bluuebunny/crossref_metadata_2025 huggingface dataset:
Emergent Mental Health Visits to a Pediatric Hospital
Authors: Uspal Neil G. , Jensen Jennifer , Sanchez-Erebia Luis , Strelitz Bonnie , Schloredt Kelly , Gallagher Chelsie , Bradford Miranda C. , Bennett Elizabeth , Paris Carolyn A.
Published: March 2020

Objective

The aims of this study were to describe firearm storage practices in homes of patients evaluated for mental health (MH) complaints at a tertiary care children's hospital and to describe storage practice changes after treatment.

Methods

We surveyed families of children with MH complaints presenting to the emergency department or psychiatry unit who stored firearms in their homes between February 12, 2016, and January 14, 2017. Patients and families received standard care, including routine counseling on limiting access to methods of suicide. Participants completed surveys at baseline, 7, and 30 days after discharge. The primary outcome was triple safe firearm storage—storage of firearms unloaded, locked, and with ammunition stored and locked separately.

Results

Ninety-one household members of MH patients who stated they had firearms were enrolled at baseline. Seventy-seven (85%) completed at least 1 follow-up survey, and 63 (69%) completed both. At baseline, 21% (19/91) of participants reported engaging in triple safe firearm storage, 26% had an unlocked firearm, 23% had a loaded firearm, and 65% stored ammunition either unlocked or with their firearm. Triple safe storage rates increased to 31% at both 7 days and 30 days. Ten (17%) of 59 (P < 0.01) participants who did not report triple safe storage at baseline and completed a follow-up survey changed to reporting triple safe storage on follow-up.

Conclusions

The majority of firearm-storing family members of children with MH complaints do not follow triple safe storage practices. Storage practices modestly improved after an emergent MH visit, but over two thirds of participants reported unsecured or partially secured firearms 7 and 30 days later.
Decadron, Diamox, and Zantac
Authors: Lang Shih-Shan , Ploof Jillian , Atkin Natalie J. , Tran-Du Kella , Kanuga Bhavya M. , Storm Phillip B. , Heuer Gregory , Yuan Ian , Abend Nicholas S. , Kirschen Matthew P. , Topjian Alexis A. , Li Yimei , Waanders Angela J. , Zorc Joseph J. , Huh Jimmy W.
Published: March 2020

Objective

Cerebral ventricular shunt failure is common and presents with symptoms that range from headaches to death. The combination of Diamox (acetazolamide), Decadron (dexamethasone), and Zantac (ranitidine) (DDZ) is used at our institution to medically stabilize pediatric patients presenting with symptomatic shunt failure before shunt revision. We describe our experience of this drug combination as a temporizing measure to decrease symptoms associated with shunt failure.

Methods

We performed a single-center retrospective chart review of patients younger than 18 years with ventricular shunt failure who underwent a shunt revision between January 2015 to October 2017 and received DDZ before surgery. The outcome variables evaluated included pre-DDZ and post-DDZ clinical symptoms, pain scores, and vital signs.

Results

There were 112 cases that received DDZ before shunt revision. The 4 most commonly reported symptoms were analyzed. Headache was observed in 42 cases pre-DDZ, and post-DDZ there was a 71% reduction in headache (P < 0.0001); emesis was reported pre-DDZ in 76 cases, and post-DDZ there was an 83% reduction (P < 0.0001); irritability was noted pre-DDZ in 30 cases, and post-DDZ there was a 77% reduction (P = 0.0003); lethargy pre-DDZ was observed in 60 cases, and post-DDZ 73% demonstrated improvement (P < 0.0001). Maximum pain scores significantly decreased post-DDZ (P < 0.0001). Heart rate, systolic, and diastolic blood pressures significantly decreased post-DDZ (P < 0.0001, P < 0.0001, P = 0.0002, respectively).

Conclusions

The combination of Decadron, Diamox, and Zantac is a novel treatment for ventricular shunt failure that may temporarily improve symptoms in patients awaiting shunt revision. Future studies could compare efficacy with other medical treatments.
Pediatric Difficult Airway Response Team Utilization in the Emergency Department
Authors: Kelly Geoffrey S. , Deanehan Julia Kathleen , Dalesio Nicholas M.
Published: March 2020

Objectives

A multidisciplinary pediatric difficult airway team was created at our institution to respond to hospital-wide airway emergencies. We report the characteristics, indications, and outcomes of these activations that occur in the pediatric emergency department (PED).

Methods

Retrospective, single-center cohort study comprised all difficult airway team activations occurring in the PED from the program's inception in 2008 to 2018. Ages of ≤18 years were included. For each case, detailed information was abstracted, including patient factors, PED context and milieu, airway interventions, and airway outcomes.

Results

There were 15 difficult airway response team activations in the PED during the study period, or 1.4 activations per year. The most common indications for activation were contaminated airways (n = 7; 47%) and history of difficult intubation (n = 4; 27%). Definitive airway management was successful in all cases, except for a single case where intervention was unnecessary. The most commonly performed definitive airway intervention was direct laryngoscopy (n = 6; 40%). There were no instances of emergency front-of-neck access.

Conclusions

Difficult airways in the PED were uncommon. Most cases were resolved with familiar equipment including direct laryngoscopy, video laryngoscopy, and supraglottic airways.
Parotitis on Ultrasound
Authors: Ng Carrie , Tupchong Keegan , Thomas-Mohtat Rosemary
Published: March 2020

The differential diagnosis for facial swelling is broad and can be a diagnostic challenge in the pediatric emergency department. We describe the first pediatric case of acute parotitis with sialolithiasis where the diagnosis was facilitated by point-of-care ultrasound.
Centralization of Prehospital Triage Improves Triage of Pediatric Trauma Patients
Authors: Gutierrez Peter S. , Travers Curtis , Geng Zhi , Little Wendalyn K.
Published: March 2020

Introduction

This study describes the experience at a level 1 pediatric trauma center before and after the centralization of prehospital trauma triage, focusing on the rate of undertriage of trauma patients. Before centralization, emergency physicians were responsible for triaging these patients with mainly physiology-based criteria; after centralization, paramedics in a communication center performed this function using the same criteria.

