bluuebunny/crossref_metadata_2025 huggingface dataset:
Opioid system modulation of cognitive affective bias: implications for the treatment of mood disorders
Authors: Varastehmoradi Bardia , Wegener Gregers , Sanchez Connie , Smith Karen L.
Published: March 2020

A significant number of patients (30%) do not adequately respond to commonly prescribed antidepressants (e.g. SSRIs, SNRIs, and TCAs). Opioid receptors and their endogenous peptides have demonstrated a clear role in the regulation of mood in animal models and may offer an alternative approach to augment existing therapies. Nevertheless, there is an urgent need to find better ways to predict a patient’s response to drug treatment, to improve overall drug responding, and to reduce the time to symptom remission using novel diagnostic and efficacy biomarkers. Cognitive processes, such as perception, attention, memory, and learning, are impaired in patients with mood disorders. These processes can be altered by emotions, a phenomenon called cognitive affective bias. Negative affective biases are a key feature of major depressive disorder (MDD) and may present concurrently with other cognitive deficits. Importantly, a significant percentage of patients report residual cognitive impairments even after effective drug treatment. This approach offers a new opportunity to predict patient treatment responses, potentially improving residual cognitive symptoms and patient outcomes. This review will (1) describe the underlying neurocircuitry of affective cognition and propose how negative biases may occur, (2) outline the role of opioid receptors in affective cognition, executive function, and MDD, and (3) present evidence from the published literature supporting a modulatory role for opioid drugs on negative affective bias, with a focus on kappa-opioid receptor antagonists, currently in development for clinical use for treatment-resistant MDD.
Superthin Thoracodorsal Artery Perforator Flap for the Reconstruction of Palmar Burn Contracture
Authors: Hattori Yoshitsugu , Harima Mitsunobu , Yamashita Shuji , Iida Takuya , Niu Atsushi
Published: March 2020

Treating burn scar contractures is challenging. Although free flap transfer is an effective tool for hand reconstruction, free flaps are often bulky, causing functional disturbance and poor cosmetic appearance. Secondary debulking operations are required, resulting in a prolonged total treatment period and delayed return to daily life and work for the patient. Therefore, 1-stage reconstruction using a thin and pliable flap is ideal. In this report, we present the superthin TDAP flap as an option for the reconstruction of postburn palmar contracture. During TDAP flap elevation, the thoracodorsal artery perforator was identified and traced distally until its penetration into the dermis. Subsequently, the subdermal tissue was removed and a uniformly superthin TDAP flap was elevated. Postoperatively, early functional recovery was achieved with excellent palmar contour and texture. No revision surgery was required and no recurrence of contractures occurred during the 6-month follow-up. This procedure is useful in elevating a superthin TDAP flap and is a feasible option for the reconstruction of working surfaces, such as the palm.
Designing Occupational Safety and Health Training Materials for Clear Communication
Authors: Sinyai Clayton , Barlet Grace
Published: March 2020

Introduction:

Printed materials are an essential part of occupational safety and health programs. Public health professionals at the Centers for Disease Control and Prevention (CDC) have created a Clear Communication Index (CCI) to guide design of health education materials for the general public.

Methods:

We revised an existing handout on heat exposure hazards in construction using the CCI and tested the old and new versions of the handout with an audience of 425 construction apprentices and journey-level workers.

Results:

Some features recommended by the CCI—such as the use of subheadings, numbering, and other visual cues—strongly conditioned the readers’ understanding of the main message.

Conclusions:

Design and layout have a significant impact on the delivery of messages in written materials. A communications-based rubric such as the CCI can help writers preparing written occupational safety and health materials for workers and general audiences.
Improvement in Bone Mineral Density after a Distal Weight-Bearing Implant in a Series of 13 Cases
Authors: Guirao Cano Lluis , Samitier Pastor Beatriz , Maldonado Garrido Dolores , Rodriguez-Piñero Duran Manuel , Exposito Tirado Jose , Peraita-Costa Isabel , Morales-Suarez-Varela Maria
Published: March 2020

Introduction

The amputation of lower limbs and the subsequent use of a prosthesis require the adoption of new biomechanical patterns of load and gait by the patient, which may favor the onset of local or generalized bone mineral density loss. Osseo-anchored implants that allow distal weight bearing of the residuum may be able to mitigate bone mineral density loss related to amputation. The objective of this study is to determine the effect of the use of a distal weight-bearing implant on the bone mineral density of the amputated limb in relation to the nonamputated limb.

Materials and Methods

An interrupted time series clinical trial carried out in the Outpatient Department of Rehabilitation of the five participant hospitals. Thirteen patients with previous transfemoral amputations of traumatic, oncologic, and vascular etiology were enrolled. These patients underwent surgical implantation of an osseo-anchored implant with a distal spacer that allows a direct load on the residuum over the distal surface of the socket. Patients were followed for a 14-month period and assessed presurgically and postsurgically using dual-energy x-ray absorptiometry of the femur neck.

Results

The mean increase in bone mineral density for the amputated limb was 0.020 g/cm2, which represented a mean percentage increase of 3.0%. For the nonamputated limb, the mean increase in bone mineral density was 0.005 g/cm2 and the mean percentage increase was 0.5%, with eight patients showing improvements in bone mineral density. The mean percentage of bone mineral density of the amputated limb in comparison with the nonamputated limb was 70.6% preimplantation and 73.2% postimplantation, with an average increase of 2.6%.

