bluuebunny/crossref_metadata_2025 huggingface dataset:
A Histopathological Study of Granulomatous Inflammation
Authors: Permi Harish S. , K. Jayaprakash Shetty , Padma Shetty K. , S. Teerthanath , Mathias Michelle , Y. Sunil Kumar , L. Kishan Prasad H. ,   Chandrika
Published: March 2020

Granulomatous inflammation is a distinctive pattern of chronic inflammation that is encountered in a limited number of infectious and non-infectious conditions. Recognisation of granulomatous pattern and finding the etiology in a biopsy specimen is very important for specific treatment and outcome of the disease. We aimed at finding the etiology of all granulomatous lesions on tissue biopsy sent for histopathogical examination. A study was done at K S Hegde Medical Academy of Nitte University, Mangalore from January 2009 to December 2010. All the cases which were diagnosed as granulomas on Hematoxylin and Eosin stained sections were selected. Special stains like Ziehl-Neelsen stain, Gomori's Methenamine silver, PAS, Fite Faraco were done whenever required. We encountered 275 granulomatous lesions in our study. The most common sites were skin and subcutaneous tissue, lymph nodes, bones and joints. The commonest cause of granulomas was tuberculosis, followed by leprosy, foreign body granulomas, fungal infections, rhinoscleroma, parasites, tumor granulomas and actinomycosis. The morphological features and special staining helped us to find the specific etiology of granulomas in 253 cases whereas it could not be determined in 22 cases even after special stains. Thus we conclude that histopathological examination of granulomatous lesions helped us to find the exact etiology of granulomas in 92 % of cases. The correlation of histopathology with polymerase chain reaction (PCR) serological tests and culture correlation would have helped to find the specific etiology in the remainder of cases.
Public Private Partnership as a Treatment Strategy for Tuberculosis Under Dots in Coastal South India
Authors: S. Rama Prakasha , G. Suresh , D'sa Ivor Peter , S. Shobha Shetty , S. Ganesh Kumar , Shetty Manamohan
Published: March 2020

Limited information is available regarding the functioning of DOTS (Directly Observed Treatment Short course) center for tuberculosis treatment under public private partnership with a medical college hospital. The present study was done to assess the various parameters related to the effectiveness of follow up treatment and its outcome in a DOTS center attached to a medical college hospital in coastal South India.

Reports of patients with tuberculosis diagnosed and treated under Revised National Tuberculosis Control Programme at KS Hegde Medical College hospital DOTS center under Mangalore TB unit were reviewed retrospectively for the period from July 2004 to June 2011. Data was described in proportion and chi square test was applied to assess the association of cases with age group and sex. Among 60 patients serially registered under DOTS, 41 (68.33 %) cases were females and 19 (31.67%) cases were males. Maximum number of cases belonged to 15-29 years age group (20, 33.3%) and the difference observed between the categories of TB and age group was found to be significant (P<0.001). Overall 23 (38.33%), 12 (20%) and 25 (41.67%) cases received Cat-I, Cat-II and Cat-III treatment respectively. Success rate for new smear positive cases was 92.85% (13/14) and for Re-treatment smear positive cases was 88.89% (8/9). Sputum conversion rate among new smear positive cases (n= 14) at 2 months and 3 months was 85.71% and 92.86% respectively. Sputum conversion rate for Re-treatment cases (n=9) at 2 months and 3 months was 55.56% and 88.89% respectively. RNTCP is running successfully in this DOTS center with very low treatment failure rate and better outcome indicators, highlighting the importance of public private partnership of poorly functioning DOTS centers with medical colleges.
Role of Living Donor Liver Transplantation for Advanced Hepatocellular Carcinoma
Authors: Montenovo Martin I.
Published: March 2020

Hepatocellular carcinoma (HCC) is the sixth most common malignant tumor worldwide and the third leading cause of cancer-related death. Despite the significant progress that has been achieved with local therapies, treatment remains limited by impaired liver function and high rate of recurrence. The purpose of the manuscript is to describe the current status of using living donor liver transplantation in patients with advanced HCC.
Randomized Controlled Trials of Headache Treatments in Pregnancy: A Systematic Review
Authors: Bushman Elisa T. , Cozzi Gabriella , Sinkey Rachel G. , Smith Catherine H. , Varner Michael W. , Digre Kathleen
Published: March 2020

Objective Headaches affect 88% of reproductive-aged women. Yet data are limited addressing treatment of headache in pregnancy. While many women experience improvement in pregnancy, primary and secondary headaches can develop. Consequently, pregnancy is a time when headache diagnosis can influence maternal and fetal interventions. This study was aimed to summarize existing randomized control trials (RCTs) addressing headache treatment in pregnancy.

Study Design We searched PubMed, CINAHL, EMBASE, ClinicalTrials.gov, Cochrane Library, CINAHL, and SCOPUS from January 1, 1970 through June 31, 2019. Studies were eligible if they were English-language RCTs addressing treatment of headache in pregnancy. Conference abstracts and studies investigating postpartum headache were excluded. Three authors reviewed English-language RCTs addressing treatment of antepartum headache. To be included, all authors agreed each article to meet the following criteria: predefined control group, participants underwent randomization, and treatment of headache occurred in the antepartum period. If inclusion criteria were met no exclusions were made. Our systematic review registration number was CRD42019135874.

