bluuebunny/crossref_metadata_2025 huggingface dataset:
An Update on the Role of Immunohistochemistry in the Evaluation of Gastrointestinal Tract Disorders
Authors: Robertson Scott , Patil Deepa T.
Published: September 2018

As in other organ systems, immunohistochemistry (IHC) serves as an ancillary diagnostic tool for a wide variety of neoplastic and non-neoplastic disorders, including infections, work-up of inflammatory conditions, and subtyping neoplasms of the gastrointestinal (GI) tract. In addition, IHC is also used to detect a variety of prognostic and predictive molecular biomarkers for carcinomas of the GI tract. The purpose of this review is to highlight the use of IHC in common diagnostic scenarios throughout the tubular GI tract. The clinical indication and guidelines for performing IHC for detecting Helicobacter pylori is discussed along with role of gastrin and neuroendocrine markers in the diagnosis of autoimmune metaplastic atrophic gastritis. The major portion of this review discusses the use of IHC in the diagnostic workup of malignant neoplasms of the GI tract, such as adenocarcinoma versus squamous cell carcinoma, workup of poorly differentiated malignant neoplasms, and evaluation of uncommon gastric neoplasms (alpha-feto protein–producing carcinomas) and switch/sucrose-nonfermenting complex-deficient carcinomas. Lastly, localization of neuroendocrine tumors of unknown origin to aid clinical management, as well as HPV-driven anal neoplasia and IHC in the workup of basaloid anal neoplasms are also reviewed.
Cyclin D1-positive Mediastinal Large B-Cell Lymphoma With Copy Number Gains of CCND1 Gene
Authors: Chen Bo-Jung , Ruminy Philippe , Roth Christine G. , Bisig Bettina , Mankel Barbara , Steinhilber Julia , Bohers Elodie , Jardin Fabrice , Fend Falko , Swerdlow Steven H. , Copie-Bergman Christiane , de Leval Laurence , Quintanilla-Martinez Leticia
Published: September 2018

Primary mediastinal large B-cell lymphoma (PMBL) is a mature large B-cell lymphoma of putative thymic B-cell origin involving the mediastinum with younger age distribution and better prognosis than diffuse large B-cell lymphoma (DLBCL), not otherwise specified. Recently, based on gene expression profile analysis and morphologic findings, cases of PMBL without mediastinal involvement have been reported. In this study, we analyzed 3 cases of nodal DLBCL with morphologic features of PMBL presenting in submandibular or supraclavicular lymph nodes, in middle-aged to elderly patients, 2 of them without clinical or radiologic evidence of mediastinal involvement. The 3 patients presented with stage I/II disease and had excellent response to R-CHOP/R-EPOCH therapy. The 3 cases showed MAL expression and were positive for CD23 and/or CD30. All 3 cases expressed cyclin D1 with copy number gains of CCND1 gene but without rearrangement. There was no rearrangement of CIITA or PDL1/PDL2. Reverse transcriptase-multiplex ligation-dependent probe amplification, a mRNA-based gene expression profile analysis revealed high probability of PMBL (87.6%, 98.7%, and 99%) in these 3 cases. Targeted next-generation sequencing analysis showed SOCS1 mutations in the 3 cases, and TNFAIP3 and XPO1 mutations in one, further supporting the diagnosis of PMBL. In conclusion, we report 3 cases of nodal PMBL, 2 of them without mediastinal mass, and expression of cyclin D1 due to copy number gains of CCND1 gene, a diagnostic pitfall with mantle cell lymphoma and DLBCL, not otherwise specified.
SATB2 Is Superior to CDX2 in Distinguishing Signet Ring Cell Carcinoma of the Upper Gastrointestinal Tract and Lower Gastrointestinal Tract
Authors: Ma Changqing , Lowenthal Brett M. , Pai Reetesh K.
Published: September 2018