Methods

This retrospective study includes 10 years of pediatric trauma registry patients at our institution, 5 years before and after centralization of prehospital triage. Rates of undertriage were calculated by both the Cribari Method and by disposition from the emergency department. Logistic regression was used to assess the effect of centralization on the incidence of undertriage while adjusting for differences in case-mix.

Results

Over the 10-year study period, 1862 trauma activations meeting inclusion and exclusion criteria were recorded in the trauma registry: 893 patients in the precentralization and 969 in the postcentralization groups. After centralization of the triage process, there were statistically significant decreases in the rates of undertriage from 8.7% to 4.2% (adjusted odds ratio, 0.49; 95% confidence interval, 0.33–0.73) when analyzed by the Cribari Method and from 37.7% to 27.7% when analyzed by disposition from the emergency department (adjusted odds ratio, 0.66; 95% confidence interval, 0.64–0.81). This represents a reduction in undertriage by 51.7% and 26.5%, respectively.

Conclusions

Centralization of prehospital trauma triage at a level 1 pediatric trauma facility significantly reduced undertriage rates. Trauma centers should consider similar processes to improve prehospital triage.
Point-of-Care Ultrasound Diagnosis of Perforated Appendicitis in the Pediatric Emergency Department: A Case Series
Authors: Azhdam Devora Bita , Marin Jennifer R.
Published: March 2020

Point-of-care ultrasound (POCUS) is being used for clinical decision making with increasing frequency across a broad range of indications in pediatric emergency medicine (PEM). We present a series of 4 patients in whom POCUS was used to facilitate a diagnosis of perforated appendicitis.
Nasolabial Revisions in Unilateral Incomplete Cleft Lip: One Surgeon’s 28-Year Experience
Authors: Tan Stephan P. K. , Ganske Ingrid M. , Mulliken John B.
Published: March 2020

Background:

Repair of unilateral incomplete cleft lip is the surgeon’s opportunity to achieve a superior result with few revisions.

Methods:

This study is a retrospective review of consecutive patients with unilateral incomplete cleft lip, defined as a defect extending 30 to 90 percent of cutaneous labial height, treated between 1985 and 2013 by one surgeon. Rates and types of revisions were collected, and photographs of patients who did not have a revision were reviewed to determine whether a revision was needed.

Results:

One hundred thirty-six patients met inclusion criteria. Fifty-seven percent needed revision of the mucosal free margin; less than 10 percent needed other minor labial revisions. Fifteen percent required a nasal revision, most commonly reelevation of the lower lateral cartilage. Over time, the only statistically significant change in frequency was increased revisions of the free border.

Conclusions:

Nasal revision rates are low in unilateral incomplete cleft lip compared to complete forms in previously published data by the senior author (J.B.M.). In contrast, labial revisions of the free margin are more common. The reason is that the surgeon became more cognizant of vermilion-mucosal deficiency on the noncleft side and more likely to offer a submucosal flap or dermis-fat graft to level the lip for normal upper incisor show.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Use of a Split Pedicled Gracilis Muscle Flap in Robotically Assisted Vaginectomy and Urethral Lengthening for Phalloplasty: A Novel Technique for Female-to-Male Genital Reconstruction
Authors: Cohen Oriana , Stranix John T. , Zhao Lee , Levine Jamie , Bluebond-Langner Rachel
Published: March 2020

The authors describe the technique of robotic vaginectomy, anterior vaginal flap urethroplasty, and use of a longitudinally split pedicled gracilis muscle flap to recreate the bulbar urethra and help fill the vaginal defect in female-to-male gender-affirming phalloplasty. Vaginectomy is performed by means of the robotically assisted laparoscopic transabdominal approach. Concurrently, gracilis muscle is harvested and passed through a tunnel between the groin and the vaginal cavity. It is then split longitudinally, and the inferior half is passed into the vaginal cavity; it is inset into the vaginal cavity. Following urethroplasty, the superior half of the gracilis flap is placed around the vaginal flap to buttress this suture line with well-vascularized tissue. From May of 2016 to March of 2018, 16 patients underwent this procedure. The average age of the patients was 35.1 ± 8.8 years, average body mass index was 31.4 ± 5.5 kg/m2, and average American Society of Anesthesiologists class was 1.8 ± 0.6. The average length of surgery was 423.6 ± 84.6 minutes, with an estimated blood loss of 246.9 ± 84.9 ml. Patients were generally out of bed on postoperative day 1, ambulating on postoperative day 2, and discharged to home on postoperative day 3 (average day of discharge, 3.4 ± 1.4 days). At a mean follow-up time of 361.1 ± 175.5 days, no patients developed urinary fistula at the urethroplasty site. The authors’ use of the longitudinally split gracilis muscle in first-stage phalloplasty represents a novel approach to providing well-vascularized tissue to achieve both urethral support and closure of intrapelvic dead space, with a single flap, in a safe, efficient, and reproducible manner.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Impact of Patient Safety Incidents Reported by the General Public in Korea
Authors: Pyo Jeehee , Lee Won , Jang Seung Gyeong , Choi Eun Young , Ock Minsu , Lee Sang-Il
Published: March 2020

Objective

The study aimed to investigate the impacts of patient safety incident (PSI) experienced by the general public.

