bluuebunny/crossref_metadata_2025 huggingface dataset:
Left Ventricular Diastolic Dysfunction in Pediatric Sepsis: Outcomes in a Single-Center Retrospective Cohort Study*
Authors: Ginsburg Sarah , Conlon Thomas , Himebauch Adam , Glau Christie , Weiss Scott , Weber Mark D. , O’Connor Matthew J. , Nishisaki Akira
Published: February 2021

Objectives:

Left ventricular diastolic dysfunction is associated with difficulty in ventilator weaning and increased mortality in septic adults. We evaluated the association of left ventricular diastolic dysfunction with outcomes in a cohort of children with severe sepsis and septic shock.

Design:

Retrospective cohort study.

Setting:

Single-center noncardiac PICU.

Patients:

Age greater than 1 month to less than 18 years old with severe sepsis or septic shock from January 2011 to June 2017 with echocardiogram within 48 hours of sepsis onset.

Interventions:

None.

Measurements and Main Results:

Echocardiograms were retrospectively assessed for mitral inflow E (early) and A (atrial) velocity and e′ (early mitral annular motion) septal and lateral velocity. Left ventricular diastolic dysfunction was defined as E/e′ greater than 10, E/A less than 0.8, or E/A greater than 1.5. Left ventricular diastolic dysfunction was present in 109 of 204 patients (53%). The data did not demonstrate an association between the presence of left ventricular diastolic dysfunction and the proportion of children requiring invasive mechanical ventilation at the time of echocardiogram (difference in proportion, +5% [72% vs 67%; 95% CI, –8% to 17%]; p = 0.52). The duration of mechanical ventilation was median 192.9 hours (interquartile range, 65.0–378.4 hr) in the left ventricular diastolic dysfunction group versus 151.0 hours (interquartile range, 45.7–244.3 hr) in the group without left ventricular diastolic dysfunction. The presence of left ventricular diastolic dysfunction was not significantly associated with ICU length of stay or mortality. Exploratory analyses revealed that an alternative definition of left ventricular diastolic dysfunction, solely defined by E/e′ greater than 10, was found to have an association with mechanical ventilation requirement at the time of echocardiogram (difference in proportion, +15%; 95% CI, 3–28%; p = 0.02) and duration of mechanical ventilation (median, 207.3 vs 146.9 hr).

Conclusions:

The data failed to show an association between the presence of left ventricular diastolic dysfunction defined by both E/e′ and E/A and the primary and secondary outcomes. When an alternative definition of left ventricular diastolic dysfunction with E/e′ alone was used, there was a significant association with respiratory outcomes.
The Mental Health Crisis in America: Recognizing Problems; Working Toward Solutions: Part 1. Defining the Crisis
Authors: PLAKUN ERIC M.
Published: February 2021

This column is the first in a series summarizing the 2-day Centennial Conference of the Austen Riggs Center. The conference framed problems in access to care and in the nature of care provided that are part of a mental health crisis in America, and then worked to propose solutions. This column focuses on framing the problems and on beginning to address what it might take to “bend the curve” in mental health outcomes.
Commentary on “Bosch-Boonstra-Schaaf Optic Atrophy Syndrome Presenting as New-Onset Psychosis in a 32-Year-Old Man: A Case Report and Literature Review”
Authors: KAHN DAVID A.
Published: February 2021

Bosch-Boonstra-Schaaf optic atrophy syndrome (BBSOAS) is a recently described autosomal dominant disorder caused by mutations in the nuclear receptor subfamily 2 group F member 1 (NR2F1) gene. Its common features include optic atrophy and/or hypoplasia, developmental delay, intellectual disability, attention deficit disorder, autism spectrum disorder, seizures, hearing defects, spasticity, hypotonia, and thinning of the corpus callosum. Mitochondrial involvement has also been described with BBSOAS. Currently, 31 cases of BBSOAS have been described in the literature. Here we report a case of undiagnosed BBSOAS presenting as psychosis in a 32-year-old man with a history of bilateral optic nerve atrophy, intellectual disability, epilepsy, and mitochondrial complex I abnormality on muscle biopsy. Whole-genome sequencing identified a heterozygous de novo nonsense mutation in the NR2F1 gene [c.253 G>T (guanine to thymine mutation in coding position 253) in exon 1, p.E85X variant (GAG>TAG) (glutamic acid to stop codon mutation; protein truncated to 85 amino acids)]. A pathogenic nonsense mutation has not previously been reported in the literature in association with BBSOAS and represents an expansion of clinically relevant variants. Psychosis has also not been previously reported in this syndrome and may represent a phenotypic expansion of BBSOAS, a manifestation of prolonged disease, or a result of disease management.
Personality Factors and Attachment Styles as Predictors of the Therapeutic Efficacy of a Short-Term Ambulatory Intervention for Depression
Authors: BARTOLOMEI JAVIER , BAERISWYL-COTTIN RACHEL , FRAMORANDO DAVID , ZANELLO ADRIANO , BACCHETTA JEAN-PIERRE , HERRMANN FRANÇOIS , SENTISSI OTHMAN
Published: February 2021

Background:

Several studies have shown a significant positive impact of intensive short-term ambulatory psychiatric interventions for depression. However, data on outcomes related to factors that are predictive of the efficacy of these interventions in terms of remission or response to treatment remain scarce. The goal of this naturalistic prospective study was to identify factors, including Big Five Inventory personality traits and attachment style, that are predictive of the efficacy of crisis interventions (CIns) in major depressive disorder.

