight. The number of stools per day and the prevalences of diarrhea and vomiting did not differ significantly between the 2 groups.

• Discussion Continuous and intermittent gastric feeding regimens have similar outcomes with respect to the number of stools per day and the prevalence of diarrhea and vomiting in pediatric intensive care patients. Further gastric feeding studies and the development of enteral feeding guidelines for critically ill children are needed.
Role of Activated Protein C in the Pathophysiology of Severe Sepsis
Authors: Dettenmeier Patricia , Swindell Bridget , Stroud Mary , Arkins Nancy , Howard April
Published: November 2019

Sepsis is a complex syndrome that can lead to multiple organ failure and death. Severe sepsis has been associated with mortality rates ranging from 28% to 50% and is the most common cause of death in the noncardiac intensive care unit. Despite advances in both antibiotic therapy and supportive care, the mortality rate due to severe sepsis has remained fundamentally unchanged in the past several decades. With increased understanding of the pathophysiology of sepsis, particularly the intricate interplay between activation of coagulation and inflammation, novel therapeutic agents that may improve clinical outcomes are being researched and developed. The epidemiology, pathophysiology, and treatment of severe sepsis are reviewed. Also discussed are the recently published results from a multicenter, randomized, placebo-controlled phase 3 clinical trial of drotrecogin alfa (activated), a recombinant form of human activated protein C, in patients with severe sepsis. The nursing implications of this new approved therapy are discussed.
B-Type Natriuretic Peptide: A Diagnostic, Prognostic, and Therapeutic Tool in Heart Failure
Authors: Prahash Annu , Lynch Trenda
Published: November 2019

B-type natriuretic peptide is a neurohormone secreted from the cardiac ventricles in response to ventricular stretch and pressure overload. It counteracts the vasoconstriction that occurs as a compensatory mechanism in heart failure. A new test for measuring plasma levels of B-type natriuretic peptide can help in the diagnosis and treatment of patients with congestive heart failure. Dyspnea associated with cardiac dysfunction is highly unlikely in patients with levels of the peptide less than 100 pg/mL. Whereas most patients with significant congestive heart failure have levels of the peptide greater than 400 pg/mL, in patients with levels of 100 to 400 pg/mL, left ventricular dysfunction without volume overload, pulmonary embolism, and cor pulmonale must be ruled out. Thus, incorporating measurement of B-type natriuretic peptide into clinical evaluation helps physicians and nurses diagnose heart failure more quickly, especially in patients who have multiple comorbid conditions. Elevated levels of B-type natriuretic peptide indicate a poor prognosis in terms of a higher mortality and more hospital readmissions. Levels of B-type natriuretic peptide could be used to guide therapy and discharge planning for patients admitted with decompensated heart failure.
Communication Ability, Method, and Content Among Nonspeaking Nonsurviving Patients Treated With Mechanical Ventilation in the Intensive Care Unit
Authors: Happ Mary Beth , Tuite Patricia , Dobbin Kathy , DiVirgilio-Thomas Dana , Kitutu Julius
Published: November 2019

• Objective To describe the communication ability, methods, and content among nonspeaking nonsurviving patients treated with mechanical ventilation in an intensive care unit.

• Methods Fifty patients who received mechanical ventilation and died during hospitalization were randomly selected from all adult patients (N = 396) treated in 8 ICUs in a tertiary medical center during a 12-month period. Clinicians’ notes, use of physical restraints, and medication records were reviewed retrospectively. Data on communication method, use of sedation/analgesia (within 4 hours of communication event), and use of physical restraints were recorded on an investigator-developed communication event record for the first 10 communication episodes documented in each patient’s record (n = 275). Message content and method were recorded for every documented communication episode (n = 694), resulting in a total of 812 content and 771 method data codes.