Results A total of 193 studies were reviewed. Of the three that met inclusion criteria all were small, with follow-up designed to measure pain reduction and showed statistical significance.

Conclusion Our systematic review of RCTs evaluating treatment of headache in pregnancy revealed only three studies. This paucity of data limits treatment, puts women at risk for worsening headache disorders, and delays diagnosis placing both the mother and fetus at risk for complications.
A versatile Johansson-type tender x-ray emission spectrometer
Authors: Nowak S. H. , Armenta R. , Schwartz C. P. , Gallo A. , Abraham B. , Garcia-Esparza A. T. , Biasin E. , Prado A. , Maciel A. , Zhang D. , Day D. , Christensen S. , Kroll T. , Alonso-Mori R. , Nordlund D. , Weng T.-C. , Sokaras D.
Published: March 2020

We present a high energy resolution x-ray spectrometer for the tender x-ray regime (1.6–5.0 keV) that was designed and operated at Stanford Synchrotron Radiation Lightsource. The instrument is developed on a Rowland geometry (500 mm of radius) using cylindrically bent Johansson analyzers and a position sensitive detector. By placing the sample inside the Rowland circle, the spectrometer operates in an energy-dispersive mode with a subnatural line-width energy resolution (∼0.32 eV at 2400 eV), even when an extended incident x-ray beam is used across a wide range of diffraction angles (∼30° to 65°). The spectrometer is enclosed in a vacuum chamber, and a sample chamber with independent ambient conditions is introduced to enable a versatile and fast-access sample environment (e.g., solid/gas/liquid samples, in situ cells, and radioactive materials). The design, capabilities, and performance are presented and discussed.
A multi-stop time-of-flight spectrometer for the measurement of positron annihilation-induced electrons in coincidence with the Doppler-shifted annihilation gamma photon
Authors: Chirayath V. A. , Gladen R. W. , McDonald A. D. , Fairchild A. J. , Joglekar P. V. , Satyal S. , Lim Z. H. , Shead T. N. , Chrysler M. D. , Mukherjee S. , Barnett B. M. , Byrnes N. K. , Koymen A. R. , Greaves R. G. , Weiss A. H.
Published: March 2020

In this study, we describe an advanced multi-functional, variable-energy positron beam system capable of measuring the energies of multiple “positron-induced” electrons in coincidence with the Doppler-shifted gamma photon resulting from the annihilation of the correlated positron. The measurements were carried out using the unique characteristics of the digital time-of-flight spectrometer and the gamma spectrometer available with the advanced positron beam system. These measurements have resulted in (i) the first digital time-of-flight spectrum of positron annihilation-induced Auger electrons generated using coincident signals from a high-purity Ge detector and a micro-channel plate, (ii) a two-dimensional array of the energy of Doppler-broadened annihilation gamma and the time-of-flight of positron-annihilation induced Auger electrons/secondary electrons measured in coincidence with the annihilation gamma photon, and (iii) the time-of-flight spectra of multiple secondary electrons ejected from a bilayer graphene surface as a result of the impact and/or annihilation of positrons. The novelty of the gamma–electron coincidence spectroscopy has been demonstrated by extracting the Doppler-broadened spectrum of gamma photons emitted due to the annihilation of positrons exclusively with 1s electrons of carbon. The width of the extracted Doppler-broadened gamma spectrum has been found to be consistent with the expected broadening of the annihilation gamma spectrum due to the momentum of the 1s electrons in carbon.
Influence of thixotropic parameters on a non-Newtonian fluid flow
Authors: Bui Cuong Mai , Ho Thinh Xuan
Published: March 2020

Non-Newtonian fluids exhibiting complex rheological characteristics, such as yield stress and thixotropy, are frequently encountered in nature and industries. Thixotropy is a time-dependent shear thinning property, associated with the microstructural evolution of materials. During a flowing process, two microstructure transition mechanisms are considered to take place simultaneously: the recovery and the breakdown; the former makes the materials more solid, while the latter makes them more liquid. The microstructure is characterized by a dimensionless structural parameter, whose evolution is modeled by a rate equation consisting of two terms representing the rate of the two mechanisms. A brief review on thixotropic models for different materials is first carried out. It is then assumed that the recovery rate depends linearly on the structural parameter, and the breakdown one is a complex function of it and the shear rate. This work aims at investigating the influence of the parameters that control the recovery and breakdown rates on the flow of a thixotropic fluid past a circular cylinder. In addition, the Bingham and/or Herschel–Bulkley model with Papanastasiou’s regularization is utilized. Various flow characteristics, such as the microstructure evolution and the flow field including the yielded and unyielded zones, are analyzed and discussed in detail. The simulation results show that the size and shape of both static and moving unyielded zones are considerably affected by the thixotropic parameters.
Science is not a signal detection problem
Authors: Wilson Brent M. , Harris Christine R. , Wixted John T.
Published: March 2020

