bluuebunny/crossref_metadata_2025 huggingface dataset:
Under Pressure: The Utility of Spacers in Univalved Fiberglass Casts
Authors: Kleis Kevin , Schlechter John A. , Doan Joshua D. , Farnsworth Christine L. , Edmonds Eric W.
Published: February 2017

Background:

Univalving fiberglass casts after fracture manipulation or extremity surgery reduces the risk of developing compartment syndrome (CS). Previous experiments have demonstrated that univalving decreases intracompartmental pressures (ICPs), but increases the risk for loss of fracture reduction due to altering the mechanical properties of the cast. The purpose of this study was to correlate cast valve width within a univalved cast model to decreasing ICP.

Methods:

Saline bags (1 L) were covered with stockinette, Webril, and fiberglass tape then connected to an arterial pressure line monitor. Resting pressure was recorded. A water column was added to simulate 2 groups (n=5 each) of clinical CS: low pressure CS (LPCS range, 28 to 31 mm Hg) and high pressure CS (HPCS, range, 64 to 68 mm Hg). After the designated pressure was reached, the fiberglass was cut (stockinette and Webril remained intact). Cast spacers were inserted into each univalve and secured with varying widths: position #1 (3 mm wide), #2 (6 mm), #3 (9 mm), and #4 (12 mm). Pressure was recorded after cutting the fiberglass and following each spacer placement.

Results:

In LPCS and HPCS groups, after univalve and placement of spacer position #1, pressure dropped by a mean of 52% and 58%, respectively. Spacer #2, decreased the pressure by a mean of 78% and 80%, respectively. Both spacer sizes significantly decreased the underlying pressure in both groups. Spacer #3 and #4 progressively reduced pressure within the cast, but not statistically significantly more than the previous spacer widths.

Conclusions:

This experimental model replicates the iatrogenic elevation in interstitial compartment pressure due to rigid cast application, not necessarily a self-sustained true CS. Increasing the univalved cast spread by ≥9 mm of the initial cast diameter will reduce pressure to a pre-CS level; however, a spread of only 6 mm can effectively reduce the pressure to <30 mm Hg depending on the initial elevated ICP. Cutting the Webril and stockinette in our model yielded a pressure decrease of 91% and 94% from the starting experimental pressure in the LPCS and the HPCS groups, respectively.

Clinical Relevance:

Although the utility of splitting fiberglass casts has been previously demonstrated, we present evidence highlighting the benefit of spacing the split by at least 6 to 9 mm.
Gross Motor Skills in Children With Idiopathic Clubfoot and the Association Between Gross Motor Skills, Foot Involvement, Gait, and Foot Motion
Authors: Lööf Elin , Andriesse Hanneke , André Marie , Böhm Stephanie , Iversen Maura D. , Broström Eva W.
Published: February 2017

Background:

Little is known regarding gross motor skills (GMS) in children with idiopathic clubfoot (IC). This study describes GMS, specifically foot involvement and asymmetries, and analyses the association between GMS, gait, and foot status in children with IC.

Methods:

Gross motor tasks and gait were analyzed in children with IC and typically developed (TD) children. GMS were assessed using videotapes and the Clubfoot Assessment Protocol (CAP). The Gait Deviation Index (GDI) and GDI-Kinetic were calculated from gait analyses. Children were divided into bilateral, unilateral clubfoot, or TD groups. To analyze asymmetries, feet within each group were further classified into superior or inferior foot, depending on their CAP scores. Correlations identified associations between CAP and GDI, GDI-Kinetic, passive foot motion, and Dimeglio Classification Scores at birth in the clubfeet.

Results:

In total, 75 children (mean age, 5 years) were enrolled (bilateral n=22, unilateral clubfoot n=25, TD=28). Children with clubfeet demonstrated significantly lower GMS, gait, and foot motion compared with TD children. One leg standing and hopping deviated in 84% and 91%, respectively, in at least one foot in children with clubfoot. Gross motor asymmetries were evident in both children with bilateral and unilateral involvement. In children with unilateral clubfoot, contralateral feet showed few deviations in GMS compared with TD; however, differences existed in gait and foot motion. The association between GMS and gait, foot motion, and initial foot status varied between poor and moderate.

Conclusions:

Gross motor deficits and asymmetries are present in children with both bilateral and unilateral IC. Development of GMS of the contralateral foot mirrors that of TD children, but modifies to the clubfoot in gait and foot motion. The weak association with gait, foot motion, and initial clubfoot severity indicates that gross motor measurements represent a different outcome entity in clubfoot treatment. We therefore, recommend gross motor task evaluation for children with IC.

Level of Evidence:

Level II—prognostic studies.
Paraspinal Muscle Passive Stiffness Remodels in Direct Response to Spine Stiffness
Authors: Gsell Kelsey Y. , Zwambag Derek P. , Fournier Dale E. , Séguin Cheryle A. , Brown Stephen H.M.
Published: February 2017

Study Design.

Basic science study of the relationship between the structural properties of the spine and its surrounding musculature.

Objective.

To determine whether an increase in spine stiffness causes an inverse compensatory change in the passive stiffness of the adjacent paraspinal muscles.

Summary of Background Data.