• Results Most charts (72%) had documentation of communication by patients at some time during mechanical ventilation. Most documented communication exchanges were between patients and nurses. Primary methods of communication were head nods, mouthing words, gesture, and writing. Physical restraints were used in half of the patients. However, most of the documented communication episodes (127/202, 62.9%) occurred when physical restraints were not in use. Communication content was primarily related to pain, symptoms, feelings, and physical needs. Patients also initiated communication about their homes, families, and conditions.

• Conclusions A clinically significant proportion of nonsurviving patients treated with mechanical ventilation in the intensive care unit communicate to nurses, other clinicians, and family members primarily through gesture, head nods, and mouthing words.
Effect Of Kinetic Therapy on Pulmonary Complications
Authors: Ahrens Thomas , Kollef Marin , Stewart Jena , Shannon William
Published: November 2019

• Background Optimal turning of critically ill patients is not well established. Kinetic therapy (systematic mechanical rotation of patients with 40° turns) may improve pulmonary function more than the improvement in function achieved via the standard of care (turning patients every 2 hours).

• Objective To determine (1) if patients receiving mechanical ventilation who tolerate kinetic therapy have better pulmonary function than do patients treated with standard turning and (2) the cost-effectiveness of kinetic therapy.

• Methods A prospective, randomized, multicenter study including 234 medical, surgical, and trauma patients (137 control patients, 97 patients receiving kinetic therapy).

• Results Kinetic therapy significantly decreased the occurrence of ventilator-associated pneumonia and lobar atelectasis. The risk of pneumonia developing was lower (P = .002) in patients receiving kinetic therapy than in the control patients. The risk of lobar atelectasis developing was decreased (P = .02) for the patients receiving kinetic therapy. Lengths of stay in the intensive care unit and in the hospital did not differ between the groups. Charges for intensive care were less in the kinetic therapy group ($81 700) than in the control group ($84 958), but not significantly less. Twenty-one patients did not tolerate kinetic therapy and were not included in the analysis.

• Conclusion Kinetic therapy helps prevent ventilator-associated pneumonia and lobar atelectasis in critically ill patients. Costs to rent the bed may be offset by the potential cost reduction associated with kinetic therapy.
Neonatal Staff and Advanced Practice Nurses’ Perceptions of Bereavement/End-of-Life Care of Families of Critically Ill and/or Dying Infants
Authors: Engler Arthur J. , Cusson Regina M. , Brockett Renee T. , Cannon-Heinrich Charlene , Goldberg Michelle A. , West Margaret Gorzkowski , Petow Wendy
Published: November 2019

• Background Parents need compassionate care when an infant dies. Nurses can provide such care and possibly facilitate grieving, yet often have inadequate preparation in bereavement/end-of-life care.

• Objective To describe neonatal nurses’ perceptions of bereavement/end-of-life care of families of critically ill and/or dying infants.

• Methods A cross-sectional, descriptive, correlational mailed survey design was used. The 55-item Bereavement End-of-Life Attitudes About Care: Neonatal Nurses Scale containing 4 sections (comfort, roles, involvement, and demographics) was mailed to 240 hospitals in the United States.

• Results The final response rate was 52% (190 completed data sets from 125 hospitals). Respondents were comfortable with many aspects of bereavement/end-of-life care. Comfort and roles scores correlated significantly with number of years as a neonatal intensive care nurse. Respondents agreed about many important aspects of their roles with patients’ families, especially the importance of providing daily support to the families. Most respondents identified caring for a dying infant, the actual death of an infant, and language or cultural differences as influential factors in the level of their involvement with families.

• Conclusions Education on bereavement/end-of-life care could affect nurses’ comfort with caring for families of critically ill and/or dying infants. Additional education on cultural competence would be helpful. Educators must promote the inclusion of content on bereavement/end-of-life care in nursing curricula. Finally, researchers must focus more attention on factors that promote and inhibit bereavement/end-of-life care of families of critically ill and/or dying infants.
Evaluation of a New Pulse Oximeter Sensor
Authors: Fernandez Marco , Burns Kathy , Calhoun Beverly , George Saramma , Martin Beverly , Weaver Chris
Published: November 2019

• Background A new forehead noninvasive oxygen saturation sensor may improve signal quality in patients with low cardiac index.

