bluuebunny/crossref_metadata_2025 huggingface dataset:
P14 The Irish National Centre for Paediatric Rheumatology experience of moving from IV to SC tocilizumab (TCZ)
Authors: MacMahon Jayne M , Lang Ciara , Peate Karen , MacDermott Emma J , Killeen Orla G
Published: October 2019

Background

Tocilizumab (TCZ) is a monoclonal antibody that targets the interleukin 6 receptor. It is approved for use in children over the age of 2 years with systemic onset juvenile idiopathic arthritis (SoJIA) and polyarticular juvenile idiopathic arthritis (pJIA) who have not responded to treatment with non-steroidal agents, corticosteroids and methotrexate mono-therapy. Previous studies from our centre have shown a positive response to IV TCZ with high rates of remission. TCZ has recently been licensed for administration via the SC route. The aim of this study is to determine how many patients receiving IV TCZ were successfully changed to SC TCZ in the first 6 months after SC TCZ paediatric licensing was obtained and to document any adverse events.

Methods

Retrospective review of patients with SoJIA or pJIA who were on IV TCZ and changed to S/C TCZ over a 6 month period from October 2018 to April 2019. Patients were identified from an in-house aseptic pharmacy database Clinichemo®. All patients on IV TCZ were identified and cross checked against the Hibernian patient referral system for home SC TCZ administration. Criteria for changing included fulfilling Wallace Criteria for clinical remission and appropriate JIA subtype. Results were analysed using Microsoft Excel.

Results

28 patients receiving IV TCZ in October 2018 were identified. 8 were excluded due to either a diagnosis other than SoJIA/pJIA or changing to an alternative biologic. Of the 20 eligible patients, 10 had successfully changed by April 2019. Of those who did not change, 1 is due to change in May 2019, 2 did not wish to change, indicating personal preference as their reason. A total of 7 were deemed unsuitable for medication change due to ongoing active disease. Of the 10 patients who successfully changed, 2 had SoJIA and 8 had pJIA. All were commenced on a dose of 162mg with frequency varying from 1 to 4 weekly as per Summary of Product Characteristics. There was no significant change in ESR, CRP, LFT or WCC demonstrated pre or post change in administration route. No adverse events were reported. 1 patient subsequently changed back to IV administration due to patient preference.

Conclusion

Our experience to date has been positive, with 50% of patients changed to SC administration within 6 months of approval. A number of other patients have been identified for a change to SC TCZ within the next 6 months. While 1 patient subsequently elected to change back to IV TCZ, to date, no patient has come off SC TCZ due to an increase in disease activity. We hope to follow this study with a patient questionnaire to determine the patient perspective of changing to SC administration of TCZ.

Conflicts of Interest

The authors declare no conflicts of interest.
P16 Is there an association between paediatric rheumatological disease and autism?
Authors: Haslam Kirsty
Published: October 2019

Background

The prevalence of autistic spectrum disorder (ASD) in children in UK is ∼1 in 100. There is emerging evidence that dysregulation of the immune system may be an underlying cause of ASD. The CARRA registry from the USA reported a frequency of 0.3% co-morbidity of autism in children with JIA. There is a paucity of data from the UK reporting this association.

Methods

The department’s database of all patients that attended the local paediatric rheumatology clinic was reviewed over a 12-month period from April 2018 to April 2019. Diagnoses were grouped broadly into inflammatory (JIA, systemic disease, non-JIA uveitis) and non-inflammatory (mechanical, bone and collagen disorder and other). Those with a co-morbidity of autism were also identified within inflammatory and non-inflammatory groups.

Results

There were 196 individual patients within the cohort of paediatric rheumatology patients seen in Bradford in April 2018 to April 2019. These were subcategorised into JIA (N = 79,40%), mechanical (N = 56, 29%), systemic rheumatological disease (N = 31, 16%), bone and collagen disorders (N = 12, 6%), other non-inflammatory diagnoses (N = 11, 6%), non-JIA associated uveitis (N = 7, 3%). This cohort was divided into 117 patients with inflammatory paediatric rheumatological conditions and 79 patients with non-inflammatory causes for joint pain. Nine children (see Table 1) had a co-morbidity of autism, of which 6 children had an inflammatory diagnosis and 3 a non-inflammatory cause for joint pain. The prevalence of autism in our cohort of children with paediatric rheumatological disease was 5%, which is higher than expected from a UK prevalence of autism of 1%.

P16 Table 1: Patients with Autism in Paediatric Rheumatology cohort. Diagnosis Age Age at presentation to paediatric rheumatology Gender Inflammatory/ Non-inflammatory Oligo JIA 5y 4y Male Inflammatory Oligo JIA 11y 10y Female Inflammatory Oligo JIA 13y 7y Female Inflammatory Ext- oligo JIA 18y 8y Male Inflammatory Ext- oligo JIA 14y 7y Male Inflammatory CTD 15y 2y Female Inflammatory Hypermobility 16y 16y Male Non-inflammatory Mechanical 14y 14y Female Non-inflammatory Mechanical 11y 11y Female Non-inflammatory

Conclusion

In this cohort of paediatric rheumatology patients there was a higher prevalence of autism than the UK average. Two of these patients were diagnosed with autism after presenting to our service. This association is compatible with the emerging recognition of dysregulation of the immune system as a potential underlying cause of ASD. It is important to consider the co-morbidity of autism in children presenting to paediatric rheumatology clinic and potentially paediatric rheumatological conditions in children already diagnosed with autism, where there may be a delay in their presentation due to communication difficulties. There is the need for a larger UK study to review this association further.

