bluuebunny/crossref_metadata_2025 huggingface dataset:
Cerebral Gaseous Microemboli are Detectable During Continuous Venovenous Hemodialysis in Critically Ill Patients: An Observational Pilot Study
Authors: Erdoes Gabor , Kietaibl Clemens , Boehme Stefan , Ullrich Roman , Markstaller Klaus , Eberle Balthasar , Klein Klaus U.
Published: March 2016

Background:

Continuous venovenous hemodialysis (CVVHD) may generate microemboli that cross the pulmonary circulation and reach the brain. The aim of the present study was to quantify (load per time interval) and qualify (gaseous vs. solid) cerebral microemboli (CME), detected as high-intensity transient signals, using transcranial Doppler ultrasound.

Materials and Methods:

Twenty intensive care unit (ICU group) patients requiring CVVHD were examined. CME were recorded in both middle cerebral arteries for 30 minutes during CVVHD and a CVVHD-free interval. Twenty additional patients, hospitalized for orthopedic surgery, served as a non-ICU control group. Statistical analyses were performed using the Mann-Whitney U test or the Wilcoxon matched-pairs signed-rank test, followed by Bonferroni corrections for multiple comparisons.

Results:

In the non-ICU group, 48 (14.5-169.5) (median [range]) gaseous CME were detected. In the ICU group, the 67.5 (14.5-588.5) gaseous CME detected during the CVVHD-free interval increased 5-fold to 344.5 (59-1019) during CVVHD (P<0.001). The number of solid CME was low in all groups (non-ICU group: 2 [0-5.5]; ICU group CVVHD-free interval: 1.5 [0-14.25]; ICU group during CVVHD: 7 [3-27.75]).

Conclusions:

This observational pilot study shows that CVVHD was associated with a higher gaseous but not solid CME burden in critically ill patients. Although the differentiation between gaseous and solid CME remains challenging, our finding may support the hypothesis of microbubble generation in the CVVHD circuit and its transpulmonary translocation toward the intracranial circulation. Importantly, the impact of gaseous and solid CME generated during CVVHD on brain integrity of critically ill patients currently remains unknown and is highly debated.
Lupus and fractures
Authors: Bultink Irene E.M. , Lems Willem F.
Published: March 2016

Purpose of review

The article reviews recent advances in the research of fractures in patients with systemic lupus erythematosus (SLE), highlighting their clinical, scientific, and economic impact.

Recent findings

Recent studies demonstrated an increased incidence of osteoporosis and symptomatic fractures in patients with SLE and age, disease duration, disease severity, and glucocorticoid use are important risk factors. A high prevalence of vertebral fractures was demonstrated, while one in three of these patients has normal bone density, which illustrates the multifactorial cause of fractures in SLE. Screening for vertebral fractures is important, as they often occur asymptomatically, but are associated with a reduced quality of life, increased future fracture risk, an increased mortality risk, and may have therapeutic implications. A recently developed Delphi consensus revealed the high economic burden of fractures as a glucocorticoid-related adverse event in SLE, whereas the majority of patients use glucocorticoids.

Recent studies revealed an increased incidence of symptomatic fractures and a relatively high prevalence of vertebral fractures in patients with SLE, and provided new insights into their multifactorial aetiology. The clinical consequences and high economic burden of fractures as glucocorticoid-related adverse events underline the importance of reducing glucocorticoid therapy and use of steroid-sparing agents.
Infection and Nonunion After Fasciotomy for Compartment Syndrome Associated With Tibia Fractures: A Matched Cohort Comparison
Authors: Blair James A. , Stoops Thomas Kyle , Doarn Michael C. , Kemper Dan , Erdogan Murat , Griffing Rebecca , Sagi H. Claude
Published: March 2016

Objectives:

The objective was to compare the rates of union and infection in patients treated with and without fasciotomy for acute compartment syndrome (ACS) in operatively managed tibia fractures.

Design:

This was a retrospective review.

Setting:

The study was conducted at both a Level 1 and Level II trauma center.

Patients/Participants:

Patients operated for tibial plateau fractures (group 1) and tibial shaft fractures (group 3) with ACS requiring fasciotomy were matched to patients without ACS (plateau: group 2, shaft: group 4) in a 1:3 ratio for age, sex, fracture pattern, and open/closed injury.

Intervention:

Surgical treatment was provided with plates/screws (plateau fractures) or intramedullary rod (shaft fractures). Patients with ACS were treated with a 2-incision 4-compartment fasciotomy.

Main Outcome Measurements:

Time to union and incidence of deep infection, nonunion, and delayed union.

Results:

One hundred eighty-four patients were included—group 1: 23 patients, group 2: 69 patients, group 3: 23 patients, and group 4: 69 patients. Time to union averaged 26.8 weeks for groups 1 and 3 and 21.5 weeks for groups 2 and 4 (P > 0.05). Nonunion occurred in 20% for groups 1 and 3 and in 5% for groups 2 and 4 (P = 0.003). Deep infection developed in 20% for groups 1 and 3 and in 4% for groups 2 and 4 (P = 0.001). There was a significant increase in infection in group 1 versus group 2 and nonunion in group 3 versus group 4. There were significantly more smokers for those with fasciotomies (46%) than without (20%, P < 0.001), though all statistical results remained similar after a binary regression analysis.

Conclusion:

Four-compartment fasciotomies in patients with tibial shaft or plateau fractures is associated with a significant increase in infection and nonunion.