• Objectives To examine agreement between oxygen saturation values obtained by using digit-based and forehead pulse oximeters with arterial oxygen saturation in patients with low cardiac index.

• MethodsA method-comparison study was used to examine the agreement between 2 different pulse oximeters and arterial oxygen saturation in patients with low cardiac index. Readings were obtained from a finger and a forehead sensor and by analysis of a blood sample. Bias, precision, and root mean square differences were calculated for the digit and forehead sensors. Differences in bias and precision between the 2 noninvasive devices were evaluated with a t test (level of significance P<.05).

• Results Nineteen patients with low cardiac index (calculated as cardiac output in liters per minute divided by body surface area in square meters; mean 1.98, SD 0.34) were studied for a total of 54 sampling periods. Mean (SD) oxygen saturations were 97% (2.4) for blood samples, 96% (3.2) for the finger sensor, and 97% (2.8) for the forehead sensor. By Bland Altman analysis, bias ± precision was −1.16 ± 1.62% for the digit sensor and −0.36 ± 1.74% for the forehead sensor; root mean square differences were 1.93% and 1.70%, respectively. Bias and precision differed significantly between the 2 devices; the forehead sensor differed less from the blood sample.

• Conclusions In patients with low cardiac index, the forehead sensor was better than the digit sensor for pulse oximetry.
AACN Synergy Model’s Characteristics of Patients: Psychometric Analyses in a Tertiary Care Health System
Authors: Brewer Barbara B. , Wojner-Alexandrov Anne W. , Triola Nora , Pacini Christine , Cline Melanie , Rust Jo Ellen , Kerfoot Karlene
Published: November 2019

• Background Models for delivery of patient care that recognize the relationship between the characteristics of the patient and the competencies of the nurse are essential for high-quality outcomes.

• Objectives (1) To test application of a case report form used to assess patients’ characteristics as defined by the American Association of Critical-Care Nurses (AACN) Synergy Model for Patient Care in a general population of pediatric and adult patients and (2) to evaluate the internal consistency reliability and construct validity of the patient characteristics measure found on the American Association of Critical-Care Nurses Web site.

• Methods A cross-sectional correlational study was conducted in 2 phases. The first phase consisted of secondary data analysis of 481 ratings of patients provided by 11 expert nurses. The second phase consisted of primary data collection of 279 ratings of patients provided by 116 general and critical care nurses. The case report form was used to rate characteristics of patients in both phases; a self-rated nursing proficiency scale was used in the second phase. Descriptive statistics were used to describe the sample. Correlational techniques were used to evaluate internal consistency reliability and evidence of construct validity.

• Results The case report form based on the AACN Synergy Model’s characteristics of patients showed satisfactory internal consistency reliability and evidence of discriminant construct validity. Exploratory factor analysis resulted in a 2-factor solution representing an intrapersonal interaction factor and an interpersonal interaction factor.

• Conclusion The case report form for assessing characteristics of patients showed utility in a general population of adult and pediatric patients, some critically ill and some not. Nurses without previous knowledge of the AACN Synergy Model were able to apply the model during routine patient care.
Availability of animal food organisms and their utilization by cyprinids in Sri Lankan hill-stream pools
Authors: Vijverberg Jacobus , Land Marco A. van der , Vreeke Albert , Amarasinghe Bandu P.B. , Kortmulder Koenraad
Published: November 2019