Signet ring cell carcinomas of the gastrointestinal (GI) tract are clinically aggressive neoplasms with frequent intra-abdominal metastases at initial presentation. Currently available immunohistochemistry (IHC) markers cannot distinguish signet ring cell carcinomas of the lower GI tract and upper GI tract, suggesting the need for more specific diagnostic markers. SATB2 is a novel, sensitive marker for colorectal carcinoma. We hypothesized that SATB2 IHC can reliably identify primary and metastatic signet ring cell carcinomas of lower GI tract origin. SATB2 and CDX2 IHC was performed on 159 primary (n=93) and metastatic (n=66) signet ring cell carcinomas of GI tract origin and 13 metastatic breast carcinomas with signet ring cell features. Positive SATB2 expression (SATB2+) was identified in 82% (27/33) of appendiceal, 88% (43/49) of colorectal, 13% (7/54) of gastric, and 35% (8/23) of esophageal/esophagogastric junction signet ring cell carcinomas. Primary and metastatic signet ring cell carcinomas of lower GI tract origin were more frequently SATB2+ than those from upper GI tract (70/82, 85% vs. 15/77, 19%, P<0.01). Compared with CDX2, SATB2+ and dual-positive staining for SATB2 and CDX2 both had higher specificities for signet ring cell carcinomas from the lower GI tract (81% vs. 49% and 86% vs. 49%, respectively, P<0.01 for both). Two (15%) metastatic breast carcinoma were SATB2+, but all 13 demonstrated negative CDX2 staining. In summary, our results show SATB2 is a relatively specific immunohistochemistry marker for both metastatic and primary signet ring cell carcinomas of lower GI tract origin.
Refined Criteria for Separating Low-grade Dysplasia and Nondysplastic Barrett Esophagus Reduce Equivocal Diagnoses and Improve Prediction of Patient Outcome
Authors: Waters Kevin M. , Salimian Kevan J. , Voltaggio Lysandra , Montgomery Elizabeth A.
Published: September 2018

The indefinite for dysplasia (IFD) category in Barrett esophagus (BE) is used for biopsies that are neither unequivocally dysplastic nor negative for dysplasia (NFD). In 2012, we refined our criteria so that BE with maintained cell polarity and surface gastric-type mucin vacuoles is considered NFD even with mild to moderate nuclear enlargement. A total of 1549 cases from 1130 patients with BE biopsies were identified from 2007 to 2016. Follow-up on patients with IFD biopsies was obtained to learn if the new thresholds better defined risk of progression. The earlier cases (2007-2011) were less likely than later cases (2012-2016) to be NFD (84.0% vs. 90.4%) and more likely to be IFD (8.4% vs. 4.3%). The proportions of low-grade dysplasia (3.9% vs. 2.5%, high-grade dysplasia (1.4% vs. 1.3%), and intramucosal carcinoma (2.3% vs. 1.6%) were similar between the earlier and later cases, respectively. Later IFD cases were more frequently dysplastic (3/21, 14.3%) on the next biopsy than earlier cases (1/48, 2.1%). The rate of dysplasia on the next biopsy for NFD cases was not higher in the later cases (6/222, 2.7%) than the earlier cases (16/360, 4.4%). Improved diagnostic criteria reduced the proportion of IFD cases by nearly 50% from 2007 to 2016. This change coincided with a higher proportion of IFD cases having dysplasia on the next biopsy. NFD patients had no increase in dysplasia on the next biopsy providing evidence that dysplastic cases are not missed by the refined criteria.
Incidence of Mismatch Repair Protein Deficiency and Associated Clinicopathologic Features in a Cohort of 104 Ovarian Endometrioid Carcinomas
Authors: Bennett Jennifer A. , Pesci Anna , Morales-Oyarvide Vicente , Da Silva Annacarolina , Nardi Valentina , Oliva Esther
Published: September 2018