Intervertebral disc degeneration causes an increase in multifidus passive stiffness; this was hypothesized to compensate for a decrease in spine stiffness associated with disc degeneration. Mice lacking equilibrative nucleoside transporter 1 (ENT1) develop progressive ectopic calcification of the fibrous connective tissues of the spine, which affects the lumbar spine by 6 months of age and likely creates a mechanically stiffer spine.

Methods.

Experiments were conducted on four groups of mice (n = 8 mice/group): wild-type (WT) and ENT1 knockout (KO) at 2 or 8 months of age. Lumbar spines were removed and tested in cyclic axial compression to determine neutral zone length and stiffness. Single muscle fibers and bundles of fibers were isolated from lumbar multifidus and erector spinae, as well as tibialis anterior (a non–spine-related control) and tested to determine elastic modulus (passive stiffness).

Results.

At 2 months of age, neither spine nor muscle stiffness was different between KO and WT. At 8 months of age, compared with WT the lumbar spines of ENT1 KO mice had a stiffer and shorter neutral zone, and the paraspinal muscle fibers were less stiff; however, fiber bundles were not different. In addition, tibialis anterior was not different between KO and WT.

Conclusion.

This work has confirmed that calcification of spinal connective tissues in the ENT1 KO mouse results in a stiffened spine, whereas the concurrent decrease in muscle fiber elastic modulus in the adjacent paraspinal muscles suggests a direct compensatory relationship between the stiffness of the spine and the muscles that are attached to it.

Level of Evidence: N/A
Liberal Versus Restrictive Transfusion Strategy in Critically Ill Oncologic Patients: The Transfusion Requirements in Critically Ill Oncologic Patients Randomized Controlled Trial*
Authors: Bergamin Fabricio S. , Almeida Juliano P. , Landoni Giovanni , Galas Filomena R. B. G. , Fukushima Julia T. , Fominskiy Evgeny , Park Clarice H. L. , Osawa Eduardo A. , Diz Maria P. E. , Oliveira Gisele Q. , Franco Rafael A. , Nakamura Rosana E. , Almeida Elisangela M. , Abdala Edson , Freire Maristela P. , Filho Roberto K. , Auler Jose Otavio C. , Hajjar Ludhmila A.
Published: February 2017

Objective:

To assess whether a restrictive strategy of RBC transfusion reduces 28-day mortality when compared with a liberal strategy in cancer patients with septic shock.

Design:

Single center, randomized, double-blind controlled trial.

Setting:

Teaching hospital.

Patients:

Adult cancer patients with septic shock in the first 6 hours of ICU admission.

Interventions:

Patients were randomized to the liberal (hemoglobin threshold, < 9 g/dL) or to the restrictive strategy (hemoglobin threshold, < 7 g/dL) of RBC transfusion during ICU stay.

Measurements and Main Results:

Patients were randomized to the liberal (n = 149) or to the restrictive transfusion strategy (n = 151) group. Patients in the liberal group received more RBC units than patients in the restrictive group (1 [0–3] vs 0 [0–2] unit; p < 0.001). At 28 days after randomization, mortality rate in the liberal group (primary endpoint of the study) was 45% (67 patients) versus 56% (84 patients) in the restrictive group (hazard ratio, 0.74; 95% CI, 0.53–1.04; p = 0.08) with no differences in ICU and hospital length of stay. At 90 days after randomization, mortality rate in the liberal group was lower (59% vs 70%) than in the restrictive group (hazard ratio, 0.72; 95% CI, 0.53–0.97; p = 0.03).

Conclusions:

We observed a survival trend favoring a liberal transfusion strategy in patients with septic shock when compared with the restrictive strategy. These results went in the opposite direction of the a priori hypothesis and of other trials in the field and need to be confirmed.
Randomized Clinical Trial of a Combination of an Inhaled Corticosteroid and Beta Agonist in Patients at Risk of Developing the Acute Respiratory Distress Syndrome*
Authors: Festic Emir , Carr Gordon E. , Cartin-Ceba Rodrigo , Hinds Richard F. , Banner-Goodspeed Valerie , Bansal Vikas , Asuni Adijat T. , Talmor Daniel , Rajagopalan Govindarajan , Frank Ryan D. , Gajic Ognjen , Matthay Michael A. , Levitt Joseph E.
Published: February 2017

Objectives:

Effective pharmacologic treatments directly targeting lung injury in patients with the acute respiratory distress syndrome are lacking. Early treatment with inhaled corticosteroids and beta agonists may reduce progression to acute respiratory distress syndrome by reducing lung inflammation and enhancing alveolar fluid clearance.

Design:

Double-blind, randomized clinical trial (ClinicalTrials.gov: NCT01783821). The primary outcome was longitudinal change in oxygen saturation divided by the Fio
2 (S/F) through day 5. We also analyzed categorical change in S/F by greater than 20%. Other outcomes included need for mechanical ventilation and development of acute respiratory distress syndrome.

Setting:

Five academic centers in the United States.

Patients:

Adult patients admitted through the emergency department at risk for acute respiratory distress syndrome.

Interventions:

Aerosolized budesonide/formoterol versus placebo bid for up to 5 days.