Methods

We conducted a self-administered online survey, in which we examined the following experiences of the patients and the caregivers: the level of harm induced by PSIs, difficulties due to PSIs, posttraumatic stress disorder (PTSD), and posttraumatic embitterment disorder, etc. A χ2 test was performed to identify differences in difficulties because of the direct and indirect experience of PSIs. A 1-way analysis of variance was performed to identify the differences in the total PTSD and posttraumatic embitterment disorder scores according to the characteristics of PSIs.

Results

Of the survey participants who indirectly experienced PSIs, 27.2% and 29.3% reported that they experienced sleep disorder and eating disorder, respectively. However, of the participants who directly experienced PSIs, 40.7% and 42.6% reported experiencing sleep disorder and eating disorder, respectively. The average PTSD scores of the participants who experienced permanent disability and death were 83.8 points for less than 6 months of elapsed time since the incident, 80.8 points for 6 months to less than 5 years, and 94.7 points for 5 years or more; they did not demonstrate a statistically significant difference (P = 0.217).

Conclusions

This study suggested that the general public who experienced PSIs have numerous difficulties at the time of the incident and the trauma or the resentment of the general public does not quickly regress even if time passes.
Detecting Spatial Cores and Temporal Trends of Repeat STIs to Plan Pre-exposure Prophylaxis (PrEP) Scale-up in DC
Authors: Das Suparna , Allston Adam , Kharfen Michael
Published: March 2020

Background:

Repeat sexually transmitted infections (STIs) in DC primarily results from untreated sexual partners. This analysis aims to identify high-risk areas and temporal trends of repeat STIs for pre-exposure prophylaxis scale-up and STI mitigation in DC.

Methods:

We identified repeat infections in the DC Department of Health STI and HIV data management systems, diagnosed from 2014 to 2018. The cases were geocoded and aggregated by census tracts. Poisson discrete scan statistic was implemented in SaTScan software to find clusters. Weighted moving average was used to compare temporal trends of repeat STIs. We used χ2 analysis to identify association with demographic variables.

Results:

We identified 8535 repeat STIs from 2014 to 2018. Of these, 61.84% were among men, most cases were among blacks (34.75%) and 47.45% represented gonorrhea cases. The high-risk spatial clusters were identified as those tracts that had relative risk (relative risk > 1; P-value < 0.001). We identified one significant radius of risk covering tracts of wards 7 and 8 and parts of wards 5 and 6. We spotted positive temporal trends in cluster 1 and outside the cluster. We found significant associations of repeat STIs with gender (χ2 = 317.27, P < 0.001), age (χ2 = 539.26, P < 0.001), HIV coinfections (χ2 = 352.06, P < 0.001), and year of diagnoses (χ2 = 1.5, P < 0.01).

Conclusions:

Our findings indicate spatial disparities in DC for repeat STIs. This analysis is critical for pre-exposure prophylaxis planning, STI prevention strategies such as expedited partner therapies and condom distribution strategies in DC should prioritize the high-risk spatial cores.
Perinatal Antiretroviral Intensification to Prevent Intrapartum HIV Transmission When Antenatal Antiretroviral Therapy Is Initiated Less Than 8 Weeks Before Delivery
Authors: Lallemant Marc , Amzal Billy , Sripan Patumrat , Urien Saïk , Cressey Tim R. , Ngo-Giang-Huong Nicole , Klinbuayaem Virat , Rawangban Boonsong , Sabsanong Prapan , Siriwachirachai Thitiporn , Jarupanich Tapnarong , Kanjanavikai Prateep , Wanasiri Phaiboon , Koetsawang Suporn , Jourdain Gonzague , Le Coeur Sophie ,   on behalf of the PHPT-5 site investigators
Published: March 2020

Introduction:

Infants born to women living with HIV initiating combination antiretroviral therapy (cART) late in pregnancy are at high risk of intrapartum infection. Mother/infant perinatal antiretroviral intensification may substantially reduce this risk.

Methods:

In this single-arm Bayesian trial, pregnant women with HIV receiving standard of care antiretroviral prophylaxis in Thailand (maternal antenatal lopinavir-based cART; nonbreastfed infants 4 weeks' postnatal zidovudine) were offered “antiretroviral intensification” (labor single-dose nevirapine plus infant zidovudine-lamivudine-nevirapine for 2 weeks followed by zidovudine-lamivudine for 2 weeks) if their antenatal cART was initiated ≤8 weeks before delivery. A negative birth HIV-DNA polymerase chain reaction (PCR) followed by a confirmed positive PCR defined intrapartum transmission. Before study initiation, we modeled intrapartum transmission probabilities using data from 3738 mother/infant pairs enrolled in our previous trials in Thailand using a logistic model, with perinatal maternal/infant antiretroviral regimen and predicted viral load at delivery as main covariates. Using the characteristics of the women enrolled who received intensification, prior intrapartum transmission probabilities (credibility intervals) with/without intensification were estimated. After including the transmission data observed in the current study, the corresponding Bayesian posterior transmission probability was derived.

Results:

No intrapartum transmission of HIV was observed among the 88 mother/infant pairs receiving intensification. The estimated intrapartum transmission probability was 2·2% (95% credibility interval 0·5–6·1) without intensification versus 0·3% (0·0–1·6) with intensification. The probability of superiority of intensification over standard of care was 94·4%. Antiretroviral intensification appeared safe.