Methods:

The study included 234 adult outpatients with major depressive disorder who completed all assessments in a study of a short-term intensive ambulatory CIn. In this study, we evaluated sociodemographic factors, and scores on the Global Assessment of Functioning Scale, the Big Five Inventory personality assessment, the Montgomery-Åsberg Depression Rating Scale, and the Adult Attachment Scale.

Results:

Mean scores on the Montgomery-Åsberg Depression Rating Scale decreased significantly from 26.3 (SD=9.0) at admission to 10.6 (SD=8.1) at the end of the CIn (t=23.9; P<0.001); 99 patients (42%) experienced remission, 151 patients (65%) were considered treatment responders, and 98 patients (42%) both responded to treatment and experienced remission. Results of multivariate regression analysis showed that education level and family intervention were associated with response to treatment. Neuroticism traits were related to a lower rate of response to treatment. The dependency dimension attachment style had a positive impact on response to treatment.

Conclusions:

Neuroticism traits can predict clinical outcomes after a short-term intensive psychiatric intervention for depression. Results of family interviews, education level, and Global Assessment of Functioning scores should also be taken into account in predicting clinical outcomes.
Drug-Drug Interactions (DDIs) in Psychiatric Practice, Part 8: Relative Receptor Binding Affinity as a Way of Understanding the Differential Pharmacology of Currently Available Antidepressants
Authors: PRESKORN SHELDON H.
Published: February 2021

This column is the eighth in a series exploring drug-drug interactions (DDIs) with a special emphasis on psychiatric medications. The first 3 columns in this DDI series discussed why patients being treated with psychiatric medications are at increased risk for taking multiple medications and thus experiencing DDIs, how to recognize such DDIs, strategies for avoiding and/or minimizing adverse outcomes from such DDIs, and pharmacokinetic considerations concerning DDIs in psychiatric practice. The fourth and fifth columns in this series presented a pair of parallel tables, one of which outlined the primary, known mechanism(s) of action of all commonly used psychiatric medications and one of which summarized major types of pharmacodynamic DDIs based on mechanism of action. Clinicians can use these 2 tables together to predict pharmacodynamically mediated DDIs. The sixth column discussed key pharmacodynamic interactions involving ethanol, opioids, and monoamine oxidase inhibitors. That column focused particularly on hypertensive crises and serotonin syndrome with monoamine oxidase inhibitors and also DDIs involving psychiatric medications with adverse effects on the cardiovascular system and on the central nervous system. The seventh column presented the concept of relative receptor binding and included a table summarizing the relative receptor binding affinity of antipsychotics including all of the newer agents as well as some of the older agents such as haloperidol. This eighth column in this series presents a parallel table to the one in the seventh column summarizing the relative receptor binding affinity of currently available antidepressants. The overall goal of this series of columns is to present a simple way of conceptualizing neuropsychiatric medications in terms of their pharmacodynamics and pharmacokinetics to allow prescribers to take these facts into consideration when they need to use ≥2 drugs in combination to optimally treat a patient.
Repetitive Transcranial Magnetic Stimulation in the Treatment of Bipolar Depression: Experience From a Clinical Setting
Authors: PHILLIPS ANGELA L. , BURR ROBERT L. , DUNNER DAVID L.
Published: February 2021

Background:

Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive Food and Drug Administration (FDA)-approved treatment for unipolar treatment-resistant depression (TRD). rTMS has been utilized clinically to treat bipolar TRD; however, there remains a lack of evidence and support for effectively utilizing this intervention for bipolar TRD. We retrospectively analyzed data from a group of patients who were treated with rTMS for unipolar or bipolar TRD and describe a case example to further delineate management techniques for employing rTMS in the treatment of bipolar TRD.

Methods:

Records of 71 patients treated with rTMS for unipolar (n=54) or bipolar (n=17) TRD between 2008 and 2017 were reviewed. The primary outcome of depression severity, the Quick Inventory of Depressive Symptomatology, was completed at baseline and after every 5 sessions throughout the course of 30 treatments. Secondary outcomes involved a comparison of outcomes and clinical characteristics within and between the bipolar and unipolar TRD groups.

Results:

In the total sample, patients’ depression improved significantly over the course of treatment. Patients with bipolar TRD showed greater response and remission rates over the course of treatment compared with patients with unipolar TRD, but this difference was not statistically significant. Both groups showed a similar pattern of depression response over treatment time. No manic or hypomanic episodes occurred during any patient’s course of rTMS treatment. A case example is provided discussing the timing of rTMS in a patient with bipolar depression to decrease the likelihood of treatment-induced hypomania.

Limitations:

Limitations included the small overall sample size, the smaller size of the patient group with bipolar TRD compared with the group with unipolar TRD, and the naturalistic setting of this study.

Conclusions:

Our data suggest that rTMS may be equally effective and safe for patients with both unipolar and bipolar depression. Patients with bipolar TRD showed a similar response profile over treatment time compared with patients with unipolar TRD.
Switch to Hypomania After Discontinuation of Tamoxifen: A Case Report
Authors: MORA HECTOR A. , KOTBI NABIL , AVARI JIMMY N.
Published: February 2021