Level of Evidence:

Prognostic level III. See Instructions for Authors for a complete description of levels of evidence.
Minimally invasive, iliac crest-sparing approach for pelvic osteotomies in children
Authors: Ghanem Ismat , Sebaaly Amer , Pedro Nakhle , Saliba Elie
Published: March 2016

The aim of this article is to describe a minimally invasive iliac crest-sparing approach (ICSA) allowing common iliac osteotomies in children. The ICSA was used for 98 hips in 72 consecutive patients who underwent a pelvic osteotomy. The mean follow-up duration ranged from 3 to 7 years. Skin incision ranged from 3 to 5.5 cm. Displacement of the distal osteotomy fragment was easy and without tension. The duration of surgery varied from 50 min in the beginning of our experience to 20–25 min for the last cases of the series. In conclusion, the ICSA fulfills all the criteria of minimally invasive surgery.
Revision pediatric anterior cruciate ligament reconstruction after failure of iliotibial band technique treated with all-epiphyseal technique in a prepubescent with Ehlers–Danlos syndrome: a case report
Authors: Erdman Mary K. , Warnick Drew E.
Published: March 2016

The increasing number of pediatric anterior cruciate ligament (ACL) injuries and the failure of nonoperative management of these patients has elicited a concordant response in the surgical community to devise reconstruction techniques that stabilize the knee joint without causing iatrogenic growth disturbances. Likewise, the rise in pediatric ACL reconstructions forecasts a consequent rise in revision ACL reconstructions in patients with open physes. In this case report, we describe a prepubescent with Ehlers–Danlos syndrome and congenital ACL deficiency, who underwent physeal-sparing iliotibial band ACL reconstruction and revision to an all-epiphyseal ACL reconstruction with allograft. We also underscore the lack of evidence addressing graft choice and outcomes for ACL reconstructions in patients with connective tissue disorders.
Iliac wing osteotomy for the closure of pelvis in the treatment of bladder exstrophy in the neonate
Authors: Oitment Colby T.A. , Bozzo Anthony , Thornley Patrick , Sivakumar Brahman
Published: March 2016

Classic bladder exstrophy is a rare disorder involving an externalized bladder through an associated pelvic diastasis. Difficulty of closure of pelvic diastasis is often encountered following urological reconstruction. Traditionally, an anterior innominate osteotomy is performed to increase pelvic volume, allowing closure of the rudimentary pubic symphysis and anatomical reduction of pelvic contents; however, this procedure can be technically difficult and has associated morbidity. We describe a novel technique of bilateral iliac wing osteotomies to achieve the same function that has not been described previously in the literature.
Does the Modified Gartland Classification Clarify Decision Making?
Authors: Leung Sophia , Paryavi Ebrahim , Herman Martin J. , Sponseller Paul D. , Abzug Joshua M.
Published: March 2016

Hypothesis:

The modified Gartland classification system for pediatric supracondylar fractures is often utilized as a communication tool to aid in determining whether or not a fracture warrants operative intervention. This study sought to determine the interobserver and intraobserver reliability of the Gartland classification system, as well as to determine whether there was agreement that a fracture warranted operative intervention regardless of the classification system.

Methods:

A total of 200 anteroposterior and lateral radiographs of pediatric supracondylar humerus fractures were retrospectively reviewed by 3 fellowship-trained pediatric orthopaedic surgeons and 2 orthopaedic residents and then classified as type I, IIa, IIb, or III. The surgeons then recorded whether they would treat the fracture nonoperatively or operatively. The κ coefficients were calculated to determine interobserver and intraobserver reliability.

Results:

Overall, the Wilkins-modified Gartland classification has low-moderate interobserver reliability (κ=0.475) and high intraobserver reliability (κ=0.777). A low interobserver reliability was found when differentiating between type IIa and IIb (κ=0.240) among attendings. There was moderate-high interobserver reliability for the decision to operate (κ=0.691) and high intraobserver reliability (κ=0.760). Decreased interobserver reliability was present for decision to operate among residents. For fractures classified as type I, the decision to operate was made 3% of the time and 27% for type IIa. The decision was made to operate 99% of the time for type IIb and 100% for type III.

There is almost full agreement for the nonoperative treatment of Type I fractures and operative treatment for type III fractures. There is agreement that type IIb fractures should be treated operatively and that the majority of type IIa fractures should be treated nonoperatively. However, the interobserver reliability for differentiating between type IIa and IIb fractures is low. Our results validate the Gartland classfication system as a method to help direct treatment of pediatric supracondylar humerus fractures, although the modification of the system, IIa versus IIb, seems to have limited reliability and utility. Terminology based on decision to treat may lead to a more clinically useful classification system in the evaluation and treatment of pediatric supracondylar humerus fractures.

Level of Evidence:

Level III—diagnostic studies.
Effects of Intraoperative Anesthetic Medications on Postoperative Urinary Retention After Single-Level Lumbar Fusion
Authors: Mayo Benjamin C. , Louie Philip K. , Bohl Daniel D. , Massel Dustin H. , Iantorno Stephanie E. , Ahn Junyoung , Tabaraee Ehsan , Modi Krishna D. , Long William W. , Singh Kern
Published: March 2016

Study Design.

Retrospective cohort analysis.

Objective.

The aim of the study was to identify medications that may potentially contribute to developing postoperative urinary retention (POUR) after lumbar spinal fusion procedures.

Summary of Background Data.