Patients with Lynch syndrome have up to a 24% risk of developing ovarian carcinoma, but universal mismatch repair (MMR) protein testing of ovarian carcinomas is not standard practice in most institutions. We reviewed 104 unselected ovarian endometrioid carcinomas (OEC) for various clinicopathologic features to determine if any are predictive of MMR loss. Immunohistochemistry for all 4 MMR proteins was performed followed by MLH1 promoter methylation analysis when indicated. Overall, patients had a mean age of 55 years and tumors averaged 12 cm. Most (72%) patients had stage I tumors, 63% were grade 1, and 30% had a synchronous stage IA endometrial endometrioid carcinoma. Peritumoral lymphocytes and intratumoral stromal inflammation were rare, but tumor-infiltrating lymphocytes averaged 47/10 high-power fields. Endometriosis was noted in 71%, adenofibromatous background in 14%, and both in 14% of tumors. Metaplastic changes were common and included squamous metaplasia (63%), clear cell change (32%), mucinous differentiation (24%), and sex cord-like elements (13%). When follow-up was available (n=99), 78% of patients were alive and well, 12% died from disease, 6% died from other causes, and 4% were alive with disease. Unmethylated, MMR-deficient OECs were identified in 7% of the cohort and included MSH2/MSH6 (n=4), MSH6 (n=2), and PMS2 (n=1). All these tumors were stage I, 71% grade 1, and 57% had a synchronous endometrial endometrioid carcinoma. Among patients in this group with follow-up (n=5), all were alive without evidence of disease (mean 150 mo). Given that no clinicopathologic features were associated with MMR deficiency on univariate analysis, this study highlights the importance of universal MMR screening in OECs.
Implementation of a Risk-Stratified Opioid and Benzodiazepine Weaning Protocol in a Pediatric Cardiac ICU
Authors: Amirnovin Rambod , Sanchez-Pinto L. Nelson , Okuhara Carol , Lieu Phuong , Koh Joyce Y. , Rodgers John W. , Nelson Lara P.
Published: September 2018

Objectives:

Opioids and benzodiazepines are commonly used to provide analgesia and sedation for critically ill children with cardiac disease. These medications have been associated with adverse effects including delirium, dependence, withdrawal, bowel dysfunction, and potential neurodevelopmental abnormalities. Our objective was to implement a risk-stratified opioid and benzodiazepine weaning protocol to reduce the exposure to opioids and benzodiazepines in pediatric patients with cardiac disease.

Design:

A prospective pre- and postinterventional study.

Patients:

Critically ill patients less than or equal to 21 years old with acquired or congenital cardiac disease exposed to greater than or equal to 7 days of scheduled opioids ± scheduled benzodiazepines between January 2013 and February 2015.

Setting:

A 24-bed pediatric cardiac ICU and 21-bed cardiovascular acute ward of an urban stand-alone children’s hospital.

Intervention:

We implemented an evidence-based opioid and benzodiazepine weaning protocol using educational and quality improvement methodology.

Measurements and Main Results:

One-hundred nineteen critically ill children met the inclusion criteria (64 post intervention, 55 pre intervention). Demographics and risk factors did not differ between groups. Patients in the postintervention period had shorter duration of opioids (19.0 vs 30.0 d; p < 0.01) and duration of benzodiazepines (5.3 vs 22.7 d; p < 0.01). Despite the shorter duration of wean, there was a decrease in withdrawal occurrence (% Withdrawal Assessment Tool score ≥ 4, 4.9% vs 14.1%; p < 0.01). There was an 8-day reduction in hospital length of stay (34 vs 42 d; p < 0.01). There was a decrease in clonidine use (14% vs 32%; p = 0.02) and no change in dexmedetomidine exposure (59% vs 75%; p = 0.08) in the postintervention period.

Conclusions:

We implemented a risk-stratified opioid and benzodiazepine weaning protocol for critically ill cardiac children that resulted in reduction in opioid and benzodiazepine duration and dose exposure, a decrease in symptoms of withdrawal, and a reduction in hospital length of stay.
Ventilator-Associated Pneumonia and Events in Pediatric Intensive Care: A Single Center Study
Authors: Chomton Maryline , Brossier David , Sauthier Michaël , Vallières Emilie , Dubois Josée , Emeriaud Guillaume , Jouvet Philippe
Published: September 2018

Objectives:

Ventilator-associated pneumonia is the second most common nosocomial infection in pediatric intensive care. The Centers for Disease Control and Prevention recently issued diagnosis criteria for pediatric ventilator-associated pneumonia and for ventilator-associated events in adults. The objectives of this pediatric study were to determine the prevalence of ventilator-associated pneumonia using these new Centers for Disease Control and Prevention criteria, to describe the risk factors and management of ventilator-associated pneumonia, and to assess a simpler method to detect ventilator-associated pneumonia with ventilator-associated event in critically ill children.

Design:

Retrospective, observational, single-center.

Setting:

PICU in a tertiary-care university hospital.