Conclusions

The results of this study show an improvement in bone mineral density in individuals with transfemoral amputation 14 months after having received a distal weight-bearing implant.
Prognostic implications of coronary artery stenosis and coronary spasm in patients with stable angina: 5-year follow-up of the Abnormal COronary VAsomotion in patients with stable angina and unobstructed coronary arteries (ACOVA) study
Authors: Seitz Andreas , Morár Nathalie , Pirozzolo Giancarlo , Athanasiadis Anastasios , Bekeredjian Raffi , Sechtem Udo , Ong Peter
Published: March 2020

Background

In the Abnormal COronary VAsomotion in patients with stable angina and unobstructed coronary arteries study, we showed that 62% of patients with stable angina and unobstructed coronary arteries had coronary spasm. In this study, we sought to assess the 5-year prognosis in these patients.

Methods

Data regarding the following endpoints were obtained: death, non-fatal myocardial infarction, coronary event (=cardiac death or non-fatal myocardial infarction), persistent angina and repeated coronary angiography. Quality of life was assessed using the Seattle Angina Questionnaire.

Results

Among patients with unobstructed coronary arteries there were three deaths (2.9%) and no non-fatal myocardial infarction. Among those with obstructive CAD 15 died (13.8%) and three had a non-fatal myocardial infarction (2.8%). Patients with obstructive CAD had a higher rate of all-cause death and coronary events compared to those without (P = 0.004). Persistent angina was more prevalent in patients with unobstructed coronaries (P = 0.042). Prognosis of patients with unobstructed coronaries regarding hard clinical events, persistent angina and repeated coronary angiography was independent of the presence of coronary spasm (all P > 0.05). However, spasm patients were more likely to take nitrate medication at follow-up (P = 0.029).

Conclusion

Patients with stable angina and unobstructed coronary arteries have a favorable prognosis regarding mortality and non-fatal myocardial infarction after 5 years compared to patients with obstructive CAD irrespective of the presence of coronary artery spasm. However, persistent angina remains a common issue in patients with unobstructed coronary arteries leading to a similar frequency of repeated invasive procedures as in patients with obstructive CAD.
Instantaneous wave-free ratio cutoff values for nonculprit stenosis classification in patients with ST-segment elevation myocardial infarction (an iSTEMI substudy)
Authors: Thim Troels , Götberg Matthias , Fröbert Ole , Nijveldt Robin , van Royen Niels , Baptista Sergio Bravo , Koul Sasha , Kellerth Thomas , Bøtker Hans Erik , Terkelsen Christian Juhl , Christiansen Evald Høj , Jakobsen Lars , Kristensen Steen Dalby , Maeng Michael
Published: March 2020

Objectives

The instantaneous wave-free ratio cutoff value of <0.90 for hemodynamic significance of coronary stenoses has been validated in stable patients. We examined different cutoff values in the evaluation of nonculprit stenoses in patients with ST-segment elevation myocardial infarction.

Methods

We measured instantaneous wave-free ratio across nonculprit stenoses in the acute setting and at follow-up in 120 patients with ST-segment elevation myocardial infarction and 157 nonculprit stenoses, of which, 113 patients with 147 nonculprit stenoses completed follow-up.

Methods

The prevalence of nonculprit stenosis hemodynamic significance was 52% in the acute setting and 41% at follow-up. With follow-up, instantaneous wave-free ratio as reference, acute instantaneous wave-free ratio >0.90 had a negative predictive value of 89%. Acute instantaneous wave-free ratio <0.90 had a positive predictive value of 68%. Acute instantaneous wave-free ratio >0.93 had a negative predictive value of 100%. Acute instantaneous wave-free ratio <0.86 and <0.83 had positive predictive values of 71 and 77%. Using acute instantaneous wave-free ratio <0.90 as cutoff for hemodynamic significance yielded the highest degree of classification agreement between acute and follow-up instantaneous wave-free ratio.

Conclusions

In patients with ST-segment elevation myocardial infarction, acute instantaneous wave-free ratio with the cutoff values <0.90 for hemodynamic significance appears optimal in the evaluation of nonculprit stenoses and has a high negative predictive value and a moderate positive predictive value.
Neuroplasticity of Cortical Planning for Initiating Stepping Poststroke: A Case Series
Authors: Peters Sue , Ivanova Tanya D. , Lakhani Bimal , Boyd Lara A. , Garland S. Jayne
Published: March 2020

Background and Purpose:

Therapeutic exercise improves balance and walking ability in individuals after stroke. The extent to which motor planning improves with therapeutic exercise is unknown. This case series examined how outpatient physical therapy affects motor planning and motor performance for stepping.

Case Description:

Individuals poststroke performed self-initiated stepping before (baseline), after (postintervention), and 1 month after (retention) intervention. Amplitude and duration of the movement-related cortical potential (MRCP) was measured using an electroencephalograph from the Cz electrode. Electromyography (EMG) of biceps femoris (BF) was collected. Additionally, clinical measures of motor impairment and function were evaluated at all 3 time points by a blinded assessor.

Intervention:

Two types of outpatient physical therapy were performed for 6 weeks: CONVENTIONAL (n = 3) and FAST (n = 4, Fast muscle Activation and Stepping Training).

Outcomes:

All 7 participants reduced MRCP duration, irrespective of the type of physical therapy. The MRCP amplitude and BF EMG onset changes were more variable. Clinical outcomes improved or were maintained for all participants. The extent of motor impairment was associated with MRCP amplitude.