Tamoxifen is a synthetic, nonsteroidal antiestrogen widely used in the treatment of hormone-sensitive breast cancer that has also been shown to inhibit the enzyme protein kinase C (PKC). Upregulation of PKC is associated with disruption of prefrontal cortical regulation of thinking and behavior, which can lead to mania-like symptoms in animal models. Lithium and valproate, 2 mood stabilizers that are widely used in the treatment of bipolar disorder, have also been shown to inhibit PKC. We describe the case of a 48-year-old woman who entered a hypomanic state after discontinuation of tamoxifen while remaining on unopposed venlafaxine prescribed for depression. This case highlights the risk of misdiagnosing unipolar depression in breast cancer patients with undiagnosed bipolar disorder who are being treated with tamoxifen and subsequently started on antidepressants. The use of antidepressants in this population should be carefully monitored to avoid the development of manic, hypomanic, or mixed symptoms in patients with underlying bipolar disorder once tamoxifen is discontinued.
Multidisciplinary Management of a Frequent Attender With Pyrexia of Unknown Origin and Psychotic Symptoms
Authors: OSUGO MARTIN , NG AUDREY
Published: February 2021

This case report details the multidisciplinary management of a frequent attender in his early 50s with no fixed abode who presented with pyrexia of unknown origin, complicated by his noncooperation with intervention and treatment because of the development of psychotic symptoms. The case required the involvement of liaison psychiatry, anesthesia, cardiology, radiology, gastroenterology, rheumatology, respiratory, hematology, and social services, highlighting not just multidisciplinary intervention but the benefits of working with a multispeciality team. The patient had previously presented to the emergency department 47 times over an 18-month period. The management during his most recent inpatient stay resulted in the patient living independently and presenting to the hospital only once over the ensuing 7 months.
Working on the Frontlines From Home: Residents’ Experiences With Telepsychiatry During the COVID-19 Pandemic
Authors: ABDULLAH SYIDAH , BURTON E. THOMASEO , BELL IVERSON C.
Published: February 2021

The coronavirus disease 2019 (COVID-19) pandemic thrust health care professionals around the globe to the frontlines to care for those affected by this medical crisis. While many surgical and procedural medical subspecialties experienced drastic declines in patient visits during this time, the demand for psychiatric services was more stable. In response to statewide stay at home orders, third-year residents in the psychiatry outpatient clinic described in this article quickly transitioned to telepsychiatry to continue providing care to their patients. While providing care from home, these residents experienced a number of challenges that serve as important lessons for enhancing competence in telepsychiatry services.
QTc, the Multitude of Ways It Is Calculated and Implications for Clinical Practice: A Case Example
Authors: PRESKORN SHELDON H. , LOCHMANN DEE BROOKE , SOHAIL ZOHAIB
Published: February 2021

QTc stands for heart-rate corrected QT interval on the electrocardiogram and is a measure of the efficiency of repolarization of the left ventricle. Excessive prolongation, generally considered to be >500 ms, can result in a potentially fatal ventricular arrhythmia known as torsade de pointes. Some psychiatric medications can cause this arrhythmia and, therefore, this issue is important to all prescribers of psychiatric medications. It is also important to keep in mind that there are multiple algorithms used to calculate the QTc. The Bazett’s algorithm, one of the most commonly used algorithms on electrocardiogram machines, can produce an artificially prolonged QTc; however, the use of this algorithm is not generally identified on the printout from the electrocardiogram machine, which can cause unnecessary concern and delay treatment of patients. For these reasons, this article explains the basic concepts of the QT interval and QTc interval and discusses why it is important for psychiatrists and other prescribers to know this information. A case report is then used to illustrate the clinical application of this knowledge so that effective treatment is not unnecessarily delayed.
Association of Sleep Quality With Greater Left Ventricular Mass in Children Aged 9 to 11 Years
Authors: Gump Brooks B. , Heffernan Kevin S. , Bendinskas Kestutis , Hruska Bryce , MacKenzie James A. , Park Aesoon , Brann Lynn S. , Atallah-Yunes Nader H.
Published: February 2021

Objective

Research has consistently found associations between sleep characteristics and cardiovascular disease risk in children, adolescents, and adults. Although primarily investigated in clinical samples (e.g., in those with sleep disorders), greater left ventricular mass is associated with poor sleep quality in nonclinical adult populations as well; however, this has not been evaluated in children or adolescents. Our study aim was to consider the relationship between objectively measured sleep characteristics and left ventricular mass in children.

Methods

We assessed sleep and cardiac structure in a biracial sample of 9- to 11-year-old children (n = 176; 41% White, 59% Black; 50% female). Sleep was assessed with actigraphy for five nights. Cardiac dimensions were assessed using echocardiography.

Results

After adjusting for covariates, we found that poor sleep quality was associated with significantly greater left ventricular mass (β = 0.13, t(167) = 2.14, p = .034, Cohen d = 0.16, for activity during sleep; β = 0.15, t(167) = 2.43, p = .016, Cohen d = 0.18, for sleep fragmentation). Other cardiac dimensions (namely, relative wall thickness and right ventricular dimension) were also significantly associated with sleep characteristics. Notably, associations did not differ as a function of sex or race.

Conclusions

The present findings are novel and unique because no prior reports have systematically documented the association between poor sleep quality with potentially detrimental cardiac remodeling in a nonclinical sample of children. However, the novelty and importance of these findings require additional research for confirmation.
Longitudinal 5-year prediction of cognitive impairment among men with HIV disease
Authors: Oliveira Natalia L. , Kennedy Edward H. , Tibshirani Ryan , Levine Andrew , Martin Eileen , Munro Cynthia , Ragin Ann B. , Rubin Leah H. , Sacktor Ned , Seaberg Eric C. , Weinstein Andrea , Becker James T.
Published: February 2021

Background:

Although combination antiretroviral therapy reduced the prevalence of HIV-associated dementia, milder syndromes persist. Our goals were to predict cognitive impairment of the Multicenter AIDS Cohort Study (MACS) participants 5 years ahead and from a large pool of factors, select the ones that mostly contributed to our predictions.