Patients:

Consecutive critically ill children mechanically ventilated for greater than or equal to 48 hours between November 2013 and November 2015.

Interventions:

None.

Measurements and Main Results:

Of 304 patients mechanically ventilated for greater than or equal to 48 hours, 284 were included. Among them, 30 (10.6%) met clinical and radiologic Centers for Disease Control and Prevention criteria for ventilator-associated pneumonia, yielding an prevalence of 7/1,000 mechanical ventilation days. Median time from mechanical ventilation onset to ventilator-associated pneumonia diagnosis was 4 days. Semiquantitative culture of tracheal aspirates was the most common microbiological technique. Gram-negative bacteria were found in 60% of patients, with a predominance of Haemophilus influenzae and Pseudomonas aeruginosa. Antibiotic therapy complied with adult guidelines. Compared with patients without ventilator-associated pneumonia, those with ventilator-associated pneumonia had significantly longer median durations of mechanical ventilation (15 vs 6 d; p < 0.001) and PICU stay (19 vs 9 d; p < 0.001). By univariate analysis, risk factors for ventilator-associated pneumonia were younger age, reintubation, acute respiratory distress syndrome, and continuous enteral feeding. Among the 30 patients with ventilator-associated pneumonia, 17 met adult ventilator-associated event’s criteria (sensitivity, 56%).

Conclusions:

Ventilator-associated pneumonia is associated with longer times on mechanical ventilation and in the PICU. Using the ventilator-associated event criteria is of interest to rapidly screen for ventilator-associated pneumonia in children. However, sensitivity must be improved by adapting these criteria to children.
Implementation and Evaluation of Training for Ultrasound-Guided Vascular Access to Small Vessels Using a Low-Cost Cadaver Model
Authors: Wagner Michael , Hauser Kirstin , Cardona Francesco , Schmölzer Georg M. , Berger Angelika , Olischar Monika , Werther Tobias
Published: September 2018

Objectives:

Critically ill neonatal and pediatric patients often require central vascular access. Real-time ultrasound guidance for central venous catheterization is beneficial. Because the diameter of central veins is much smaller in neonates than in adults, extensive training is needed to master the visualization and catheterization of central veins in neonates. This study assessed the learning effect of a standardized simulation-based teaching program on ultrasound-guided cannulation in a low-cost cadaver tissue model.

Design:

This simulation-based prospective study assessed physician competence in the ultrasound-guided central venous catheterization procedure. Analyses were conducted before and after the teaching course.

Setting:

Pediatric simulation center at a tertiary care center.

Subjects:

Staff physicians from the Neonatal ICU and PICUs at the Medical University of Vienna.

Interventions:

Two latex tubes, with internal diameters of 2 and 4 mm, were inserted in parallel into cadaver tissue to mimic vessels and create a model for central venous catheterization.

Measurements and Main Results:

Under ultrasound guidance, each participant attempted to puncture and insert a guide-wire into each of the latex tubes using in-plane and out-of-plane techniques, both before and after the teaching course. The training program was assessed using a questionnaire and a performance checklist. Thirty-nine physicians participated in this study. The rates of failure of guide-wire insertion into 2-mm tubes were significantly lower after than before the teaching course, using both in-plane (p = 0.001) and out-of-plane (p = 0.004) techniques. Teaching, however, did not significantly reduce the insertion failure rate into 4-mm tubes, either in-plane (p = 0.148) or out-of-plane (p = 0.069). The numbers of successful cannulations on the first attempt increased after the teaching in all methods (p = 0.001).

Conclusions:

Implementation of a skills training program for ultrasound-guided central venous catheterization in a cadaver tissue model was feasible and cost- and time-effective. The number of attempts until successful cannulation of small vessels (2-mm tube) was significantly lower after than before the standardized teaching program.
Correlation of Bedside Pediatric Early Warning System Score to Interventions During Peritransport Period
Authors: Page-Goertz Christopher K. , Dasgupta Mahua , Hoffmann Raymond G. , Parshuram Christopher , Forbes Michael L. , Meyer Michael T.
Published: September 2018

Background:

The Bedside Pediatric Early Warning System score is a validated measure of severity of illness in acute care inpatient settings. Its potential as a remote assessment tool for interfacility transport has not been evaluated. We hypothesized that the Bedside Pediatric Early Warning System score was associated with need for intervention during the peritransport period and patient disposition.