Conflicts of Interest

The authors declare no conflicts of interest.
P19 Mycophenolate mofetil in paediatric uveitis: an early experience
Authors: Tadrous Amany , Warrier Kishore , Pradeep Archana , Camina Nikki , Rangaraj Satyapal
Published: October 2019

Background

Juvenile idiopathic arthritis (JIA) is the commonest cause of uveitis in children. Uveitis is a significant cause of visual impairment in children with potential complications such as band keratopathy, cataract, posterior synechiae, glaucoma, cystoid macular oedema and a retinal problems. Following the initial treatment with topical and systemic corticosteroids, a wide variety of immunosuppressant agents have been used in the treatment of non-infective uveitis including methotrexate (MTX) and biologic therapy, most of which are administered parenterally.

Mycophenolate Mofetil (MMF) is an oral immunosuppressant that inhibits the proliferation of T and B lymphocytes, which has been tried in children with uveitis with mixed results. We started using MMF in children seen in our paediatric uveitis clinic initially as a third line agent when the inflammation is not well controlled despite therapeutic doses of MTX and Adalimumab, as the NHS England Clinical Commissioning Policy does not recommend the use of Infliximab in uveitis not associated with JIA. Buoyed by some favourable result, we have since then used MMF as second line and even first line agent in children with uveitis.

Methods

Retrospective analysis of the clinical profile of children with uveitis on MMF at a tertiary paediatric rheumatology centre with focus on response to treatment.

Results

Of the 8 patients who received MMF, six (75%) were girls. Half of them (4/8) had idiopathic uveitis and the rest, associated with JIA. 2/8 patients had MMF as third line agent on top of MTX and Adalimumab, while five of them had it as second line agent on top of Adalimumab due to either MTX intolerance or needle phobia. One patient was started on MMF as first line agent following topical steroids. 6 (75%) of the patients responded/stayed in remission following the addition of/switch to MMF.

Conclusion

MMF has shown initial promise in the treatment of uveitis in children with uveitis in this small cohort, in line with some existing evidence. It was initially used in patients who were not keen on injections/intolerant to MTX or had failed all existing options. This is a small cohort of patients and we would welcome more research in this area.

Conflicts of Interest

The authors declare no conflicts of interest.
The neural basis of shared preference learning
Authors: Farmer Harry , Hertz Uri , Hamilton Antonia F de C
Published: October 2019

During our daily lives, we often learn about the similarity of the traits and preferences of others to our own and use that information during our social interactions. However, it is unclear how the brain represents similarity between the self and others. One possible mechanism is to track similarity to oneself regardless of the identity of the other (Similarity account); an alternative is to track each other person in terms of consistency of their choice similarity with respect to the choices they have made before (consistency account). Our study combined functional Magnetic Resonance Imaging (fMRI) and computational modelling of reinforcement learning (RL) to investigate the neural processes that underlie learning about preference similarity. Participants chose which of two pieces of artwork they preferred and saw the choices of one agent who usually shared their preference and another agent who usually did not. We modelled neural activation with RL models based on the similarity and consistency accounts. Our results showed that activity in brain areas linked to reward and social cognition followed the consistency account. Our findings suggest that impressions of other people can be calculated in a person-specific manner, which assumes that each individual behaves consistently with their past choices.
How redistributive institutions affect pay inequality and heterogeneity among top managers
Authors: Angeles Renira C , Kemmerling Achim
Published: October 2019

In recent years, many scholars have investigated the incredible rise of executive pay and the role of institutions as moderators of this trend. We argue that a crucial problem for attempts to moderate these increases remains the heterogeneity among top managers. Redistributive institutions can better target pay inequality among management than institutions that treat all managers or companies the same. To show this, we use a novel data set of executive pay across 17 OECD countries. We compare the effect of different institutional factors: corporate and personal income taxation, union bargaining power, and regulation (shareholder protection). We find that redistributive institutions such as personal income tax and union bargaining power seem to be more effective in addressing this heterogeneity in pay and in moderating remuneration in firms with very large market value than smaller firms.
The Workplace, Social Work, and Social Justice: Framing an Emerging Research and Practice Agenda
Authors: Sabbath Erika L
Published: October 2019

Protecting the health and well-being of workers naturally aligns with the social work mission to advance human dignity. The workplace can both create and perpetuate health disparities by shaping health and well-being at multiple levels and in socially patterned ways. Yet workplace issues are rarely on social work research and practice agendas. This article serves as a call to action for social work, as a discipline, to engage with the workplace as a means of advancing the field's core values. It first provides evidence for why engagement with workplaces is critical for advancing social justice. It then presents evidence for the ways in which workplace exposures and experiences, at multiple levels, shape worker health and well-being. Finally, it provides concrete steps for how the skills and values of the social work profession can be applied to the workplace through research, practice, education, and policy efforts, and by extension improve population health and well-being.
Better Groundwork Can Avoid Troubled Waters: A Developing Country Perspective on Drowning
Authors: Samprathi Madhusudan , Agarwal Ashish , Jayashree Muralidharan , Bansal Arun , Baranwal Arun , Nallasamy Karthi , Angurana Suresh Kumar
Published: October 2019

Objective

Drowning is a leading cause of unintentional injury-related death in low- and middle-income countries (LMICs). This study was undertaken to know the epidemiology, intensive care needs and predictors of outcome of children with drowning.