The food and feeding of cyprinid fishes in three stream pools in South West Sri Lanka, was investigated from 29 June 1984 to 25 February 1986. S.W. Sri Lanka was chosen as a study site because the rainforest and its fish fauna are here severely threatened. Feeding ecology was studied by gut contents analysis. The availability of prey organisms in the environment was quantified and food utilization in each pool was estimated by comparing diet compositions of the fish species with the food availability. Seven cyprinid species represented more than 98% of the fish numbers caught. These were Pethia cumingii (PC), Puntius dorsalis (PD), Dawkinsia singhala (DS), Pethia nigrofasciata (PN), Systomus pleurotaenia (SP), Devario malabaricus (DM) and Rasbora daniconius (RD). Three of these species: the two surface feeders DM and RD and the generalist SP fed > 33 % (biovolume) on terrestrial arthropods. Since we were not able to quantify the availability of terrestrial arthropods - mainly ants falling from the trees into the stream - these three species were not included in part of the analysis. Chironomid larvae were most abundant and, on basis of biovolume, the most important animal food items of the remaining four cyprinid species (PC, PD, DS, PN). PD and PN strongly positively selected chironomid larvae, but DS and PC only weakly negatively. Although coleopterans and ephemeropterans were after chironomid larvae the most abundant food items in the environment the former were often negatively selected and ephemeropterans positively, so that the latter were generally after chironomid larvae the most frequently eaten food items.
Development of gonads and evidence of protogyny in Spangled emperor (Lethrinus nebulosus) from the coastal waters off Negombo, Sri Lanka.
Authors: Ranatunga R. R. M. K. P. , Rathnayaka Shreemali
Published: November 2019

Gonad development and maturation of the spangled emperor Lethrinus nebulosus (Forsskål, 1775) inhabiting coastal waters off Negombo, Sri Lanka was investigated to understand the reproductive strategies. Sexual ontogeny was investigated using histological examinations of the gonads and changes in sex ratio with body size. Cellular characteristics and the most advanced germ cells presented in the gonads were considered for determining the sex and maturity stages. The transitional gonads were characterized by changes in internal gonad structure such as the appearance of spermatocyte and degenerated oocytes in the same developmental stage. Thick strands of stromal tissue within the lamellae and branched secondary strands were observed in transitional individuals. Increased blood vessels and sperm sinuses within the gonad wall were also an indications of sex transition. Therefore, L. nebulosus living in coastal waters off Negombo exhibited an early indication of protogynous hermaphroditism among adults. The sizes at 50% sexual maturity of males and females were estimated to be 29.5 cm and 39.5 cm respectively. A dramatic change in the sex ratio of the adult size classes suggested that female to male sex transition observed between 28.5- 40.4 cm body sizes. Sex ratios were 1.23: 0.46: 1 for female: transitional: males indicating slightly female-biased overall sex ratios. Female dominance in smaller size classes and male dominance in larger size classes were also evident Mean size at first capture recorded for L. nebulosus (19.6 cm) was well below the mean sizes of maturity for both male and female. Size-speciﬁc differences in sex ratios and reproductive potential indicate that conventional regulations that impose size limits for capture would not be very effective for the management of L. nebulosus.
Posteroinferior cerebellar artery aneurysms: Influence of angioanatomy on the safety of flow diversion treatment
Authors: Ghali Michael , Zhang Yi , Kan Peter , Britz Gavin
Published: November 2019

Several anatomical variables critically influence therapeutic strategies for posteroinferior cerebellar artery (PICA) aneurysms and, specifically, the safety of flow diversion for these lesions. We review the microsurgical anatomy of the PICA, discussing and detailing these considerations in the treatment of aneurysms of this vessel from a theoretical perspective and in light of our previously published clinical results.
Outcomes of the endoscopic transsphenoidal surgery for resection of pituitary adenomas utilizing extracapsular dissection technique with a cotton swab
Authors: Skulsampaopol Janissardhar , Hansasuta Ake
Published: November 2019

