bluuebunny/crossref_metadata_2025 huggingface dataset:
Combining Nuclear and Mitochondrial Loci Provides Phylogenetic Information in the Philopterus Complex of Lice (Psocodea: Ischnocera: Philopteridae)
Authors: Najer Tomas , Papousek Ivo , Sychra Oldrich , Sweet Andrew D , Johnson Kevin P
Published: August 2020

The Philopterus Complex includes several lineages of lice that occur on birds. The complex includes the genera Philopterus (Nitzsch, 1818; Psocodea: Philopteridae), Philopteroides (Mey, 2004; Psocodea: Philopteridae), and many other lineages that have sometimes been regarded as separate genera. Only a few studies have investigated the phylogeny of this complex, all of which are based on morphological data. Here we evaluate the utility of nuclear and mitochondrial loci for recovering the phylogeny within this group. We obtained phylogenetic trees from 39 samples of the Philopterus Complex (Psocodea: Philopteridae), using sequences of two nuclear (hyp and TMEDE6) and one mitochondrial (COI) marker. We evaluated trees derived from these genes individually as well as from concatenated sequences. All trees show 20 clearly demarcated taxa (i.e., putative species) divided into five well-supported clades. Percent sequence divergence between putative species (~5–30%) for the COI gene tended to be much higher than those for the nuclear genes (~1–15%), as expected. In cases where species are described, the lineages identified based on molecular divergence correspond to morphologically defined species. In some cases, species that are host generalists exhibit additional underlying genetic variation and such cases need to be explored by further future taxonomic revisions of the Philopterus Complex.
Localizing merging black holes with sub-arcsecond precision using gravitational-wave lensing
Authors: Hannuksela Otto A , Collett Thomas E , Çalışkan Mesut , Li Tjonnie G F
Published: August 2020

The current gravitational-wave (GW) localization methods rely mainly on sources with electromagnetic counterparts. Unfortunately, a binary black hole does not emit light. Due to this, it is generally not possible to localize these objects precisely. However, strongly lensed gravitational waves, which are forecasted in this decade, could allow us to localize the binary by locating its lensed host galaxy. Identifying the correct host galaxy is challenging because there are hundreds to thousands of other lensed galaxies within the sky area spanned by the GW observation. However, we can constrain the lensing galaxy’s physical properties through both GW and electromagnetic observations. We show that these simultaneous constraints allow one to localize quadruply lensed waves to one or at most a few galaxies with the LIGO/Virgo/Kagra network in typical scenarios. Once we identify the host, we can localize the binary to two sub-arcsec regions within the host galaxy. Moreover, we demonstrate how to use the system to measure the Hubble constant as a proof-of-principle application.
Redefining the H-NS protein family: a diversity of specialized core and accessory forms exhibit hierarchical transcriptional network integration
Authors: Fitzgerald Stephen , Kary Stefani C , Alshabib Ebtihal Y , MacKenzie Keith D , Stoebel Daniel M , Chao Tzu-Chiao , Cameron Andrew D S
Published: August 2020

H-NS is a nucleoid structuring protein and global repressor of virulence and horizontally-acquired genes in bacteria. H-NS can interact with itself or with homologous proteins, but protein family diversity and regulatory network overlap remain poorly defined. Here, we present a comprehensive phylogenetic analysis that revealed deep-branching clades, dispelling the presumption that H-NS is the progenitor of varied molecular backups. Each clade is composed exclusively of either chromosome-encoded or plasmid-encoded proteins. On chromosomes, stpA and newly discovered hlpP are core genes in specific genera, whereas hfp and newly discovered hlpC are sporadically distributed. Six clades of H-NS plasmid proteins (Hpp) exhibit ancient and dedicated associations with plasmids, including three clades with fidelity for plasmid incompatibility groups H, F or X. A proliferation of H-NS homologs in Erwiniaceae includes the first observation of potentially co-dependent H-NS forms. Conversely, the observed diversification of oligomerization domains may facilitate stable co-existence of divergent homologs in a genome. Transcriptomic and proteomic analysis in Salmonella revealed regulatory crosstalk and hierarchical control of H-NS homologs. We also discovered that H-NS is both a repressor and activator of Salmonella Pathogenicity Island 1 gene expression, and both regulatory modes are restored by Sfh (HppH) in the absence of H-NS.
Real-world Time to Positivity of 2 Widely Used Commercial Blood Culture Systems in Patients With Severe Manifestations of Sepsis: An Analysis of the FABLED Study
Authors: Butler-Laporte Guillaume , Yansouni Cedric P , Paquette Katryn , Lawandi Alexander , Stabler Sarah N , Akhter Murtaza , Davidson Adam C , Gavric Marko , Jinah Rehman , Saeed Zahid , Demir Koray , Sangsari Sassan , Huang Kelly , Mahpour Amirali , Shamatutu Chris , Caya Chelsea , Troquet Jean-Marc , Clark Greg , Wong Titus , Lee Todd C , Stenstrom Robert , Sweet David , Cheng Matthew P
Published: August 2020

Background

Of all microbiological tests performed, blood cultures have the most impact on patient care. Timely results are essential, especially in the management of sepsis. While there are multiple available blood culture systems on the market, they have never been compared in a prospective study in a critically ill population.

Methods

We performed an analysis of the FABLED study cohort to compare culture results and time to positivity (TTP) of 2 widely used blood culture systems: BacT/Alert and BACTEC. In this multisite prospective study, patients with severe manifestations of sepsis had cultures drawn before antibiotics using systematic enrollment criteria and blood drawing methodology allowing for minimization of pre-analytical biases.