Discussion:

Changes in MRCP duration suggest that outpatient physical therapy may promote neuroplasticity of motor planning of stepping movements after stroke; however, a larger sample is needed to determine whether this finding is valid.

This case series suggests motor planning for initiating stepping may improve after 6 weeks of outpatient physical therapy for persons with stroke.

Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A307).
A 12-month Prospective Study of Tear Osmolarity in Contact Lens Wearers Refitted with Daily Disposable Soft Contact Lenses
Authors: Garaszczuk Izabela Katarzyna , Mousavi Maryam , Szczesna-Iskander Dorota H. , Cerviño Alejandro , Iskander D. Robert
Published: March 2020

SIGNIFICANCE

Tear osmolarity has been reported as one of the best diagnostic tests for dry eye disease and its management. Contact lens wear is thought to influence tear homeostasis. Understanding how regular wear of contact lenses and their type affect tear osmolarity is important.

PURPOSE

The purpose of this study was to assess changes in tear osmolarity and ocular symptoms over a period of 12 months following refitting contact lens wearers with daily disposable contact lenses.

METHODS

Fifty subjects aged (mean ± SD) 26 ± 4 years were refitted with either silicone-hydrogel (delefilcon A, SiHy, n = 34) or hydrogel (omafilcon A, Hy, n = 16) daily disposable soft contact lenses. Study included seven visits: baseline measurements without contact lenses; two visits for contact lens fit and selection; follow-up measurements after 3, 6, and 12 months of contact lens wear; and a post-study visit without contact lenses. Lens type selection was based on a set of objective measurements. Subjects were instructed to follow strict wearing rules. Impedance-based osmometer was used to collect samples from the lower tear meniscuses. The Ocular Surface Disease Index (OSDI) and the eight-item Contact Lens Dry Eye Questionnaire were used to assess subject-reported ocular symptoms and contact lens discomfort, respectively.

RESULTS

Downward trend of tear osmolarity was noted over the time course of study. Statistically significant differences were noted in tear osmolarity (Friedman test, χ2= 21.91 [P< .001], and χ2= 13.89 [P= .003]) for the right and left eyes, respectively. A statistically significant decrease in tear osmolarity was apparent only for initially symptomatic subjects (for OSDI ≥13: χ2= 26.25,P< .001; for OSDI <13: χ2= 5.65,P= .13). Statistically significant differences were not noted in OSDI and the eight-item Contact Lens Dry Eye Questionnaire between the baseline and 12-month visit (χ2= 5.92 [P= .12] andR= 0.015 [P= .87], respectively). There was a difference between baseline and post-study visits (P= .002) in OSDI, showing lower score at the latter visit.

CONCLUSIONS

Refitting with daily disposable contact lenses was demonstrated to lower tear osmolarity.
Evaluation Using Spectral-Domain Optical Coherence Tomography of the Effects of Malnutrition on Ocular Parameters in Pediatric Patients
Authors: Tekin Mehmet , Simsek Ali , Bilak Semsettin , Konca Capan , Almis Habip , Bilen Abdurrahman
Published: March 2020

SIGNIFICANCE

We determined decreases in choroidal thickness and retinal nerve fiber layer (RNFL) thickness in all quadrants. Our findings show that the choroid and RNFL are affected before the emergence of ocular symptoms in malnourished children.

PURPOSE

We aimed to determine whether the RNFL, a component of the neuronal structure, and the choroid, supplying the retina, are affected in children with malnutrition using spectral-domain optical coherence tomography.

METHODS

One hundred twenty-six malnourished patients without ocular symptoms, aged between 5 and 10 years, and 116 healthy children were included in the study. Age, sex, weight-for-age (WFA) z score, height-for-age z score, body mass index–for–age z score, and spectral-domain optical coherence tomography data were recorded.

RESULTS

Average RNFL thickness was 96.5 μm (82.0 to 128.0 μm) in the malnutrition group and 111.0 μm (95.0 to 128.0 μm) in the control group (P < .001). Retinal nerve fiber layer thickness was statistically significantly lower in all quadrants in malnourished patients compared with the control group. Median choroidal thickness in the foveal center was 304.0 μm (250.0 to 375.0 μm) in the malnutrition group and 345.0 μm (280.0 to 403.0 μm) in the control group (P < .001). Choroidal thickness in all quadrants was also statistically significantly lower in malnourished patients. Positive correlation was determined between average RNFL thicknesses and WFA z score. Average RNFL thickness decreased as WFA z score decreased (r = 0.730 and P < .001). Positive correlation was also observed between choroidal thickness in the foveal center and WFA z score. Foveal center choroidal thickness decreased in line with WFA z score (r = 0.786 and P < .001).

CONCLUSIONS

Our results show that the retinal nerve fiber layer and choroidal thickness decreased in malnourished children without clinically reported ocular symptoms. A decreased retinal nerve fiber layer and choroidal thickness may be an important clue to the prevention of retinal pathologies that may develop at later ages if the malnutrition is not addressed.
An International Survey Comparing Different Physician Models for Health Care Delivery to Critically Ill Children With Heart Disease
Authors: Bhaskar Priya , Rettiganti Mallikarjuna , Sadot Efraim , Paul Thomas , Garros Daniel , Frankel Lorry R. , Reemtsen Brian , Butt Warwick , Gupta Punkaj
Published: March 2020

Objectives:

To explore relationships between the training background of cardiac critical care attending physicians and self-reported perceived strengths and weaknesses in their ability to provide clinical care.

Design:

Cross-sectional observational survey sent worldwide to ~550 practicing cardiac ICU attending physicians.