Methods

Records of children below 12 years admitted with drowning to the emergency room and/or paediatric intensive care unit (PICU) of a tertiary care hospital in North India were retrospectively analysed. ‘Favourable outcome’ was defined as normal neurological status at discharge (normal cognition and no motor deficits) and ‘unfavourable outcome’ as death or abnormal neurological status at discharge. Multivariable analysis was done for predictors of unfavourable outcome.

Results

Twenty-seven children were analyzed, 14 (51.8%) were boys. Median (IQR) age was 18 months (12–30). The median (IQR) duration of submersion was 4 min (3–9). Six children (22.2%) presented in pulseless arrest, and 7 (43.7%) had both hypoxaemia (saturation <94% on room air) and encephalopathy (GCS <13) at admission. Ten children (37%) were transferred to PICU; principal indications being hypoxic ischaemic encephalopathy (HIE) (n = 6) and ventilation (n = 4). One child died, four survived with sequalae. Predictors of unfavourable outcome on univariable analysis were hypoxaemia, or pulseless arrest at admission, HIE and need for mechanical ventilation; none of these could predict outcome on multivariable analysis.

Conclusion

Hypoxaemia or pulseless arrest at admission, HIE and need for ventilation predict unfavourable outcome. Appropriate on-site resuscitation and early stabilization may improve outcome in children with drowning in LMIC.
A Spatiotemporal Analysis and Dispersal Patterns of the Potato Cyst NematodeGlobodera pallidain Idaho
Authors: Contina J. B. , Dandurand L. M. , Knudsen G. R.
Published: October 2019

The potato cyst nematode Globodera pallida is a globally regulated potato pest. It was detected for the first time in the United States in the state of Idaho in 2006, and as of February 2019, the infestation is limited to 1,326 hectares. G. pallida is a specialized obligate sedentary endoparasite that can survive in the soil for up to 30 years in the absence of its potato host. In highly infested fields, the nematode can reduce tuber yields up to 80% and is spread mainly through the movement of soil, tubers, or farm equipment. The objectives of this study were to describe the spatiotemporal pattern of G. pallida in infested fields and model its dispersal patterns in southeastern Idaho. We used geostatistical tools and simulation models for precise mapping and to describe the relationships between G. pallida incidence and the spatial configurations. We found that the nematode is spatially clustered and prevalent around edges of fields, and its dispersal pattern followed the direction of cultivation. We found that the absence of potato in an infested field significantly reduced the number of cysts sampled each year subsequent to the initial delimitation sampling in 2007. Phytosanitary measures prohibiting the growth of potato contributed to stopping nematode reproduction, and the use of chemical fumigants and biofumigant cover crops contributed to a significant reduction in egg viability. We observed a process of a nonlinear decline in the prevalence of cysts as the distance separation from the primary infestation focus increased. A power law model was used to fit G. pallida dispersal capabilities. This study contributed to describing G. pallida infestation for Idaho. The goal of this study is to provide information on the spatial pattern and landscape ecology of G. pallida in Idaho for policy makers, industry, and researchers as well as facilitate common understandings on the challenges and opportunities for controlling this pest in Idaho.
Preconception Perceived Stress Is Associated with Reproductive Hormone Levels and Longer Time to Pregnancy
Authors: Schliep Karen C. , Mumford Sunni L. , Silver Robert M. , Wilcox Brian , Radin Rose G. , Perkins Neil J. , Galai Noya , Park Jihye , Kim Keewan , Sjaarda Lindsey A. , Plowden Torie , Schisterman Enrique F.
Published: October 2019

Background:

Women who experience pregnancy loss are especially prone to high stress, though the effects of stress on reproductive outcomes in this vulnerable population are unknown. We assessed relationships between perceived stress and hormones, anovulation, and fecundability among women with prior loss.

Methods:

One thousand two hundred fourteen women with 1–2 prior losses were followed for ≤6 cycles while attempting pregnancy and completed end-of-cycle stress assessments. For cycles 1 and 2, women also collected daily urine and completed daily perceived stress assessments. We assessed anovulation via. an algorithm based on human chorionic gonadotropin (hCG), pregnanediol-3-glucuronide (PdG), luteinizing hormone (LH), and fertility monitor readings. Pregnancy was determined via. hCG. Adjusted weighted linear mixed models estimated the effect of prospective phase-varying (menses, follicular, periovulatory, and luteal) perceived stress quartiles on estrone-1-glucuronide (E1G), PdG, and LH concentrations. Marginal structural models accounted for time-varying confounding by hormones and lifestyle factors affected by prior stress. Poisson and Cox regression estimated risk ratios and fecundability odds ratios of cycle-varying stress quartiles on anovulation and fecundability. Models were adjusted for age, race, body mass index (BMI), parity, and time-varying caffeine, alcohol, smoking, intercourse, and pelvic pain.