Conclusion:

Mother/infant antiretroviral intensification was effective in preventing intrapartum transmission of HIV in pregnant women receiving ≤8 weeks antepartum cART.
Semiautomated Renal Cortex Volumetry in Multislice Computed Tomography: Effect of Slice Thickness and Iterative Reconstruction Algorithms
Authors: Houbois Christian , Haneder Stefan , Merkt Martin , Holz Jasmin A. , Morelli John , Kiel Alexandra , Doerner Jonas , Maintz David , Puesken Michael
Published: March 2020

Objective

The aim of the study was to evaluate the effect of slice thickness, iterative reconstruction (IR) algorithm, and kernel selection on measurement accuracy and interobserver variability for semiautomated renal cortex volumetry (RCV) with multislice computed tomography (CT).

Methods

Ten patients (62.4 ± 17.2 years) undergoing abdominal biphasic multislice computed tomography were enrolled in this retrospective study. Computed tomography data sets were reconstructed at 1-, 2-, and 5-mm slice thickness with 2 different IR algorithms (iDose, IMRST) and 2 different kernels (IMRS and IMRR) (Philips, the Netherlands). Two readers independently performed semiautomated RCV for each reconstructed data set to calculate left kidney volume (LKV) and split renal function (SRF). Statistics were calculated using analysis of variance with Geisser-Greenhouse correction, followed by Tukey multiple comparisons post hoc test. Statistical significance was defined as P ≤ 0.05.

Results

Semiautomated RCV of 120 data sets (240 kidneys) was successfully performed by both readers. Semiautomated RCV provides comparable results for LKV and SRF with 3 different slice thicknesses, 2 different IR algorithms, and 2 different kernels. Only the 1-mm slice thickness showed significant differences for LKV between IMRR and IMRS (P = 0.02, mean difference = 4.28 bb) and IMRST versus IMRS (P = 0.02, mean difference = 4.68 cm3) for reader 2. Interobserver variability was low between both readers irrespective of slice thickness and reconstruction algorithm (0.82 ≥ P ≥ 0.99).

Conclusions

Semiautomated RCV measurements of LKV and SRF are independent of slice thickness, IR algorithm, and kernel selection. These findings suggest that comparisons between studies using different slice thicknesses and reconstruction algorithms for RCV are valid.
Can Dual-Energy Computed Tomography Quantitative Analysis and Radiomics Differentiate Normal Liver From Hepatic Steatosis and Cirrhosis?
Authors: Doda Khera Ruhani , Homayounieh Fatemeh , Lades Felix , Schmidt Bernhard , Sedlmair Martin , Primak Andrew , Saini Sanjay , Kalra Mannudeep K.
Published: March 2020

Objectives

This study aimed to assess if dual-energy computed tomography (DECT) quantitative analysis and radiomics can differentiate normal liver, hepatic steatosis, and cirrhosis.

Materials and Methods

Our retrospective study included 75 adult patients (mean age, 54 ± 16 years) who underwent contrast-enhanced, dual-source DECT of the abdomen. We used Dual-Energy Tumor Analysis prototype for semiautomatic liver segmentation and DECT and radiomic features. The data were analyzed with multiple logistic regression and random forest classifier to determine area under the curve (AUC).

Results

Iodine quantification (AUC, 0.95) and radiomic features (AUC, 0.97) differentiate between healthy and abnormal liver. Combined fat ratio percent and mean mixed CT values (AUC, 0.99) were the strongest differentiators of healthy and steatotic liver. The most accurate differentiating parameters of normal liver and cirrhosis were a combination of first-order statistics (90th percentile), gray-level run length matrix (short-run low gray-level emphasis), and gray-level size zone matrix (gray-level nonuniformity normalized; AUC, 0.99).

Conclusion

Dual-energy computed tomography iodine quantification and radiomics accurately differentiate normal liver from steatosis and cirrhosis from single-section analyses.
Peristaltic Contrast Media Injection Improved Image Quality and Decreased Radiation and Contrast Dose When Compared With Direct Drive Injection During Liver Computed Tomography
Authors: Saade Charbel , Karout Lina , Khalife Sarah , Mayat Ahmad , Pillay Sugendran , Chan Edward , Maroun Gilbert , Alam Raquelle , Shattal Mohammad Abu , Naffaa Lena
Published: March 2020

Purpose

The aim of this study was to compare hepatic vascular and parenchymal image quality between direct and peristaltic contrast injectors during hepatic computed tomography (HCT).

Methods

Patients (n = 171) who underwent enhanced HCT and had both contrast media protocols and injector systems were included; group A: direct-drive injector with fixed 100 mL contrast volume (CV), and group B: peristaltic injector with weight-based CV. Opacification, contrast-to-noise ratio, signal-to-noise ratio, radiation dose, and CV for liver parenchyma and vessels in both groups were compared by paired t test and Pearson correlation. Receiver operating characteristic curve, visual grading characteristics, and Cohen κ were used.

Results

Contrast-to-noise ratio: compared with hepatic vein for functional liver, contrast-to-noise ratio was higher in group B (2.17 ± 0.83) than group A (1.82 ± 0.63); portal vein: higher in group B (2.281 ± 0.96) than group A (2.00 ± 0.66). Signal-to-noise ratio for functional liver was higher in group B (5.79 ± 1.58 Hounsfield units) than group A (4.81 ± 1.53 Hounsfield units). Radiation dose and contrast media were lower in group B (1.98 ± 0.92 mSv) (89.51 ± 15.49 mL) compared with group A (2.77 ± 1.03 mSv) (100 ± 1.00 mL). Receiver operating characteristic curve demonstrated increased reader in group B (95% confidence interval, 0.524–1.0) than group A (95% confidence interval, 0.545–1.0). Group B had increased revenue up to 58% compared with group A.