Measurements and Main Results:

Sixty-one patients were enrolled from September 3, 2013, to June 9, 2015. Median time from presentation to first study drug was less than 9 hours. More patients in the control group had shock at enrollment (14 vs 3 patients). The longitudinal increase in S/F was greater in the treatment group (p = 0.02) and independent of shock (p = 0.04). Categorical change in S/F improved (p = 0.01) but not after adjustment for shock (p = 0.15). More patients in the placebo group developed acute respiratory distress syndrome (7 vs 0) and required mechanical ventilation (53% vs 21%).

Conclusions:

Early treatment with inhaled budesonide/formoterol in patients at risk for acute respiratory distress syndrome is feasible and improved oxygenation as assessed by S/F. These results support further study to test the efficacy of inhaled corticosteroids and beta agonists for prevention of acute respiratory distress syndrome.
Sepsis Patients Display a Reduced Capacity to Activate Nuclear Factor-κB in Multiple Cell Types*
Authors: Hoogendijk Arie J. , Garcia-Laorden M. Isabel , van Vught Lonneke A. , Wiewel Maryse A. , Belkasim-Bohoudi Hakima , Duitman JanWillem , Horn Janneke , Schultz Marcus J. , Scicluna Brendon P. , van ‘t Veer Cornelis , de Vos Alex F. , van der Poll Tom
Published: February 2017

Objectives:

Sepsis is a complex clinical condition associated with high morbidity and mortality. A distinctive feature of sepsis is the reduced capacity of leukocytes to release proinflammatory cytokines in response to ex vivo stimulation. Cellular signaling events leading to immunosuppression in sepsis are not well defined. We investigated cell-specific signaling events underlying the immunosuppressed phenotype in sepsis.

Design:

Ex vivo study.

Setting:

ICU of an academic hospital.

Patients:

Nineteen patients with sepsis and 19 age-matched healthy controls.

Interventions:

None.

Measurements and Main Results:

The phosphorylation state of p38 mitogen activated protein kinase and nuclear factor kappa-light-chain-enhancer of activated B cells were determined in ex vivo stimulated CD4 T cells, CD8 T cells, B cells, monocytes, and neutrophils. Messenger RNA expression levels of p38 mitogen activated protein kinase and nuclear factor kappa-light-chain-enhancer of activated B cells and negative regulators tumor necrosis factor-α–induced protein 3 (A20) and mitogen activated protein kinase phosphatase-1 were determined in neutrophils and peripheral blood mononuclear cells. Upon ex vivo stimulation, monocytes of sepsis patients were less capable in phosphorylating nuclear factor kappa-light-chain-enhancer of activated B cells. Sepsis was also associated with reduced phosphorylation of nuclear factor kappa-light-chain-enhancer of activated B cells in stimulated B cells, CD4 and CD8 T cells. Messenger RNA expression levels of nuclear factor kappa-light-chain-enhancer of activated B cells and A20 were diminished in peripheral blood mononuclear cells of sepsis patients, whereas p38 mitogen activated protein kinase messenger RNA was up-regulated. In neutrophils of sepsis patients, mitogen activated protein kinase phosphatase-1 messenger RNA levels were down-regulated.

Conclusions:

Sepsis-induced immunosuppression associates with a defect in the capacity to phosphorylate nuclear factor kappa-light-chain-enhancer of activated B cells in lymphoid cells and monocytes.
Use of Electronic Health Records by Nurses for Symptom Management in Inpatient Settings
Authors: Ozkaynak Mustafa , Reeder Blaine , Hoffecker Lilian , Makic Mary Beth , Sousa Karen
Published: February 2017

Symptom management is one of the essential functions of nurses in inpatient settings; yet, little is understood about the manner in which nurses use electronic health records for symptom documentation. Therefore, the purpose of this systematic review is to characterize nurses’ use of electronic health records for documentation of symptom assessment and management in inpatient settings, to inform design studies that better support electronic health records for patient symptom management by nurses. We searched the Ovid Medline (1946-current), Cumulative Index to Nursing and Allied Health Literature (EBSCO, 1981-current), and Excerpta Medica Database (Embase.com, 1974-current) databases from inception through May 2015 using multiple subject headings and “free text” key words, representing the concepts of electronic medical records, symptom documentation, and inpatient setting. One thousand nine hundred eighty-two articles were returned from the search. Eighteen publications from the years 2003 to 2014 were included after abstract and full text review. Studies heavily focused on a pain as symptom. Nurses face challenges when using electronic health records that can threaten quality and safety of care. Clinical, design, and administrative recommendations were identified to overcome the challenges of nurses’ electronic health record use. A call for interdisciplinary, comprehensive, systematic interventions and user-centered design of information systems is needed.
Nurses' Error Management in Critical Care Units
Authors: Nasrabadi Alireza Nikbakht , Peyrovi Hamid , Valiee Sina
Published: February 2017