Results:

Women in the highest versus lowest stress quartile had lower E1G and PdG concentrations, a marginally higher risk of anovulation [1.28; 95% confidence interval (CI) = 1.00, 1.63], and lower fecundability (0.71; 95% CI = 0.55, 0.90).

Conclusion:

Preconception perceived stress appears to adversely affect sex steroid synthesis and time to pregnancy. Mechanisms likely include the effects of stress on ovulatory function, but additional mechanisms, potentially during implantation, may also exist.
Associations between ambient air pollution and noise from road traffic with blood pressure and insulin resistance in children from Denmark
Authors: Pedersen Marie , Halldorsson Thorhallur I. , Ketzel Matthias , Grandström Charlotta , Raaschou-Nielsen Ole , Jensen Steen S. , Grunnet Louise G. , Vaag Allan , Sørensen Mette , Olsen Sjurdur F.
Published: October 2019

Background:

Road traffic is a major source of air pollution and noise. Both exposures may contribute to increased blood pressure and metabolic disease; however, few studies have examined these relationships in children.

Objectives:

We aimed to investigate whether long-term exposures to air pollution and noise from road traffic were associated with increased blood pressure and insulin resistance in children.

Methods:

Cardiometabolic outcomes were derived from a follow-up examination of 629 children (10–15 years old) enrolled in the Danish National Birth Cohort. We evaluated associations with prenatal and postnatal residential exposure to nitrogen dioxide (NO2) and noise from road traffic (Lden) using historical addresses and linear regression models.

Results:

A 10-unit increase in postnatal exposure to NO2 and Lden was associated with a 0.31 (−0.87, 1.48) and 0.18 (−0.61, 0.96) mmHg changes in diastolic blood pressure, respectively. In contrast, both exposures were associated with decreased systolic blood pressure. After adjustment and mutual adjustment for NO2, exposure to Lden was associated with a statistical significant decrease in systolic blood pressure both during prenatal and postnatal life, but the majority of the associations evaluated did not reach statistical significance. Inverse associations were observed for plasma fasting glucose, insulin, and HOMA of insulin resistance for both exposures, exposure windows, before and after adjustment.

Conclusions:

The findings do not support evidence of associations between long-term exposures to air pollution and road traffic noise, increased blood pressure, and a metabolic profile characteristic of increased risk for glucose intolerance or type 2 diabetes later in life.
Mobile technology for family planning
Authors: Peterson Sarah F. , Fok Wing Kay
Published: October 2019

Purpose of review

To evaluate the recent literature on mobile health applications available to patients for contraception and abortion care.

Recent findings

Women are increasingly interested in contraceptive tools utilizing mobile technology, and a majority of women expect them to be science-based. The largest number of available mobile apps supports natural family planning methods, which is recognized as the least effective contraceptive method. Many available apps cannot be relied on for accurate, science-based pregnancy prevention methods. Further, there is a paucity of data regarding use of mobile technology for women seeking or receiving abortion.

Further research is needed to evaluate mobile health apps and how they can best provide patient consumers with accurate, evidence-based information to support the prevention of unintended pregnancy.
Revisiting the basis for haemoglobin screening in pregnancy
Authors: Daru Jahnavi , Sobhy Soha , Pavord Sue
Published: October 2019

Purpose of review

Anaemia affects up to 50% of pregnancies worldwide, and is associated with maternal and neonatal morbidity and mortality. Prevention and management of anaemia remains a priority. Despite this, there is ongoing debate on the optimal approach to identifying anaemia in pregnant women and the best strategies for prevention and management. The objective of this review is to describe the current landscape of haemoglobin testing in pregnancy in low and high-income countries.

Recent findings

Current definitions of anaemia in pregnancy comprise a laboratory threshold of haemoglobin below which treatment is offered. Haemoglobin measurement is not sensitive in detecting iron deficiency – the most common cause of maternal anaemia. Furthermore, these historical thresholds were derived from heterogeneous populations comprising men and women. Women with anaemia in pregnancy are offered iron therapy, without testing for the underlying cause. This may be appropriate in high-income settings, where iron deficiency is the likely cause, but may not address the complex causes of anaemia in other geographical areas.

Current thresholds of haemoglobin defining anaemia in pregnancy are under review. Further research and policy should focus on optimal strategies to identify women at risk of anaemia from all causes.
Combined hormonal contraception and migraine: are we being too strict?
Authors: Voedisch Amy J. , Hindiyeh Nada
Published: October 2019

Purpose of review

Combined hormonal contraception has been contraindicated in migraines, especially in migraines with aura, because of ischemic stroke risk. Newer formulations are now available and physicians may unnecessarily be limiting access to contraceptive and medical therapeutic options for patients with migraines. This review summarizes the available data regarding ischemic stroke risk of modern combined hormonal contraception in the setting of migraines.

Recent findings

Limited data exists on current formulations of combined hormonal contraception and outcomes in migraine patients. Studies indicate ischemic stroke risk may be estrogen dose related with high dose formulations having the highest risk. Absolute risk of ischemic stroke with combined hormonal contraception and migraines is low.