Conclusions

Image quality improvement is achieved with lower CV and radiation dose when using peristaltic injector with weight-based CV in HCT.
The Impact of Arterial Phase on the Detection of Cervical Lymph Node Metastasis From Papillary Thyroid Carcinoma: A Quantitative Evaluation on Multiphasic Computed Tomography
Authors: Gürsoy Çoruh Ayşegül , Uzun Çağlar , Kul Melahat , Akkaya Zehra , Halil Elhan Atilla , Gökcan Kürşat
Published: March 2020

Objective

The purpose of this study was to assess the diagnostic performance of multiphasic computed tomography (CT) in the discrimination of metastatic lymph nodes (LNs) of papillary thyroid cancer by using quantitative parameters.

Methods

This study enrolled 272 pathologically proven metastatic and benign LNs. Multiphasic CT was utilized by using nonenhanced, arterial (25-second delay), and venous (80-second delay) phases. Mean tissue attenuation values (MAVs) of metastatic and benign LNs were measured, and normalized MAV (common carotid artery and paraspinal muscle) and wash-in and wash-out percentages were also calculated.

Results

The arterial phase showed the highest diagnostic performance in differentiation (area under the curve ± standard error, 0.97 ± 0.02; 95% confidence interval, 0.94–1.0; P < 0.001). Cutoff values for MAVs, normalized MAVs, and wash-in and wash-out percentages to predict metastatic LNs were calculated as 109 HU, 0.33, 1.93, 122.5, and −5.6 (sensitivity: 93.4%, 93.3%, 90.4%, 94.1%, and 97.8%, and specificity: 99.3%, 90.4%, 98.5%, 92.6%, and 99.3%, respectively).

Conclusions

Early-phase enhanced CT and the use of quantitative parameters derived from multiphasic CT improve the detection of cervical lymph node metastasis from papillary thyroid cancer.
Diffuse Alveolar Hemorrhage in Primary Versus Secondary Antiphospholipid Syndrome
Authors: Sangli Swathi S. , Ryu Jay H. , Baqir Misbah
Published: March 2020

Background

Diffuse alveolar hemorrhage (DAH) occurs in patients with both primary and secondary antiphospholipid antibody syndrome (APS). We sought to determine the differences in clinical presentation, management, and outcomes of DAH in these patients.

Methods

We performed a medical records review study and reviewed 30 patients with DAH in the setting of primary and secondary antiphospholipid syndrome seen at our institution between January 1, 1997, and December 31, 2018. We analyzed their demographics, clinical presentation, laboratory values, imaging studies, lung pathology results, management, and outcomes.

Results

The patients in the secondary APS cohort were younger (median age, 48.5 vs 58 years) and comprised more females (75% vs 17%) compared with those with primary APS (p < 0.05). Two thirds of patients in the secondary APS group were anemic compared with less than one fourth in the primary APS group (p = 0.005). At the time of the first episode of DAH, the patients in the secondary APS required invasive and noninvasive ventilation, antibiotics, and combination immunosuppressive therapy (includes a combination of glucocorticoids with immunosuppressants or intravenous immunoglobulins or plasma exchange) more often compared with those with primary APS. There was only one in-hospital death (3% in-hospital mortality). One-year and 5-year mortality rates were 20% and 27%, respectively, with no significant difference between the primary and secondary APS groups.

Conclusions

Diffuse alveolar hemorrhage in the setting of APS, especially secondary APS, can be severe. However, in-hospital mortality is uncommon with current management strategies.
Examining Fall Risk Assessment in Geriatric Rehabilitation Settings Using Translational Research
Authors: Rivers Catherine A. , Roher Haley , Boissonault Bruce A. , Klinger Christopher A. , Mirza Raza M. , Foty Richard
Published: March 2020

Purpose

The objective of this study was to identify gaps in and to improve the falls prevention strategy (FPS) of an inpatient rehabilitation facility (IRF) in Toronto, Canada.

Design

A modified version of the Stanford Biodesign Methodology was used.

Methods

Chart reviews, a focus group (n = 8), and semistructured interviews (n = 8) were conducted to evaluate the FPS.

Findings

Admission Functional Independence Measure score, age, and gender significantly correlated with risk for a fall. The tool used at this IRF was not effectively capturing patients who were at high risk for falls. All healthcare providers interviewed were knowledgeable of fall risks; however, a patient’s fall risk status was rarely discussed as a team.

Conclusions

The findings informed recommendations to improve the overall FPS at this IRF.

Clinical Relevance

Staff may require more coaching for implementing preventative measures/ensuring accountability and evaluating whether current strategies work. These insights can guide improvement initiatives at similar facilities elsewhere.
Management and Reconstruction of a Massive Neonatal Neck Teratoma
Authors: Aivaz Marudeen , Manrique Monica , Bryant Justin R. , Mantilla-Rivas Esperanza , Oh Albert K. , Rogers Gary F. , Boyajian Michael J.
Published: March 2020

Cervical teratoma is a rare tumor comprised of multiple tissue types. These masses can result in significant functional and aesthetic complications, and surgical intervention is the mainstay of treatment. The authors report the treatment and 8-year follow-up of a patient born with a massive cervicofacial teratoma. The mass was diagnosed in utero and required perinatal airway management. The patient underwent several procedures to enhance his appearance and function early on in life with an excellent outcome at intermediate follow-up.
Incidence of Fistula Formation and Velopharyngeal Insufficiency in Early Versus Standard Cleft Palate Repair
Authors: Eliason Michael J. , Hadford Stephen , Green Lauren , Reeves Travis
Published: March 2020

The goals of cleft palate repair are well-established; however, there does exist difference in practice patterns regarding the most appropriate patient age for palatoplasty. The optimal timing is debated and influenced by cleft type, surgical technique, and the surgeon's training. The objective of this study was to compare the rates of post-operative fistula formation and velopharyngeal insufficiency (VPI) in “early” versus “standard” cleft palate repair in a cohort of patients treated at a single craniofacial center.