Methods:

We retrospectively evaluated children transported by a regional pediatric team during a 6-month period. Bedside Pediatric Early Warning System scores were calculated at the triage phone call, the transport team arrival, and at transfer of care to the hospital team. The primary outcome was the receipt of significant intervention during the peritransport period, with additional outcomes of destination (ICU, ward, emergency department) in the regional hospital. Scores are presented as median values (interquartile range).

Results:

There were 564 children who underwent transport; 139 (25%) received interventions; and 205 (36%) were transferred to the PICU, 231 (41%) to the ward, and 127 (23%) to the emergency department. Scores were 2 (1–5; median interquartile range) in children receiving no in-transport interventions, 8 (5–11) in children receiving any intervention (p < 0.001), and 10 (7–14) in children receiving more than one intervention. Children transferred to the PICU had higher scores 6 (3–10), than children transferred to a ward 3 (1–6) or the emergency department 2 (1–3) (p < 0.001).

Conclusions:

The Bedside Pediatric Early Warning System score at the time of initial referral is a useful measure of severity of illness reflected by the subsequent provision of significant peritransport intervention and the transfer destination.
Unexpected Diagnosis in an Adolescent With Bruises and Ecchymosis
Authors: Er Anil , Çağlar Aykut , Kuyum Pinar , Akgül Fatma , Ulusoy Emel , Çitlenbik Hale , Aksoy Betül Yandim , Yilmaz Durgül , Arslan Nur , Duman Murat
Published: September 2018

Acquired coagulopathy is a rare but challenging diagnosis for pediatric emergency physicians. Although the coagulopathy usually presents with mild skin and mucosal hemorrhages, it also can lead to life-threatening events. Thus, accurate interpretation of hints obtained from a detailed history, physical examination, and laboratory findings is essential for the prompt diagnosis and management. This case demonstrates an uncommon cause of coagulopathy; celiac disease that presented with spontaneous bruises and ecchymosis in an adolescent.
Not All Stridor Is Croup
Authors: Gardner Alison , Ruch Alison
Published: September 2018

Background

Emergency providers often attribute stridor to croup in pediatric patients. However, even in children who are having other symptoms of a viral etiology, several other causes need to be considered.

Case

A 6-month-old term male without significant past medical history presented to the emergency department with stridor with likely underlying laryngospasm. He was initially ascribed the diagnosis of croup and was discharged home after receiving steroids and racemic epinephrine. However, he returned hours later after a seizure event at home. A thorough evaluation revealed an ionized calcium of 0.49 mmol/L, and further history revealed the patient was being fed a coconut water–based homemade solution for several months. He was subsequently found to have rickets and delay in milestone achievement. Awareness of hypocalcemia as a possible cause of laryngospasm is important because of the potential life-threatening effects of critically low calcium. Hypocalcemia should be included in the differential diagnosis of any child who presents with stridor, especially if lacking other symptoms of a viral illness.
PI3K Pathway Effectors pAKT and FOXO1 as Novel Markers of Endometrioid Intraepithelial Neoplasia
Authors: Strickland Amanda L. , Rivera Glorimar , Lucas Elena , John George , Cuevas Ileana , Castrillon Diego H.
Published: September 2018