Purpose: The purpose of this study was to determine the effectiveness and safety of a cotton swab for extracapsular dissection in endoscopic transsphenoidal surgery (ETSS) for pituitary adenoma (PA). Materials and Methods: A retrospective review of patients undergoing ETSS for PA from 2014 to 2017 was undertaken. Only patients with extracapsular dissection by cotton swab with the intent to completely remove the tumor were included. Assessment of the prospectively recorded clinical, laboratory, and radiographic presentation as well as the intra- and postoperative data was carried out. Factors influencing the extent of resection were analyzed. Results: Of the 222 patients, one hundred cases met the inclusion criteria. The cohort consisted of 81 nonfunctioning and 19 functioning PAs. Fifty patients presented with visual disturbance and 34 patients had prior surgical treatment. The majority of PAs was macroadenoma (97%) with 73% modified Hardy Stage C and 38% Knosp Grade 4. Intraoperative cerebrospinal fluid (CSF) leakage was the most frequently noted complication (78%). Meningitis occurred in three cases and repeat ETSS for CSF leakage repair was necessary in three patients. No death or vascular injury was observed. At 12 months after ETSS, magnetic resonance imaging scan confirmed 43% complete tumor resection. Previous surgery and Knosp Grade 4 were the strong factors for incomplete PA removal by multivariate logistic regression analysis. For functioning PAs, thirteen patients (68.42%) achieved biochemical remission. Conclusion: Cotton swab for extracapsular dissection proved its clinical effectiveness and safety. In spite of the technique, negative predictors for complete PA resection were parasellar extension and previous surgery.
X-ray and computed tomography scan-based morphometric analysis of skull baselines in Indian population
Authors: Marathe Nandan , Dahapute Aditya , Desai Jigar , Dhole Kiran , Bhaladhare Shubhanshu , Shah Swapneel
Published: November 2019

Introduction: The study aims at providing an overview of morphometric measurements of the skull baselines in normal Indian population and compares these dimensions with those of other races and ethnicities. This study will help in defining “normal” baseline values for Indian population. It will also compare dimensions as measured on X-ray and computed tomography (CT) scan to assess the reliability of X-ray as a diagnostic modality for the assessment of the skull baselines in Indian population. Materials and Methods: Retrospective study with a sample size of 116 patients and duration of 30 months. Results: The mean value for distance between dens tip and Chamberlain line on CT was 0.498 mm and on X-ray was 0.528 mm and for the distance between dens tip and McGregor line on CT was 0.213 mm and on X-ray was 0.228 mm. The mean distance between the dens tip and McRae line was 4.67 1.69 mm on CT scan and 4.7 1.76 mm on X-ray. Conclusion: There was not a single patient in whom the dens tip crossed the McRae line. Any protrusion of the dens tip beyond the foramen magnum is abnormal. Hence, the McRae line is easiest to understand and remember. Furthermore, the Chamberlain and McGregor lines rely on identifying the hard palate, which may not be included in routine X-ray, CT, and magnetic resonance imaging studies depend on the field of view. Hence, we recommend the use of McRae line for screening purposes while evaluating pathologies of the craniovertebral junction. X-ray is a reliable diagnostic technique for assessing morphometry of the skull baselines in an emergency or rural setting if facility for CT scan is not available.
World Health Organization grade III supratentorial extraventricular ependymomas in adults: Case series and review of treatment modalities
Authors: Kalfas Fotios , Scudieri Claudia
Published: November 2019

Context: Supratentorial ependymomas and their anaplastic variants are relatively uncommon central nervous system neoplasms that afflict both adults and children. Aims: Discuss the clinical and pathological features of patients with anaplastic ependymomas involving an extraventricular supratentorial location and review modalities and options of treatment for those rare tumors. Settings and Design: Whereas the treatment algorithm in the pediatric population is well established, however, treatment in the adult population is less defined. Treatment options are exposed through the author's cases and review of the literature. Subjects and Methods: In our case series of two adult patients with supratentorial ependymomas World Health Organization (WHO) Grade III (anaplastic variant), patients presented in both cases in the emergency room after having a generalized tonic–clonic seizure at home the first case, and mild hemiparesis the second case. Results: Patients underwent surgical treatment, and a gross total resection was achieved in both cases. The histopathological examination revealed a diagnosis of anaplastic ependymoma (WHO Grade III). Both patients had additional radiotherapy, and in the first case, adjuvant platinum-based chemotherapy was administered due to leptomeningeal gliomatosis. Conclusion: In our experience, gross total resection was achieved in all patients with supratentorial extraventricular ependymomas WHO Grade III with additional radiotherapy and platinum-based chemotherapy. Patients require initial close serial imaging follow-up. The role of chemotherapy is still uncertain but may be necessary in younger patients and in tumors that behave more like the pediatric ependymomas.
Spontaneous closure of a cavernous sinus dural arteriovenous fistula with spinal perimedullary drainage (Cognard V) during attempted transvenous embolization
Authors: Iampreechakul Prasert , Wangtanaphat Korrapakc , Lertbutsayanukul Punjama , Wattanasen Yodkhwan , Siriwimonmas Somkiet
Published: November 2019