A retrospective chart review identified 525 patients treated for cleft palate from 2000 to 2017 with 216 meeting inclusion criteria. “Early repair” is defined as palatoplasty before 6-months of age (108 patients). “Standard repair” is palatoplasty at or beyond 6-months old (108 patients). Rates of fistula formation were found to be significantly higher in early repairs (Chi-square statistic 9.0536, P value = 0.0026). Development of VPI was not significantly different between the 2 groups (Chi-square statistic 1.2068, P value = 0.27196). As expected, the incidence of post-palatoplasty VPI was significantly higher in patients who had a post-operative fistula when compared to those who healed without fistula formation (Chi-square statistic 4.3627, P value = 0.0367).

There is significant debate regarding the optimal timing of cleft repair to maximize speech outcomes and minimize risks. The authors’ data show that post-operative fistula formation occurs at a higher rate when performed prior to 6 months old. Furthermore, while the rate of VPI was not significantly affected by age at time of surgery, it was significantly higher in those who experienced a post-operative fistula.
Effects of a Glycogen Synthase Kinase 3 Inhibitor Tideglusib on Bone Regeneration With Calvarial Defects
Authors: Lektemur Alpan Aysan , Çalişir Metin , Kizildağ Alper , Özdede Melih , Özmen Özlem
Published: March 2020

Tideglusib is a glycogen synthase kinase 3 (GSK-3) inhibitor which has shown the effects of bone regeneration, used for the treatment of Alzheimer disease. The aim of the study was to determine the effects of Tideglusib in the apoptosis and the bone regeneration in rats with calvarial defects. Twenty male Wistar rats (aged 11–13 weeks) were used for the study. Full-thickness flap elevated to exposure calvarial bone. Two 5 mm critical size calvarial defects were created on each rat calvarium. The defects were divided into 4 study groups: 1-Control (n = 10); 2- Gelatin sponge+Tideglusib (Gs+TDG; n = 10); 3- Autogenous bone (AB; n = 10); 4-Autogenous bone+Tideglusib (AB+TDG; n = 10). Then, the rats were sacrificed at fourth week. Three-dimensional imaging, histopathologic and immunohistochemical examinations were performed to evaluate the samples. The most increased bone formation and interaction between graft and new bone were observed in AB+TDG group. Bone morphogenic protein-2 (BMP-2), alkaline phosphatase (ALP), collagen type 1 (Col 1) and osteocalcin (OCN) was determined significantly higher in Tideglusib received groups compared with those of Control and AB groups (P < 0.05). Osteoclast numbers found to be higher in Gs+TDG and AB+TDG groups as well as RANKL expression dis not affected in Gs+TDG group but decreased in AB+TDG group comparing those of Control and AB groups. In addition, Tideglusib increased the Bcl-2 levels (P < 0.05) and decreased Bax levels (P > 0.05) in Tideglusib received groups compared with their controls. The administration of Tideglusib in calvarial bone defects increased bone mineral density, new bone area and total bone area by decreasing apoptosis and increasing osteoblastogenesis.
Intraoperative Hemorrhagic Shock in Cancer Surgical Patients: Short and Long-Term Mortality and Associated Factors
Authors: Hamon Annabelle , Mokart Djamel , Pouliquen Camille , Guibert Jean Manuel de , Cambon Sylvie , Duong Lam Nguyen , Lambaudie Eric , Sannini Antoine , Chow-Chine Laurent , Bisbal Magali , Ewald Jacques , Turrini Olivier , Faucher Marion
Published: March 2020

Background:

Management of hemorrhagic shock is well codified by international guidelines. These guidelines are predominantly based on trauma patients. We aimed to evaluate factors associated with 30-day mortality and long-term survival after intraoperative hemorrhagic shock during major oncological surgery.

Methods:

This retrospective study was conducted in a cancer referral center from January 2013 to February 2018. All adult cancer patients admitted in the operative room for scheduled or emergency oncological surgery associated with an intraoperative hemorrhagic shock were included.

Results:

Eighty-four patients were included in this study. The 30-day mortality rate was 26% (n = 22), the mean follow-up from the time of ICU admission was 20 months (95% CI, 15–25 months), 39 (46%) patients died during this period. Using logistic regression for multivariate analysis, factors independently associated with 30-day mortality were SAPS II score (odds ratio (OR) =1.056, 95% confident interval (CI) =1.010–1.1041), delta SOFA (SOFA score at day 3 – SOFA score at day 1) (OR= 1.780, 95% CI 1.184–2.677) and ISTH-DIC score (OR = 2.705, 95% CI 1.108–6.606). Using Cox multivariate analysis, factors associated with long-term mortality were delta SOFA (hazard ratio (HR) =1.558, 95% CI 1.298–1.870), ISTH-DIC score (HR = 1.381, 95% CI 1.049–1.817), hepatic dysfunction (HR = 7.653, 95% CI 2.031–28.842), and Charlson comorbidity index (HR = 1.330, 95% CI 1.041–1.699).