The diagnosis of endometrioid intraepithelial neoplasia (EIN) is challenging owing to limited sampling, hormonal status, and other confounding histologic variables. Markers such as PTEN or PAX2 can delineate EIN in some cases, but are not wholly reliable. Clearly, new markers of EIN are needed. We explored several potential markers of EIN based rationally on molecular pathways most frequently misregulated in endometrial cancer: the 3-phosphoinositide kinase (PI3K)/AKT, β-catenin, and mismatch repair pathways. We studied PTEN, PAX2, β-catenin, and MLH1, in conjunction with 2 new markers—FOXO1 and phosphorylated AKT (pAKT)—not previously investigated in EIN. Benign (n=14) and EIN (n=35) endometria were analyzed by immunohistochemistry. Staining patterns were interpreted, tabulated, and scored by “clonal distinctiveness” in neoplastic lesions; that is, pattern alterations relative to normal glands. In normal endometria, FOXO1 was cytoplasmic in proliferative phase, but nuclear in secretory phase, showing that PI3K/FOXO1 participates in endometrial cycling and that FOXO1 is a readout of PI3K status. pAKT expression was low across normal endometria. FOXO1 or pAKT expression was altered in the majority of EINs (27/35, 77%), with FOXO1 and pAKT being co-altered only in some (20/35, 57%). β-catenin or MLH1 also exhibited clonal distinctiveness in EINs, showing that these are also useful markers in some cases. This is the first study to demonstrate the potential of pAKT and FOXO1 as biomarkers in the histopathologic evaluation of EIN. However, variability in expression poses challenges in interpretation.
Expanded In-School Instructional Time and the Advancement of Health Equity: A Community Guide Systematic Review
Authors: Peng Yinan , Finnie Ramona K. C. , Hahn Robert A. , Truman Benedict I. , Johnson Robert L. , Fielding Jonathan E. , Muntaner Carles , Fullilove Mindy T. , Zhang Xinzhi
Published: September 2018

Expanded in-school instructional time (EISIT) may reduce racial/ethnic educational achievement gaps, leading to improved employment, and decreased social and health risks. When targeted to low-income and racial/ethnic minority populations, EISIT may thus promote health equity. Community Guide systematic review methods were used to search for qualified studies (through February 2015, 11 included studies) and summarize evidence of the effectiveness of EISIT on educational outcomes. Compared with schools with no time change, schools with expanded days improved students' test scores by a median of 0.05 standard deviation units (range, 0.0-0.25). Two studies found that schools with expanded day and year improved students' standardized test scores (0.04 and 0.15 standard deviation units). Remaining studies were inconclusive. Given the small effect sizes and a lack of information about the use of added time, there is insufficient evidence to determine the effectiveness of EISIT on academic achievement and thus health equity.
Effectiveness of the Dual Dispatch to Cardiac Arrest Policy in Houston, Texas
Authors: Raun Loren , Pederson John , Campos Laura , Ensor Katherine , Persse David
Published: September 2018

Context:

Houston policy is to dual dispatch medically trained firefighters, in addition to emergency medical services (EMS) units to out-of-hospital cardiac arrest (OHCA) cases. While believed to improve public health outcomes, no research exists supporting the policy that when firefighters respond before a better-equipped EMS unit, they increase the probability of survival.

Objective:

To inform EMS policy decisions regarding the effectiveness of dual dispatch by determining the impact of medically trained firefighter dispatch on return of spontaneous circulation (ROSC), a measure of survivability, in OHCA 911 calls while controlling for the subsequent arrival of an EMS unit.

Design:

This retrospective study uses logistic regression to determine the association between ROSC and response time for fire apparatus first responders controlling for arrival of the EMS unit.

Setting:

Out-of-hospital cardiac arrest cases in Houston between May 2008 and April 2013 when dual dispatch was used.

Participants:

A total of 6961 OHCA cases with the complete data needed for the analysis.

Main Outcome Measures:

Logistic regression of the dependence of OHCA survival using the indicator ROSC, as related to the fire first responder response times controlling for subsequent arrival of the EMS.

Results:

Fire apparatus arrived first in 46.7% of cases, a median value of 1.5 minutes before an EMS unit. Controlling for subsequent arrival time of EMS has no effect on ROSC achieved by the fire first responder. If the firefighters had not responded, the resulting 1.5-minute increase in response time equates to a decrease in probability of attaining ROSC of 20.1% for cases regardless of presenting heart rhythm and a 47.7% decrease for ventricular fibrillation cases in which bystander cardiopulmonary resuscitation was initiated.

Conclusions:

The firefighter first responder not only improved response time but also greatly increased survivability independent of the arrival time of the better-equipped EMS unit, validating the public health benefit of the dual dispatch policy in Houston.
Influence of Massive Weight Loss on the Perception of Facial Age: The Facial Age Perceptions Cohort
Authors: Valente Denis Souto , Braga da Silva Jefferson , Cora Mottin Claudio , Benzano Bumaguin Daniela , Santos Rossi Daniele dos , Grimaldi Lerias Aline , Souto Valente Sibelie , Vontobel Padoin Alexandre
Published: September 2018

Background:

Knowledge is scarce about the role of massive weight loss in facial age perception. The aim of this study was to verify whether there is a change in the perception of facial age when comparing people with morbid obesity before surgery and 1 year after the procedure.