Results

We enrolled 315 patients; 144 had blood cultures (47 positive) with BacT/Alert and 171 with BACTEC (53 positive). Patients whose blood cultures were processed using the BacT/Alert system were younger (median, 64 vs 70 years; P = .003), had a higher proportion of HIV (9.03% vs 1.75%; P = .008) and a lower qSOFA (P = .003). There were no statistically significant differences in the most commonly identified bacterial species. TTP was shorter for BACTEC (median [interquartile range {IQR}], 12.5 [10–14] hours) compared with BacT/Alert (median [IQR], 17 [14–21] hours; P < .0001).

Conclusions

In this large prospective multi-centre study comparing the two blood culture systems among patients with severe manifestations of sepsis, and using a rigorous pre-analytical methodology, the BACTEC system yielded positive culture results 4.5 hours earlier than BacT/Alert. These results apply to commonly isolated bacteria. However, our study design did not allow direct comparison of TTP for unusual pathogens nor of clinical sensitivity between systems. More research is needed to determine the clinical implications of this finding.
Improving Intranasal Naloxone Prescribing Through EMR Modification and Automation
Authors: Crusco Salvatore , Smith Earl , Rajupet Sritha
Published: August 2020

Background:

In 2017, approximately 11.4 million Americans used opioids inappropriately. Nearly 47,600 deaths in 2017 were attributable to overdose on opioids. Intranasal naloxone was approved by the Food and Drug Administration in 2015 as a rescue medication for opioid overdose. New York State launched a prescription drug monitoring program in 2012, the Internet System for Tracking Over-Prescribing (I-STOP), that required completion before dispensing any controlled substance. Currently, prescribing naloxone at our institution requires 10 clicks and 2 free text boxes. The goal of this project was to increase the prescribing of intranasal naloxone by utilizing EMR automation and visualization tools.

Methods:

Our intervention embedded a section within the required I-STOP note, displaying the last date naloxone was prescribed and an option to “prescribe intranasal naloxone.” If checked, a prepopulated order dialog box was generated.

Results:

Intranasal naloxone orders for the institution totaled 65 for 2 months before the intervention and 203 for 2 months after the intervention, with 112 (55%) coming directly from the I-STOP note modification. Ease of prescribing improved as total clicks were reduced from 10 to 2, and free text boxes from 2 to 0.

Conclusions:

Our findings suggest that a clinical decision support system can be an effective way to increase hospital-wide naloxone prescribing rates. We were able to increase prescribing rates by more than three-fold, significantly increasing the availability of a rescue medication to individuals at high-risk for overdose. Intranasal naloxone prescribing increased with the implementation of a visual reminder and a more intuitive ordering experience while preserving provider autonomy.
Topical Vancomycin Powder Decreases the Proportion of Staphylococcus aureus Found in Culture of Surgical Site Infections in Operatively Treated Fractures
Authors: Qadir Rabah , Costales Timothy , Coale Max , Zerhusen Timothy , Joshi Manjari , O'Toole Robert V.
Published: August 2020

Objectives:

To determine whether patients with operatively treated fractures and surgical site infection after use of topical vancomycin powder have a lower proportion of Staphylococcus aureus infections than patients who did not receive topical vancomycin powder.

Design:

Retrospective cohort study.

Setting:

Level I trauma center.

Patients:

Treatment group: 10 of 133 patients (145 fractures) with surgical site infections who received intrawound vancomycin powder at the time of wound closure for fracture fixation. Control group: 175 patients who sustained deep surgical site infections during the same period but did not receive vancomycin powder.

Intervention:

Vancomycin powder or no vancomycin powder.

Main Outcome Measurement:

Proportion of patients' cultures positive for S. aureus.

Results:

The proportion of cultures positive for S. aureus was significantly lower in patients with surgical site infection who received vancomycin powder than in those who did not receive vancomycin powder (10% [1 of 10 patients in the treatment group] vs. 50% [87 of 175 patients in the control group]; P = 0.02). A trend was observed for a lower proportion of methicillin-resistant S. aureus (0% vs. 23%; P = 0.12).

Conclusions:

Vancomycin powder might alter the bacteriology of surgical site infections and decrease the proportion in culture of the most common organism typically present after fracture surgery infection. These findings suggest that the application of vancomycin powder might change the bacteriology of surgical site infections when they occur, regardless of the effect on overall infection rates. Although our bacteriology results are clinically and statistically significant, these findings must be confirmed in larger randomized controlled trials.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Do Fully Threaded Transiliac–Transsacral Screws Improve Mechanical Stability of Vertically Unstable Pelvic Fractures? A Cadaveric Biomechanical Analysis
Authors: Shannon Steven F. , Oppizzi Giovanni , Schloss Michael G. , Atchison Jared , Nascone Jason , Sciadini Marcus , Zhang Li-Qun , O'Toole Robert V. , Jaeblon Todd
Published: August 2020

Objective:

To determine whether fully threaded transiliac–transsacral (TI-TS) fixation is biomechanically superior to partially threaded TI-TS fixation of vertically unstable transforaminal sacral fractures.

Methods:

Vertically unstable zone 2 sacral fractures were created in 20 human cadaveric pelves with a unilateral osteotomy and resection of 1 cm of bone through the foramen of the sacrum to represent comminution. Ten specimens received either 2 7.3-mm fully threaded or 2 7.3-mm partially threaded TI-TS screw fixation at the S1 and S2 body, and every specimen received standard 3.5-mm 8-hole parasymphyseal plating anteriorly. Each pelvis was loaded to 250 N at 3 Hz for 100,000 cycles and then loaded to failure. The primary outcome was fracture displacement at the S1 foramen, which was measured at 25,000, 50,000, 75,000, and 100,000 cycles. Secondary outcomes were simulated clinical failure of ≥1 cm displacement at the S1 foramen to determine occurrence probability of failure, and load at failure was defined as 2.5 cm of the linear loading system displacement. Specimens in the fully threaded and partially threaded cohorts were otherwise respectively comparable in regards to age, gender, and bone density.