The perceived replication crisis and the reforms designed to address it are grounded in the notion that science is a binary signal detection problem. However, contrary to null hypothesis significance testing (NHST) logic, the magnitude of the underlying effect size for a given experiment is best conceptualized as a random draw from a continuous distribution, not as a random draw from a dichotomous distribution (null vs. alternative). Moreover, because continuously distributed effects selected using a
P
< 0.05 filter must be inflated, the fact that they are smaller when replicated (reflecting regression to the mean) is no reason to sound the alarm. Considered from this perspective, recent replication efforts suggest that most published
P
< 0.05 scientific findings are “true” (i.e., in the correct direction), with observed effect sizes that are inflated to varying degrees. We propose that original science is a screening process, one that adopts NHST logic as a useful fiction for selecting true effects that are potentially large enough to be of interest to other scientists. Unlike original science, replication science seeks to precisely measure the underlying effect size associated with an experimental protocol via large-
N
direct replication, without regard for statistical significance. Registered reports are well suited to (often resource-intensive) direct replications, which should focus on influential findings and be published regardless of outcome. Conceptual replications play an important but separate role in validating theories. However, because they are part of NHST-based original science, conceptual replications cannot serve as the field’s self-correction mechanism. Only direct replications can do that.
Integrated structural and evolutionary analysis reveals common mechanisms underlying adaptive evolution in mammals
Authors: Slodkowicz Greg , Goldman Nick
Published: March 2020

Understanding the molecular basis of adaptation to the environment is a central question in evolutionary biology, yet linking detected signatures of positive selection to molecular mechanisms remains challenging. Here we demonstrate that combining sequence-based phylogenetic methods with structural information assists in making such mechanistic interpretations on a genomic scale. Our integrative analysis shows that positively selected sites tend to colocalize on protein structures and that positively selected clusters are found in functionally important regions of proteins, indicating that positive selection can contravene the well-known principle of evolutionary conservation of functionally important regions. This unexpected finding, along with our discovery that positive selection acts on structural clusters, opens previously unexplored strategies for the development of better models of protein evolution. Remarkably, proteins where we detect the strongest evidence of clustering belong to just two functional groups: Components of immune response and metabolic enzymes. This gives a coherent picture of pathogens and xenobiotics as important drivers of adaptive evolution of mammals.
Immunotoxin SS1P is rapidly removed by proximal tubule cells of kidney, whose damage contributes to albumin loss in urine
Authors: Liu Xui-Fen , Wei Junxia , Zhou Qi , Molitoris Bruce A. , Sandoval Ruben , Kobayashi Hisataka , Okada Ryuhei , Nagaya Tadanobu , Karim Baktiar , Butcher Donna , Pastan Ira
Published: March 2020

Significance

This paper shows that the major pathway of degradation of immunotoxins in mice is rapid filtration through the glomerulus of the kidney and degradation by proximal tubular cells. It also shows that SS1P treatment damages proximal tubular cells and enhances loss of albumin in the urine, which can contribute to capillary leak syndrome, a major side effect of immunotoxin therapy. Because lysine administration diminishes kidney uptake of SS1P, it could also protect against SS1P-induced capillary leak syndrome.
Lactate dehydrogenase inhibition synergizes with IL-21 to promote CD8
+
T cell stemness and antitumor immunity
Authors: Hermans Dalton , Gautam Sanjivan , García-Cañaveras Juan C. , Gromer Daniel , Mitra Suman , Spolski Rosanne , Li Peng , Christensen Stephen , Nguyen Rosa , Lin Jian-Xin , Oh Jangsuk , Du Ning , Veenbergen Sharon , Fioravanti Jessica , Ebina-Shibuya Risa , Bleck Christopher , Neckers Leonard M. , Rabinowitz Joshua D. , Gattinoni Luca , Leonard Warren J.
Published: March 2020

Interleukin (IL)-2 and IL-21 dichotomously shape CD8
+
T cell differentiation. IL-2 drives terminal differentiation, generating cells that are poorly effective against tumors, whereas IL-21 promotes stem cell memory T cells (T
SCM
) and antitumor responses. Here we investigated the role of metabolic programming in the developmental differences induced by these cytokines. IL-2 promoted effector-like metabolism and aerobic glycolysis, robustly inducing lactate dehydrogenase (LDH) and lactate production, whereas IL-21 maintained a metabolically quiescent state dependent on oxidative phosphorylation. LDH inhibition rewired IL-2–induced effects, promoting pyruvate entry into the tricarboxylic acid cycle and inhibiting terminal effector and exhaustion programs, including mRNA expression of members of the NR4A family of nuclear receptors, as well as
Prdm1
and
Xbp1
. While deletion of
Ldha
prevented development of cells with antitumor effector function, transient LDH inhibition enhanced the generation of memory cells capable of triggering robust antitumor responses after adoptive transfer. LDH inhibition did not significantly affect IL-21–induced metabolism but caused major transcriptomic changes, including the suppression of IL-21–induced exhaustion markers LAG3, PD1, 2B4, and TIM3. LDH inhibition combined with IL-21 increased the formation of T
SCM
cells, resulting in more profound antitumor responses and prolonged host survival. These findings indicate a pivotal role for LDH in modulating cytokine-mediated T cell differentiation and underscore the therapeutic potential of transiently inhibiting LDH during adoptive T cell-based immunotherapy, with an unanticipated cooperative antitumor effect of LDH inhibition and IL-21.
From grammatical categories to processes of categorization
Authors: Behrens Heike
Published: March 2020