Nursing errors are common in critical care units, and nurses are in the first line of confrontation. The purpose of this study was to explore the processes of managing nursing errors in critical care units in Iran and to develop a theoretical explanation of the phenomenon. This was a grounded theory study. We recruited a sample of 18 critical care nurses for the study. The sampling method was purposive and then changed to theoretical. The data were collected through in-depth interviews. For data analysis, we employed the constant comparative analysis technique. The core category of the study was “continuous situational analysis.” The main categories were situational analysis and error removal. When nurses confronted an error, they opted for analyzing the error situation in terms of the nature of error, probable consequences, monitoring, and life threat. Accordingly, they employed error removal strategies such as self-action, cooperation, notifying, and censoring. These steps happened concurrently, successively, or cyclically. To manage their committed errors, nurses usually go through an informal process. Nurse-managers need to design effective error management strategies and require the practicing nurses to adhere to them. A practical model for effective prevention and management of nursing errors in critical care units is necessary.
Preparing the Family and Children for Surgery
Authors: Yahya AL-Sagarat Ahmad , Al-Oran Haytham Mohammad , Obeidat Hala , Hamlan Adlah Mohammad , Moxham Lorna
Published: February 2017

The focus of this literature analysis is the concept of preparing the family and children for surgery. As posited in the literature, surgery causes stress and anxiety that have a negative impact on both parents and their children. Therefore, the need for health care professionals to facilitate positive preparation for surgery to minimize anxiety and enhance postoperative recovery is important. Preparing the family and children for surgery is discussed in depth under the following themes: Preoperative Anxiety in Children, the Impact of Preoperative Anxiety on the Pediatric Patients and Parents, Preoperative Psychological Preparation for Children and Parents, and the Role of Nurse Practitioners in Preoperative Preparation. Through reviewing the literature, it would appear that some areas of preparation for parents are not as sufficient as they could be, particularly with regard to adequate preoperative education programs. The majority of studies reported that therapeutic play and clown interventions used for psychological preparation of parents and their children have been effective in minimizing and decreasing anxiety levels.
Clinical Simulation Learning in Critical Care
Authors: Hudgins Kerstin
Published: February 2017

Nurses are expected to master many skills, especially in critical care; thus, competency is crucial. Clinical educators must determine whether nurses who are new to the skill set have attained an acceptable level of achievement in performance; hence, are they capable of providing quality and safe patient care? Simulation learning is used in the hospital setting and largely in academic centers. Strategies include for the instructor to acquire an aspect of abilities and deficits as a basis upon which to create learning experiences that enable nurses to develop essential clinical competence.
Implementing iRound
Authors: Brady Darcie
Published: February 2017

Many hospitals use rounding or auditing as a tool to help identify gaps and needs in quality and process performance. Some hospitals are also using rounding to help improve patient experience. It is known that purposeful rounding helps improve Hospital Consumer Assessment of Healthcare Providers and Systems scores by helping manage patient expectations, provide service recovery, and recognize quality caregivers. Rounding works when a standard method is used across the facility, where data are comparable and trustworthy. This facility had a pen-and-paper process in place that made data reporting difficult, created a silo culture between departments, and most audits and rounds were completed differently on each unit. It was recognized that this facility needed to standardize the rounding and auditing process. The tool created by the Advisory Board called iRound was chosen as the tool this facility would use for patient experience rounds as well as process and quality rounding. The success of the iRound tool in this facility depended on several factors that started many months before implementation to current everyday usage.
Improving Nurse Satisfaction With Open Visitation in an Adult Intensive Care Unit
Authors: Kozub Elizabeth , Scheler Stephanie , Necoechea Gloria , O'Byrne Noeleen
Published: February 2017

The focus on patient- and family-centered care (PFCC) has become increasingly prevalent throughout health care. In the intensive care unit (ICU), family involvement becomes critical, as patients are often unable to fully engage in their care. After expanding family visitation to 24 hours, nurses in a surgical ICU perceived that they did not have the ability to tailor the visitation to meet the patient's condition and there was an opportunity to improve nurse satisfaction related to PFCC. The objective of this performance improvement project was to increase nurse satisfaction related to PFCC and create consistency across clinicians for visitation practices. The Unit Practice Council developed staff guidelines for family visitation that included scripting prompts the nurse could use when communicating with families. The adoption of staff guidelines for family visitation was helpful in creating a culture change toward PFCC. Nurses' overall mean stress level with PFCC decreased, and their perception of having difficulty in reducing patients' or families' anxieties also decreased. The development of guidelines for family visitation can be easily implemented across other critical care environments. Scripting prompts along with the visitation guidelines can serve as a useful strategy to build nurses' skills in communicating with families.
Simple Strategies for Surviving the Night Shift
Authors: Crooks Laura
Published: February 2017

Without a doubt, working nights is stressful and can wreak havoc on your physical, mental, and emotional health. It is like fitting a square peg into a round hole; you are living on a schedule opposite from most of the world. Your internal rhythms are disrupted socially and biologically when you work nights. But it does not have to be as disruptive as we let it be. There are lifestyle strategies to better manage working nights; some are mental approaches and some are physical or behavioral tactics.
Central Venous Access
Authors: Herring Matthew
Published: February 2017

Hospital-acquired conditions are conditions that never should happen to a patient while in the care of physicians, nurses, and the health care facility. Central line-associated bloodstream infections plague the nation's health care facilities. With increasing rates of infections being reported during hospitalization, hospital-acquired conditions, namely, infections, and more specifically central line-associated bloodstream infections, are now at the top of patient safety concerns and impact organization's reimbursement. Increased surveillance of infections by regulatory agencies and the implementation of value-based purchasing have hospitals racing to put into place strategic plans to reduce and eliminate infections that occur while the patient is hospitalized. There are many ways to reduce and eliminate these infections from the nation's health care facilities. The development and implementation of a specialty vascular access team to insert, maintain, and care for central lines are strategies that can be a power tool for all health care facilities.
Factors Influencing Weaning Older Adults From Mechanical Ventilation
Authors: Stieff Karen V. , Lim Fidelindo , Chen Leon
Published: February 2017