Conclusion:

The worsening of organ dysfunctions during the first 3 days of ICU admission as well as intraoperative coagulation disturbances (increased ISTH-DIC score) are independently associated with short and long-term mortality. Comorbidities (Charlson comorbidity index) and postoperative hepatic dysfunction were independently associated with long-term mortality. Early perioperative bundle strategies should be evaluated in order to improve patient's survival in this specific situation.
Time to Hemorrhage Control in a Hybrid ER System: Is It Time to Change?
Authors: Tatum Danielle , Pereira Bruno , Cotton Bryan , Khan Mansoor , Brenner Megan , Ferrada Paula , Hörer Tal , Kauvar David , Kirkpatrick Andrew , Ordonez Carlos , Pirouzram Artai , Roberts Derek , Duchesne Juan
Published: March 2020

Time to hemorrhage control is critical, as mortality in patients with severe hemorrhage that arrive to trauma centers with sign of life remains over 40%. Prompt identification and management of severe hemorrhage is paramount to reducing mortality. In traditional US trauma systems, the early hospital course of a severely hemorrhaging patient typically proceeds from the trauma resuscitation bay to the operating room or angiography suite with a potential stop for radiological imaging. This protracted journey can prove fatal as it consumes valuable minutes. In contrast to the current US system is a newly developed and increasingly adopted system in Japan called the hybrid emergency room system (HERS). The hybrid ER is equipped to allow resuscitation, imaging, and damage control intervention to occur in the ER without the need to transport the patient to a subsequent destination. The HERS is relatively new and remains restricted to a small number of institutions, limiting the ability to robustly examine impact(s) on patient outcomes. Even if proven to yield superior outcomes, there are significant obstacles to adopting the HERS in the US. Challenges such as the high cost of building and implementing a HER system, return on investment, and the significant differences between the US and Japan in terms of physician training, trauma center, and reimbursement schemes may render the hybrid ER system to be unfeasible in most current trauma centers. Barriers aside, the Japanese hybrid ER system remains the most novel recent advancement in the quest to reduce potentially preventable mortality from hemorrhage.
Validation of the American Association for the Surgery of Trauma grading system for acute appendicitis severity
Authors: Mouch Charles A. , Cain-Nielsen Anne H. , Hoppe Beckie L. , Giudici Maria P. , Montgomery John R. , Scott John W. , Machado-Aranda David A. , Hemmila Mark R.
Published: March 2020

OBJECTIVE

The American Association for the Surgery of Trauma (AAST) developed an anatomic grading system to assess disease severity through increasing grades of inflammation. Severity grading can then be utilized in risk-adjustment and stratification of patient outcomes for clinical benchmarking. We sought to validate the AAST appendicitis grading system by examining the ability of AAST grade to predict clinical outcomes used for clinical benchmarking.

METHODS

Surgical quality program data were prospectively collected on all adult patients undergoing appendectomy for acute appendicitis at our institution between December 2013 and May 2018. The AAST acute appendicitis grade from 1 to 5 was assigned for all patients undergoing open or laparoscopic appendectomy. Primary outcomes were occurrence of major complications, any complications, and index hospitalization length of stay. Multivariable models were constructed for each outcome without and with inclusion of the AAST grade as an ordinal variable. We also developed models using International Classification of Diseases, 9th or 10th Rev.—Clinical Modification codes to determine presence of perforation for comparison.

RESULTS

A total of 734 patients underwent appendectomy for acute appendicitis. The AAST score distribution included 561 (76%) in grade 1, 49 (6.7%) in grade 2, 79 (10.8%) in grade 3, 33 (4.5%) in grade 4, and 12 (1.6%) in grade 5. The mean age was 35.3 ± 14.7 years, 47% were female, 20% were nonwhite, and 69% had private insurance. Major complications, any complications, and hospital length of stay were all positively associated with AAST grade (p < 0.05). Risk-adjustment model fit improved after including AAST grade in the major complications, any complications, and length of stay multivariable regression models. The AAST grade was a better predictor than perforation status derived from diagnosis codes for all primary outcomes studied.

CONCLUSION

Increasing AAST grade is associated with higher complication rates and longer length of stay in patients with acute appendicitis. The AAST grade can be prospectively collected and improves risk-adjusted modeling of appendicitis outcomes.

LEVEL OF EVIDENCE

Prospective/Epidemiologic, Level III.
Disparities in rural versus urban field triage: Risk and mitigating factors for undertriage
Authors: Deeb Andrew-Paul , Phelos Heather M. , Peitzman Andrew B. , Billiar Timothy R. , Sperry Jason L. , Brown Joshua B.
Published: March 2020

BACKGROUND

There are well-known disparities for patients injured in rural setting versus urban setting. Many cite access to care; however, the mechanisms are not defined. One potential factor is differences in field triage. Our objective was to evaluate differences in prehospital undertriage (UT) in rural setting versus urban settings.

METHODS

Adult patients in the Pennsylvania Trauma Outcomes Study (PTOS) registry 2000 to 2017 were included. Rural/urban setting was defined by county according to the Pennsylvania Trauma Systems Foundation. Rural/urban classification was performed for patients and centers. Undertriage was defined as patients meeting physiologic or anatomic triage criteria from the National Field Triage Guidelines who were not initially transported to a Level I or Level II trauma center. Logistic regression determined the association between UT and rural/urban setting, adjusting for transport distance and prehospital time. Models were expanded to evaluate the effect of individual triage criteria, trauma center setting, and transport mode on UT.

RESULTS

There were 453,112 patients included (26% rural). Undertriage was higher in rural patients (8.6% vs. 3.4%,p< 0.01). Rural setting was associated with UT after adjusting for distance and prehospital time (odds ratio [OR], 3.52; 95% confidence interval [CI], 1.82–6.78;p< 0.01). Different triage criteria were associated with UT in rural/urban settings. Rural setting was associated with UT for patients transferred to an urban center (OR, 3.32; 95% CI, 1.75–6.25;p< 0.01), but not a rural center (OR, 0.68; 95% CI, 0.08–5.53;p= 0.72). Rural setting was associated with UT for ground (OR, 5.01; 95% CI, 2.65–9.46;p< 0.01) but not air transport (OR, 1.18; 95% CI, 0.54–2.55;p= 0.68).