Design:

Longitudinal, natural and treated history of HIV infection among MSM.

Methods:

The MACS is a longitudinal study of the natural and treated history of HIV disease in MSM; the neuropsychological substudy aims to characterize cognitive disorders in men with HIV disease.

Results:

We modeled on an annual basis the risk of cognitive impairment 5 years in the future. We were able to predict cognitive impairment at individual level with high precision and overperform default methods. We found that while a diagnosis of AIDS is a critical risk factor, HIV infection per se does not necessarily convey additional risk. Other infectious processes, most notably hepatitis B and C, are independently associated with increased risk of impairment. The relative importance of an AIDS diagnosis diminished across calendar time.

Conclusion:

Our prediction models are a powerful tool to help clinicians address dementia in early stages for MACS paticipants. The strongest predictors of future cognitive impairment included the presence of clinical AIDS and hepatitis B or C infection. The fact that the pattern of predictive power differs by calendar year suggests a clinically critical change to the face of the epidemic.
Rectal microbiota diversity in Kenyan MSM is inversely associated with frequency of receptive anal sex, independent of HIV status
Authors: Gebrebrhan Henok , Kambaran Cheli , Sivro Aida , Adhiambo Wendy , Siele Naomi , Becker Michael G. , Li Jie , Choi Sandra , Mwatelah Ruth S. , Reyes N. Vincent , Akolo Maureen , Njogu Peter , Cholette François , Ho John , Kim John , Peterson Shelley W. , Martin Irene , Sandstrom Paul , Mehta Supriya D. , Lorway Robert R. , Ball T. Blake , Kimani Joshua , Mclaren Paul J. , Ji Hezhao , McKinnon Lyle R.
Published: February 2021

Objective:

Both HIV infection and identifying as MSM have been linked to altered rectal microbiota composition, but few studies have studied sexual behavioural associations with rectal microbiota within MSM. In addition, most rectal microbiota studies in MSM have been limited geographically to Europe and North America, and replication of findings in lower and middle-income countries is lacking.

Design:

A cross-sectional study.

Methods:

We enrolled MSM from Nairobi, Kenya, and determined their HIV/sexually transmitted infection status. Rectal specimens were obtained for 16s rRNA sequencing of the rectal microbiota, and sexual behaviour was characterized using a standardized questionnaire. Microbiome differences were modelled using nonparametric statistics, Bray-Curtis ecological distance metrics and analyses of differential taxa abundance. Multivariable linear regression was used to model HIV status and recent sexual activity as predictors of alpha diversity, controlling for a range of covariates.

Results:

Alpha diversity was consistently lower in Kenyan HIV-infected MSM (n = 80), including those on antiretroviral therapy (ART) compared with HIV-uninfected MSM. A statistical trend was observed for clustering of HIV status by Prevotella or Bacteroides dominance (P = 0.13). Several taxa were enriched in HIV-positive men, including Roseburia, Lachnospira, Streptococcus and Granulicatella. Receptive anal sex with several types of sexual partners (paying, regular, casual) was associated with lower Chao1 and Simpson diversity, independent of HIV status, while HIV infection was associated lower Chao1 (P = 0.030) but not Simpson diversity (P = 0.49).

Conclusion:

Both HIV infection and sexual behaviour were associated with rectal microflora alpha diversity, in particular richness, but not Prevotella spp. dominance, in Kenyan MSM. Associations were more robust for sexual behaviour.
Cognitive trajectories after treatment in acute HIV infection
Authors: Chan Phillip , Kerr Stephen J. , Kroon Eugène , Colby Donn , Sacdalan Carlo , Hellmuth Joanna , Reiss Peter , Vasan Sandhya , Ananworanich Jintanat , Valcour Victor , Spudich Serena , Paul Robert
Published: February 2021

Objective:

People with HIV continue to exhibit cognitive symptoms after suppressive antiretroviral therapy (ART). It remains unclear if initiating ART during acute HIV-1 infection (AHI) uniformly improves cognitive outcomes.

Methods:

Sixty-seven individuals (96% men, median age 28 years) initiated ART immediately after AHI diagnosis and maintained viral suppression for 6 years. They underwent a four-test neuropsychological battery that measured fine motor speed and dexterity, psychomotor speed, and executive functioning at baseline (pre-ART AHI), weeks 12, 24 and 96, and annually thereafter through week 288. Performances were standardized to calculate an overall (NPZ-4) score and frequencies of impaired cognitive performance (≤-1 SD on at least two tests, or ≤-2 SD on at least one test). Group-based trajectory analysis (GBTA) was applied to identify distinct neuropsychological trajectories modelled from baseline to week 288. Posthoc analyses examined HIV-1 and demographic factors that differed between trajectory subgroups.

Results:

NPZ-4 scores improved from baseline to week 96 (P < 0.001) and from weeks 96 to 288 (P < 0.001), with frequencies of impaired performance of 30, 6 and 2% at the respective time-points. The amplitude of NPZ-4 improvement throughout the period was more than 0.5 SD and beyond practice effects. GBTA identified three NPZ-4 trajectory subgroups that all showed improvement over-time. The subgroup with lowest baseline performance exhibited worse depressive symptoms at baseline (P = 0.04) and the largest improvement among the three. HIV-1 indices did not differ between the subgroups.