POUR is a concerning event that may occur after routine orthopedic surgery. The relation between intraoperative medications and POUR after lumbar spine surgery has not been well characterized.

Methods.

A prospectively maintained database of patients who underwent a primary single-level, minimally invasive transforaminal lumbar interbody fusion between 2009 and 2013 was reviewed. POUR was defined as a bladder scan of 300 mL or higher, the postoperative necessity of a straight catheterization, or a urology consult for urinary retention. The use and dose-response of intraoperative medications between patients with and without POUR were compared. Potential risk factors for developing POUR were analyzed using multivariate analysis.

Results.

A total of 205 patients were included in the study, 17% of whom experienced POUR (n = 34). Administration of phenylephrine and neostigmine was associated with POUR (phenylephrine: 32.3% vs. 13.8%, P = 0.017; neostigmine: 19.5% vs. 6.5%, P = 0.042). Parametric analysis demonstrated an association of increasing dose of neostigmine with POUR (4.66 vs. 4.22 mg, P = 0.023). Similarly, a nonparametric analysis demonstrated an association of increasing doses of both neostigmine and phenylephrine with POUR (neostigmine: 4.25 vs. 3.16 mg, P = 0.02; phenylephrine: 105.88 vs. 40.64 mg, P = 0.008).

Conclusion.

Approximately 20% of patients may develop POUR after routine lumbar spine surgery. The use of certain intraoperative anesthetics such as phenylephrine and neostigmine is strongly associated with the development of POUR postoperatively. This finding suggests that there may be modifiable anesthetic risk factors to prevent the development of POUR in patients undergoing lumbar spine surgery. Future prospective, controlled studies specifically addressing these findings could lead to improved patient care and decreased healthcare costs.

Level of Evidence: 4
Sagittal Plane Correction Using the Lateral Transpsoas Approach
Authors: Melikian Rojeh , Yoon Sangwook Tim , Kim Jin Young , Park Kun Young , Yoon Caroline , Hutton William
Published: March 2016

Study Design.

Cadaveric biomechanical study.

Objective.

To determine the degree of segmental correction that can be achieved through lateral transpsoas approach by varying cage angle and adding anterior longitudinal ligament (ALL) release and posterior element resection.

Summary of Background Data.

Lordotic cage insertion through the lateral transpsoas approach is being used increasingly for restoration of sagittal alignment. However, the degree of correction achieved by varying cage angle and ALL release and posterior element resection is not well defined.

Methods.

Thirteen lumbar motion segments between L1 and L5 were dissected into single motion segments. Segmental angles and disk heights were measured under both 50 N and 500 N compressive loads under the following conditions: intact specimen, discectomy (collapsed disk simulation), insertion of parallel cage, 10° cage, 30° cage with ALL release, 30° cage with ALL release and spinous process (SP) resection, 30° cage with ALL release, SP resection, facetectomy, and compression with pedicle screws.

Results.

Segmental lordosis was not increased by either parallel or 10° cages as compared with intact disks, and contributed small amounts of lordosis when compared with the collapsed disk condition. Placement of 30° cages with ALL release increased segmental lordosis by 10.5°. Adding SP resection increased lordosis to 12.4°. Facetectomy and compression with pedicle screws further increased lordosis to approximately 26°. No interventions resulted in a decrease in either anterior or posterior disk height.

Conclusion.

Insertion of a parallel or 10° cage has little effect on lordosis. A 30° cage insertion with ALL release resulted in a modest increase in lordosis (10.5°). The addition of SP resection and facetectomy was needed to obtain a larger amount of correction (26°). None of the cages, including the 30° lordotic cage, caused a decrease in posterior disk height suggesting hyperlordotic cages do not cause foraminal stenosis.

Level of Evidence: N/A
Glycated Hemoglobin A1c Levels Are Not Affected by Critical Illness
Authors: Luethi Nora , Cioccari Luca , Tanaka Aiko , Kar Palash , Giersch Emma , Deane Adam M. , Mårtensson Johan , Bellomo Rinaldo
Published: March 2016

Objectives:

Glycated hemoglobin A1c is used to estimate glycemic control. However, its value upon ICU admission may be altered by critical illness and not reflect true glycemic status. We assessed the relationship between ICU admission glycated hemoglobin A1c and premorbid glycated hemoglobin A1c levels.

Design:

Retrospective observational cohort study.

Setting:

Two tertiary ICUs in Australia.

Patients:

Cohort of 69 critically ill patients with diabetes and glycated hemoglobin A1c levels measured upon ICU admission and during the month prior to admission.

Interventions:

Measurement of glycated hemoglobin A1c.

Measurements and Main Results:

Mean (sd) glycated hemoglobin A1c level was 7.5% (1.8%) upon ICU admission and 7.8% (2.0%) in previous measurements from the preceding 30 days. The change in glycated hemoglobin A1c did not correlate with time elapsed between the two measurements (r
2 = 0.00005; p = 0.95), but there was a strong correlation between admission glycated hemoglobin A1c levels and premorbid glycated hemoglobin A1c levels (r
2 = 0.89; p < 0.001).