This study aim was to describe the influences that affect weaning from mechanical ventilation among older adults in the intensive care unit (ICU). Adults older than 65 years comprised only 14.5% of the US population in 2014; however, they accounted up to 45% of all ICU admissions. As this population grows, the number of ICU admissions is expected to increase. One of the most common procedures for hospitalized adults 75 years and older is mechanical ventilation. An integrative review methodology was applied to analyze and synthesize primary research reports. A search for the articles was performed using the PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases; using the keywords and Boolean operators “older adults,” “weaning,” “mechanical ventilation,” and intensive care unit. Although physiologic changes that occur with aging place older adults at higher risk for respiratory complications and mortality, there are many factors, other than chronological age, that can determine a patient's ability to be successfully weaned from mechanical ventilation. Of the 6 studies reviewed, all identified various predictors of weaning outcome, which included maximal inspiratory pressure, rapid shallow breathing index, fluid balance, comorbidity burden, severity of illness, emphysematous changes, and low serum albumin. Age, in and of itself, is not a predictor of weaning from mechanical ventilation. More studies are needed to describe the influences affecting weaning older adults from mechanical ventilation.
Family Socioeconomic Status Moderates Associations Between Television Viewing and School Readiness Skills
Authors: Ribner Andrew , Fitzpatrick Caroline , Blair Clancy
Published: February 2017

Objective:

We examined whether the negative relation between television viewing that exceeds the recommendations of the American Academy of Pediatrics (AAP) and school readiness varied by family income.

Methods:

Data were collected from 807 children from diverse backgrounds. Parents reported hours of television viewing, as well as family income. Children were assessed using measures of math, knowledge of letters and words, and executive function (EF).

Results:

Television viewing was negatively associated with math and EF but not with letter and word knowledge. An interaction between television viewing and family income indicated that the effect of television viewing in excess of the AAP recommended maximum had negative associations with math and EF that increased as a linear function of family income. Furthermore, EF partially mediated the relation between television viewing and math.

Conclusion:

Television viewing is negatively associated with children's school readiness skills, and this association increased as family income decreased. Active efforts to reinforce AAP guidelines to limit the amount of television children watch should be made, especially for children from middle- to lower-income families.
Access to Developmental Pediatrics Evaluations for At-Risk Children
Authors: Jimenez Manuel E. , Martinez Alcaraz Emmanuel , Williams Jerome , Strom Brian L.
Published: February 2017

Objective:

To determine a national average wait time for developmental pediatric evaluations and to understand differences in access based on whether an appointment is requested by an English or Spanish-speaking caller.

Methods:

We conducted a mystery shopper study in which a bilingual research assistant called developmental pediatrics programs affiliated with US children's hospitals listed on a public directory requesting an appointment for his simulated child experiencing a developmental problem. If an appointment was not provided, a wait time estimate was requested. Programs that provided an estimate in English were called within 24 hours using a translated script. We excluded programs that did not include a developmental pediatrician, only accepted referrals from within their health system or plan, focused on specific disorders, or did not conduct initial evaluations.

Results:

Of 244 hospitals listed, 140 unique programs were identified and called in English. One hundred four programs were reached. Ninety programs met inclusion criteria, 75 provided an estimated wait time. The mean estimate was 5.4 months (standard deviation: 4.5). Among these 75 programs, 62 were reached in Spanish but only 55% provided a wait time estimate; 31% did not provide language accommodations. The difference between average estimates obtained in English and Spanish was not statistically significant.

Conclusion:

Among a national sample of US children's hospitals, we identified barriers to evaluations conducted by developmental pediatricians including long wait times and inadequate Spanish language accommodations at some programs. More work is needed to identify optimal strategies to connect children with developmental concerns to evaluations when necessary.
Association Between Night Waking and Child Health During the First 3 Years of Life
Authors: Hsu Hui-Chin
Published: February 2017

Objective:

Night awakening is a common concern for parents and professionals in early childhood and a risk factor for child growth and development. This study examined the concurrent and longitudinal associations of night awakening with child health and illness during the first 3 years of life.

Methods:

Longitudinal data from 1364 infants in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development were used in this study. At ages 6, 15, 24, and 36 months, mothers reported on the frequency of their child's night awakening in the past week, overall health, and occurrences of illness. Information on demographic factors, including child sex and ethnicity/race, maternal education, and family income as well as child breastfeeding status was obtained at 1 month. Structural equation modeling, including latent growth curve modeling, was performed.

Results:

Age-related changes in weekly frequency of night awakening and overall child health were characterized by curvilinear patterns between 6 and 36 months. Although more frequent night awakenings were associated with poorer health at 6 months, a faster decline in night awakenings was associated with a slowed health decline over time. Furthermore, more frequent night awakenings were concurrently associated with more occurrences of illness at ages 6, 15, and 24 months. The association between night awakening and illness dissipated by 36 months.