Results:

Five of the 10 TI-TS partially threaded specimens experienced simulated clinical failure with >1 cm displacement at the S1 foramen compared with 0 of the 10 TI-TS fully threaded cohort (50% vs. 0%, P = 0.03). The mean maximal displacement at the S1 foramen was greater in the partially threaded cohort (9.3 mm) compared with the fully threaded cohort (3.6 mm; P = 0.004). Fully threaded specimens also demonstrated greater mean force to failure than the partially threaded specimens (461 N vs. 288 N; P = 0.0001).

Conclusions:

Fully threaded TI-TS screw fixation seems to be mechanically superior to partially threaded fixation in a cadaveric vertically unstable transforaminal sacral fracture model with significantly less displacement of the posterior pelvic ring and greater load to failure.
Dural Leak: Is It Deterrent to Outcomes in Spine Surgery?
Authors: Patel Jwalant , Kundnani Vishal , Kuriya Suraj
Published: August 2020

Study Design.

Retrospective case-control study.

Objectives.

To review the incidence of dural leaks, evaluate the efficacy of primary closure of durotomy and to study its effect on clinical outcome. The secondary aim is to classify the dural leaks and proposing a treatment algorithm for dural leaks.

Summary of Background Data.

Dural leaks are described as one of the fearful complications in spine surgery. Literature evaluating the actual incidence, ideal treatment protocol, efficacy of primary repair techniques and its effects on long-term surgical outcomes are scanty.

Methods.

It was a retrospective analysis of 5390 consecutively operated spine cases over a period of 10 years. All cases were divided into two groups—study group (with dural leak-255) and control group (without dural leak-5135). Dural leaks were managed with the proposed treatment algorithm. Blood loss, surgical time, hospital stay, time for return to mobilization, pain free status, and clinical outcome score (ODI, VAS, NDI, and Wang criteria) were assessed in both groups at regular intervals. The statistical comparison between two groups was established with chi-square and t-tests.

Results.

The overall incidence of dural leaks was 4.73% with highest incidence in revision cases (27.61%). There was significant difference noted in mean surgical blood loss (P 0.001), mean hospital stay (P 0.001), time to achieve pain-free status after surgery, and return to mobilization between two groups. However, no significant difference was noted in operative time (P 0.372) and clinical outcome scores at final follow-up between the two groups.

Conclusion.

Primary closure should be undertaken in all amenable major dural leak cases. Dural leaks managed as proposed by the author's treatment algorithm have shown a comparable clinical outcome as in patients without dural leaks. Dural leak is a friendly adverse event that does not prove a deterrent to long-term clinical outcome in spine surgeries.

Level of Evidence: 4
Opioid Use in Adults With Low Back or Lower Extremity Pain Who Undergo Spine Surgical Treatment Within 1 Year of Diagnosis
Authors: Fatemi Parastou , Zhang Yi , Ho Allen , Lama Roberto , Jin Michael , Veeravagu Anand , Desai Atman , Ratliff John K.
Published: August 2020

Study Design.

Retrospective longitudinal cohort.

Objective.

We investigated opioid prescribing patterns amongst adults in the United States diagnosed with low back or lower extremity pain (LBP/LEP) who underwent spine surgery.

Summary of Background Data.

Opioid-based treatment of LBP/LEP and postsurgical pain has separately been associated with chronic opioid use, but a combined and large-scale cohort study is missing.

Methods.

This study utilizes commercial inpatient, outpatient, and pharmaceutical insurance claims. Between 2008 and 2015, patients without previous prescription opioids with a new diagnosis of LBP/LEP who underwent surgery within 1 year after diagnosis were enrolled. Opioid prescribing patterns after LBP/LEP diagnosis and after surgery were evaluated. All patients had 1-year postoperative follow-up. Low and high frequency (6 or more refills in 12 months) opioid prescription groups were identified.

Results.

A total of 25,506 patients without previous prescription opioids were diagnosed with LBP/LEP and underwent surgery within 1 year of diagnosis. After LBP/LEP diagnosis, 18,219 (71.4%) were prescribed opioids, whereas 7287 (28.6%) were not. After surgery, 2952 (11.6%) were prescribed opioids with high frequency and 22,554 (88.4%) with low frequency. Among patients prescribed opioids before surgery, those with high-frequency prescriptions were more likely to continue this pattern postoperatively than those with low frequency prescriptions preoperatively (OR 2.15, 95% CI 1.97–2.34). For those prescribed opioids preoperatively, average daily morphine milligram equivalent (MME) decreased after surgery (by 2.62 in decompression alone cohort and 0.25 in arthrodesis cohort, P < 0.001). Postoperative low-frequency patients were more likely than high-frequency patients to discontinue opioids one-year after surgery (OR 3.78, 95% CI 3.59–3.99). Postoperative high-frequency patients incurred higher cost than low-frequency patients. Postoperative high-frequency prescribing varied widely across states (4.3%–20%).

Conclusion.

A stepwise association exists between opioid use after LEP or LBP diagnosis and frequency and duration of opioid prescriptions after surgery. Simultaneously, the strength of prescriptions as measured by MME decreased following surgery.

Level of Evidence: 3
Neurological Disturbance of the Upper Extremities After Cervical Laminoplasty
Authors: Yoshioka Nao , Takayama Motohiro , Kobayashi Tamaki , Murai Nozomu , Ioroi Yoshihiko
Published: August 2020

Study Design.

A retrospective study.

Objective.