Setting:

Hospitals providing cardiac critical care.

Subjects:

Practicing cardiac critical care physicians.

Interventions:

None.

Measurements and Main Results:

We received responses from 243 ICU attending physicians from 82 centers (14 countries). The primary training background of the respondents included critical care (62%), dual training in critical care and cardiology (16%), cardiology (14%), and other (8%). We received 49 responses from medical directors in nine countries, who reported that the predominant training background for attending physicians who provide cardiac intensive care at their institutions were critical care (58%), dual trained (18%), cardiology (12%), and other (11%). A greater proportion of physicians trained in either critical care or dual-training reported feeling confident managing multiple organ failure, neurologic conditions, brain death, cardiac arrest, and performing procedures like advanced airway placement and inserting chest- and abdominal-drains. In contrast, physicians with cardiology and dual-training reported feeling more confident managing intractable arrhythmias, understanding cardiopulmonary interactions, and interpreting echocardiogram, electrocardiogram, and cardiac catheterization. Overall, only 57% of the respondents felt comfortable based on their current training background to manage patients with complex cardiac issues without collaboration with other specialists.

Conclusions:

Our survey demonstrates that intensivists trained in critical care are more comfortable with critical care skills, cardiology-trained intensivists are more comfortable with cardiology skills, and dual-trained physicians are comfortable with both critical care skills and cardiology skills. These findings may help inform future efforts to optimize the educational curriculum and training pathways for future cardiac intensivists. These data may also be used to shape continuing medical education activities for cardiac intensivists who have already completed their training.
Readiness for Hospital Discharge, Stress, and Coping in Mothers of Children Undergoing Cardiac Surgeries: A Single-Center Prospective Study
Authors: Poh Pei-Fen , Lee Jan Hau , Loh Yee Jim , Tan Teng Hong , Cheng Karis Kin Fong
Published: March 2020

Objectives:

To examine the relationship between stress, coping, and discharge readiness in mothers of children undergoing congenital heart surgeries.

Design:

Quantitative descriptive study at three time points: pre surgery (time point I), day of hospital discharge (time point II) and 2 weeks following discharge (time point III).

Setting:

Tertiary care pediatric hospital in Singapore.

Participants:

One hundred mothers whose children had undergone congenital heart surgeries.

Measurements and Main Results:

Data collection included self-reported questionnaires of the Pediatric Inventory for Parents and the Coping Health Inventory for Parents across three time points. Readiness for Hospital Discharge Scale was administered at hospital discharge (time point II). The utilization of health services and support was reported at post discharge (time point III). One-hundred mothers participated in this study between May 2016 and July 2017. Their mean age was 35.8 years (sd = 7.0), and the mean age of their children was 3.7 years (sd = 4.6). There was significant reduction in mean stress difficulty (Pediatric Inventory for Parents) of mothers (F = 4.58; p = 0.013) from time point I to III. No significant changes were found in the overall mean coping score (Coping Health Inventory for Parents) of mothers across time. The mean overall score for the readiness for discharge (Readiness for Hospital Discharge Scale) of mothers at hospital discharge was 207.34 (sd = 29.22). Coping through family integration subscale and communication stress predicted discharge readiness of mothers (adjusted R
2 = 0.11; p = 0.034). Mothers who reported higher overall stress (Pediatric Inventory for Parents) 2 weeks post discharge were more likely to call a friend or family member, visit the emergency department, or have their child readmitted to hospital following hospital discharge.

Conclusions:

We identified coping by family integration and communication-related stress as predictors of readiness for discharge. Strategies targeted at communication and family integration for discharge preparation may improve caregivers’ readiness for hospital discharge.
Methylene Blue for Refractory Shock in Children: A Systematic Review and Survey Practice Analysis
Authors: Otero Luna Andrea V. , Johnson Rachel , Funaro Melissa , Canarie Michael F. , Pierce Richard W.
Published: March 2020

Objectives:

Shock refractory to fluid and catecholamine therapy has significant morbidity and mortality in children. The use of methylene blue to treat refractory shock in children is not well described. We aim to collect and summarize the literature and define physicians’ practice patterns regarding the use of methylene blue to treat shock in children.

Design:

We conducted a systematic search of MEDLINE, Embase, PubMed, Web of Science, Cochrane for studies involving the use of methylene blue for catecholamine-refractory shock from database inception to 2019. Collected studies were analyzed qualitatively. To describe practice patterns of methylene blue use, we electronically distributed a survey to U.S.-based pediatric critical care physicians. We assessed physician knowledge and experience with methylene blue. Survey responses were quantitatively and qualitatively evaluated.

Setting:

Pediatric critical and cardiac care units.

Patients or Subjects:

Patients less than or equal to 25 years old with refractory shock treated with methylene blue.

Interventions:

None.

Measurements and Main Results:

One-thousand two-hundred ninety-three abstracts met search criteria, 139 articles underwent full-text review, and 24 studies were included. Studies investigated refractory shock induced by a variety of etiologies and found that methylene blue was generally safe and increased mean arterial blood pressure. There is overall lack of studies, low number of study patients, and low quality of studies identified. Our survey had a 22.5% response rate, representing 125 institutions. Similar proportions of physicians reported using (40%) or never even considering (43%) methylene blue for shock. The most common reasons for not using methylene blue were unfamiliarity with this drug, its proper dosing, and lack of evidentiary support.