Conclusion:

Night awakening is concurrently and longitudinally associated with poorer health and more illnesses in early childhood.
Reconstruction of Through-and-through Oromandibular Defect: Comparison of Four Different Techniques
Authors: Wu John Chung-Han , Lee Yi-Chieh , Cheng Yu-Chun , Wu Chih-Wei
Published: February 2017

Background:

Through-and-through oromandibular defects originate from surgical intervention of tumors of the oral cavity involving external skin, soft tissue, bone, and oral lining. Reconstruction of such composite defects is primarily achieved by 4 methods using distinct flaps in Chang Gung Memorial Hospital, including a single anterolateral thigh (ALT) flap, a single fibula flap, an osteomyocutaneous peroneal artery-based combined flap, and a combination of a fibular flap and an ALT flap, also known as a double flap.

Methods:

In this retrospective study, 41 patients with through-and-through oromandibular defects reconstructed in Chang Gung Memorial Hospital Linkou branch from July 2007 to June 2009 using either of the 4 flaps were evaluated. Patients were divided into 4 groups according to the choice of flap, and their surgical outcomes, immediate and late complications, and their general condition were studied. Group 1 included 12 patients reconstructed with a single ALT flap, whereas group 2 included 15 patients using fibular flaps. Group 3 included 8 patients with osteomyocutaneous peroneal artery-based combined flaps, and group 4 included 6 patients who underwent reconstruction with double flaps.

Results:

Among all statistical results, we found that none of the differences regarding either patient demography or surgical outcomes between groups were statistically significant, except for squamous cell carcinoma staging.

Conclusions:

Although the results were insignificant, trends within the data could be seen that support previous notions regarding each reconstruction method. For future studies, we strongly recommend a larger sample size.
Ultrasound and Histologic Examination after Subcutaneous Injection of Two Volumizing Hyaluronic Acid Fillers: A Preliminary Study
Authors: Micheels Patrick , Besse Stéphanie , Sarazin Didier , Quinodoz Pierre , Elias Badwi , Safa Marva , Vandeputte Joan
Published: February 2017

Background:

This study examined the influence of hyaluronic acid (HA) crosslinking technology on the ultrasound and histologic behavior of HA fillers designed for subcutaneous injection.

Methods:

One subject received subcutaneous injections of 0.25 ml Cohesive Polydensified Matrix (CPM) and Vycross volumizing HA in tissue scheduled for abdominoplasty by bolus and retrograde fanning techniques. Ultrasound analyses were performed on days 0 and 8 and histologic analyses on days 0 and 21 after injection. A series of simple rheologic tests was also performed.

Results:

Day 0 ultrasound images after bolus injection showed CPM and Vycross as hypoechogenic papules in the hypodermis. CPM appeared little changed after gentle massage, whereas Vycross appeared more hyperechogenic and diminished in size. Ultrasound images at day 8 were similar. On day 0, both gels appeared less hypoechogenic after retrograde fanning than after bolus injection. Vycross was interspersed with hyperechogenic areas (fibrous septa from the fat network structure) and unlike CPM became almost completely invisible after gentle massage. On day 8, CPM appeared as a hypoechogenic pool and Vycross as a long, thin rod. Day 0 histologic findings confirmed ultrasound results. Day 21 CPM histologic findings showed a discrete inflammatory reaction along the injection row after retrograde fanning. Vycross had a more pronounced inflammatory reaction, particularly after retrograde fanning, with macrophages and giant cells surrounding the implant. Rheologic tests showed CPM to have greater cohesivity and resistance to traction forces than Vycross.

Conclusions:

CPM HA volumizer appears to maintain greater tissue integrity than Vycross after subcutaneous injection with less inflammatory activity.
A Troubled Asset Relief Program for the Patient-Centered Medical Home
Authors: Wasson John
Published: February 2017

The patient-centered medical home (PCMH) costs a lot to build and maintain. Deficiencies have become apparent: it has provided few of its advertised benefits and is becoming a troubled asset. A troubled asset relief program for the PCHM is needed (PCMH-TARP). This report presents a PCMH-TARP that places patients' interests first. The PCMH-TARP addresses regulatory barriers and greatly simplifies the complexity of the PCMH blueprint. A disruptively renovated PCMH will stand on a foundation of measures that matter to patients.
Physician Payment Methods and the Patient-Centered Medical Home
Authors: Quinn Kevin
Published: February 2017

This commentary analyzes the patient-centered medical home (PCMH) model within a framework of the 8 basic payment methods in health care. PCMHs are firmly within the fee-for-service tradition. Changes to the process and structure of the Resource Based Relative Value Scale, which underlies almost all physician fee schedules, could make PCMHs more financially viable. Of the alternative payment methods being considered, shared savings models are unlikely to transform medical practice whereas capitation models place unrealistic expectations on providers to accept epidemiological risk. Episode payment may strike a feasible balance for PCMHs, with newly available episode definitions presenting opportunities not previously available.
Association Between Cardiovascular Risk and Depressive Symptoms Among People With Serious Mental Illness
Authors: Naslund John A. , Aschbrenner Kelly A. , Pratt Sarah I. , Lohman Matthew C. , Scherer Emily A. , McHugo Gregory J. , Marsch Lisa A. , Unützer Jürgen , Bartels Stephen J.
Published: February 2017