Conclusions:

Glycated hemoglobin A1c levels are not altered by the onset of critical illness. Glycated hemoglobin A1c quantified at ICU admission can, therefore, be used to reliably estimate chronic glycemic control and guide acute glycemic therapy.
Patient-derived tumor xenograft strategies for informed management of patients with metastatic melanoma
Authors: Qassemyar Ahmad , Gabert Pierre-Elliott , Kluza Jerome , Duquennoy-Martinot Véronique , Mortier Laurent , Marchetti Philippe , Guerreschi Pierre
Published: March 2016

Metastatic melanoma has benefited from immunotherapy and targeted therapy advances. Faced with the inescapable onset of treatment resistance, the choice of a second-line treatment can be guided by a patient-derived tumor xenograft (PDTX). This new approach requires an excellent multidisciplinary collaboration where the surgeon has a key role to play. Each patient included (stage IIIC or IV) presented with subcutaneous melanoma metastasis that could be surgically resected. The surgeon performed orthotopic PDTX on CB17-SCID mice. To validate the model, tumor material was amplified over three successive generations of animals to obtain cohorts compatible with carrying out a study to compare treatment response by targeted therapy (vemurafenib versus controls). Tumors were characterized (histologically and genetically) at all stages of the generations’ amplification. Functional imaging by fluorine-18 fluorodeoxyglucose PET scan was performed for the third generation PDTX. Seventeen patients with a mutated BRAF V600E subcutaneous metastasis were included, yielding 257 PDTX. Clinical, histological, and genetic characteristics of the grafted tumors were stable over the three mice generations. The treatment response to vemurafenib was observed for all PDTX. The fluorine-18 fluorodeoxyglucose PET scan evidenced a decreased in glucose uptake in the treated tumors. PDTX models are being widely used in fundamental research and are more compatible with clinical issues. If PDTX are simple and easily reproducible in metastatic melanoma, an organized multidisciplinary platform is essential to implement them. In our experience, surgeons have a key role to play in the cohesion of this new therapeutic approach.
New-onset toxicity with programmed death-1 inhibitor rechallenge
Authors: Ludlow Steven P. , Andrews Stephanie , Pasikhova Yanina , Hill Eboné
Published: March 2016

Immunotherapy has become a mainstay in the treatment of metastatic melanoma. Cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) inhibitors and programmed death-1 (PD-1) inhibitors, which have been added more recently, represent two of the main classes of immunomodulating agents. PD-1 inhibitors are well tolerated and are known to have a decreased rate of occurrence of adverse effects compared with CTLA-4 inhibitors. However, the risk remains for serious immune-mediated adverse reactions. Given their long half and extended efficacy, treatment with a CTLA-4 inhibitor before use of a PD-1 inhibitor may increase the risk of adverse effects. In addition, caution should be exercised when rechallenging grade 3 or 4 adverse effects with the same agent or a different agent of the same class. The re-emergence of a previous toxicity may occur or, as found in this case, a new severe effect may arise. This article will present a case of fatal immune-related hepatoxicity in a patient treated with a CTLA-4 inhibitor, followed by treatment with a PD-1 inhibitor. The mechanisms of action and safety profiles for both classes of drugs will also be reviewed.
Potential of Food and Natural Products to Promote Endothelial and Vascular Health
Authors: Auger Cyril , Said Amissi , Nguyen Phuong Nga , Chabert Philippe , Idris-Khodja Noureddine , Schini-Kerth Valérie B.
Published: March 2016

Endothelial dysfunction is now well established as a pivotal early event in the development of major cardiovascular diseases including hypertension, atherosclerosis, and diabetes. The alteration of the endothelial function is often triggered by an imbalance between the endothelial formation of vasoprotective factors including nitric oxide (NO) and endothelium-dependent hyperpolarization, and an increased level of oxidative stress involving several prooxidant enzymes such as NADPH oxidase and, often also, the appearance of cyclooxygenase-derived vasoconstrictors. Preclinical studies have indicated that polyphenol-rich food and food-derived products such as grape-derived products, black and red berries, green and black teas and cocoa, and omega-3 fatty acids can trigger activating pathways in endothelial cells promoting an increased formation of nitric oxide and endothelium-dependent hyperpolarization. Moreover, intake of such food-derived products has been associated with the prevention and/or the improvement of an established endothelial dysfunction in several experimental models of cardiovascular diseases and in humans with cardiovascular diseases. This review will discuss both experimental and clinical evidences indicating that different types of food and natural products are able to promote endothelial and vascular health, as well as the underlying mechanisms.
Molecular Imaging and Its Role in the Management of Breast Cancer
Authors: KISER JACKSON
Published: March 2016

Molecular imaging plays an important role in the management of breast cancer. An understanding of all the available technologies and their appropriate use are important to navigate patient care in this evolving specialty. The information gained from molecular imaging will impact patient care and may become a springboard for molecular therapy.
Cerclage: Shirodkar, McDonald, and Modifications
Authors: WOOD S. LINDSAY , OWEN JOHN
Published: March 2016

As the concept of cervical insufficiency has evolved from a poorly defined clinical/anatomic entity into 1 component of the spontaneous preterm birth syndrome, so have cerclage applications. Originally developed to treat history-defined cervical insufficiency and acute cervical insufficiency, cerclage is now utilized on a larger scale for the prevention of recurrent spontaneous preterm birth. As its role expands, the need for prospective data evaluating cerclage techniques and modifications is emphasized. Herein, we will review the techniques, modifications, risks, efficacy, and evidence-based applications of the cerclage procedure in contemporary clinical practice.
Mammographic Breast Density and Breast Cancer Risk: Implications of the Breast Density Legislation for Health Care Practitioners
Authors: GREEN VICTORIA L.
Published: March 2016

Breast density has emerged as a critical phenotypic marker of increased breast cancer risk. The breast density legislation, passed in multiple states, requires patient notification of the implications of the breast density on breast cancer risk and screening. Supplemental screening may be suggested in the state regulation; however, there are limited data to guide conversations with patients. This article will review the current state of supplemental screening in women with dense breasts and discuss theories of the mechanism of action. Guidance is provided to assist in shared decision making and appropriate patient counseling.
INTRAVITREAL DEXAMETHASONE IMPLANTATION FOR BIRDSHOT CHORIORETINOPATHY
Authors: Walsh James , Reddy Ashvini K.
Published: March 2016

Purpose:

Birdshot chorioretinopathy is a rare form of posterior uveitis. This article reports a case series of patients with HLA-A29+ birdshot chorioretinopathy managed with intravitreal dexamethasone implants.