The authors describe a patient with spontaneous closure of a spontaneous cavernous sinus dural arteriovenous fistula (CSDAVF), Cognard type V, during transvenous attempt. A 39-year-old woman experienced mild proptosis, redness of the left eye, and diplopia. Four months later, she developed left retro-orbital pain and left-sided headache. Cerebral angiography revealed the left CSDAVF exclusively draining into the superior petrosal sinus with subsequent drainage into the veins surrounding the medulla oblongata, and finally into the perimedullary spinal veins, classified as Cognard type V. The feeders arise from the dural branches of both the left external and internal carotid arteries. Following 2 h period of attempted transvenous embolization, the fistula disappeared spontaneously. Follow-up angiography obtained 6 months later confirmed complete resolution of the CSDAVF. At 2-year follow-up, the patient has remained clinically asymptomatic. The mechanism of thrombosis in this fistula related to the endovascular procedure. We speculated that putting the wire tip in the draining vein may induce the spontaneous thrombosis in the venous side. In addition, precipitating factors may include small, low-flow fistula, and pre-existing thrombosis.
Primary pineal rhabdomyosarcoma: A rare case
Authors: Vaidya Mihir , Shenoy Asha , Goel Naina
Published: November 2019

Primary pineal rhabdomyosarcoma (RMS) is extremely rare, and only three cases have been reported so far. Here, we report a case of 12-year-old male who presented with complaints of diplopia and diminution of vision since 15 days. He also had left-sided facial paresis. Magnetic resonance imaging brain revealed a space-occupying lesion in the region of pineal gland. The patient underwent midline suboccipital craniectomy with excision of tumor. Microscopic examination revealed a highly cellular tumor with areas showing small round cells admixed with cells having abundant eosinophilic cytoplasm resembling rhabdomyoblasts and multinucleated giant cells. Differential diagnoses of pineal anlage tumor and primary RMS were considered. The tumor cells were positive for desmin while being negative for synaptophysin and glial fibrillary acidic protein. Myogenin was used to confirm the diagnosis of RMS, which showed focal nuclear positivity. INI1 was retained. All the markers for germ cell tumors were negative.
Clinico-radiological efficacy of posterior instrumentation, decompression, and transpedicular bone grafting in osteoporotic burst fracture associated with neurological deficit
Authors: Mehta Gaurav , Patel Ankit , Jain Sanyam , Merchant Zahir , Kundnani Vishal
Published: November 2019