Conclusion:

Cognitive performance improved in a sustained and stable manner after initiating ART during AHI. Largest improvements were seen in participants with worst baseline cognitive performance.
MRE Evaluation of Intestinal Inflammation
Authors: Grand David J. , Deepak Parakkal , Rimola Jordi
Published: February 2021

Magnetic resonance enterography (MRE) is a powerful tool for evaluation and management of patients with Crohn disease. Changes of active inflammation of the small bowel can reliably and reproducibly be detected and monitored. Findings indicative of active inflammation include bowel wall thickening, intramural edema and mural hyperenhancement. These changes are most commonly reported qualitatively; however, quantitative indices have also been developed and validated to measure and monitor inflammation both for clinical care and research purposes. This article describes the essential findings of active inflammation on MRE as well as the fundamentals of both qualitative and quantitative assessment and reporting.
Synchronized “One-Step” Resection and Cranio-Orbital Reconstruction for Spheno-Orbital Lesions With Custom Made Implant
Authors: Bassi Massimo , Antonelli Vincenzo , Tomassini Alessia , Maimone Giuseppe , D’Andrea Marcello , Campobassi Angelo , Gessaroli Manlio , Tosatto Luigino
Published: February 2021

Background:

In the last few years, skull base tumors involving the fronto-orbital region have been approached with complex, invasive, and time-consuming cranial reconstruction techniques. On the other hand, recent custom-made implants allow easier and faster procedures, with excellent aesthetic results. The authors propose an easy surgical-planned protocol with a synchronized “one-step” resection and reconstruction of these complex lesions, with a preformed poly-methyilmethacrylate (PMMA) cranioplasty.

Methods:

Our technique consists of a 2-phases procedure. In the first one, the so-called “virtual” phase, the authors get a tailored 3D-PMMA model based on high-resolution (HR) CT-scans of the patient's skull. Afterward, the authors perform the planned craniotomy on the 3D-PMMA model with the assistance of intraoperative navigation system. Therefore, a further CT-scan of the resected model is performed to develop the final implant. In the second phase, the “surgical phase,” a single procedure consisting in a cranial resection and custom reconstruction is performed with the assistance of stealth-navigation. The authors describe 6 cases of complex fronto-orbital-sphenoidal benign tumors that required skull reconstruction. All patients were examined 3 months after surgery through cosmetic (facial and eyes symmetry and globe position) and ophthalmology tests (visual field, visual impairment, and diplopia). Postsurgical HR CT-scans of the head and MRI-scans of the brain documented a total resection of the tumor and an optimal accuracy of skull reconstruction.

Results:

In all cases, the authors obtained a highly accurate skull reconstruction following cranio-orbital tumor resection, with a less aggressive and faster procedure compared to autologous bone graft. Final cosmetic and functional results were excellent, with good results in cases of presurgical exophthalmos and orbital asymmetry. None of the patients developed implant-related complications.

Conclusions:

The “one-step” resection and reconstruction of benign tumors involving the spheno-orbital region with neuronavigation assistance is a technique that allows an accurate tumor removal and a cranial-bone reconstruction within a single surgical procedure, with fewer complications and excellent cosmetic and functional results.
A New Preoperative Upright Design for Dermatochalasis Correction
Authors: Chen Ben , Woo David Meng-da , Liu Jia , Zhu Xiuying , Lin Yanyan , Ma Yingjie , Chen Xi
Published: February 2021

Background:

Conventional assessment of the height of upper eyelid skin excision in dermatochalasis correction is performed with patient's eyes closed in supine position. It is not able to consider the effects of gravity on the upper eyelid, thus may lead to asymmetric postoperative appearance. The authors herein report a novel preoperative upright design (PUD) that can accurately determine the amount of skin excision with patients’ eyes open in dermatochalasis correction.

Methods:

Patients with dermatochalasis underwent PUD during blepharoplasty were enrolled and were followed-up for 9 to 15 months.

Results:

A total of 116 patients (mean age 55.1 ± 6.1 years, range 46–78 years) successfully underwent the surgery. Using the PUD, the vertical height of skin excision was 8.2 ± 2.4 mm (6–19 mm), the preoperative margin fold distance was −0.5 ± 1.0 mm (−4 – 1 mm), which improved to 2.1 ± 0.6 mm (1–3 mm, P < 0.05) at the last follow-up visit. A total of 107 of 116 patients (92.2%) were judged as “good” (natural double eyelid folds with symmetric margin fold distance), 9 patients (7.8%) were judged as “fair” (natural double eyelid folds with the differences of margin fold distance between fellow eyelids within 2 mm), and no one was judged as “poor” (unsmooth double eyelid folds or the differences of margin fold distance between fellow eyelids is more than 2 mm).

Conclusion:

Preoperative upright design is a simple and effective method to accurately determine the amount of skin excision in blepharoplasty, and help to achieve symmetric double eyelids.
Objective Craniometric Versus Subjective Outcome Ratings in Endoscopic and Open Sagittal Synostosis Surgery
Authors: Mooney James , Lepard Jacob , Akbari S. Hassan A. , Arynchyna Anastasia , Myers René P. , Grant John , Johnston James
Published: February 2021

Background:

Despite advances in surgical treatments and assessments of objective outcomes in surgery for sagittal synostosis, there is no agreement regarding the optimal assessment of postoperative outcomes. Additionally, few studies have evaluated subjective assessments of cranial morphology after surgical correction. This study sought to evaluate the utility of subjective aesthetic outcome assessment and compare these assessments to established craniometric outcomes in patients undergoing surgery for isolated sagittal synostosis.