Current version of usage-based grammars propose that grammatical categories are language-specific local generalizations rather than universal building blocks of linguistic structure. This changes the perspective on what learning syntax or morphology is about. Instead of activating innate knowledge that provides the access to possible syntactic structures, children need to build the grammatical representations based on the linguistic input they receive in their communicative interactions. In doing so, they go through processes of re-representation regarding the underlying concepts and the structural generalizations. The process of conceptual integration is illustrated with the domain of space, where there is no direct connection between percepts and linguistically encoded notions. Language learning itself tunes the child’s attention to the distinctions made in the target language. Morphological categories differ in their conceptual unity and morphological regularity and provide different learning problems. Plural marking serves as an example to show how a category with conceptual unity raises learning challenges because of allomorphy (several affixes that encode the same concept). Finally, the acquisition German case marking is discussed to raise the question whether “case” as such is a useful concept in acquisition research, as case markers are polysemous in encoding different kinds of relations, and formally heterogeneous (pronomimal and nominal paradigms differ in their sub-regularities). These learning problems can only be solved with a bottom-up approach, if we assume that children learn language from language use.
Control of electron beam energy-spread by beam loading effects in a laser-plasma accelerator
Authors: Li Guangyu , Ain Quratul , Li Song , Saeed Muhammad , Papp Daniel , Kamperidis Christos , Hafz Nasr A M
Published: March 2020

We present experimental results from a laser wakefield electron accelerator driven by 70 TW ultrashort laser pulses in Helium and Helium–Nitrogen gaseous plasmas with two different Nitrogen concentrations, showing distinct electron-beam qualities. In order to get a clear view of the involved phenomenon, two-dimensional particle-in-cell simulations are performed which not only agreed with the experimental results but also provided an investigation on the evolution of accelerating structures. The experimental and simulation results depict that the beam loading effect can strongly modify the longitudinal accelerating electric field of the wake wave, imposing diametrically opposite effects on the final electron-beam qualities, especially the energy-spread, in the Helium–Nitrogen gas mixtures with different Nitrogen concentrations. In the Helium–Nitrogen-mixed plasma with a lower Nitrogen concentration (0.5%), if appropriately controlled, the beam loading effect can be employed to flatten the accelerating electric field for reducing the electron-beam energy spread. In contrast, in the Helium–Nitrogen-mixed plasmas with a higher Nitrogen concentration (5%), the accelerating electric field of the wake is locally reversed by the self-fields of the overloaded electron bunch, and the correspondingly generated negative-slope region of electric field increases the electron-beam energy-spread.
Channel activation of CHSH nonlocality
Authors: Zhang Yujie , Bravo Rodrigo Araiza , Lorenz Virginia O , Chitambar Eric
Published: March 2020

Quantum channels that break CHSH nonlocality on all input states are known as CHSH-breaking channels. In quantum networks, such channels are useless for distributing correlations that can violate the CHSH Inequality. Motivated by previous work on activation of nonlocality in quantum states, here we demonstrate an analogous activation of CHSH-breaking channels. That is, we show that certain pairs of CHSH-breaking channels are no longer CHSH-breaking when used in combination. We find that this type of activation can emerge in both uni-directional and bi-directional communication scenarios.
On the character variety of the three–holed projective plane
Authors: Maloni Sara , Palesi Frédéric
Published: March 2020

We study the (relative)

S
L

(
2
,

C

)

\mathrm {SL}(2,\mathbb {C})

character variety of the three-holed projective plane and the action of the mapping class group on it. We describe a domain of discontinuity for this action, which strictly contains the set of primitive stable representations defined by Minsky, and also the set of convex-cocompact characters.
A Validated LC–MS/MS Method for Simultaneous Determination of 3-O-Acetyl-11-Keto-β-Boswellic Acid (AKBA) and its Active Metabolite Acetyl-11-Hydroxy-β-Boswellic Acid (Ac-11-OH-BA) in Rat Plasma: Application to a Pharmacokinetic Study
Authors: Sharma Tarun , Jana Snehasis
Published: March 2020

The aim of this study was to develop and validate a new, rapid, sensitive, selective and reliable liquid chromatography–tandem mass spectrometry method for simultaneous determination of 3-O-Acetyl-11-keto-β-boswellic acid (AKBA) and its active metabolite 3-O-Acetyl-11-hydroxy-β-boswellic acid (Ac-11-hydroxy-BA) in rat plasma. Both analytes (AKBA and Ac-11-hydroxy-BA) and the internal standard (IS, ursolic acid) were extracted from 100 μL of rat plasma by protein precipitation. Chromatographic separation was achieved on PRP-H1 RP-C18 column (75 mm × 2 mm, 1.6 μm) using acetonitrile–water (95.5 v/v) as the mobile phase. Mass detection was conducted by electrospray ionization in positive ion multiple reaction monitoring (MRM) mode. A linear dynamic range of 1–1,000 ng/mL for both AKBA and Ac-11-hydroxy-BA was established with mean correlation coefficient (r (1)) of 0.999. Intra- and inter-day precision (% CV) of analysis were found in the range of 1.9–7.4%. The accuracy determined for these analytes ranged from 92.4 to 107.2%. The extraction recoveries for both analytes ranged from 92.6 to 97.3% for spiked plasma samples and were consistent. The % change in stability samples compared to nominal concentration ranged from 0.4 to 4.2%. This method was successfully tested to a pharmacokinetic (PK) study for estimation of AKBA and acetyl-11-hydroxy-BA in rat plasma following oral administration of AKBA. This method has been validated with the advantage of shorter run time that can be used for high-throughput analysis and has been successfully applied to the pharmacokinetic study of AKBA in rats.
Financing the Belt and Road Initiative: Can Singapore Help in Securitizing It?
Authors: Tjio Hans
Published: March 2020