Methods:

Retrospective case report.

Results:

Three patients with birdshot chorioretinopathy (6 eyes) were seen from 2013 to 2015 and managed with dexamethasone intravitreal implant; there was an average of 6 months between implants. All 3 experienced control of ocular inflammation and macular edema with intravitreal dexamethasone and achieved best-corrected visual acuity of at least 20/25 during the course of treatment. Two patients tolerated serial dexamethasone implants for over a year without glaucoma or cataract surgery. Dexamethasone implantation was not repeated in one patient with preexisting uveitic glaucoma because of persistently elevated intraocular pressure. In this series, all patients had improvement in visual acuity, macular edema, intraocular inflammation, and quality of life, and no patients developed visually significant cataracts. Only one eye with preexisting uveitic glaucoma exhibited an increased intraocular pressure requiring discontinuation of therapy.

Conclusion:

Intravitreal dexamethasone implant can be an effective alternative in the management of birdshot chorioretinopathy.
Idiopathic Orbital Inflammation Associated With Relapsing Polychondritis
Authors: Mariani Angeline F. , Malik Amina I. , Chevez-Barrios Patricia , Smith Stacy V. , Lee Andrew G.
Published: March 2016

The authors describe a patient with recurrent idiopathic orbital inflammatory disease as an unusual presentation of relapsing polychondritis. There are very few reported cases in the literature of relapsing polychondritis associated with idiopathic orbital inflammation. Clinicians should be aware of the orbital and ophthalmic presentations of relapsing polychondritis.
Attitudes of Turkish Nursing Students Related to Ageism
Authors: Özdemir Özlem , Bilgili Naile
Published: March 2016

Background:

The sociocultural structure of society, changes in attitude and behaviors, and individual and social perspectives on aging all affect the nature of services that are offered to elderly people. “Ageism” is one of the problems that has an impact on the level and quality of service that is provided to the older adults.

Purpose:

This study was undertaken to examine the attitudes of Turkish undergraduate nursing students toward aging.

Methods:

A cross-sectional survey was given to 495 nursing students in four universities in Turkey. A questionnaire developed from the related literature and the Ageism Attitude Scale were used to collect data, which was analyzed using standard descriptive statistical methods.

Results:

The variables of school year, age, cohabitation with an elderly person (yes/no), prior experience with the older adults (yes/no), and willingness to work with the older adults after graduation all significantly influenced the attitudes of participants toward aging (p < .05).

Conclusions/Implications for Practice:

The results from the Ageism Attitude Scale revealed that the participants held a generally positive attitude toward aging. It is of great importance to include more lessons on the older adults and the aging process and to increase activities to develop awareness of ageism, to help students develop positive attitudes and perspectives toward the care of the older adults. Because experience caring for the older adults is important in developing a positive attitude toward the older adults, arranging relevant clinical practice, especially at institutions with an elderly population, may be an effective approach to strengthening the communication and experiences of nursing students.
Duration of ECMO Is an Independent Predictor of Intracranial Hemorrhage Occurring During ECMO Support
Authors: Omar Hesham R. , Mirsaeidi Mehdi , Mangar Devanand , Camporesi Enrico M.
Published: March 2016

We assessed the incidence and predictors of intracranial hemorrhage (ICH) occurring during extracorporeal membrane oxygenation (ECMO) support. Of 154 patients who received ECMO, 12 (7.8%) developed ICH. Patients with ICH had a longer ECMO duration (9.41 vs. 5.37 days, p = 0.007), and higher activated clotting time (activated clotting time, p= 0.016). They also experienced higher frequency of bleeding at other sites (p = 0.017) and required more platelet transfusion (p = 0.016). Multivariate analysis showed that a longer ECMO duration (odds ratio [OR] = 1.074, 95% confidence interval [CI] = 1.005–1.148, p = 0.035) is independently associated with the risk of ICH. We recommend routine neurological checks, monitoring of coagulation parameters, and attempt earlier rather than late weaning from ECMO whenever feasible.
Large arterial occlusive strokes as a medical emergency: need to accurately predict clot location
Authors: Vanacker Peter , Faouzi Mohamed , Eskandari Ashraf , Maeder Philippe , Meuli Reto , Michel Patrik
Published: March 2016

Background

Endovascular treatment for acute ischemic stroke with a large intracranial occlusion was recently shown to be effective. Timely knowledge of the presence, site, and extent of arterial occlusions in the ischemic territory has the potential to influence patient selection for endovascular treatment. We aimed to find predictors of large vessel occlusive strokes, on the basis of available demographic, clinical, radiological, and laboratory data in the emergency setting.

Methods

Patients enrolled in ASTRAL registry with acute ischemic stroke and computed tomography (CT)-angiography within 12 h of stroke onset were selected and categorized according to occlusion site. Easily accessible variables were used in a multivariate analysis.