Conclusions:

Methylene blue appears safe and may benefit children with refractory shock. There is a stark divide in familiarity and practice patterns regarding its use among physicians. Studies to formally assess safety and efficacy of methylene blue in treating pediatric shock are warranted.
Spontaneous Breathing and Imposed Work During Pediatric Mechanical Ventilation: A Bench Study*
Authors: van Dijk Jefta , Blokpoel Robert G. T. , Koopman Alette A. , Brandsema Ruben , Newth Christopher J. L. , Kneyber Martin C. J.
Published: March 2020

Objectives:

To calculate imposed work of breathing during simulated spontaneous breathing at a given tidal volume across the range of normal length or shortened pediatric endotracheal tube sizes and endotracheal tubes with an intraluminal catheter in situ.

Design:

In vitro study.

Setting:

Research laboratory.

Interventions:

A bench model (normal compliance, no airway resistance) simulating sinusoid flow spontaneous breathing used to calculate imposed work of breathing for various endotracheal tube sizes (3.0–7.5 mm). Imposed work of breathing was calculated by integrating inspiratory tidal volume over the end-expiratory difference between the positive end-expiratory pressure and the tracheal pressure. Measurements were taken at different combinations of set spontaneous tidal volume (2.5, 5.0, 7.5, and 10 mL/kg), age-appropriate inspiratory times, length of endotracheal tube, and presence of intraluminal catheter.

Measurements and Main Results:

Overall median imposed work of breathing (Joules/L) was not significantly different between the four age groups: 0.047 Joules/L (interquartile range, 0.020–0.074 Joules/L) for newborns, 0.077 Joules/L (interquartile range, 0.032–0.127 Joules/L) for infants, 0.109 Joules/L (interquartile range, 0.0399–0.193 Joules/L) for small children, and 0.077 Joules/L (interquartile range, 0.032–0.132 Joules/L) for adolescents. Shortening the endotracheal tubes resulted in a significant difference in reduction in overall imposed work of breathing, but the absolute reduction was most notable in small children (0.030 Joules/L) and the least effect in neonates (0.016 Joules/L). Overall imposed work of breathing increased in each age group when an intraluminal catheter was in situ: 91.09% increase in imposed work of breathing in neonates to 0.168 Joules/L, 84.98% in infants to 0.142 Joules/L, 81.98% in small children to 0.219 Joules/L, and 55.45% in adolescents to 0.140 Joules/L.

Conclusions:

Calculated imposed work of breathing were not different across the range of endotracheal tube sizes. The low imposed work of breathing values found in this study might be appreciated as clinically irrelevant. Our findings add to the change in reasoning that it is appropriate to perform spontaneous breathing trials without pressure support. Nonetheless, our findings on the measured imposed work of breathing values need to be confirmed in a clinical study.
Extracorporeal Membrane Oxygenation for Group B Streptococcal Sepsis in Neonates: A Retrospective Study of the Extracorporeal Life Support Organization Registry
Authors: Schlapbach Luregn J. , Chatfield Mark D. , Rycus Peter , MacLaren Graeme
Published: March 2020

Objectives:

Neonatal group B streptococcal sepsis remains a leading cause of neonatal sepsis globally and is characterized by unique epidemiologic features. Extracorporeal membrane oxygenation has been recommended for neonatal septic shock refractory to conventional management, but data on extracorporeal membrane oxygenation in group B streptococcal sepsis are scarce. We aimed to assess outcomes of extracorporeal membrane oxygenation in neonates with group B streptococcal sepsis.

Design:

Retrospective study of the international registry of the Extracorporeal Life Support Organization.

Setting:

Extracorporeal membrane oxygenation centers contributing to Extracorporeal Life Support Organization registry.

Patients:

Patients less than or equal to 30 days treated with extracorporeal membrane oxygenation and a diagnostic code of group B streptococcal sepsis between January 1, 2007, and December 31, 2016.

Interventions:

None.

Measurements and Main Results:

In-hospital mortality was the primary outcome. Univariable and multivariable logistic regression models to predict mortality were established. One hundred ninety-two runs in 191 neonates were identified meeting eligibility criteria, of which 55 of 191 (29%) died. One hundred thirty-seven (71%) were treated with venoarterial extracorporeal membrane oxygenation. One hundred sixty-nine runs (88%) occurred during the first week of life for early-onset sepsis and 23 (12%) after 7 days of life. The in-hospital mortality for extracorporeal membrane oxygenation used after 7 days of life was significantly higher compared with early-onset sepsis (65% vs 24%; p < 0.01). In addition, lower weight, lower pH, lower bicarbonate, and surfactant administration precannulation were significantly associated with mortality (p < 0.05). Adjusted analyses confirmed that age greater than 7 days, lower weight, and lower pH were associated with higher mortality (p < 0.05). One hundred fifty-one of 192 runs (79%) experienced a major complication. The number of major complications during extracorporeal membrane oxygenation was associated significantly with mortality (p < 0.001; adjusted odds ratio, 1.27 [1.08–1.49; p = 0.004]).

Conclusions:

This large registry-based study indicates that treatment with extracorporeal membrane oxygenation for neonatal group B streptococcal sepsis is associated with survival in the majority of patients. Future quality improvement interventions should aim to reduce the burden of major extracorporeal membrane oxygenation–associated complications which affected four out of five neonatal group B streptococcal sepsis extracorporeal membrane oxygenation patients.
Population Pharmacokinetics of Vancomycin in the Pediatric Ventricular Assist Device Population
Authors: Moffett Brady S. , Humlicek Timothy J. , Akcan-Arikan Ayse , Anders Marc , Tume Sebastian
Published: March 2020

Objectives:

Determine the pharmacokinetic disposition of vancomycin in the pediatric ventricular assist device population.