Ischemic stroke risk in combined hormonal contraception users in the setting of migraines is low and an individual approach may be more appropriate than current guidelines.
The Microvascular Peroneal Artery Perforator Flap as a "Lifeboat" for Pedicled Flaps
Authors: Jakubietz Rafael G. , Jakubietz Danni F. , Horch Raymund E. , Gruenert Joerg G. , Meffert Rainer H. , Jakubietz Michael G.
Published: October 2019

Background:

Pedicled perforator flaps have expanded reconstructive options in extremity reconstruction. Despite preoperative mapping, intraoperative findings may require microvascular tissue transfer when no adequate perforators can be found. The free peroneal artery perforator flap may serve as a reliable back-up plan in small defects.

Methods:

In 16 patients with small soft tissue defects on the upper and lower extremities, perforator-based propeller flaps were planned. The handheld Doppler device was used to localize potential perforators for a propeller flap in close proximity to the defect. Perforators of the proximal peroneal artery were also marked to allow conversion to microvascular tissue transfer.

Results:

In 6 cases, no adequate perforators were found intraoperatively. In 4 patients, the peroneal artery perforator flap was harvested and transferred. The pedicle length did not exceed 4 cm. No flap loss occurred.

Conclusions:

When no adequate perforator capable of nourishing a propeller flap can be found intraoperatively, the free peroneal artery flap is a good option to reconstruct small soft tissue defects in the distal extremities. The short vascular pedicle is less ideal in cases with a large zone of injury requiring a more distant site of anastomosis or when recipient vessels are located in deeper tissue planes.
Successful Immediate Staged Breast Reconstruction with Intermediary Autologous Lipotransfer in Irradiated Patients
Authors: Crawford Kristina M. , Lawlor Denis , Alvis Emily , Moran Kevin O. , Endara Matthew R.
Published: October 2019

Background:

As indications for radiotherapy in mastectomized patients grow, the need for greater reconstructive options is critical. Preliminary research suggests an ameliorating impact of lipotransfer on irradiated patients with expander-to-implant reconstruction. Herein, we present our technique using lipotransfer during the expansion stage to facilitate implant placement.

Methods:

A retrospective review of postmastectomy patients with expander-to-implant reconstruction by one reconstructive surgeon was performed. All patients were treated with immediate expander and ADM placement at the time of mastectomy. Irradiated patients underwent a separate lipotransfer procedure after completion of radiotherapy but prior to prosthesis exchange. Our study compared postoperative outcomes between non-radiated patients and irradiated patients who underwent this intermediary lipotransfer. Clinical endpoints of interest included: overall complications, infection, delayed wound healing, dehiscence, capsular contracture, implant failure, and reoperation.

Results:

One hundred and thirty-one breast reconstructions were performed; 18 (13.74%) were irradiated and 113 (86.26%) were not. Overall complication risk (infection, implant failure, or reoperation) was no higher in irradiated breasts treated with lipotransfer than non-irradiated breasts (p=0.387). Fifteen patients who had one radiated and one non-radiated breast were separately analyzed; no difference in complication by radiotherapy exposure (p=1) was found. Age, BMI, smoking status, and nipple-sparing versus skin-sparing mastectomy did not vary significantly between study groups (p=0.182, p=0.696, p=0.489, p=1 respectively).

Conclusions:

Comparable postoperative outcomes were found between non-radiated breasts and radiated breasts treated with intermediary lipotransfer. The ameliorating effects of autologous lipotransfer on radiotoxicity may therefore offer irradiated patients the option of expander-to-implant reconstruction with acceptable risk and cosmesis.
A Clinical Case of Breast Reconstruction with Greater Omentum Flap for Treatment of Upper Extremity Lymphedema
Authors: Sinelnikov Mikhail Y. , Chen Kuo , Sukorceva Natalia S. , Lan Mu , Bikov Igor I. , Zakirova Albina A. , Reshetov Igor V.
Published: October 2019

Patients presenting with complications regarding breast cancer surgery require individualized surgical protocol for correction and reconstruction. This clinical case summarizes our clinical experience in the application of the free greater omentum flap for treatment of upper extremity lymphedema and breast reconstruction. This method combines aesthetic reconstruction of the breast with functional correction. The presented clinical vignette features a patient with post-biquadrantectomy upper extremity lymphedema. A free greater omentum flap was chosen for the purpose of breast reconstruction and vascularized lymph node transfer to treat upper extremity lymphedema. Upper extremity circumferences were monitored before and after surgical correction. The revascularized flap survived well after the operation and the reconstructed breast had a natural appearance. Six months after the operation, the patient’s upper extremity circumferences decreased significantly, and the pain and swelling were also alleviated. The patient was satisfied with the results. The use of the free greater omentum flap for breast reconstruction and treatment of upper extremity lymphedema provides both aesthetic and functional patient rehabilitation. The application of this technique requires proper patient selection and thorough surgical planning.
Publications from Saudi Arabia in Plastic Surgery in the Recent Five Years
Authors: Almarghoub Mohammed A. , Al-Qattan Mohammad M.
Published: October 2019

Background:

In the last 5 years, many universities and medical centers have contributed immensely to medical research in Saudi Arabia. The aim of this study is to review the publications in the last 5 years in the field of plastic and reconstructive surgery from Saudi Arabia.

Methods:

An electronic search was carried out using PubMed website for all plastic and reconstructive surgery-related articles published from Saudi Arabia. The type, subject, region, institute, and subspecialty were collected from the articles.