Objective: The aim of this study is to evaluate clinico-radiological outcomes of posterior surgery (decompression + instrumentation + transpedicular bone graft) in osteoporotic burst fracture associated with neurological deficit [OFND]. Materials and Methods: Forty patients with neurological deficit due to delayed osteoporotic vertebral collapse managed by posterior surgery (decompression + instrumentation + transpedicular bone graft) with minimum 2 years follow-up were included in the study. Approval from the Institutional Review Board was taken. Demographic data (age, sex, mode of injury, and the severity of osteoporosis); clinical parameters (Visual Analog Score [VAS], Oswestry Disability Index [ODI], Frankel grade), radiological parameters (local kyphosis), and surgical variables (blood loss, surgery duration, and intraoperative events) were recorded. Neurological worsening/improvement, complications, and implant failures were noted. Results: Significant improvement was noted in VAS (preoperative 8.20 ± 0.65/postoperative 4.1 ± 0.64) and ODI (preoperative 76.54 ± 6.96/postoperative 30.5 ± 6.56). Complete neurological recovery was noted in 37 patients (Frankel Grade E), three patients remained nonambulatory (Frankel Grade C). Significant improvement was noted in local kyphosis angle (preoperative = 21.80 ± 2.70; postoperative 11.40 ± 1.80), with 10% loss of correction (2.5 ± 0.90) at final follow-up. Symptomatic implant failure was noted in two patients and proximal junctional failure in one patient requiring an extension of fixation. Conclusions: OFND can be managed with a single posterior-only surgery with significant improvement in neurology and functional scores of patients. Aggressive kyphosis correction is often not required and optimal correction of kyphosis is noticed due to prone-positioning alone. Transpedicular grafting is safe and simple alternative to cement augmentation or anterior surgery for collapsed vertebrae.
Unusual Source of Gastrointestinal Bleed and Endoscopic Management
Authors: Choudhary Narendra S , Bansal Rinkesh Kumar , Puri Rajesh , Gupta Mahesh Kumar , Patil Gaurav , Shah Vinit , Nasa Mukesh , Sud Randhir
Published: November 2019

Gastrointestinal (GI) bleeding due to jejunal diverticula is very rare. Capsule endoscopy is a useful diagnostic tool for localizing the bleeding site, but single‑balloon enteroscopy is a good therapeutic modality for the management. Here, we report two cases, in whom the cause of GI bleeding was jejunal diverticula and they managed successfully with endoscopic management.
“Ampullary Gangliocytic Paraganglioma:” A Rare Neuroendocrine Tumor Can Be Safely Treated with Ampullectomy
Authors: Sharma Manik , Mohiuddin Syed Adnan , Kaabi Saad Al , Mujeeb Imad Bin , Deviere Jacques
Published: November 2019

Ampullary Gangliocytic paraganglioma is a rare gastro-entero-pancreatic neuroendocrine tumor with a characteristic histologic appearance involving epitheliod, spindle and ganglion cells. Endoscopic ultrasound is useful to determine depth of invasion and regional metastasis. Endoscopic resection, Ampullectomy and pancreato-duodenenectomy have been described as management options in literature but no consensus has been established. The index case describes an asymptomatic 42 y/o lady with a background of plexiform neurofibromatosis referred for cholestatic derangement of liver function. She was found to have a dilated biliary system with a periampullary mass which proved to be a Gangliocytic Paraganglioma without local lymph node metastasis. She underwent successful endoscopic ampullectomy with complete normalization of LFT and decompression of the biliary system with no clinical or endoscopic recurrence at 2 years follow up. We
advocate that Partial Ampullectomy could be done safely as a treatment of localized Ampullary GP allowing long term resolution of symptoms.
Isolated Terminal Ileal Mucosal Changes: When is the Bite Indicated?
Authors: Jain Mayank , Srinivas M. , Ravi R. , Mahadevan B. , Michael Tom , Venkataraman Jayanthi
Published: November 2019