The aim of this study was to explore the relationship between postoperative neurological disturbance of the upper extremities (NDUE) after cervical laminoplasty and intervertebral foraminal stenosis.

Summary of Background Data.

The relationship between foraminal stenosis and neurological disturbance in the C5 segment (C5 palsy) has been reported, but the relationship at other levels has not been examined before. We evaluated foraminal stenosis morphologically using three-dimensional computed tomography (3D-CT), alongside other risk factors for NDUE.

Methods.

We retrospectively reviewed patients treated by open-door laminoplasty at the authors’ institution between January and June 2016. NDUE was defined as postoperative motor deterioration and/or newly emerged sensory disturbance within 2 weeks of surgery. Radiological measurements were performed in bilateral intervertebral foramina from C5 to C8, using 3D-CT. Investigation using magnetic resonance imaging (MRI) was also performed.

Results.

Thirty-one patients were reviewed, and 10 (32.3%) developed NDUE. Nineteen NDUE were observed: seven were in the C5 segment, five in the C6 segment, three in the C7 segment, and four in the C8 segment. Four patients (40%) had NDUE from multiple segments. The mean width of the foramen was 2.60 ± 1.26 mm and 3.66 ± 1.66 mm (P = 0.007), and cross-sectional area was 32.8 ± 10.8 mm2 and 41.6 ± 12.4 mm2 (P = 0.003), in symptomatic (n = 19) and nonsymptomatic (n = 187) foramina, respectively. The mean transverse diameter of bony spurs and the maximum shift of the spinal cord on MRI was significantly larger in the NDUE group. The odds ratio of having a foraminal cross-sectional area under 28.0 mm2 in combination with a maximum spinal shift over 3.10 mm was 14.6 (P < 0.001).

Conclusion.

Stenosis of the intervertebral foramen could be a risk factor for NDUE after cervical laminoplasty, and could be aggravated by excessive posterior spinal cord shift.

Level of Evidence: 3
Plasma Exchange: An Effective Rescue Therapy in Critically Ill Patients With Coronavirus Disease 2019 Infection
Authors: Fernandez Javier , Gratacos-Ginès Jordi , Olivas Pol , Costa Montserrat , Nieto Susana , Mateo Dolors , Sánchez María Belén , Aguilar Ferran , Bassegoda Octavi , Ruiz Pablo , Caballol Berta , Pocurull Anna , Llach Joan , Mustieles María Jesús , Cid Joan , Reverter Enric , Toapanta Nestor David , Hernández-Tejero María , Martínez José Antonio , Claria Joan , Fernández Carlos , Mensa José , Arroyo Vicente , Castro Pedro , Lozano Miquel ,   for the Covid Clinic Critical Care (CCCC) Group
Published: August 2020

Objectives:

Infection by severe acute respiratory syndrome coronavirus-2 can induce uncontrolled systemic inflammation and multiple organ failure. The aim of this study was to evaluate if plasma exchange, through the removal of circulating mediators, can be used as rescue therapy in these patients.

Design:

Single center case series.

Setting:

Local study.

Subjects:

Four critically ill adults with coronavirus disease 19 pneumonia that failed conventional interventions.

Interventions:

Plasma exchange. Two to six sessions (1.2 plasma volumes). Human albumin (5%) was used as the main replacement fluid. Fresh frozen plasma and immunoglobulins were administered after each session to avoid coagulopathy and hypogammaglobulinemia.

Measurements and Main Results:

Serum markers of inflammation and macrophage activation. All patients showed a dramatic reduction in inflammatory markers, including the main cytokines, and improved severity scores after plasma exchange. All survived to ICU admission.

Conclusions:

Plasma exchange mitigates cytokine storm, reverses organ failure, and could improve survival in critically ill patients with coronavirus disease 2019 infection.
Understanding Barriers to Access and Utilization of Developmental Disability Services Facilitating Transition
Authors: Bear Ami , Drew Christine , Zuckerman Katharine E. , Phelps Randall A.
Published: August 2020

Objective:

To explore the barriers faced by parents of individuals with intellectual and developmental disabilities when obtaining and using Developmental Disability Services (DDS) to support adolescent transition.

Methods:

The authors conducted a basic interpretive qualitative study using semistructured interviews. Interviews were manually coded by the team of university-based researchers using constant comparative analysis. The codes were grouped into themes. Thematic saturation occurred after 18 interviews with parents (n = 10) and service coordinators for DDS (n = 8).

Results:

Barriers to DDS enrollment included emotional and administrative burden, fear of invasion of privacy, lack of a qualifying diagnosis, difficulties in accessing information about services, and misinformation about services. Barriers to DDS use once enrolled were difficulty in finding/hiring direct support professionals, high turnover of direct support professionals, and lack of training and skill among direct support professionals. Participants also noted high turnover among service coordinators, further administrative burden from hiring direct support professionals, and required home visits by service coordinators as additional barriers to service use. Participants reported benefits of DDS including increased inclusion for clients in the community, the use of person-centered skill building, and access to respite care and system navigation support.