Results:

A total of 142 articles were found, of which 45 were case reports (31.9%). The highest number of publications was 35 papers in 2018. Most of the papers were published from King Saud University (59.6%). A total of 123 articles (87.2%) were published from the central region of the kingdom. Hand surgery was the most common published topic, with 60 articles (43%).

Conclusions:

We concluded that there is an increase in the number of publications in the recent 5 years. However, most of these publications are case reports and series, which are low-quality researches in the era of evidence-based medicine.
Flow-through Omental Flap for Vascularized Lymph Node Transfer: A Novel Surgical Approach for Delayed Lymphatic Reconstruction
Authors: Johnson Anna Rose , Bravo Miguel G. , Granoff Melisa D. , Kang Christine O. , Critchlow Jonathan F. , Tsai Leo L. , Lee Bernard T. , Singhal Dhruv
Published: October 2019

The vascularized omental free flap has been described as a reliable option for the treatment of peripheral lymphedema. However, the flap has been associated with venous hypertension which may require venous supercharging or intra-flap arteriovenous fistula creation to offload the arterial inflow. The aim of this study is to introduce and present our experience using a flow-through omental flap as a novel approach to optimize flap hemodynamics. A retrospective review of a prospectively maintained quality improvement database was performed. Seven consecutive patients with unilateral breast cancer-related lymphedema (BCRL) who underwent delayed lymphatic reconstruction using a flow-through omental free flap were identified. In all patients, the right gastroepiploic artery and vein were anastomosed to the proximal end of the radial artery and to one venae comitante, respectively. An anastomosis of the distal end of the radial artery to the left gastroepiploic artery was performed. The flap was then supercharged by anastomosing the left gastroepiploic vein to the cephalic or basilic vein. There were no flap losses or other surgical complications. A distinct advantage of this inset includes the ability to moderate the arterial in-flow to the omental flap to avoid an inflow-outflow mismatch and alleviate venous hypertension. Further study is needed to validate this technique in a larger study sample with longer follow-up.
Von Willebrand Disease: From In Vivo to In Vitro Disease Models
Authors: de Boer Suzan , Eikenboom Jeroen
Published: October 2019

Von Willebrand factor (VWF) plays an essential role in primary hemostasis and is exclusively synthesized and stored in endothelial cells and megakaryocytes. Upon vascular injury, VWF is released into the circulation where this multimeric protein is required for platelet adhesion. Defects of VWF lead to the most common inherited bleeding disorder von Willebrand disease (VWD). Three different types of VWD exist, presenting with varying degrees of bleeding tendencies.

The pathophysiology of VWD can be investigated by examining the synthesis, storage and secretion in VWF producing cells. These cells can either be primary VWF producing cells or transfected heterologous cell models. For many years transfected heterologous cells have been used successfully to elucidate many aspects of VWF synthesis. However, those cells do not fully reflect the characteristics of primary cells. Obtaining primary endothelial cells or megakaryocytes with a VWD phenotype, requires invasive procedures, such as vessel collection or a bone marrow biopsy. A more recent and promising development is the isolation of endothelial colony forming cells (ECFCs) from peripheral blood as a true‐to‐nature cell model. Alternatively, various animal models are available but limiting, therefore, new approaches are needed to study VWD and other bleeding disorders. A potential versatile source of endothelial cells and megakaryocytes could be induced pluripotent stem cells (iPSCs).

This review gives an overview of models that are available to study VWD and VWF and will discuss novel approaches that can be considered to improve the understanding of the structural and functional mechanisms underlying this disease.
Femtosecond Laser-Assisted Penetrating Keratoplasty for Treating Infective Keratitis
Authors: Hosny Mohamed , Marrie Ayah , Anis Mohamed , El Shewy Ahmed
Published: October 2019

Purpose:

To report the results of penetrating keratoplasty (PKP) assisted by femtosecond laser in the treatment of persistent infective keratitis.

Methods:

Seven eyes of 7 patients with diagnosed infective keratitis were recruited. They showed no improvement on maximal medical therapy for a week. The causative organisms were Pseudomonas aeruginosa in 3 cases and Fusarium in 4 cases. All cases underwent femtosecond laser-assisted PKP with a mushroom-shaped cut. Postoperative antimicrobial medications were continued for 8–12 weeks. Sutures were removed after 6 months. Therapeutic success was defined as eradication of primary infection. Functional success was considered when visual function improves to 20/200 or better.

Results:

All 7 eyes underwent femtosecond laser-assisted PKP. There were no intraoperative complications, and all patients had uneventful recipient cornea separation. Anatomic, therapeutic, and functional success was achieved in all patients. During the 6-month follow-up period, no recurrence of infection was reported. The average preoperative corrected distance visual acuity (CDVA) was 2.07 log of the minimal angle of resolution (LogMAR) ± 0.21, whereas at 6 months postoperatively, the average CDVA was 0.17 LogMAR ± 0.13, with a P value of 0.00025.