China’s ambitious Belt and Road Initiative (BRI) is perhaps the modern equivalent of the Marshall Plan and will hopefully provide the aggregate demand lost due to the global financial crisis. At the moment, much of the financing has come from the government and financial institutions. If more private sector financing is needed for the BRI, this could involve, perhaps, having established ways of project finance that we have seen with the large infrastructural projects of the past as well as modern methods of asset securitization. Lawyers and financiers would be needed, and the West has traditionally held a comparative advantage in these entities, whereas China’s advantage is in building and making things. Singapore, perhaps, is now well placed to offer its services in a way that brings the East and the West together and that would hopefully provide a balanced approach that distributes benefits to all involved in the BRI. Its experiences are far from perfect, but it has learned painful lessons to position itself as a financial centre supporting the real economy that can now hopefully begin to rival New York, London, and Hong Kong. The areas examined in this article include Singapore’s development of property and infrastructural trusts, its bond and derivatives markets, its restructuring regime, and its legal expertise in project finance.
Genome Sequence of an Emerging Salmonella enterica Serovar Infantis and Genomic Comparison with Other S. Infantis Strains
Authors: Cohen Emiliano , Rahav Galia , Gal-Mor Ohad
Published: March 2020

Salmonella enterica serovar Infantis (S. Infantis) is one of the dominant serovars of the bacterial pathogen S. enterica. In recent years, the number of human infections caused by S. Infantis has been increasing in many countries, and often the emerging population harbors a unique virulence-resistant megaplasmid called plasmid of emerging S. Infantis (pESI). Here, we report the complete gap-free genome sequence of the S. Infantis Israeli emerging clone and compare its chromosome and pESI sequences with other complete S. Infantis genomes. We show a conserved presence of the Salmonella pathogenicity islands 1–6, 9, 11, 12, and CS54 and a common integration of five bacteriophages in the S. Infantis chromosome. In contrast, we found variable presence of additionally three chromosomally integrated phages and eight modular regions in pESI, which contribute to the genetic and phenotypic diversity (including antimicrobial resistance) of this ubiquitous foodborne pathogen.
Consumer protection in cloud computing contracts stipulating non-monetary remuneration
Authors: Żok Krzysztof
Published: March 2020

The convenience of cloud services rapidly increases their popularity among consumers. Although the services are often marketed as free, the consumer may be required to provide remuneration. Instead of charging a fee, however, providers usually collect assets other than money, in particular consumer’s personal data. This raises serious questions about consumer protection which until recently has mainly covered ‘paid’ contracts. Moreover, treating some forms of non-monetary remuneration as payment is controversial due to the special status of the information provided by the consumer in exchange for the service.

The article analyses the impact of non-monetary remuneration on consumer protection in cloud computing contracts, taking as reference points Directives 2011/83 (with the latest amendments) and 2019/770. The following considerations highlight the disadvantages of both Directives, concluding that they do not remove all the concerns associated with cloud computing contracts. The article also indicates possible solutions to the issue of non-monetary remuneration.
Cultivated Collaboration in Transitional Justice Practice and Research: Reflections on Tunisia’s Voices of Memory Project
Authors: Ladisch Virginie , Yakinthou Christalla
Published: March 2020

ABSTRACT∞

The Voices of Memory project started with a fairly simple premise: to highlight women’s life experiences under dictatorship. What started as a one-week workshop in 2017 evolved into a collaborative process of co-creation – the Voices of Memory project – using creative means of expression to help raise awareness of the impact of repression on Tunisian women. A formative principle, and primary contribution of this project, was a fully collaborative methodology. In this article, we reflect on and make explicit an approach we adopted intuitively and experimentally, drawing also on best practice in participatory action research and methods of co-creation.
The Researcher and the Researched: Navigating the Challenges of Research in Conflict-Affected Environments
Authors: Gordon Eleanor
Published: March 2020

Ethical concerns associated with social science research are heightened in conflict-affected environments, due to increased insecurity and the vulnerability of many research participants. This article considers some of the main challenges faced by researchers in conflict-affected environments and how they can be addressed, focusing in particular on ethical and security challenges. It also considers other challenges, which are often overlooked, such as the epistemological and methodological challenges of acquiring knowledge in conflict-affected environments, where research participants may be from different cultures, may speak different languages, and may be deeply traumatized and distrustful of others. In such places, research participants may employ techniques to assuage or discourage the researcher, including projecting borrowed narratives or remaining silent. This article argues that navigating security and ethical challenges, attending to issues of power, and remaining genuinely self-reflective can help fulfill the optimal potential of research in conflict-affected environments, which is to challenge narratives that perpetuate conflict, harm, and insecurity and to contribute to a better understanding and, thus, response to the challenges of conflict and peacebuilding.
13 Macronutrient Intake and Wound Healing in Critically Ill Burn Patients
Authors: Rupert Sarah S , Shields Beth A , Bustillos Brenda D , Cancio Leopoldo C
Published: March 2020