Methods:

Nineteen raters (5 parents, 4 surgeons, 5 trainees and 5 nurses) evaluated fifty patients who underwent surgical correction of isolated sagittal synostosis using standardized postoperative patient photos and a five-point Likert scale. Previously established anthropomorphic measurements were recorded postoperatively in these same patients and comparisons were made between the objective anthropomorphic and subjective outcome evaluations.

Results:

There were no statistically significant correlations between age-controlled cephalic index, head circumference, or euryon-euryon diameter and subjective aesthetic scores. Lay persons assigned a significantly lower proportion of scores (37.9%) as middle values (2, 3, or 4) compared with faculty (64.8%). There was a statistically significant association between high scores given by surgical faculty and laypersons (P < 0.001).

Conclusions:

Subjective measurement of cosmetic outcome is a useful metric in surgical correction of craniosynostosis. Although no correlations were found between objective measurements and subjective aesthetic scores, cosmetic assessments by surgeons demonstrated strong correlation with lay perception, indicating that these ratings may be a good gauge of overall cosmetic outcome. When used in combination, objective and subjective measurements provide unique value to assess outcomes after surgery for craniosynostosis.
Endoscopic Resection of a Massive Ossifying Fibroma in the Sinonasal Cavity
Authors: Wang Yunxiu , Cao Zhiwei , Gu Zhaowei
Published: February 2021

An ossifying fibroma (OF) is a type of benign fibro-osteoma that rarely involves the sinonasal cavity. Recent developments in endoscopic sinus surgery allow the removal of large benign tumors from the nasal cavity and sinuses. Here, the athors report the case of a 48-year-old female who underwent endoscopic sinus surgery under general anesthesia to completely remove a large OF involving the sphenoid sinus and nasal cavity. No recurrence was noted during the recent 3-year follow-up. Endoscopic resection of OFs is an excellent choice for very experienced surgeons, affording the advantages of direct observation as well as visual enhancement and magnification, thus reducing intra- and post-operative morbidity.
Noninvasive Beat-To-Beat Stroke Volume Measurements to Determine Preload Responsiveness During Mini-Fluid Challenge in a Swine Model: A Preliminary Study
Authors: Ko Ryoung Eun , Jang Geuk Young , Chung Chi Ryang , Lee Jin Young , Oh Tong In , Suh Gee Young , Kim Yongmin , Woo Eung Je
Published: February 2021

Cardiac output (CO) is an important parameter in fluid management decisions for treating hemodynamically unstable patients in intensive care unit. The gold standard for CO measurements is the thermodilution method, which is an invasive procedure with intermittent results. Recently, electrical impedance tomography (EIT) has emerged as a new method for noninvasive measurements of stroke volume (SV). The objectives of this paper are to compare EIT with an invasive pulse contour analysis (PCA) method in measuring SV during mini-fluid challenge in animals and determine preload responsiveness with EIT. Five pigs were anesthetized and mechanically ventilated. After removing 25% to 30% of the total blood from each animal, multiple fluid injections were conducted. The EIT device successfully tracked changes in SV beat-to-beat during varying volume states, i.e., from hypovolemia and preload responsiveness to target volume and volume overload. From a total of 50 100-mL fluid injections on five pigs (10 injections per pig), the preload responsiveness value was as large as 32.3% in the preload responsiveness state while in the volume overload state it was as low as −4.9%. The bias of the measured SV data using EIT and PCA was 0 mL, and the limits of agreement were ±3.6 mL in the range of 17.6 mL to 51.0 mL. The results of the animal experiments suggested that EIT is capable of measuring beat-to-beat SV changes during mini-fluid challenge and determine preload responsiveness. Further animal and clinical studies will be needed to demonstrate the feasibility of the EIT method as a new tool for fluid management.
Immunopathological Roles of Neutrophils in Virus Infection and COVID-19
Authors: Cui Shu-Nan , Tan Hong-Yu , Fan Guo-Chang
Published: February 2021

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been spread around the world and is currently affecting global public health. Clinical evidence indicates that the elevated number of peripheral neutrophils and higher ratio of neutrophils-to-lymphocytes are correlated with severe outcomes in COVID-19 patients, suggesting the possible immunopathological role of neutrophils during SARS-CoV-2 infection. As an abundant innate immune cell type, neutrophils are well known for their contributions to antimicrobial defense. However, their dysfunction is also associated with different inflammatory signatures during the pathogenesis of infection. Herein, in this mini-review, we summarize the recent progress on the potential role of neutrophils during COVID-19-associated inflammatory responses. In particular, we highlight the interactions between neutrophils and viruses as well as the relationship of neutrophils with cytokine storm and thrombosis in COVID-19 patients. Lastly, we discuss the importance of neutrophils as potential therapeutic targets for COVID-19.
Neutrophil Extracellular Trap Formation and Syndecan-1 Shedding Are Increased After Trauma
Authors: Goswami Julie , MacArthur Taleen , Bailey Kent , Spears Grant , Kozar Rosemary A. , Auton Matthew , Dong Jing-Fei , Key Nigel S. , Heller Stephanie , Loomis Erica , Hall Nathan W. , Johnstone Andrea L. , Park Myung S.
Published: February 2021

Background:

Damage-associated molecular patterns (DAMPs) stimulate endothelial syndecan-1 shedding and neutrophil extracellular traps (NET) formation. The role of NETs in trauma and trauma-induced hypercoagulability is unknown. We hypothesized that trauma patients with accelerated thrombin generation would have increased NETosis and syndecan-1 levels.