Results

Of 1645 patients enrolled, a significant proportion (46.2%) had a large vessel occlusion in the ischemic territory. The main clinical predictors of any arterial occlusion were in-hospital stroke [odd ratios (OR) 2.1, 95% confidence interval 1.4–3.1], higher initial National Institute of Health Stroke Scale (OR 1.1, 1.1–1.2), presence of visual field defects (OR 1.9, 1.3–2.6), dysarthria (OR 1.4, 1.0–1.9), or hemineglect (OR 2.0, 1.4–2.8) at admission and atrial fibrillation (OR 1.7, 1.2–2.3). Further, the following radiological predictors were identified: time-to-imaging (OR 0.9, 0.9–1.0), early ischemic changes (OR 2.3, 1.7–3.2), and silent lesions on CT (OR 0.7, 0.5–1.0). The area under curve for this analysis was 0.85. Looking at different occlusion sites, National Institute of Health Stroke Scale and early ischemic changes on CT were independent predictors in all subgroups.

Conclusion

Neurological deficits, stroke risk factors, and CT findings accurately identify acute ischemic stroke patients at risk of symptomatic vessel occlusion. Predicting the presence of these occlusions may impact emergency stroke care in regions with limited access to noninvasive vascular imaging.
Hospital Readmission and Length of Stay Over Time in Patients Undergoing Major Cardiovascular and Orthopedic Surgery
Authors: Sedrakyan Art , Kamel Hooman , Mao Jialin , Ting Henry , Paul Subroto
Published: March 2016

Background:

Readmission and length of stay (LOS) are increasingly accepted as quality measures for surgical care. Centers for Medicare & Medicaid Services will soon assess penalties for excessive readmissions after coronary artery bypass graft (CABG) surgery and hip and knee replacements.

Objective:

To determine and compare population level changes in LOS and relationship with 30-day readmission over time for patients undergoing CABG and hip and knee replacements. Secondary objective was to determine relationship between LOS and discharge disposition as well as mortality.

Research Design:

Observational cohort study of patients undergoing CABG and hip and knee replacements in New York and California. Temporal trends in LOS, discharge disposition, 30-day readmission, and mortality were examined. Generalized linear-mixed models, accounting for hospital clustering, were used to assess differences in outcomes.

Subjects:

Patients undergoing CABG and hip and knee replacements in New York and California between 2005 and 2011.

Measures:

Trends in LOS, discharge disposition, 30-day readmission and mortality, and risk-adjusted odds of all-cause 30-day readmission.

Results:

We identified 206,784, 336,271, and 416,391 patients who underwent CABG, hip, and knee replacements, respectively, in New York State and California between 2005 and 2011. The risks of readmission within 30 days decreased over time in both states. LOS decreased by 1 day after hip and knee surgery and remained unchanged after CABG. Adjusted analysis confirmed these trends. In secondary analyses patients in New York had higher overall odds of 30-day readmission compared with patients in California.

Conclusions:

We found no evidence of inverse relationship between LOS and readmission over time. In hip and knee replacement there is strong evidence that both LOS and readmission have been reduced simultaneously.
Are Older Adults With Hip Fractures Disadvantaged in Level 1 Trauma Centers?
Authors: Metcalfe David , Olufajo Olubode A. , Zogg Cheryl K. , Gates Jonathan D. , Weaver Michael J. , Harris Mitchel B. , Rios-Diaz Arturo J. , Haider Adil H. , Salim Ali
Published: March 2016

Background:

Large regional hospitals achieve good outcomes for patients with complex conditions. However, recent studies have suggested that some patient groups might not benefit from treatment in higher-level trauma centers.

Objective:

To test the hypothesis that older adults with isolated hip fractures experience delayed surgical treatment and worse clinical outcomes when treated in higher-level trauma centers.

Research Design:

Retrospective cohort study using a statewide longitudinal database that captured 98% of inpatients within California (2007–2011).

Subjects:

All older adults (aged 65 y and above) admitted with an isolated hip fracture who did not require interhospital transfer.

Measures:

Days to operation, length of stay, inhospital mortality, 30-day risk of unplanned readmission, 30-day venous thromboembolism, decubitus ulcers, and pneumonia.

Results:

There were 91,401 patients, 6.1% of whom were treated in a level 1 trauma center (L1TC), 17.7% in a level 2 trauma center (L2TC), and 70.2% in a nontrauma center (NTC). Within multivariable logistic and generalized linear regression models, patients treated in L1TCs underwent surgery later (predicted mean difference: 0.30 d; 95% CI, 0.08–0.53), had prolonged inpatient stays (0.99 d, 0.40–1.59), and had higher odds of both 30-day readmission (aOR=1.62; 95% CI, 1.35–1.93) and venous thromboembolism (aOR=1.32, 1.01–1.74) relative to NTCs. There were no differences in mortality, decubitus ulcers, or pneumonias. L2TCs were not different from NTCs across any of the measured outcomes.