Conclusion:

Although all participants reported benefits of acquiring services, there are significant barriers to acquiring and maintaining these services. Recommendations based on these barriers are provided for DDS, federal policy makers, and local support professionals along with a toolkit of potential strategies to support families.
Specimen Pooling to Conserve Additional Testing Resources When Persons’ Infection Status Is Correlated
Authors: Rewley Jeffrey
Published: August 2020

In the early stages of a novel pandemic, testing is simultaneously in high demand and low supply, making efficient use of tests of paramount importance. One approach to improve the efficiency of tests is to mix samples from multiple individuals, only testing individuals when the pooled sample returns a positive. To reflect potential clusters of cases that might queue at a testing site and that might increase the efficiency of batch testing, I simulate 10,000 persons being tested in sequence. I use a prevalence ranging from 1% to 45% and batch sizes ranging from 3 to 25 and assume the increased probability of consecutive infections ranges from 0% to 45%. I find that as the likelihood of clustered infections increases, the efficiency of specimen pooling increases. This analysis suggests that when clusters of infected persons exist at testing sites, specimen pooling can remain efficient even as prevalence increases. See video abstract: http://links.lww.com/EDE/B729.
Development and validation of an instrument to measure nursing workload in the postanaesthesia care unit
Authors: Idoffsson Åsa , Olsson Charlotte , Holmén Anders , Granberg-Axell Anetth , Chew Michelle S.
Published: August 2020

BACKGROUND

There are no instruments specifically developed for the measurement of nursing workload in postanaesthesia care units (PACUs). An objective and valid instrument is essential for planning work flow and staffing in this unique hospital environment that encompasses elements of elective and acute postsurgical care. Previous studies show that increased workload is associated with increased complication rates in ICUs. Thus, workload assessment may be an important tool for improving postsurgical outcomes.

OBJECTIVE

The aim of this study was to develop and validate a postanaesthesia workload instrument (PAWI) for measurement of workload in PACUs for adults above 18 years of age.

DESIGN

Development and validation consisted of three parts: Delphi consensus to establish content validity; internal validation including feasibility, face validity and inter-rater reliability testing; and national external validation consisting of feasibility, inter-rater reliability, criterion validity, construct and face validities.

SETTING

PACUs in nine university and regional hospitals in Sweden.

RESULTS

The final instrument consisted of 11 workload domains. The response rate was 98% and overall feasibility of PAWI was 100%. Content and face validity were demonstrated by consensus after two Delphi rounds. In national external validation, good agreement between experts was demonstrated with Cohen's κ greater than 0.75 in nine domains and 0.6 to 0.74 in the remaining two domains. A significant relationship was seen between PAWI and the nine equivalents of nursing manpower use score (NEMS) (r = 0.439, P < 0.001). There were no floor or ceiling effects. There was a significant association between PAWI points and American Society of Anesthesiologists’ (ASA) physical status grade (P = 0.007) but not between PAWI points and age.

CONCLUSION

We developed and validated PAWI, an instrument for objectively measuring workload in postanaesthesia care units. PAWI demonstrated good feasibility and metric properties.
First pass success of tracheal intubation using the C-MAC PM videolaryngoscope as first-line device in prehospital cardiac arrest compared with other emergencies
Authors: Hossfeld Bjoern , Thierbach Sylvi , Allgoewer Andreas , Gaessler Holger , Helm Matthias
Published: August 2020

BACKGROUND

Successful airway management is a priority in the resuscitation of critically ill or traumatised patients. Several studies have demonstrated the importance of achieving maximum first pass success, particularly in prehospital advanced airway management.

OBJECTIVE

To compare success rates of emergency intubations between patients requiring cardiopulmonary resuscitation (CPR) for cardiac arrest (CPR group) and other emergencies (non-CPR group) using the C-MAC PM videolaryngoscope.

DESIGN

Ongoing analysis of prospective collected prehospital advanced airway management core variables.

SETTING

Single helicopter emergency medical service (HEMS) ‘Christoph 22’, Ulm Military Hospital, Germany, May 2009 to July 2018.

PATIENTS

We included all 1006 HEMS patients on whom prehospital advanced airway management was performed by board-certified anaesthesiologists on call at HEMS ‘Christoph 22’.

INTERVENTIONS

The C-MAC PM was used as the first-line device. The initial direct laryngoscopy was carried out using the C-MAC PM without the monitor in sight. After scoring the direct laryngoscopic view according to the Cormack and Lehane grade, the monitor was folded within the sight of the physician and tracheal intubation was performed using the videolaryngoscopic view without removing the blade.

MAIN OUTCOME MEASURES

The primary outcome was successful airway management. Secondary outcomes were the patient's position during airway management, necessity for suction, direct and videolaryngoscopic view according to Cormack and Lehane grading, as well as number of attempts needed for successful intubation.

RESULTS

A patent airway was achieved in all patients including rescue techniques. There was a lower first pass success rate in the CPR group compared with the non-CPR group (84.4 vs. 91.4%, P = 0.01). In the CPR group, direct laryngoscopy resulted more often in a clinically unfavourable (Cormack and Lehane grade 3 or 4) glottic view (CPR vs. non-CPR-group 37.2 vs. 26.7%, P = 0.0071). Using videolaryngoscopy reduced the clinically unfavourable grading to Cormack and Lehane 1 or 2 (P < 0.0001). The odds of achieving first pass success were approximately 12-fold higher with a favourable glottic view than with an unfavourable glottic view (OR 12.6, CI, 6.70 to 23.65).

CONCLUSION

Airway management in an anaesthesiologist-staffed HEMS is associated with a high first pass success rate but even with skilled providers using the C-MAC PM videolaryngoscope routinely, patients who require CPR offer more difficulties for successful prehospital advanced airway management at the first attempt.

TRIAL REGISTRATION

German Clinical trials register (drks.de) DRKS00020484
Multivariable haemodynamic approach to predict the fluid challenge response
Authors: Messina Antonio , Romano Salvatore M. , Ozdemirkan Aycan , Persona Paolo , Tarquini Riccardo , Cammarota Gianmaria , Romagnoli Stefano , Della Corte Francesco , Bennett Victoria , Monge García Manuel I. , Cecconi Maurizio , Payen Didier
Published: August 2020

BACKGROUND

Beat-to-beat stroke volume (SV) results from the interplay between left ventricular function and arterial load. Fluid challenge induces time-dependent responses in cardiac performance and peripheral vascular and capillary characteristics.