Design:

A retrospective, population pharmacokinetic study.

Setting:

Large, quaternary care children’s hospital.

Patients:

Less than 19 years old initiated on vancomycin while undergoing ventricular assist device therapy from 2011 to 2018 in our institution.

Interventions:

Patient data were summarized by using descriptive statistical methods, and population pharmacokinetic analysis was performed by using NONMEM (Icon, PLC, Dublin, Ireland). Simulation was performed to identify a vancomycin dosing strategy that resulted in a trough concentration less than 15 mg/L and an area under the curve0–24:minimum inhibitory concentration ratio of greater than 400.

Measurements and Main Results:

A total of 69 patients (male 50.7%, median age 7.1 years [interquartile range, 2.4–11.9]) met study criteria (HeartWare [Framingham, MA] = 37, Berlin Heart [Berlin, Germany] = 22, Impella [Abiomed, Danvers, MA] = 4, RotaFlow [Maquet, Hirrlingen, Germany] right ventricular assist device = 3, HeartMate II [Abbott Laboratories, Abbott Park, IL] = 2, Berlin Heart biventricular assist device = 1). Patients received a median of 21 doses (interquartile range, 13–44 doses) of IV vancomycin (14.8 ± 1.8 mg/kg/dose) along with vancomycin as an intrathoracic irrigation (n = 48; 69.6%). The mean serum concentration was 12.2 ± 5.2 mg/L at 11.2 ± 6.9 hours after a dose. A one-compartment pharmacokinetic model best fit the data with allometric scaling on clearance and volume of distribution. Clearance was characterized by total body weight and serum creatinine, and volume of distribution was characterized by total body weight. Simulation identified doses greater than 15 mg/kg/dose with extended intervals were necessary to achieve endpoints.

Conclusions:

Vancomycin dosing in pediatric ventricular assist device patients should be altered in comparison to nonventricular assist device patients and should be accompanied with frequent serum concentration monitoring.
Economic Evaluation: Onsite HSV PCR Capabilities for Pediatric Care
Authors: Weber Zachary , Sutter Deena , Baltensperger Austin , Carr Nicholas
Published: March 2020

Objective:

Herpes simplex virus (HSV) encephalitis has an overall mortality rate of 11%–29% with treatment. Although rare, HSV encephalitis is frequently tested for and empirically treated, especially in the neonatal population. HSV infection can be diagnosed with polymerase chain reaction (PCR) testing, although this frequently requires sending samples to reference laboratories. The inherent delay in results may lead to prolonging empiric treatment and hospital stay, resulting in increased costs. This study investigates whether onsite HSV PCR testing decreases hospitalization duration, acyclovir treatment duration, and financial cost on an institution.

Project design:

This single-center project utilized the IHI model for improvement to evaluate third-party HSV PCR processing versus an implemented onsite PCR-based meningitis–encephalitis panel for HSV central nervous system evaluation. The primary outcome was hospital cost differential with secondary outcomes, including duration of acyclovir administration and time to result.

Results:

We identified 96 children age 0–18 from 2010 to 2016, 74 patients utilizing offsite third-party testing, and 22 patients utilizing onsite. We observed a per-patient cost savings of $428 ($618.43–$190.43, P = 0.029) upon the implementation of onsite testing. The mean duration of acyclovir therapy decreased from 3.7 to 0.26 days per patient (P < 0.001). Time to result decreased from 4.6 to 0.13 days (P < 0.001).

Conclusions:

Acquisition of real-time local HSV PCR capabilities significantly decreased time to result and empiric medication use while significantly reducing hospital costs in a military treatment facility.
ED RAPID: A Novel Children’s Hospital Direct Admission Process Utilizing the Emergency Department
Authors: Louie Jeffrey P. , Furnival Ronald A. , Roback Mark G. , Jacob Abraham K. , Marmet Jordan , Nerheim Daniel , Hendrickson Marissa A.
Published: March 2020

Introduction:

Direct hospital admission of children without evaluation in the emergency department (ED) is common, but few guidelines exist to maximize safety by assessing patient stability. This report describes a novel approach to support patient safety.

Methods:

An interdisciplinary children’s hospital team developed a brief ED-based evaluation process called the ED Rapid Assessment of Patients Intended for Inpatient Disposition (ED RAPID). It entails a brief evaluation of vital signs and clinical stability by the ED attending physician and nurse. Children deemed stable are admitted to inpatient wards, whereas those requiring immediate intervention undergo full ED evaluation and disposition. We assessed outcomes for all children evaluated through this process from March 2013 through February 2015.

Results:

During the study period, we identified 715 patients undergoing ED RAPID evaluation. Of these, we directly admitted 691 (96.4%) to the hospital ward after ED RAPID evaluation; median ED treatment time was 4.0 minutes. We transitioned 24 (3.4%) to full ED evaluation, 14 (2.0%) because a ward bed was unavailable, and 10 (1.4%) for clinical reasons identified in the evaluation. We admitted four of the 10 stopped (40% of stops, 0.6% of total) to an intensive care unit, and 6 (60% of stops, 0.8% of total) to the hospital ward after ED care. Eight children (1.1%) admitted to the hospital ward after ED RAPID evaluation required a transfer to an intensive care unit within 12 hours.