Aim: This study aims to determine the clinical presentation, and ileal mucosal changes during colonoscopy for which terminal ileal (TI) biopsies were taken at our center and to determine the specific histopathology which had the best yield for specific colonoscopy findings. Materials and Methods: Retrospective audit of all patients who underwent colonoscopy with ileoscopy between 2012 and 2016. All patients with TI mucosal changes and normal colonic mucosa, who underwent ileal biopsy, were included in this study. Patient data regarding age, gender, indication for ileocolonoscopy (screening for colorectal cancers, inflammatory bowel disease [IBD], or irritable bowel syndrome [IBS]) and histopathology changes were collected. Appropriate statistical tests were used and P < 0.05 was considered statistically significant. Results: One hundred and nine patients had isolated ileal lesions. The median age was 44.1 years (range 8–80
years). Men outnumbered women in a ratio of 82:27. The major clinical indications for ileocolonoscopy were IBS (64.2%), followed by IBD (22%). Ulcers (aphthoid) were the most frequent finding followed by mucosal nodularity and nonspecific findings. Ulcers in ileum were most often reported as chronic ileitis (46.2%), followed by nonspecific changes (35.2%) Biopsy from nodular ileal lesions, were predominantly nonspecific (74.4%), followed by acute (15.4%) and chronic ileitis (10.2%). About 50% of specimens with nonspecific ileal changes had nonspecific histological changes. Ileal ulcers had the highest sensitivity, PPV, and NPV for significant histological findings. Conclusion: Ileal ulcers are the significant colonoscopy findings where tissue biopsy is likely to yield a definitive diagnosis and justify specific management. Biopsies from nonspecific ileal changes and nodularity should be discouraged as it is unlikely to pick up
any major abnormality.
Electrification System Modeling with Machine/Deep Learning for Virtual Drive Quality Prediction
Authors: Borkar Brijesh , Maria Francis John Bosco , Arora Pankaj
Published: November 2019

A virtual 'model' is generally a mathematical surrogate of a physical system and when well correlated, serves as a basis for understanding the physical system in part or in entirety. Drive Quality (DQ) defines a driver's 'experience' of a blend of controlled responses to an applied input. The 'experience' encompasses physical, biological and bio- chemical perception of vehicular motion by the human body. In the automotive domain, many physical modeling tools are used to model the sub-components and its integration at the system level. Physical Modeling requires high domain expertise and is not only time consuming but is also very 'compute-resource' intensive. In the path to achieving 'vDQP (Virtual Drive Quality Prediction)' goal, one of the requirements is to establish 'well-correlated' virtual environments of high fidelity with respect to standard test maneuvers. This helps in advancing many developmental activities from a Analysis, Controls and Calibration standpoint. Recently, machine/deep learning have proven to be very effective in pattern recognition, classification tasks and human-level control to model highly nonlinear real world systems. This paper investigates the effectiveness of machine/deep learning with various algorithms for the modeling of an electric vehicle system, integration with virtual embedded controllers, drive quality analysis and correlation to vehicle data, thereby enabling scope for 'front- loading' iterative activity in the developmental cycle and enable laptop-based fine tuning of software calibrations.
Assessment of the potential of duckweed (Lemna minor L.) in treating lead-contaminated water through phytoremediation in stationary and recirculated set-ups
Authors: Ubuza Lanel Jane A , Padero Palcon Cres S , Nacalaban Charie May N , Tolentino Jasmin T , Alcoran Dominick C , Tolentino Janice C , Ido Alexander L , Mabayo Val Irvin F , Arazo Renato O
Published: November 2019

The problems of heavy metal contamination in water have become alarming and necessitate efficient remediation. However, conventional water and wastewater treatment techniques are considered costly, and some are even not environment-friendly. These problems trigger the idea of utilizing plants in the treatment process of metal-contaminated water. The current work investigated the potential of duckweed (Lemna minor L.) in treating lead-contaminated water through phytoremediation. The duckweed was used as bioaccumulator of lead (Pb) in the prepared stationary and recirculated set-ups at 3, 6, and 9 d. The physicochemical characteristics such as pH, BOD5, DO, turbidity, and temperature of the influent and effluent were compared. The highest bioaccumulation of 62.8% was achieved at 3 d in the recirculated set-up. The result of the analysis showed that duckweed has the potential in phytoremediation considering better quality effluent. The concentration of Pb in the effluent of 0.93 mg/L in the recirculated set-up with duckweed in 3 d was much lower compared to the initial concentration in the influent at 2.5 mg/L. This study demonstrated that duckweed could be a suitable plant for Pb removal from water with big implications in remediating heavy metal-contaminated water from various industries.