OBJECTIVE

To assess whether analysis of the determinants of the haemodynamic response during fluid challenge can predict the final response at 10 and 30 min.

DESIGN

Observational multicentric cohort study.

SETTING

Three university ICUs.

PATIENTS

85 ICU patients with acute circulatory failure diagnosed within the first 48 h of admission.

INTERVENTION(S)

The fluid challenge consisted of 500 ml of Ringer's solution infused over 10 min. A SV index increase at least 10% indicated fluid responsiveness.

MAIN OUTCOME MEASURES

The SV, pulse pressure variation (PPV), arterial elastance, the systolic–dicrotic pressure difference (SAP-Pdic) and cardiac cycle efficiency (CCE) were measured at baseline, 1, 2, 3, 4, 5, 10, 15 and 30 min after the start of the fluid challenge. All haemodynamic data were submitted to a univariable logistic regression model and a multivariable analysis was then performed using the significant variables given by univariable analysis.

RESULTS

The multivariable model including baseline PPV, and the changes of arterial elastance at 1 min and of the CCE and SAP-Pdic at 5 min when compared with their baseline values, correctly classified 80.5% of responders and 90.7% of nonresponders at 10 min. For the response 30 min after starting the fluid challenge, the model, including the changes of PPV, CCE, SAP-Pdic at 5 min and of arterial elastance at 10 min compared with their baseline values, correctly identified 93.3% of responders and 91.4% of nonresponders.

CONCLUSION

In a selection of mixed ICU patients, a statistical model based on a multivariable analysis of the changes of PPV, CCE, arterial elastance and SAP-Pdic, with respect to baseline values, reliably predicts both the early and the late response to a standardised fluid challenge.

TRIAL REGISTRATION

ACTRN12617000076370.
Serratus anterior plane block for video-assisted thoracoscopic surgery
Authors: De Cassai Alessandro , Boscolo Annalisa , Zarantonello Francesco , Piasentini Eleonora , Di Gregorio Guido , Munari Marina , Persona Paolo , Zampirollo Stefano , Zatta Matteo , Navalesi Paolo
Published: August 2020

BACKGROUND

The serratus anterior plane block (SAPb) is a promising interfascial plane technique able to provide profound thoracic analgesia. As only a few studies with quite small patient samples are presently available, the analgesic efficacy of adding SAPb to general anaesthesia in video-assisted thoracoscopic surgery (VATS), compared with general anaesthesia only, remains unclear.

OBJECTIVES

Our primary aim was to assess the analgesic efficacy of SAPb for VATS peri-operative pain control. The secondary aims were to evaluate differences in postoperative opioid use, intra-operative hypotension, postoperative side-effects and complications, time to chest tube removal, length of hospital stay.

DESIGN

Systematic review of randomised controlled trials (RCTs) with meta-analyses.

DATA SOURCES PubMed, Web of Science, Google Scholar and the Cochrane Library, searched up to 6 December 2019.

ELIGIBILITY CRITERIA RCTs including adult patients undergoing VATS who received single shot SAPb (cases), compared with general anaesthesia (controls).

RESULTS

Seven RCTs, with a total of 489 patients were included. SAPb reduced pain scores peri-operatively, compared with controls: 6 h [mean difference −1.86, 95% confidence interval (CI) −2.35 to −1.37, P < 0.001]; 12 h (mean difference −1.45, 95% CI −1.66 to −1.25, P < 0.001); 24 h (mean difference −0.98, 95% CI −1.40 to −0.56, P < 0.001). SAPb also reduced the use of postoperative opioids (mean difference: −4.81 mg of intravenous morphine equivalent, 95% CI −8.41 to −1.22, P < 0.03) and decreased the incidence of nausea and vomiting (risk ratio 0.53, 95% CI 0.36 to 0.79, P < 0.002).

CONCLUSION

Compared with general anaesthesia only and if no other locoregional techniques are used, SAPb significantly reduces postoperative pain and nausea and vomiting in patients undergoing VATS. Grading of Recommendations Assessment, Development and Evaluation rating are, nonetheless, quite low, due to high heterogeneity. Well designed and properly powered RCTs are necessary to confirm these preliminary findings.
The effect of oral Δ-9-tetrahydrocannabinol on the minimal alveolar concentration of sevoflurane
Authors: Müller Johannes , Plöchl Walter , Reiter Birgit , Stimpfl Thomas , Graf Alexandra , Baron-Stefaniak Joanna , Infanger Lukas , Hamp Thomas
Published: August 2020

BACKGROUND

Cannabis has increasingly been used for medical and recreational purposes. The main pharmacological compound in cannabis is tetrahydrocannabinol (THC), which has sedative, anxiolytic and analgesic effects. In some animal models, THC has also been shown to reduce the minimum alveolar concentration (MAC) of halothane and cyclopropane, but its effect on sevoflurane, currently the most commonly used inhalational anaesthetic agent, has not been investigated.

OBJECTIVE

To investigate the effect of THC on the MAC of sevoflurane in rats.

METHODS

Observer-blinded, randomised controlled trial.

SETTING

Centre for Biomedical Research of the Medical University of Vienna, 2019.

INDIVIDUALS

Thirty-eight adult Wistar rats.

INTERVENTIONS

The rats were allocated randomly into one of two groups. Group A received THC 10 mg kg−1 and group B received the corresponding volume of placebo via gastric gavage (administration through a tube placed in the distal oesophagus). The rats were then individually anaesthetised in an airtight sevoflurane-flooded chamber, and the MAC in both groups was determined using Dixon's up-and-down method. Blood samples were drawn to measure serum concentrations of THC.

MAIN OUTCOME MEASURES

The primary outcome was the MAC of sevoflurane in Groups A and B.