Conclusion:

The ED RAPID evaluation process for children directly admitted to the hospital was feasible and effective in this setting.
Evaluation of Communication Skills Among Physicians: A Systematic Review of Existing Assessment Tools
Authors: Boucher Vincent Gosselin , Gemme Claudia , Dragomir Anda I. , Bacon Simon L. , Larue Florent , Lavoie Kim L.
Published: March 2020

Objective

The importance of physician training in communication skills for motivating patients to adopt a healthy life-style and optimize clinical outcomes is increasingly recognized. This study inventoried and systematically reviewed the psychometric properties of, and the skills assessed by, existing assessment tools used to evaluate communication skills among physicians.

Methods

This review was conducted in accordance with the PRISMA guidelines (PROSPERO: CRD42018091932). Four databases (PUBMED, EMBASE, PsychINFO, and SCOPUS) were searched up to December 2018, generating 3902 unique articles, which were screened by two authors. A total of 57 articles met the inclusion criteria and underwent full data extraction.

Results

Forty-five different assessment tools were identified. Only 47% of the studies mentioned underlying theories or models for designing the tool. Fifteen communication skills were assessed across the tools, the five most prevalent were information giving (46%) or gathering (40%), eliciting patients’ perspectives (44%), planning/goal setting (37%), and closing the session (32%). Most tools (93%) assessed communication skills using in-person role play exercises with standardized (61%) or real (32%) patients, but only 54% described the expertise of the raters who performed the evaluations. Overall, reporting of the psychometric properties of the assessment tools was poor-moderate (4.5 ± 1.3 out of 9).

Conclusions

Despite identifying several existing physician communication assessment tools, a high degree of heterogeneity between these tools, in terms of skills assessed and study quality, was observed, and most have been poorly validated. Research is needed to rigorously develop and validate accessible, convenient, “user-friendly,” and easy to administer and score communication assessment tools.
Interobserver Variability in the Computed Tomography Assessment of Pulmonary Injury and Tumor Recurrence After Stereotactic Body Radiotherapy
Authors: Guerreiro Nicolau F.C. , Araujo-Filho Jose A.B. , Horvat Natally , Lee Hye Ju , Oliveira Bernardo S.P. , Ynoe de Moraes Fabio , Castro Isac , Miranda Degrande Fabiana Accioli , Abreu Carlos E.V. , Giassi Karina de S.
Published: March 2020

Purpose:

To evaluate the interobserver agreement of chest computed tomography (CT) findings in the diagnosis of expected changes and local recurrence after stereotactic body radiation therapy (SBRT) in patients with early-stage lung cancer or a single pulmonary metastasis.

Materials and Methods:

A total of 54 patients with early-stage lung cancer or pulmonary metastasis who were treated with SBRT from 2007 to 2015 were included. The exclusion criteria were patients who presented with pulmonary infection during follow-up and patients who underwent a single CT during follow-up. The imaging features on CT were assessed by 3 blinded radiologists at the following 2 time points after SBRT: (a) early follow-up and (b) late follow-up (≥6 mo). The radiologists classified the findings as expected changes after SBRT or recurrence. Interobserver agreement was assessed by kappa and Wilcoxon statistics.

Results:

A total of 13 women and 41 men with a mean age of 75.3 (±8.9) years were selected. The total and per fraction SBRT doses were 54 Gy (interquartile range: 45 to 54) and 18 Gy (interquartile range: 15 to 18), respectively. All expected changes and findings suggestive of recurrence had an almost perfect agreement (κ>0.85) among readers, except for diffuse consolidation in the early period (κ=0.65).

Conclusion:

CT findings demonstrate high interobserver agreement for expected changes and for findings indicating recurrence after SBRT.
Nasal Alar Surface Area Differences After Unilateral Cleft Lip Repair: Long-Term Effects of the Perialar Incision
Authors: Perdanasari Aurelia Trisliana , Wagner Ryan D. , Davis Matthew J. , Masoumy Mohamad , Eisemann Bradley S. , Olshinka Asaf , Buchanan Edward P.
Published: March 2020

Background:

The Millard rotation-advancement cleft lip repair is the most commonly performed cleft lip repair. An extended perialar incision allows for further advancement of the lateral lip element and improved positioning of the alar base. There is a lack of data evaluating differences in nasal alar growth when the perialar incision is utilized. This study compares the long-term effects of a perialar incision on the alar surface area of unilateral cleft lip patients who underwent a Millard cleft lip repair.

Methods:

Thirty-seven patients with a diagnosis of unilateral cleft lip treated with a Millard primary lip repair were studied. A perialar incision was utilized in 16 patients while 21 patients underwent a standard Millard repair. 3dMD facial images were taken at least 10 years after the initial lip repair. Using the patient's non-cleft side as an internal control, the Alar Ratio (AR) was calculated, defined as the cleft alar surface area divided by the non-cleft alar surface area.

Results:

The AR was significantly greater in the standard Millard repair group compared to the perialar incision group, 0.74 and 0.64 respectively (P = .02). The incomplete cleft population demonstrated a more profound difference between the treatment groups (0.82 and 0.62, respectively).