Methods:

In this pilot study, we analyzed 50 citrated plasma samples from 30 trauma patients at 0 h (n = 22) and 6 h (n = 28) from time of injury (TOI) and 21 samples from healthy volunteers, for a total of 71 samples included in analysis. Thrombin generation was quantified using calibrated automated thrombogram (CAT) and reported as lag time (LT), peak height (PH), and time to peak (ttPeak). Nucleosome calibrated (H3NUC) and free histone standardized (H3Free) ELISAs were used to quantify NETs. Syndecan-1 levels were quantified by ELISA. Results are presented as median [interquartile range] and Spearman rank correlations.

Results:

Plasma levels of H3NUC were increased in trauma patients as compared with healthy volunteers both at 0 h (89.8 ng/mL [35.4, 180.3]; 18.1 ng/mL [7.8, 37.4], P = 0.002) and at 6 h (86.5 ng/mL [19.2, 612.6]; 18.1 ng/mL [7.8, 37.4], P = 0.003) from TOI. H3Free levels were increased in trauma patients at 0 h (5.74 ng/mL [3.19, 8.76]; 1.61 ng/mL [0.66, 3.50], P = 0.002) and 6 h (5.52 ng/mL [1.46, 11.37]; 1.61 ng/mL [0.66, 3.50], P = 0.006). Syndecan-1 levels were greater in trauma patients (4.53 ng/mL [3.28, 6.28]; 2.40 ng/mL [1.66, 3.20], P < 0.001) only at 6 h from TOI. H3Free and syndecan-1 levels positively correlated both at 0 h (0.376, P = 0.013) and 6 h (0.583, P < 0.001) from TOI. H3NUC levels and syndecan-1 levels were positively correlated at 6 h from TOI (0.293, P = 0.041). TtPeak correlated inversely to H3 NUC (−0.358, P = 0.012) and syndecan-1 levels (−0.298, P = 0.038) at 6 h from TOI.

Conclusions:

Our pilot study demonstrates that trauma patients have increased NETosis, measured by H3NUC and H3Free levels, increased syndecan-1 shedding, and accelerated thrombin generation kinetics early after injury.
Synchronization of Pupil Dilations Correlates With Team Performance in a Simulated Laparoscopic Team Coordination Task
Authors: He Wenjing , Jiang Xianta , Zheng Bin
Published: February 2021

Background

Modern surgery crucially relies on teamwork between surgeons and assistants. The science of teamwork has been and is being studied extensively although the use of specific objective methodologies such as shared pupil dilations has not been studied as sufficiently as subjective methods. In this study, we investigated team members' shared pupil dilations as a surrogate for surgeon's team performance during a simulated laparoscopic procedure.

Methods

Fourteen subjects formed dyad teams to perform a simulated laparoscopic object transportation task. Both team members' pupil dilation and eye gaze were tracked simultaneously during the procedure. Video analysis was used to identify key event movement landmarks for subtask segmentation to facilitate data analysis. Three levels of each teams' performance were determined according to task completion time and accuracy (object dropping times). The determined coefficient of determination (R
2) was used to calculate the similarity in pupil dilations between 2 individual members' pupil diameters in each team. A mixed-design analysis of variance was conducted to explore how team performance level and task type were correlated to joint pupil dilation.

Results

The results showed that pupil dilations of higher performance teams were more synchronized, with significantly higher similarities (R
2) in pupil dilation patterns between team members than those of lower performance teams (0.36 ± 0.22 vs. 0.21 ± 0.14, P < 0.001).

Conclusions

Levels of pupil dilation synchronization presented among teams reflect differences in performance levels while executing simulated laparoscopic tasks; this demonstrated the potential of using joint pupil dilation as an objective indicator of surgical teamwork performance.
Simulation for Neonatal Endotracheal Intubation Training
Authors: Soghier Lamia M. , Walsh Heather A. , Goldman Ellen F. , Fratantoni Karen R.
Published: February 2021

Introduction

Neonatal endotracheal intubation is a critical skill that is difficult for learners to acquire even with simulation-based training (SBT). Trainees prefer clinical experiences over SBT. The objective of the study was to explore the differences between SBT and clinical practice in acquiring neonatal intubation skills to inform mannequin design and to improve fidelity.

Methods

A basic qualitative study using semistructured interviews was conducted to determine the experience of newly competent trainees (second- and third-year neonatal-perinatal medicine fellows) and their instructors in developing intubation skills. Participants were asked to compare learning through SBT with clinical practice in terms of context, equipment, and environment. Their responses were analyzed using an inductive approach.

Results

Thirty-two participants (20 fellows and 12 faculty) indicated that SBT does not equal the real experience. Specifically, the look, feel, and function of the simulators differ enough from the real patient and the clinical environmental that they do not elicit the desired learning responses. The clinical environment prompted heightened emotions and had a chaotic atmosphere that was not fully captured by SBT. Participants suggested that programs use SBT in the initial phases of training only to gain basic skills and they provided several solutions for mannequin and SBT session design.

Conclusions

Simulation-based training does not fully prepare neonatal-perinatal medicine fellows for neonatal intubation. Mannequins with unique active features, such as multiple airway configurations, slipperiness, secretions, and softer textures should be developed. Realistic environments that replicate the interprofessional nature and stressors of the clinical environment might better prepare learners for the complexity of clinical practice.
Long-term Outcomes of a Randomized Controlled Trial of Single-incision Versus Multi-port Laparoscopic Colectomy for Colon Cancer
Authors: Watanabe Jun , Ishibe Atsushi , Suwa Hirokazu , Ota Mitsuyoshi , Fujii Shoichi , Kubota Kazumi , Kunisaki Chikara , Endo Itaru
Published: February 2021

Objective:

The aim of this study was to evaluate the long-term outcomes that were the secondary endpoints of a RCT of multi-port laparoscopic colectomy (MPC) versus SILC in colon cancer surgery.