Conclusions:

Femtosecond laser-assisted PKP was found to be an effective method for treating infective keratitis (particularly that caused by Pseudomonas aeruginosa and Fusarium) that did not respond to medical treatment. Early surgical intervention before the disease becomes advanced is recommended.
Renal Medullary Carcinoma With Metastasis to the Temporal Fossa and Orbit
Authors: Chumdermpadetsuk Ritah , Tooley Andrea A. , Godfrey Kyle J. , Krawitz Brian , Feldstein Neil , Kazim Michael
Published: October 2019

A 22-year-old Hispanic man with sickle cell trait presented with blurred vision, double vision, and pain with OD movement. MRI demonstrated an extra-axial mass centered around the temporal bone with extension into the middle cranial fossa and lateral aspect of the extra-conal right orbit, and mass effect on the lateral rectus muscle. Biopsy of the lesion was consistent with renal medullary carcinoma. CT chest/abdomen/pelvis confirmed a primary tumor in the right kidney. No additional metastases were found. Renal medullary carcinoma is a rare, highly aggressive malignancy, which almost exclusively affects young men of African descent with sickle cell trait or sickle cell disease. The authors present the second confirmed case of renal medullary carcinoma metastatic to the orbit, with ocular symptoms prior the typical presenting symptoms of flank pain and hematuria.

Renal medullary carcinoma is a highly aggressive malignancy, most commonly seen in African American patients with sickle cell disease. Involvement of the orbit is rare and visual symptoms may precede systemic diagnosis.
“We Deal Here With Grey”: Exploring Professional Boundary Development in a Forensic Inpatient Service
Authors: Pettman Hannah , Loft Niki , Terry Rachel
Published: October 2019

Background:

Maintaining appropriate professional boundaries with clients in mental health settings can be complex, particularly for forensic inpatient nurses and healthcare workers. The literature in this area has mainly focused on boundary violations, with little research on how staff members develop and maintain boundaries in forensic inpatient units, despite safe working relationships being beneficial for staff experience and client recovery.

Method:

Interviews with 11 nurses and healthcare workers from forensic inpatient wards were analyzed using a constructivist grounded theory methodology.

Results:

A cyclical model of boundary development was developed in which staff initially acclimatize to the forensic environment before entering a calibration phase of constantly assessing and addressing professional boundary issues in daily working life. Staff members use this experience alongside reflection, social learning, and clinical supervision to undergo individual learning and team development. In the fourth phase, they use this learning to recalibrate their views on boundaries, themselves, and how they work with clients. This recalibration impacts on staff members' further management of daily boundaries, providing more materials for learning, which leads to further recalibration.

Conclusions:

This study echoes previous literature suggesting the importance of supervision and reflective spaces in professional boundary understanding. The model is comparable with existing learning theory and reflects a clinical drive toward safe uncertainty. The importance of social and experiential learning is highlighted and has important implications for forensic nurses.
The patient with severe traumatic brain injury: clinical decision-making: the first 60 min and beyond
Authors: van Dijck Jeroen T.J.M. , Bartels Ronald H.M.A. , Lavrijsen Jan C.M. , Ribbers Gerard M. , Kompanje Erwin J.O. , Peul Wilco C.
Published: October 2019

Purpose of review

There is an urgent need to discuss the uncertainties and paradoxes in clinical decision-making after severe traumatic brain injury (s-TBI). This could improve transparency, reduce variability of practice and enhance shared decision-making with proxies.

Recent findings

Clinical decision-making on initiation, continuation and discontinuation of medical treatment may encompass substantial consequences as well as lead to presumed patient benefits. Such decisions, unfortunately, often lack transparency and may be controversial in nature. The very process of decision-making is frequently characterized by both a lack of objective criteria and the absence of validated prognostic models that could predict relevant outcome measures, such as long-term quality and satisfaction with life. In practice, while treatment-limiting decisions are often made in patients during the acute phase immediately after s-TBI, other such severely injured TBI patients have been managed with continued aggressive medical care, and surgical or other procedural interventions have been undertaken in the context of pursuing a more favorable patient outcome. Given this spectrum of care offered to identical patient cohorts, there is clearly a need to identify and decrease existing selectivity, and better ascertain the objective criteria helpful towards more consistent decision-making and thereby reduce the impact of subjective valuations of predicted patient outcome.

Recent efforts by multiple medical groups have contributed to reduce uncertainty and to improve care and outcome along the entire chain of care. Although an unlimited endeavor for sustaining life seems unrealistic, treatment-limiting decisions should not deprive patients of a chance on achieving an outcome they would have considered acceptable.
Coagulopathy in the surgical patient: trauma-induced and drug-induced coagulopathies
Authors: Peralta Ruben , Thani Hassan Al , Rizoli Sandro
Published: October 2019

Purpose of review

Coagulopathy is the derangement of hemostasis that in surgical patients may result in excessive bleeding, clotting or no measurable effect. The purpose of this review is to provide an overview of the most current evidence and practical approach to trauma- and drug-induced coagulopathy in surgical patients.

Recent findings

Early identification and timely correction of coagulopathy in surgical patients with significant bleeding is paramount to prevent death and other consequences of hemorrhage. Trauma-induced coagulopathy is managed by protocols recommending fibrinogen replacement, FFP, platelets, TXA and frequent lab monitorization including viscoelastic tests. For warfarin- or DOAC-induced coagulopathy, the management follows similar principles plus drug reversal. Warfarin is diagnosed by prolonged international normalized ratio and reversed by PCC or FFP. DOACs are inconsistently diagnosed by routine coagulation tests, and reversed by a combination of TXA, PCC and specific antidotes (if available).