Depressive symptoms have debilitating effects on the physical health and functioning of people with serious mental illness. We examined change in depressive symptoms among overweight and obese adults with serious mental illness (n = 343) using data combined from two randomized trials comparing the 12-month In SHAPE program to a gym membership control condition. In SHAPE consists of a gym membership, weekly individual meetings with a fitness trainer, and instruction on healthy eating and nutrition. Depressive symptoms were measured at baseline, 3, 6, and 12 months. Change in depressive symptoms did not differ between groups, but depressive symptoms decreased over time across the entire sample (p = 0.045). At 12 months, reduced depressive symptoms were associated with clinically significant improved cardiorespiratory fitness (p = 0.030), 10% or more weight loss (p = 0.044), and cardiovascular risk reduction (p = 0.028) across both groups. Our findings suggest that participation in health promotion programs resulting in cardiovascular risk reduction may be associated with reduced depressive symptoms.
Clinicopathologic Features of the Non-CNS Primary Ewing Sarcoma Family of Tumors in the Head and Neck Region
Authors: Woo Chang Gok , Lee Bora , Song Joon Seon , Cho Kyung-Ja
Published: March 2017

Ewing sarcoma family of tumor (ESFT) is a group of malignant neoplasms that affect children and young adults. Primary ESFT does not commonly arise from the head and neck region. This study aimed to elucidate the clinicopathologic characteristics of ESFT of the head and neck region except for central nervous system primitive neuroectodermal tumors. Among the 207 cases of ESFT of the bone and soft tissue, diagnosed at Asan Medical Center during a 20-year period, 25 (12.1%) involved the head and neck region. Of those, 21 were available for histologic, immunohistochemical, and molecular studies. EWSR1 rearrangement was detected in 19 cases by reverse transcriptase-polymerase chain reaction and/or fluorescence in situ hybridization. Primary sites included the cranial area (6 cases, 31.6%), sinonasal tract (6 cases, 31.6%), paraspinal space (4 cases, 21.0%), and other spaces (3 cases, 15.8%). The 5-year overall survival and disease-free survival rates for all cases were 69.7% and 33.6%, respectively. A large tumor size (>5 cm) correlated significantly with overall survival (P=0.009), but not with disease-free survival (P=0.210). Microscopically, 8 cases (42.1%) showed nested growth pattern. Clear and/or eosinophilic cytoplasm was observed in 68.4% cases. Immunopositivity for CD99, Friend leukaemia integration-1 (FLI-1), CD57, and caveloin-1 were detected in 100%, 88.9%, 83.3%, and 50% cases, respectively. ESFT in the head and neck region had a favorable prognosis and frequent atypical and epithelioid features. An awareness of these histologic and immunophenotypic characteristics will improve the diagnostic accuracy for head and neck round cell malignancies.
Distribution of RANK and RANK Ligand in Normal Human Tissues as Determined by an Optimized Immunohistochemical Method
Authors: Taylor Clive R. , Branstetter Daniel , Manna Edward , Dougall William C. , Bussiere Jeanine , Johnson Carol W.
Published: March 2017

The expression and tissue distribution of RANK (Receptor Activator of Nuclear Factor κ B) and RANK Ligand (RANKL) are of critical interest in relation to efficacy and safety of antibodies against RANK or RANKL that are approved or under consideration as potential therapeutic agents. Data from the literature using protein or mRNA analyses of rodent and human tissues or immunohistochemical (IHC) studies with a variety of antibodies and methods have provided some background of the distribution of RANK and RANKL but have yielded inconsistent findings. The present study reports the generation of carefully validated antibodies to RANK and RANKL and the development of an optimized IHC method, with confirmatory data from 2 well-validated alternative protocols that were developed and performed in separate laboratories at USC and at Amgen. Tissue expression of RANK and RANKL is reported for the optimized IHC assay.
Does the Effect of Inferior Turbinate Outfracture Persist?
Authors: Lee Dong Chang , Jin Sang-Gyun , Kim Boo Young , Yoo Soonil , Han Sungwoo , Lee Yong Joo , Jung Young Hoon , Kim Jeongmin , Kim Soo Whan , Kim Sung Won
Published: February 2017

Background:

To resolve nasal obstruction in rhinoplasty, inferior turbinate outfracture is performed widely alone or combined with other procedures. There are conflicting reports on the effect of inferior turbinate outfracture. This study evaluated the persistence of morphologic changes after inferior turbinate outfracture.

Methods:

This retrospective study enrolled 55 patients who underwent inferior turbinate outfracture without septal surgery to approach the sphenoid sinus for brain tumor removal. Coronal paranasal sinus computed tomographic images obtained preoperatively and 6 months postoperatively were compared. The authors measured the shortest distance from the median line to the medial border of the conchal bone and the shortest distance from the medial border of the conchal bone to the lateral nasal line. The authors also gauged the projection angle of the conchal bone and constitutional thickness of the inferior turbinate.

Results:

After inferior turbinate outfracture, the shortest distance from the median line to the medial border of the conchal bone increased, and shortest distance from the medial border of the conchal bone to the lateral nasal line decreased. The projection angle decreased significantly by 6 months postoperatively. After outfracture, the thickness of the medial mucosa had increased significantly, wheras the thickness of the conchal bone had decreased significantly (p < 0.05).