CONCLUSION

Undertriage is more common in rural settings. Specific triage criteria are associated with UT in rural settings. Lack of a rural trauma center requiring transfer to an urban center is a risk factor for UT of rural patients. Air medical transport mitigated the risk of UT in rural patients. Provider and system interventions may help reduce UT in rural settings.

LEVEL OF EVIDENCE

Care Management, Level IV.
Georgenia wutianyii sp. nov. and Georgenia yuyongxinii sp. nov. isolated from plateau pika (Ochotona curzoniae) on the Qinghai–Tibet plateau of China
Authors: Tian Zhi , Zhang Dezhu , Lu Shan , Jin Dong , Yang Jing , Pu Ji , Lai Xin-He , Huang Ying , Lei Wenjing , Zhang Sihui , Li Junqin , Dong Kui , Wang Suping , Xu Jianguo
Published: March 2020

Four novel bacterial strains, designated Z294T, Z311, Z443T and Z446, were isolated from the intestinal contents of plateau pika (Ochotona curzoniae) on the Qinghai–Tibet Plateau of China. Cells were Gram-stain-positive, catalase-positive, oxidase-negative, aerobic, non-motile and short-rod shaped. Phylogenetic analyses based on 16S rRNA gene sequences indicated that the four isolates belong to the genus

Georgenia

, but clearly separate from the currently recognized species. Both type strains (Z294T and Z443T) shared low 16S rRNA gene sequence similarity, digital DNA–DNA hybridization relatedness and average nucleotide identity values with Georginia satyanarayanai NBRC 107612T,

G. subflava

JCM 19765T,

G. ruanii

JCM 15130T and

G. thermotolerans

DSM 21501T and against each other. The genomic DNA G+C contents of strains Z294T and Z443T were 73.3 and 70 %, respectively. The major cellular fatty acids of strain Z294T were anteiso-C15 : 0, anteiso-C15 : 1 A and C16 : 0, in contrast to anteiso-C15 : 0 and anteiso-C15 : 1 A for strain Z443T. Both type strains (Z294T and Z443T) shared the following common features: glucose, rhamnose and ribose as cell-wall sugars; MK-8(H4) as major menaquinone; alanine, glutamic acid and lysine as cell-wall amino acids; and diphosphatidylglycerol, phosphatidylglycerol, phosphatidylinositol, phosphatidylinositol mannoside and one unidentified phosphoglycolipid as polar lipids. Comparing the phenotypic and phylogenetic features among the four strains and their related organisms, strains Z294T and Z443T represent two novel species within the genus

Georgenia

, for which the names Georgenia wutianyii sp. nov. (type strain Z294T=CGMCC 1.16428T=DSM 106344T) and Georgenia yuyongxinii sp. nov. (type strain Z443T=CGMCC 1.16435T=DSM 106174T) are proposed.
Giving Voice to Patients Through Interviews and Qualitative Analysis- A Pilot Study
Authors: Loxton Matthew H , Okoli Ebele
Published: March 2020

Modern healthcare is drowning in data, and burdened by quality, safety, financial, and operational metrics, but few relate directly to how patients experiences their care. The literature lacks sufficient specificity on how care processes are seen through the eyes of the patient.

To fill a gap in awareness of the patient experience of the radiology processes, we used a multimethod qualitative approach to elicit the patient view of their radiology experiences and insights from the patient voice. We developed a typology of patient experiences of the radiology processes that centered on communication gaps, and reflected opacity, fragility, and unpredictability of administrative and care processes in radiology that failed to interconnect efficiently or effectively, and did not work well as an end-to-end patient journey. Care processes were described by participants as fragile, solitary, and opaque, and required constant vigilance, supervision, and assistance by patients. Participants described a need for improved communication between radiology staff and patients that focuses on the patient journey and helps to identify and mitigate causes of process opacity and fragility.
Regaining perspective on SARS-CoV-2 molecular tracing and its implications
Authors: Mavian Carla , Marini Simone , Manes Costanza , Capua Ilaria , Prosperi Mattia , Salemi Marco
Published: March 2020

During the past three months, a new coronavirus (SARS-CoV-2) epidemic has been growing exponentially, affecting over 100 thousand people worldwide, and causing enormous distress to economies and societies of affected countries. A plethora of analyses based on viral sequences has already been published, in scientific journals as well as through non-peer reviewed channels, to investigate SARS-CoV-2 genetic heterogeneity and spatiotemporal dissemination. We examined all full genome sequences currently available to assess the presence of sufficient information for reliable phylogenetic and phylogeographic studies. Our analysis clearly shows severe limitations in the present data, in light of which any finding should be considered, at the very best, preliminary and hypothesis-generating. Hence the need for avoiding stigmatization based on partial information, and for continuing concerted efforts to increase number and quality of the sequences required for robust tracing of the epidemic.
Automatic multi-object organ detection and segmentation in abdominal CT data
Authors: Mietzner Oliver , Mastmeyer Andre
Published: March 2020

The ability to generate 3D patient models in a fast and reliable way, is of great importance, e.g. for the simulation of liver punctures in virtual reality simulations. The aim is to automatically detect and segment abdominal structures in CT scans. In particular in the selected organ group, the pancreas poses a challenge. We use a combination of random regression forests and 2D U-Nets to detect bounding boxes and generate segmentation masks for five abdominal organs (liver, kidneys, spleen, pancreas). Training and testing is carried out on 50 CT scans from various public sources. The results show Dice coefficients of up to 0.71. The proposed method can theoretically be used for any anatomical structure, as long as sufficient training data is available.