Introduction

Nutrition support is an important component of the care of the critically ill burn patient. The European Society for Parenteral and Enteral Nutrition recommends less than 35% of calories from fat and less than 60% from carbohydrate (CHO); however, favorable clinical outcomes have been found in randomized controlled trials when burn patients were given 12–27% fat and 46–65% CHO. These benefits include lower rates of pneumonia and mortality. The purpose of this research was to examine macronutrient intake of critically ill burn patients and the association with wound healing.

Methods

A retrospective study was approved by the Institutional Review Board and included patients admitted to our burn intensive care unit over an 11 year period who were ≥18 years of age, had ≥20% total body surface area burns. Subjects who required hospitalization for ≥8 days and required nutrition support were included in this analysis. Subjects who were admitted over a week after injury and those who underwent limb amputations were excluded. Caloric intake from CHO, fat, and protein was obtained from enteral nutrition, parenteral nutrition, and oral intake for the first eight days following hospitalization. Wound healing was defined as achieving < 10% TBSA open wound. Univariate analysis was used to identify factors significantly associated with wound healing. Variables found to be significant (p< 0.05) were subjected to logistic regression.

Results

A total of 309 patients (89% male) were included. Patients were 37 ± 17 years old and had 46 ± 18% TBSA burns. Wound healing was achieved by 77% of patients, with 26% mortality. Those who healed were significantly younger (34 ± 15 vs. 47 ± 19 years, p< 0.001), were taller (70 ± 3 vs. 68 ± 4 inches, p< 0.001), with smaller burns (44 ± 16% vs. 54 ± 20% TBSA, p< 0.001), predominantly male (92% vs. 77%, p< 0.001), received a higher amount of CHO (1166 ± 465 vs. 902 ± 494 kcals, p< 0.001), and received a higher amount of fat (455 ± 234 vs. 360 ± 220 kcals, p=0.003). After logistic regression, factors negatively associated with wound healing included increased age (p< 0.001), female gender (p=0.032), and larger burn size (p< 0.001); a positive association was seen with 8-day average calories from CHO (p=0.027).

Conclusions

This study identified several factors significantly associated with healing in burn patients; however, higher CHO intake was the only modifiable factor. Further research is needed to determine the optimal CHO intake to improve patient outcomes.

Applicability of Research to Practice

Consideration should be made for high-CHO enteral nutrition in critically ill burn patients.
29 Symptoms of PTSD in a Burn Outpatient Clinic: Prevalence and Engagement Challenges for the Burn Team
Authors: McAleavey Andrew , Emrich Mariel , Jick Adina R , McGuire Collette L , Difede JoAnn
Published: March 2020

Introduction

Psychological distress, including posttraumatic stress disorder, acute stress disorder, and depressive disorders, are common after burn injury. These conditions are major determinants of long-term quality of life and productivity loss among burn patients, yet are generally under treated. Among the many reasons for limited treatment are lack of accessible quality care, limited clinical staff expertise in assessing these conditions, and patient avoidance of effective services.

Methods

During December 2018 to September, 2019, patients awaiting outpatient visits at an urban burn center were asked to complete brief standardized self-report questionnaires assessing symptoms of posttraumatic distress, anxiety, and depression. Using pre-defined criteria, we attempted to reach individuals with greater than moderate distress using contact information provided voluntarily and engage these patients in outpatient mental health services.

Results

747 questionnaires were completed by 511 individuals in the assessment period, and of these 98 (19.2%) individuals had a likely PTSD diagnosis. Visual analog scale assessments for current anxiety, depression and stress all suggested high average distress in the overall group. Using pre-defined criteria to identify potential distress, we identified 195 people (38.2%) to whom we would proactively offer services. Only 159 provided contact information, and several more were not eligible for available clinical services so were not contacted. We called 128 individuals (81%). This led to direct communication with 48 patients (37.5% of those contacted), but only 22 individuals (17.2% of all those contacted) still endorsed distress at the time of the phone call (which was planned to occur within one week of the patients’ report) and 11 individuals were interested in seeking mental health services. Of these, 4 were referred to other services, 3 declined specific offers of service, 4 were scheduled for appointments and only 2 individuals attended appointments with the in-hospital psychological trauma group.

Conclusions

Psychological distress is highly prevalent in the burn outpatient clinic, with roughly one in five patients likely meeting criteria for PTSD. However, engaging patients in psychological and psychiatric treatment remains a major challenge for the effective care in this population. We discuss strategies tried here and systemic barriers to overcome in future research and care.