Summary of Background Data:

The actual long-term outcomes, such as the 5-year RFS, OS, and recurrence patterns after surgery, have not been evaluated by a RCT.

Methods:

Patients with histologically proven colon carcinoma located in the cecum, ascending, sigmoid or rectosigmoid colon clinically diagnosed as stage 0-III were eligible for this study. Patients were preoperatively randomized and underwent complete mesocolic excision. The 5-year RFS, OS, and recurrence patterns were analyzed (UMIN-CTR 000007220).

Results:

Between March 1, 2012, and March 31, 2015, a total of 200 patients were randomly assigned to either the MPC arm (n = 100) or SILC arm (n = 100). The median follow-up for all patients was 61.0 months. An intention-to-treat analysis showed that the 5-year RFS was 91.0% [95% confidence interval (CI) 85.1%–96.9%] in the MPC arm and 88.0% (95% CI 82.1%–93.9%) in the SILC arm (hazard ratio: 1.37; 95% CI 0.58–3.24; P = 0.479). The 5-year OS was 95.0% (95% CI 91.1%–98.9%) in the MPC arm and 93.0% (87.1%–98.9%) in the SILC arm (hazard ratio: 1.39; 95% CI 0.44–4.39; P = 0.568). There were no significant differences in the recurrence patterns between the 2 arms.

Conclusions:

Even though the results of the 5-year OS and RFS in this trial were exploratory and underpowered, there were no statistically significant differences between the SILC and MPC arms. SILC may be an acceptable treatment option for select patients with colon cancer.
Genital Hiatus Size as a Predictor of Progression of Pelvic Organ Prolapse
Authors: Woll Abbigail , Mbaye Marieme , Edenfield Autumn , Swift Steven
Published: February 2021

Objective

This study aimed to determine if genital hiatus (GH) size is a predictor of worsening pelvic organ prolapse and a preference for a therapeutic intervention in women with pelvic organ prolapse who opt for expectant management over therapeutic intervention at their initial encounter.

Methods

This was a retrospective cohort study analyzing the GH size of women who opted for expectant management in the initial treatment of pelvic organ prolapse at one academic institution from 2002 to 2015. Participants were divided into 2 groups: (1) large GH was defined as ≥4 cm and (2) normal GH was defined as <4 cm. The primary outcome was women opting for therapeutic intervention for their prolapse at a later visit, defined as pessary insertion or surgical intervention. Secondary measures evaluated GH as a predictor of worsening anatomy or symptoms.

Results

One hundred eleven participants were enrolled. Fifty-two women had a large GH, and 59 women had a normal GH. Median length of follow-up was 24 months (range, 6–110 months). Of the 52 with a large GH, 22 (42%) opted for intervention; of the 59 women with a normal GH, 16 (27%) opted for intervention. There was no statistically significant difference between groups in the number who eventually chose intervention (P = 0.09). There was no difference in secondary outcomes between groups with respect to worsening bother, worsening pelvic organ prolapse quantification stage, or an increase in the prolapse leading edge of ≥2 cm.

Conclusions

Women with a large GH, when compared with those with a normal GH, were not more likely to choose intervention over continued observation.
Characterization of Gut Microbiome in Liver Transplant Recipients With Nonalcoholic Steatohepatitis
Authors: Satapathy Sanjaya K. , Banerjee Pratik , Pierre Joseph F. , Higgins Daleniece , Dutta Soma , Heda Rajiv , Khan Sabrina D. , Mupparaju Vamsee K. , Mas Valeria , Nair Satheesh , Eason James D. , Kleiner David E. , Maluf Daniel G.
Published: February 2021

Background.

Nonalcoholic fatty liver disease (NAFLD) and its progressive form nonalcoholic steatohepatitis (NASH) are a growing problem globally and recur even after liver transplant (LT). We aim to characterize the gut dysbiosis in patients who developed recurrent NAFLD compared with patients without recurrence following LT.

Methods.

Twenty-one patients who received LT for NASH and had a protocol liver biopsy performed beyond 1-y post-LT were included prospectively (January 2018–December 2018). Genomic DNA extraction, next-generation sequencing, and quantitative PCR analysis were performed on stool samples collected within 1.1 ± 1.6 y from time of liver biopsy.

Results.

Recurrent NAFLD was noted in 15 of the 21 included patients. Stool microbiome analysis at the genus level showed significant loss of Akkermansia and increasing Fusobacterium associated with NAFLD recurrence. Quantitative PCR analysis revealed significantly decreased relative abundance of Firmicutes in patients with NAFLD activity scores (NASs) ≥5 as compared with patients with lower NAS scores, whereas Bacteroidetes were significantly increased with higher NAS (P < 0.05). Firmicutes (P = 0.007) and Bifidobacterium group (P = 0.037) were inversely correlated, whereas Bacteroidetes (P = 0.001) showed a positive correlation with higher hepatic steatosis content. The Firmicutes/Bacteroidetes ratios were higher in patients without NAFLD or NASH as compared with patients diagnosed with NAFLD or NASH at the time of sample collection.

Conclusions.

Akkermansia, Firmicutes, and Bifidobacterium may play protective roles in the development of recurrent NAFLD in LT recipients, whereas Fusobacteria and Bacteroidetes may play pathogenic roles. These findings highlight the potential role of the “gut-liver” axis in the pathogenesis of NAFLD recurrence after LT.