Conclusions:

Older adults with hip fractures may be disadvantaged in L1TCs. Further research should aim to develop our understanding of this disparity to ensure that all patient groups benefit from the resources and expertise available within these hospitals.
Developing the Pediatric Gastrointestinal Endoscopy Unit
Authors: Pall Harpreet , Lerner Diana , Khlevner Julie , Reynolds Carrie , Kurowski Jacob , Troendle David , Utterson Elizabeth , Evans Pamela M. , Brill Herbert , Wilsey Michael , Fishman Douglas S.
Published: March 2016

There is significant variability in the design and management of pediatric endoscopy units. Although there is information on adult endoscopy units, little guidance is available to the pediatric endoscopy practitioner. The purpose of this clinical report, prepared by the NASPGHAN Endoscopy and Procedures Committee, is to review the important considerations for setting up an endoscopy unit for children. A systematic review of the literature was undertaken in the preparation of this report regarding the design, management, needed equipment, motility setup, billing and coding, and pediatric specific topics.
Effects of 3,4-Methylenedioxymethamphetamine on Patient Utterances in a Psychotherapeutic Setting
Authors: Corey Vicka Rael , Pisano Vincent D. , Halpern John H.
Published: March 2016

3,4-Methylenedioxymethamphetamine (MDMA) administered as an adjunct to talk therapy influences patient speech content and increases improvement in treatment-resistant posttraumatic stress disorder (PTSD). Data came from the recordings of Mithoefer et al. (2011). In the third therapeutic session studied, patients were assigned, double blind, to an MDMA or a placebo group. Condition-blind scorers listened to therapy recordings and scored utterances where patients initiated topics that were empathic (regarding others' emotions), entactic (requesting or appreciating physical touch), or ensuic (describing a change in their sense of themselves). Patients who received MDMA produced high levels of ensuic, empathic, and entactic utterances compared with those who received the placebo. Interrater discourse scoring was reliable. The relationship between the number of scored utterances and the Clinician Administered PTSD Scale scores measuring PTSD severity after the treatment was significant, and reanalysis grouped bimodally into “many” or “few” such utterances remained significant. MDMA assisted these patients in having meaningful and disorder-resolving thoughts and discourse in talk therapy.
Immunohistochemical Study of TGF-β1 in Oral Leukoplakia and Oral Squamous Cell Carcinoma: Correlations Between Clinicopathologic Factors and Overall Survival
Authors: Wagner Vivian P. , Cardoso Paula R. , dos Santos Jean N. , Meurer Luise , Vargas Pablo A. , Fonseca Felipe P. , Carrard Vinicius C. , Martins Manoela D.
Published: March 2016

The aim of the present study was to analyze transforming growth factor β1 (TGF-β1) expression in cases of leukoplakia and oral squamous cell carcinoma (OSCC) and to correlate these expression profiles with proliferative labeling index, clinicopathologic factors, and clinical outcome. Clinical data for 24 cases of leukoplakia and 87 cases of OSCC were retrieved from medical records. OSCC tissues were included into tissue microarray blocks and sections of normal mucosa, leukoplakia, and OSCC tissue microarray’s were prepared on slides. Immunohistochemistry was used to detect expression of TGF-β1 and Ki67. The expression of TGF-β1 and Ki67 were significantly increased from normal mucosa, through leukoplakia to OSCC. High expression of TGF-β1 correlated with an increase in proliferative labeling index. No association between TGF-β1 expression and the clinicopathologic factors examined was observed. Expression of TGF-β1 also did not associate with clinical outcome in either of groups. Our results suggest that changes in TGF-β1 are associated with the progression of oral carcinogenesis.
Benign Paroxysmal Positional Vertigo in 2 Children: A Case Series
Authors: Fay Jennifer L.
Published: March 2016

Purpose:

The purpose of this case report is to present the cases of 2 boys with benign paroxysmal positional vertigo (BPPV).

Key Points:

Patient A (11 years old) and Patient B (9 years old) had complaints of vertigo with position changes. Both exhibited left torsion upbeating nystagmus in the left Dix-Hallpike (DH) test and complaints of vertigo with reproduction of their symptoms, indicating BPPV. Both were treated with a left canalith repositioning maneuver and reported decreased incidence of positional vertigo upon reevaluation. Scores on the Dizziness Handicap Inventory and the Visual Analog Scale for Dizziness decreased after treatment for 1 of the boys.

Conclusion:

Benign paroxysmal positional vertigo is considered rare in children. Migraines may also cause vertigo. Differential diagnosis in these cases was made by performing the DH test.

Recommendations for Clinical Practice:

Children with vertigo should be screened for BPPV through use of history taking, and the DH test.
Building the Composite Face Lift: A Personal Odyssey
Authors: Hamra Sam T.
Published: March 2016

This article is a 42-year history of the development of a comprehensive face-lift technique by the author. It describes how the composite rhytidectomy has been constructed, anatomical area by anatomical area, over the author’s lifetime career as a plastic surgeon. Over the course of these years, beginning with Skoog’s 1973 description of using the platysma muscle of the lower face, it describes how progressively the other significant structures of anatomy necessary to be used in achieving significant rejuvenation have been analyzed by the author and in turn surgically repositioned. The theory was based on creating a composite flap of the face, keeping the orbicularis oculi muscle, facial platysma muscle, and cheek fat in their normal anatomical and intimate relationship with each other by using the skin as the carriage. In addition, differences of vectors between the composite rhytidectomy and traditional techniques are demonstrated. The gradual and persistent pursuit of periorbital rejuvenation using the lower eyelid fat and the septal orbitale is described. Each of the anatomical structures involved and the description of their importance and surgical execution have been published over the surgical career of the author, including use of the same principles for reversing suboptimal face-lift results.
High Variability of Hormonal Levels and No Clinically Relevant Interaction Between Ethinyl Estradiol, Desogestrel and Lopinavir/Ritonavir in a Small Sample of HIV-positive Adolescents
Authors: Kancheva Landolt Nadia , Bunupuradah Torsak , Kosalaraksa Pope , Ubolyam Sasiwimol , Thammajaruk Narukjaporn , Cremers Serge , Zott Roseann , Kerr Stephen , Ananworanich Jintanat ,   on behalf of HIV-NAT 176 study
Published: March 2016

Background:

We report the pharmacokinetic interactions of combined oral contraceptive (COC) containing ethinyl estradiol (EE2)/desogestrel (DSG) with lopinavir/ritonavir (LPV/r) in 16 HIV-positive adolescents.