Applicability of Research to Practice

High prevalence of PTSD in outpatient burn clinics and difficulty engaging patients in separate outpatient mental health services suggest co-located and collaborative care models would be highly helpful in this population.
87 Evaluating Endothelial Dysfunction in Thermally-injured Patients with syndecan-1, Tissue Factor Pathway Inhibitor, and Thrombomodulin as Predictors of Mortality
Authors: Keyloun John W , Nisar Saira , Brummel-Ziedins Kathleen , Bravo Maria , Gissell Matthew , McLawhorn Melissa M , Orfeo Thomas , Carney Bonnie C , Moffatt Lauren T , Pusateri Anthony , Shupp Jeffrey W
Published: March 2020

Introduction

Endotheliopathy in burn patients is largely uncharacterized. Syndecan-1 (SDC-1), thrombomodulin (TM), and tissue factor pathway inhibitor (TFPI) are components of the vascular endothelial glycocalyx. Proteolytic cleavage of these moieties may yield biomarkers for endothelial damage. The aim of this study is to evaluate endotheliopathy after burn injury by monitoring plasma levels of these biomarkers over time to investigate potential relationship to mortality.

Methods

Burn injured patients presenting to a regional burn center from 2012 to 2017 were prospectively enrolled. Blood samples were collected at 0, 2, 4, 8, 12, 24, 36, 48, 60, and 72 hours from admission. Plasma SDC-1, TM, and TFPI levels were quantified by ELISA. Demographic data and injury characteristics were obtained from the medical chart. Patients with concomitant inhalation injury, trauma, or < 10% total body surface area (TBSA) burns were excluded. Statistical analysis was performed using mixed-effect models with Sidak’s correction for multiple comparisons. Significance was set at p =0.05. Data are presented as mean ± standard deviation.

Results

A cohort of 22 patients was identified with an average age of 45±14 years, TBSA of 30±15%, with 6 patients who died from their injuries. The deceased group was older (59±13 vs. 40±10 years, p = 0.01), and there was no significant difference in burn size. Mean SDC-1 levels were higher in the deceased group at all time points (p=0.0004) and this difference was significant at hour 12 (106±11 vs. 41±31 ng/mL, p = 0.0002), hour 24 (160±39 vs. 35±20 ng/mL, p = 0.04) and hour 72 (100±3 vs. 35±38 ng/mL, p = 0.01). Mean soluble TM levels were higher in the deceased group after hour 12 (p = 0.04) and there was a trend towards higher TFPI levels after hour 12 in the deceased group.

Conclusions

Biomarkers are elevated in patients following burn injury who die, when inhalation injury and trauma are excluded. Given equivalent TBSA, older patients appear more sensitive to thermally induced glycocalyx degradation. SDC-1 shows the greatest promise as a prognostic indicator as levels tend to be higher among deceased patients on admission and are significantly higher as early as hour 12.

Applicability of Research to Practice

Reliable assessment of the patient’s endothelial damage may hold predictive value for clinicians and could assist in clinical decision making. Further research must investigate endotheliopathy in burn patients.
93 Optical Coherence Tomography: A New Imaging Technique for Burn Injuries
Authors: Anderson Jeffrey H , Qiu Qian , Deegan Anthony J , Mills Brianna , Wang Ruikang , Mandell Samuel P
Published: March 2020

Introduction

Accurate assessment of burn depth and healing time remains elusive. As a result, some patients may wait weeks, through painful wound care only to have surgery. Others may have early surgery on wounds that may have healed with a good outcome. Expert opinion remains the most common method of wound evaluation. We sought to evaluate if Optical Coherence Tomography (OCT) with Microangiography (OMAG) can predict burn wound healing.

Methods

We prospectively enrolled a cohort of 17 burned subjects whose attending physician initially evaluated the depth of the wound as indeterminate. Burn wounds were scanned on enrollment and weekly, until healed or grafted, using a clinical prototype swept source OCT with OMAG capability. Wounds were also assessed by the attending physician for depth of injury and healing time. Wounds were photographed at the time of each scan. OCT and OMAG scans were then used to quantitatively determine blood vessel depth and density within the wound. Univariate regression with clustering and panel effects evaluated the association with healing time. Photographs and scans of each wound from all time points were evaluated by 5 blinded assessors (four surgeons and an OCT engineer) for time to wound healing. Kappa was used to measure the interrater reliability between evaluators.

Results

The mean patient age was 46 years with a mean burn size of 10% body surface area. Fourteen patients ultimately healed their wounds. Three patients underwent excision and grafting. There was no significant association between vessel depth or density and healing time (Table). Similarly, vessel depth was not predictive of the need for surgery. However, vessel density £ 0.255 perfectly predicted the need for surgery. There was no agreement between evaluators regarding predicted healing looking at OCT and OMAG scans (Kappa 0.003). There was moderate agreement between evaluators predicting healing from photos (Kappa 0.047).

Conclusions

This preliminary data demonstrates that quantitative OCT/OMAG data shows promise in predicting which patients undergo surgical therapy. Variation of healing estimates from provider image assessment support the best use of this tool as a quantitative measure. Larger studies are needed to explore these findings and the role of this technology.