Despite different understandings of the pathophysiology, trauma- and drug-induced coagulopathies are managed following similar protocols. In most of cases of significant surgical bleeding, timely and protocolized approach to correct the coagulopathy is likely to improve patients’ outcome.
Comparative effectiveness of all levels miniplate fixation versus a modified hybrid fixation in cervical expansive open-door laminoplasty
Authors: Yang Zechuan , Liu Chaoxu , Lin Yang , Hu Weihua , Chen Wenjian , Li Feng , Zeng Heng
Published: October 2019

In this study, we first reported of a modified hybrid fixation method in expansive open-door laminoplasty (EOLP) in order to reduce medical costs. The purpose of the present study is to compare the surgical outcomes and cost-effectiveness of the modified fixation with all levels miniplate fixation in EOLP for multilevel cervical spondylotic myelopathy.

Data of 67 patients who underwent EOLP from July 2015 to June 2016 were retrospectively analyzed, with 33 in the modified group and 34 in the all miniplate group based on their surgical approaches. Laminae were kept open with alternate levels miniplate and anchor fixation in the modified group, while with all levels miniplate fixation in the all miniplate group. Medical costs and clinical results including Japanese Orthopedic Association (JOA) scores, Visual Analogue Scale (VAS) scores and occurrences of complications were investigated and compared between the 2 groups. After evaluation on X-ray, CT, and MRI, radiographic data reflecting cervical alignments, spinal canal enlargement and spinal cord decompression were collected and compared within each group and between the 2 groups.

After a follow-up period of about 18 months, no significant differences in operation time, intraoperative blood loss, complication rates, VAS scores, neurological recovery rates and postoperative hospital stays were observed between the 2 groups. However, EOLP with the modified fixation costed less. When comparing the 2 groups, cervical curvature index (CCIs) which reflected cervical alignments and anteroposterior diameters (APDs) reflecting spinal canal enlargement at all the follow-ups had no significant differences. Postoperative open angles which reflected spinal cord decompression of C4 and C6 were significantly smaller in the modified group. However, that difference was no longer detected at the final follow-up. Within each group, APDs increased significantly after surgery. However, no significant differences in CCIs and open angles at different follow-ups were observed in each group.

Compared with all miniplate fixation, the modified hybrid fixation in EOLP showed almost the same clinical and radiographic results. However, the modified hybrid fixation method could reduce costs.
Rare purulent pericarditis caused by carbapenem-resistant Acinetobacter baumannii
Authors: Liu Jingjing , Xiao Xuefei , Cen Chaoqun , Yuan Hong , Yang Mingshi
Published: October 2019

Background:

Pericardial infection caused by Acinetobacter baumannii is rare, particularly that of carbapenem-resistant A baumannii (CRAB).

Case presentation:

We describe a rare case of purulent pericarditis due to CRAB in a 76-year-old man with acute myocardial infarction and acute kidney injury. The man was admitted to the intensive care unit for a catheter-related bloodstream infection. Pericardial effusion was detected via the bedside X-ray and ultrasound, and pericardiocentesis was performed. Cultures of the pericardial fluid, catheter tip, and blood independently revealed the presence of CRAB. These findings confirmed a diagnosis of purulent pericarditis.

Conclusions:

Clinicians should be reminded that CRAB infection can lead to purulent pericarditis, particularly in patients with congestive heart failure or renal insufficiency.
Clinical significance of serum magnesium levels in patients with heart failure with preserved ejection fraction
Authors: Nishihara Taiki , Yamamoto Eiichiro , Sueta Daisuke , Fujisue Koichiro , Usuku Hiroki , Oike Fumi , Takae Masafumi , Arima Yuichiro , Araki Satoshi , Takashio Seiji , Nakamura Taishi , Suzuki Satoru , Sakamoto Kenji , Soejima Hirofumi , Kawano Hiroaki , Kaikita Koichi , Tsujita Kenichi
Published: October 2019

Although serum magnesium (Mg) levels are closely associated with the prognosis of heart failure (HF) patients, the clinical significance of sMg levels on the cardiovascular outcomes of HF with preserved ejection fraction (HFpEF) patients is not fully understood. This study was a retrospective, single-center, observational study. We enrolled 452 consecutive HFpEF patients admitted to Kumamoto University Hospital. We defined lower sMg as <2.0 mg/dl (=0.8 mmol/L) based on recent clinical evidence and compared their clinical characteristics and prognosis. There were no significant differences between groups in the use of all medications (loop diuretics, mineralocorticoid receptor antagonists, renin-angiotensin-aldosterone system inhibitors, calcium channel blockers, beta blockers, statins, and Mg preparations). The lower sMg group showed a significantly higher prevalence of diabetes mellitus (DM), uric acid levels, and BNP levels compared with the higher sMg group. Kaplan–Meier curve revealed a significantly higher probability of HF-related events in the lower sMg group compared with the higher sMg group (log-rank test, P = .012). Multivariate Cox-proportional-hazard analysis revealed that the lower sMg group had significantly and independently higher probabilities of HF-related events compared with the higher sMg group (hazard ratio = 2.37, 95% confidence intervals = 1.27–4.41, P = .007). We reclassified the risk of HF-related events after adding the lower sMg to the other prognostic factors (age, previous hospitalization for HF, DM, Ln-BNP); the continuous net reclassification improvement was 29.0% (P = .041). sMg levels might provide important prognostic information in regard to HFpEF.