RESULTS

The bootstrap estimate of the MAC of sevoflurane was 2.1 (95% confidence interval 1.8 to 2.4) vol% in the THC group and 2.8 (95% confidence interval 2.7 to 2.9) vol% in the placebo group, corresponding to a significant MAC reduction of 26% in response to THC.

CONCLUSION

Gastric administration of THC 10 mg kg−1 significantly reduced the MAC of sevoflurane by 26%.

TRIAL REGISTRATION

Not applicable.
A New Application of Sohrabi Albedo Neutron Dosimeters around a Plasma Focus Device
Authors: Sohrabi Mehdi , Soltani Zahra
Published: August 2020

A new application of the Sohrabi albedo neutron dosimeters is reported for the first time for determination of very low-level neutron ambient dose equivalents on and around a 3.5 kJ plasma focus device (PFD). The Sohrabi dosimeters basically use a polycarbonate track detector as bare and/or in contact with 10B convertor(s) under special cadmium cover arrangements. Its sensitivity was improved by using enriched 10B under new cadmium arrangements in order to detect epithermal neutrons in addition to fast and thermal neutrons. Results of 12 dosimeters installed externally around the PFD at different azimuthal (φ) and polar (θ) angles showed that azimuthal (φ) fast, epithermal, thermal, and total neutron ambient dose equivalents were symmetric and isotropic, respectively, with values 55.15 ± 8.36, 1.36 ± 02, 0.53 ± 03, and 57.04 ± 8.62 μSv/shot at ~25 cm from anode top. Polar (θ) neutron ambient dose equivalent values on z-axis relative to 90o angle were relatively higher. Results of 38 dosimeters placed on PFD facility walls for workplace monitoring and on a BOMAB phantom at operator’s location for personal dose equivalent determination showed values below minimum detection limits after exposure to 130 PFD shots. However, an operator’s personal dose equivalents at ~1.0 and ~3.0 m from the anode top were estimated to be, respectively, ~13.7 and ~1.52 mSv y−1 using azimuthal angle (φ) values if the PFD operates, for example, up to 20 shots per day for 200 d y−1. Even under such an extreme assumption, annual personal dose equivalent is still much below 20 mSv, the annual ICRP dose limit for workers.
Proteus mirabilis Keratitis: Risk Factors, Clinical Features, Treatment Outcomes, and Microbiological Characteristics
Authors: Mo Shelley , Durrani Asad F. , Safiullah Zaid , Kowalski Regis P. , Jhanji Vishal
Published: August 2020

Purpose:

To characterize the risk factors, clinical presentations, management choices, and outcomes of Proteus mirabilis keratitis.

Methods:

In this retrospective study, 26 culture-proven cases of P. mirabilis infections were diagnosed and treated between 1998 and 2019 at the University of Pittsburgh Medical Center. Medical records were available for 14 keratitis cases and were reviewed for demographic information, ocular risk factors, and treatment outcomes.

Results:

Sixteen eyes of 14 patients were included in the study. The average age was 47.8 ± 19.3 years, with a median follow-up time of 6 months. The most common ocular risk factors were poor ocular surface and contact lens use in 57.1% and 42.9% of cases, respectively. Eleven of the 14 patients (78.6%) had positive corneal cultures, and 13 of the 14 patients (92.9%) had positive conjunctiva or eyelid cultures. All isolates were susceptible to ciprofloxacin, ofloxacin, moxifloxacin, gatifloxacin, and cefazolin. Surgical intervention was required in 4 patients (28.6%). Average LogMAR visual acuity was 1.3 ± 1.0 at presentation and 0.9 6 ± 1.0 at the most recent follow-up visit.

Conclusions:

Proteus mirabilis is an uncommon cause of microbial keratitis. Patients with poor ocular surface and those who use contact lens are at increased risk for developing this cause of keratitis. Empiric treatment with fortified antibiotics or fluoroquinolones seemed to provide effective coverage for P. mirabilis.
Measurement Reliability for Keratitis Morphology
Authors: Kriegel Matthias F. , Loo Jessica , Farsiu Sina , Prajna Venkatesh , Tuohy Megan , Kim Kyeong Hwan , Valicevic Autumn N. , Niziol Leslie M. , Tan Huan , Ashfaq Hamza A. , Ballouz Dena , Woodward Maria A.
Published: August 2020

Purpose:

To evaluate the reliability of manual annotation when quantifying cornea anatomical and microbial keratitis (MK) morphological features on slit-lamp photography (SLP) images.

Methods:

Prospectively enrolled patients with MK underwent SLP at initial encounter at 2 academic eye hospitals. Patients who presented with an epithelial defect (ED) were eligible for analysis. Features, which included ED, corneal limbus (L), pupil (P), stromal infiltrate (SI), white blood cell (WBC) infiltration at the SI edge, and hypopyon (H), were annotated independently by 2 physicians on SLP images. Intraclass correlation coefficients (ICCs) were applied for reliability assessment; dice similarity coefficients (DSCs) were used to investigate the area overlap between readers.

Results:

Seventy-five MK patients with an ED received SLP. DSCs indicate good to fair annotation overlap between graders (L = 0.97, P = 0.80, ED = 0.94, SI = 0.82, H = 0.82, WBC = 0.83) and between repeat annotations by the same grader (L = 0.97, P = 0.81, ED = 0.94, SI = 0.85, H = 0.84, WBC = 0.82). ICC scores showed good intergrader (L = 0.98, P = 0.78, ED = 1.00, SI = 0.67, H = 0.97, WBC = 0.86) and intragrader (L = 0.99, P = 0.92, ED = 0.99, SI = 0.94, H = 0.99, WBC = 0.92) reliabilities. When reliability statistics were recalculated for annotated SI area in the subset of cases where both graders agreed WBC infiltration was present/absent, intergrader ICC improved to 0.91 and DSC improved to 0.86 and intragrader ICC remained the same, whereas DSC improved to 0.87.