Applicability of Research to Practice

OCT/OMAG is a quantitative tool that shows promise in predicting which patients undergo surgical therapy.
108 An Evidence Based Laser Therapy Algorithm for the Treatment of Burn Scars
Authors: Roggy David , Sood Rajiv
Published: March 2020

Introduction

Hypertrophic scarring after burn injury can be extremely painful, cause profound itching, and affect the way patients view themselves and how the outside world perceives them. We have utilized laser therapy as a modality for scar modulation for our patients since 2013. In 2014, we initiated and completed a prospective IRB approved study to evaluate the outcome of scars treated with fractional CO2 laser therapy (FLT) utilizing objective and subjective tools. Recently, we have completed a prospective study evaluating the use of pulse dye laser (PDL) therapy and the impact on post-burn pruritis. In reviewing the outcomes from these two studies, we have developed an evidence based laser therapy algorithm for burn scar management.

Methods

The FLT study entailed a series of three CO2 laser treatments minimally 4–6 weeks apart with scar measurements and POSAS form completion performed prior to each laser treatment and four weeks after the last FLT. Scar measurements that included color, pliability, and scar thickness; and completion of the POSAS form were obtained prior to each laser therapy session and four weeks after the third laser treatment. The measurements of color, pliability, and scar thickness were measured with the Colorimeter, Cutometer, and ultrasound. The PDL study utilized the 5-D Itch scale to evaluate post-burn pruritis. A baseline measurement was obtained prior to any laser treatments. Each patient underwent two PDL sessions and a 5-D itch scale was completed four to six weeks after the second PDL session. The baseline measurement was then compared to the final 5-D itch scale measurement.

Results

Data from the FLT study is in Table 1 and shows that there were statistically significant improvements in the Patient and Observer POSAS scores, patient rated Itch score, scar thickness, and measured skin density. Changes to patient rated scar pain, scar color, and pliability were noted but were not of statistical significance. Data from the PDL study is in Table 2 and shows a statistically significant decrease in the treated patients’ post-burn pruritis.

Conclusions

In reviewing the outcomes of these two studies, we have developed an algorithm based on our studies. All of our patients undergoing laser therapy receive two PDL sessions that are four to six weeks apart followed by 3 FLT sessions. The use of both PDL and FLT decreases post-burn pruritis, decreases scar thickness, decreases pain, and increases patient satisfaction as shown in our research.

Applicability of Research to Practice

This research shows the benefit of the combination of PDL and FLT in an algorithmic approach to treat hypertrophic scars and burn pruritis.
513 Simplified Approach to Incorporating Glycemic Response Within a Continuous Insulin Infusion Algorithm to Improve Incidence of Hypoglycemia in a Single Burn Center
Authors: Hill David M , Hendrix Hayden , Velamuri Sai R , Sultan-Ali Ibrahim , Arif Faisal , Hickerson William L
Published: March 2020

Introduction

Attaining adequate glycemic control in burn patients can reduce infection-related mortality. Previous internal evaluation of four insulin infusion protocols showed a hypoglycemia (< 60 mg/dL) rate of 0.6% and an average time within goal glycemic range (70-149 mg/dL) of 13.8 hours per day. A new algorithm underwent six iterations over two years before the final version was implemented. The purpose of our study was to assess the post-implementation performance of the newly-developed continuous insulin infusion (CII) protocol designed to adjust dosage based on glycemic fluctuation.

Methods

This study was a two year retrospective, IRB approved, review of adult patients admitted to a single burn center, who received a CII. The pre-implementation study served as a historical control comparator. The current study was powered to detect a 50% reduction in hypoglycemic events, requiring 4,245 point-of-care samples. Based on average usage, at least 20 patients were required for adequate power of 80 % and alpha of 0.05. Demographics, insulin infusion data, infection, and mortality outcomes were collected. Nominal data were analyzed by Fisher’s exact test. Continuous variables were compared using either Mann-Whitney U test or student’s t-test, depending on normality.

Results

Of the 27 records screened for inclusion, seven were excluded. The average patient was a 59-year-old Caucasian male with diabetes and a total body surface area burn of 17%. There were no differences in demographics between groups. Among the 20 records reviewed, 5,239 point-of-care glucoses were assessed. Post implementation, hypoglycemia rates were significantly lower (0.6% vs 0.2%; p < 0.001). There was no difference in median blood glucose between groups (149.9 mg / dL vs. 146.5 mg / dL; p = 0.56) or time to achieve the goal glycemic range (6 vs 6.5 hours; p = 0.28). Time spent within goal glycemic range was not significantly different (13.8 vs. 14.7 hours / day; p = 0.23). The overall median time until glucoses were monitored after holding CII for down trending glucoses was 65.7 (53.5–111.3) minutes. Of the times CII were held, 53 of the follow up glucoses (25%) surpassed 200 mg / dL before subsequently settling. There was no differences in infection, length of stay, or survival.

Conclusions

The consolidation, education, and implementation of a single, dynamic CII algorithm reduced the incidence of hypoglycemia. The authors expect, education and diligence with follow up glucose monitoring will further improve time within goal glycemic range by preventing rebound hyperglycemia.

Applicability of Research to Practice

Improving glycemic control can be obtained by simple means. Implementing a two step algorithm that incorporates glycemic response and goal with vigorous education will reduce hypoglycemia and improve glycemic control.