Methods:

We measured Ctrough of EE2 and etonogestrel (ENG), the active metabolite of DSG, in HIV-positives on LPV/r-based ART; Ctrough of LPV/r with and without COC; endogenous progesterone. EE2/ENG levels were compared with our own historical data of HIV-negative controls.

Results:

Ctrough of EE2 and ENG varied from 3 to 57 pg/mL and from 1051 to 5000 pg/mL, respectively. The geometric mean ratios (GMR) of Ctrough in HIV-positives on LPV/r with COC versus HIV-negative controls with COC only were 0.68 (95% CI: 0.42 to 1.08) or 32% decreased (P = 0.10) for EE2; and 1.08 (95% CI: 0.73 to 1.60) or 8% increased (P = 0.68) for ENG. Endogenous progesterone was <1.0 ng/mL in all participants, consistent with anovulation. Ctrough of LPV decreased statistically insignificantly with COC and remained above the desired therapeutic minimum of 1.0 mg/L in all.

Conclusions:

The study found no clinically relevant interaction between EE2/DSG and LPV/r. This was supported by suppressed ovulation, assessed by low endogenous progesterone levels in all participants; and preserved antiretroviral activity, assessed by LPV/r levels above the desired therapeutic minimum in all participants. However, the high variability of hormonal levels warrants individual monitoring and further investigation. Condom use should always be encouraged for infection prevention.
AVOCADO: Visualization of Workflow-Derived Data Provenance for Reproducible Biomedical Research
Authors: Stitz Holger , Luger Stefan , Streit Marc , Gehlenborg Nils
Published: March 2016

A major challenge of data-driven biomedical research lies in the collection and representation of data provenance information to ensure reproducibility of findings. In order to communicate and reproduce multi-step analysis workflows executed on datasets that contain data for dozens or hundreds of samples, it is crucial to be able to visualize the provenance graph at different levels of aggregation. Most existing approaches are based on node-link diagrams, which do not scale to the complexity of typical data provenance graphs. In our proposed approach we reduce the complexity of the graph using hierarchical and motif-based aggregation. Based on user action and graph attributes a modular degree-of-interest (DoI) function is applied to expand parts of the graph that are relevant to the user. This interest-driven adaptive provenance visualization approach allows users to review and communicate complex multi-step analyses, which can be based on hundreds of files that are processed by numerous workflows. We integrate our approach into an analysis platform that captures extensive data provenance information and demonstrate its effectiveness by means of a biomedical usage scenario.
Adaptive divergence in transcriptome response to heat and acclimation inArabidopsis thalianaplants from contrasting climates
Authors: Zhang Nana , Vierling Elizabeth , Tonsor Stephen J.
Published: March 2016

Phenotypic variation in stress response has been widely observed within species. This variation is an adaptive response to local climates and is controlled by gene sequence variation and especially by variation in expression at the transcriptome level. Plants from contrasting climates are thus expected to have different patterns in gene expression. Acclimation, a pre-exposure to sub-lethal temperature before exposing to extreme high temperature, is an important adaptive mechanism of plant survival. We are interested to evaluate the gene expression difference to heat stress for plants from contrasting climates and the role of acclimation in altering their gene expression pattern. NaturalArabidopsis thalianaplants from low elevation mediterranean and high elevation montane climates were exposed to two heat treatments at the bolting stage: a) 45°C: a direct exposure to 45°C heat; b) 38/45°C: an exposure to 45°C heat after a 38°C acclimation treatment. Variation in overall gene expression patterns was investigated. We also explored gene expression patterns for Hsp/Hsf pathway and reactive oxygen species (ROS) pathway. In both heat treatments, high elevation plants had more differentially expressed (DE) genes than low elevation plants. In 45°C, only Hsp/Hsf pathway was activated in low elevation plants; both Hsp/Hsf and ROS pathways were activated in high elevation plants. Small Hsps had the highest magnitude of change in low elevation plants while Hsp70 and Hsp90 showed the largest magnitude of fold in high elevation plants. In 38/45°C, Hsp/Hsf and ROS pathways were activated in both low and high elevation plants. Low elevation plants showed up-regulation in all Hsps, especially small Hsps; high elevation plants showed down-regulation in all Hsps. Low elevation and high elevation also adopted different genes in the ROS pathway. We also observed genes that shifted expression in both low and high elevation plants but with opposite directions of change. This study indicates that low and high elevation plants have evolved adaptive divergence in heat stress response. The contrasting patterns of temperature variation in low and high elevation sites appears to have played a strong role in the evolution of divergent patterns to high temperature stress, both pre-acclimation and direct exposure gene expression responses.

Molecular Ecology

The Plant Journal IF: 6.8 (TPJ welcomes functional genomics manuscripts when a scientific question, rather than the technology used, has driven the research)