Conclusions:

Manual annotation indicates usefulness of area quantification in the evaluation of MK. However, variability is intrinsic to the task. Thus, there is a need for optimization of annotation protocols. Future directions may include using multiple annotators per image or automated annotation software.
Postoperative Changes in Central Corneal Thickness and Intraocular Pressure in a Prospective Cohort of Congenital Cataract Patients
Authors: Chang Pingjun , Kou Jiaojiao , Zhang Bing , Wang Jiajun , Tian Tong , Zhao Yun-e
Published: August 2020

Purpose:

To evaluate changes in central corneal thickness (CCT) and intraocular pressure (IOP) in children after surgery for congenital cataracts and to investigate the association between CCT and IOP.

Methods:

For this prospective observational cohort study, we recruited patients undergoing surgery for unilateral or bilateral congenital cataracts. CCT and IOP were measured before surgery and 1, 3, 6, 12, and 24 months after surgery.

Results:

Seventy-six children (152 eyes) were enrolled; 33 eyes were unaffected by cataracts, 77 were aphakic, and 42 were pseudophakic. In aphakic eyes, mean CCT increased by 31.14 ± 44.32 μm at 12 months postoperation and 33.09 ± 35.42 μm at 24 months postoperation; this increase was significantly higher than that in pseudophakic eyes 12 months after surgery (8.36 ± 19.91 μm; P < 0.001) and 24 months after surgery (0.31 ± 14.19 μm; P = 0.024). However, no significant differences in IOP were found between the different phakic states at 12 and 24 months postoperation (P = 0.672 and P = 0.080, respectively). There were also no significant differences in CCT and IOP before and after surgery in the unaffected eyes.

Conclusions:

Mean CCT peaked at 12 months, and the mean IOP remained normal in both the aphakic and pseudophakic eyes during this study. CCT and IOP were positively correlated, regardless of the phakic status or age, a relationship which suggests that both parameters should be monitored closely in postsurgical patients for up to 12 months and in this time, may impact the ability to diagnose glaucoma.
Normative Values of Various Pentacam HR Parameters for Pediatric Corneas
Authors: Hashem Ahmed Osama , Roshdy Maged Maher , Wahba Sherine Shafik , Saleh Mohamed Ibrahim , Elkitkat Rania Serag
Published: August 2020

Purpose:

To provide a normative database of several Pentacam parameters for a healthy pediatric population.

Methods:

This was a retrospective study conducted at Al Watany Eye Hospitals, Cairo, Egypt. We explored the Pentacam HR database and collected the data of 432 normal right eyes of children and teenagers aged 3 to 18 years. The subjects were classified into the following 3 groups: group 1 (3–6 years, 17 eyes), group 2 (6–12 years, 126 eyes), and group 3 (12–18 years, 289 eyes). The parameters of the study cohort were compared with those of a healthy adult cohort.

Results:

The mean age of the study cohort was 13.5 (13.2–13.8) years. There were significant differences in the following indices among the 3 age groups: anterior chamber (depth and volume), curvature (index of height decentration, index of vertical asymmetry, and center keratoconus index), elevation (front and back elevations from the best fit toric ellipsoid), and pachymetric (minimum and average pachymetric progression indices and average Ambrosio relational thickness) parameters (P values 0.001, 0.001, 0.002, 0.04, <0.001, <0.001, 0.03, 0.02, 0.01, and 0.03, respectively).

Conclusions:

There were significant differences in the normative values of several Pentacam indices between the pediatric and adult cohorts. Based on this finding, it is more credible to incorporate separate software cutoff values for pediatric patients. However, because there were no clinically significant differences in the parameters of the pediatric subgroups, there is no need to consider a separate cutoff value for each pediatric age range.
Treatment of Severe Infectious Keratitis With Scleral Contact Lenses as a Reservoir of Moxifloxacin 0.5%
Authors: Polania-Baron Eduardo J. , Santana-Cruz Omar , Lichtinger Alejandro , Graue-Hernandez Enrique O. , Navas Alejandro
Published: August 2020

Purpose:

To report the outcomes of using scleral contact lenses as antibiotic reservoirs as a therapeutic approach in a case series of severe infectious keratitis and to discuss the clinical potential.

Methods:

This was a prospective consecutive case series study of 12 eyes treated for infectious keratitis at the “Conde de Valenciana” Institute of Ophthalmology. A scleral lens (SL) filled with 0.5% moxifloxacin was used as a reservoir and replaced every 24 hours until epithelization was complete or the culture report and/or antibiogram demonstrated either a microorganism not susceptible to or resistant to moxifloxacin.

Results:

The study included 12 eyes of 12 patients (7 women; 58.33%; average age of 63 ± 20.11 years). All patients completed at least 1 month of follow-up. Patients had a diagnosis of infectious keratitis, and the SL was fitted on initial consultation. Of the 12 eyes, 7 had culture-positive bacterial infection, 2 eyes were mycotic, and 3 eyes had no culture growth. In 3 eyes, SL was discontinued because of the lack of response (one eye) and to the presence of mycotic infection (2 eyes). All infections resolved favorably at the final follow-up.

Conclusions:

The use of SLs could be an alternative for antibiotic impregnation and treatment of infectious keratitis. No complications or side effects were observed related to the use of the scleral contact lens as a reservoir for the antibiotic. This treatment modality could offer a comfortable treatment for the patient, ensuring good impregnation and maintenance of antibiotic concentrations during the 24-hour wear periods.