Conclusions:

This study reveals an association between a perialar incision and decreased alar surface area. Long-term follow up results suggest a perialar scar restricts alar growth leading to significant asymmetry between the cleft and non-cleft sides. Therefore, surgical technique must be carefully considered prior to utilizing a perialar incision during unilateral cleft lip repair.
Does the Technique for Assessing Loss of Resistance Alter the Magnitude of Epidural Needle Tip Overshoot?
Authors: Cometa M. Anthony , Lopez Brandon M. , Vasilopoulos Terrie , Destephens Anthony J. , Bigos André , Lizdas David E. , Gravenstein Nikolaus , Lampotang Samsun
Published: March 2020

Introduction

Postdural puncture headache due to accidental dural puncture is a consequence of excessive needle tip overshoot distance after entering the epidural space via a loss of resistance (LOR) technique. We are not aware of any quantitative comparison of the magnitude of needle tip overshoot (distance traveled by the needle tip beyond the point where LOR can be discerned) for the various LOR assessment techniques that are taught. Such a comparison may provide insight into contributing factors of accidental dural puncture and associated postdural puncture headache.

Methods

A custom-built simulator was used to evaluate the following 3 LOR assessment techniques: incremental needle advancement, intermittent LOR assessment (II); continuous needle advancement, high-frequency intermittent LOR assessment (CI); and continuous needle advancement, continuous LOR assessment (CC).

Results

There were significant mean differences in maximum overshoot past a virtual LOR plane due to technique (F
(2,124) = 79.31, P < 0.001) (Fig. 2). Specifically, maximum overshoot was greater with technique II [mean = 3.8 mm, 95% confidence interval (CI) = 3.4–4.3] versus either CC (mean = 1.9 mm, 95% CI = 1.5–1.8, P < 0.001) or CI (mean = 1.4 mm, 95% CI = 0.9–2.3, P < 0.001). Differences in maximum overshoot between CC and CI were not statistically different (P = 0.996). Maximum overshoot was greater at 4 cm (mean = 3.0 mm, 95% CI = 2.6–3.4) compared with 5 cm (mean = 2.3 mm, 95% CI = 2.0–2.5, P = 0.044), 6 cm (mean = 2.0 mm, 95% CI = 1.9–2.2, P = 0.054), 7 cm (mean = 1.9 mm, 95% CI = 1.7–2.1, P = 0.002), and 8 cm (mean = 1.8 mm, 95% CI = 1.6–2.1, P = 0.001). In addition, maximum overshoot at 5 cm was greater than that at 7 cm (P = 0.020) and 8 cm (P = 0.037). The other LOR depths were not statistically significantly different from each other. Depth did not have a significant interaction with technique (P = 0.517). Technique preference had neither a significant relationship to maximum overshoot (P = 0.588) nor a significant interaction with LOR assessment technique (P = 0.689).

Discussion

Technique II LOR assessment produced the greatest needle overshoot past the simulated LOR plane after obtaining LOR. This was consistent across all LOR depths. In this bench study, the II technique resulted in the deepest needle tip maximum overshoot. We are in the process of designing a clinical study to collect similar data in patients.
Impact of Simulation-Based Learning on National Ranking Medical Examination Results in France
Authors: Galland Joris , Martis Nihal , Levraut Michael , Hani Hind , Baumann Cedric , Fournier Jean-Paul , Braun Marc
Published: March 2020

Introduction

In France, the National Ranking Examination (ECNi) evaluates medical students based on their clinical reasoning. Simulation-based education on ECNi preparation has not been assessed. Our objective is to establish the added value of high-fidelity (HF) simulation-based learning in ECNi preparation compared with the current standard.

Methods

We performed a controlled, prospective study. Fifth-year medical students from Nancy and Nice participated in a 3-phase process. In phase 1, students were tested on 6 themes (A–F) that were each presented as an ECNi clinical case and were randomized into 2 groups (#1 and #2). A 20-point grading scale was used. In phase 2, group #1 carried out HF simulation on themes A, B, and C, whereas group #2 did so on themes D, E, and F. Students were tested, in phase 3, with a new set of clinical cases on the same 6 themes. Progression in scores between phases 1 and 3 was analyzed.

Results

One hundred sixty-six medical students randomized into 2 groups partook in the study. In phase 1, there was no significant difference in scores between groups. In phase 3, group #1 had significantly higher scores than group #2 for cases A, B, and C. Scores were significantly higher in group #2 for cases D, E, and F. Average scoring significantly improved between phases 1 and 3 with a 1.4-point gain for cases A, B, and C in group #1 and a 2.10-point gain for cases D, E, and F in group #2.

Conclusions

Our study shows that HF simulation learning significantly increases ECNi-like test results when compared with traditional forms.
Tumor necrosis factor α reduces gonadotropin-releasing hormone release through increase of forkhead box protein O1 activity
Authors: Shi Chun , SHI Rongjie , Guo Han
Published: March 2020

It has been found that hypothalamus helps to control aging, and hypothalamus-driven programmatic aging is associated with nuclear factor-κB (NF-κB)-mediated decrease of gonadotropin-releasing hormone (GnRH). However, the molecular mechanism(s) underlying aging-associated hypothalamic GnRH decline are largely unknown. Forkhead box O (FOXO), a family of transcription factors, has been demonstrated to be associated with aging. GnRH neuronal cell line GT1-7 was used in this study to determine whether FOXO1 was involved in tumor necrosis factor α (TNF-α)-induced decrease of GnRH. Our data showed that FOXO1 activity was increased by TNF-α through inhibition of its phosphorylation. Increased FOXO1 activity inhibited gnrh1 gene and activated NF-κB, thereby impairing the secretion of GnRH from GT1-7 cells. The increase of FOXO1 activity contributes to TNF-α-induced decrease of GnRH release, which may underscore the significance of this event to the development of aging and therapeutic interventions against age-dependent pathologies.