Conclusions:

The effect of inferior turbinate outfracture is preserved for at least 6 months. Moreover, compensatory hypertrophy of the medial mucosa develops in the inferior turbinate after outfracture. Therefore, outfracture with medial submucosal volume reduction would be recommended as the best procedure for treating inferior turbinate hypertrophy.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Blood Congestion Can Be Rescued by Hemodilution in a Random-Pattern Skin Flap
Authors: Kanayama Koji , Mineda Kazuhide , Mashiko Takanobu , Wu Szu-Hsien , Feng Jingwei , Kinoshita Kahori , Sunaga Ataru , Yoshimura Kotaro
Published: February 2017

Background:

There is no standard method to ensure survival of random-pattern skin flaps. The authors developed a rat anemia model to observe survival of random-pattern skin flaps after blood transfusion and hemodilution.

Methods:

Anemia was induced by withdrawal of 35 percent blood volume followed by compensation with the same amount of blood (blood transfusion model) or plasma equivalent (normovolemic hemodilution). Control rats were subjected to a sham procedure. Subsequently, a random-pattern skin flap (1.5 × 6 cm) was elevated on the back of each rat. Physiologic assessments of flap vascularity/viability were performed using laser Doppler spectrophotometry before and after flap elevation.

Results:

The normovolemic hemodilution group showed anemia (hemoglobin, 9.5 ± 0.8 g/dl) but less flow occlusion and greater flap survival (72.8 ± 8.6 percent) compared with control (57.4 ± 9.6 percent; p < 0.01) and blood transfusion (62.1 ± 6.5 percent; p < 0.089) groups. In control and blood transfusion groups but not the normovolemic hemodilution group, blood flow was decreased and relative quantity of hemoglobin was increased toward the flap tip, indicating congestion. In control and blood transfusion groups, blood flow and tissue oxygen saturation dropped after flap elevation, but recovered by day 7; congestion gradually improved by day 7.

Conclusions:

The authors determined that congestion promoted necrosis and hemodilution reduced microcirculatory occlusion and increased blood flow and oxygenation in skin flaps. It was suggested that perioperative hemodilution is superior to blood transfusion in any flap operations unless there is a critical systemic need for blood transfusion.
Emergency Department Wait Time and Treatment of Traumatic Digit Amputation: Do Race and Insurance Matter?
Authors: Mahmoudi Elham , Swiatek Peter R. , Chung Kevin C.
Published: February 2017

Background:

Little is known about the association between the quality of trauma care and management of nonfatal injuries. The authors used emergency department wait times as a proxy for hospital structure, process, and availability of on-call surgeons with microsurgical skills. They evaluated the association between average hospital emergency department wait times and likelihood of undergoing digit replantation for patients with traumatic amputation digit injuries. The authors hypothesized that hospitals with shorter emergency department wait times were associated with higher odds of replantation.

Methods:

Using the 2007 to 2012 National Trauma Data Bank, the authors’ final sample included 12,126 patients. Regression modeling was used to first determine factors that were associated with longer emergency department wait times among patients with digit amputation injuries. Second, the authors examined the association between emergency department wait times for this population at a hospital level and replantation after all types of digit amputation and after complicated thumb amputation injuries only.

Results:

For patients with simple and complicated thumb amputation injuries, and patients with complicated thumb amputation injuries only, longer emergency department wait times were associated with lower odds of replantation. In addition, being minority and having no insurance were associated with longer emergency department wait times; teaching hospitals were associated with shorter emergency department wait times; and finally, for patients with complicated thumb amputation injuries only, there was no association between patients’ minority or insurance status and replantation.

Conclusion:

Variation in emergency department wait time and its effects on treatment of traumatic digit amputation may reflect maldistribution of hand or plastic surgeons with the required microsurgical skills among trauma centers across the United States.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
The Effect of Patient Age on the Success Rate of Digital Replantation
Authors: Kwon Gi-Doo , Ahn Byung-Moon , Lee Jae-Sung , Park Yong-Gum , Chang Geun-Wu , Ha Yong-Chan
Published: February 2017

Background:

The purpose of this study was to evaluate outcomes and risk factors for failure after digital replantation in elderly patients, with a special focus on the effect of patient age on replantation success.

Methods:

Replantation patients older than 60 years were analyzed thoroughly to characterize outcomes and risk factors for failure in older patients. Survival rates of all age groups older than 20 years were then analyzed to determine the specific effect of patient age on replantation success. The clinical and functional outcomes and risk factors for failure were evaluated at a minimum 1-year follow-up.

Results:

Among 161 patients older than 60 years, 189 of 208 replanted digits survived completely (91 percent survival). The only factors predictive of failure were mechanism of injury and age. Excellent or good results (Chen criteria) were obtained in 58 percent of patients, and 94 percent of patients were completely or fairly satisfied. Analysis of all age groups older than 20 (1648 patients) demonstrated a significant increase in failure rate in those aged 70 years and older.

Conclusions:

The authors demonstrated a high rate of digit replantation success in elderly patients. However, 70 years and older was identified as an important factor predicting replantation failure.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, III.