Methods:

Patients with morbid obesity have been analyzed, through a prospective cohort, before and 1 year after undergoing bariatric surgery. Seven plastic surgeons estimated the age of each subject.

Results:

Seventy patients participated. Five patients were excluded because of the exclusion criteria. There was no drop-off among the subjects participating in this cohort. Before surgery, the mean facial age perception was 40.8 years; after surgery, mean facial age perception was 43.7 years (95 percent CI, 0.58 to 2.95; p = 0.004). Men older than 40 years, with a preoperative body mass index between 40 and 49.9 kg/m2, weight greater than 127.65 kg before surgery, and percentage of excess weight lost greater than 75.13 percent demonstrated greater perceived facial aging.

Conclusion:

Massive weight loss appears to produce facial aging.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Treatment of Infected Wounds in the Age of Antimicrobial Resistance: Contemporary Alternative Therapeutic Options
Authors: Karinja Sarah J. , Spector Jason A.
Published: September 2018

As antibiotic resistance increases and antimicrobial options diminish, there is a pressing need to identify and develop new and/or alternative (non–antimicrobial-based) wound therapies. The authors describe the implications of antibiotic resistance on their current wound treatment paradigms and review the most promising non–antibiotic-based antimicrobial agents currently in research and development, with a focus on preclinical and human studies of therapeutic bacteriophages, antimicrobial peptides, cold plasma treatment, photodynamic therapy, honey, silver, and bioelectric dressings.
Evolution in Tissue Expander Design for Breast Reconstruction: Technological Innovation to Optimize Patient Outcomes
Authors: Pacella Salvatore J.
Published: September 2018

Tissue expander design in breast reconstruction has evolved substantially over the last 60 years. An insightful appreciation of breast aesthetics, coupled with competition among industry partners, has resulted in innovative and disruptive technology to benefit patients desiring immediate reconstruction following mastectomy. In this article, we discuss the evolution of breast expander technology and the implications in improving patient outcomes in breast reconstruction.
Clinical Results on Innovation in Breast Implant Design
Authors: Chang Edward I. , Hammond Dennis C.
Published: September 2018

Breast implants have been shadowed in controversy since their introduction to the market; however, they represent a multi-million dollar industry and play a critical role both for cosmetic augmentation and enhancement and for reconstruction following treatment for cancer. With advancements in technology, breast implants have evolved tremendously over the years. Further, with the cessation of the FDA implemented moratorium on silicone, the use of silicone implants has grown exponentially over the years. Novel designs in the outer shell, breast implant fill particularly the cohesivity of the silicone gel, texturing of the outer shell, and the shape and projection of breast implants have produced a broad array of implants that can be employed by plastic and reconstructive surgeons to maximize outcomes for patients. However, despite the innovations in breast implant design and engineering, it is unclear whether these have had any influence on outcomes and patient satisfaction. The present article aims to provide a comprehensive review of the technological advancements in breast implant technology in optimizing patient outcomes and minimizing complications associated with placement of breast implants for aesthetic as well as reconstructive procedures. The article will provide a synopsis of round versus shaped breast implants, saline versus silicone especially the advent of cohesive silicone gel implants, and the texturing of the outer shell, and how each of these components should be considered when counseling patients and deciding which implants offer the optimal benefits for each individual patient.
Fat Grafting for Pedal Fat Pad Atrophy in a 2-Year, Prospective, Randomized, Crossover, Single-Center Clinical Trial
Authors: Minteer Danielle M. , Gusenoff Beth R. , Gusenoff Jeffrey A.
Published: September 2018

Background:

By age 60, 30 percent of Americans suffer from fat pad atrophy of the foot. Forefoot fat pad atrophy results from long-term aggressive activity, genetically dictated foot type, multiple forefoot steroid injections, surgery, and foot trauma.

Methods:

The authors present data from a 2-year, prospective, randomized crossover study performed to assess pain and disability indexes, fat pad thickness, forces, and pressures of stance and gait. Group 1 underwent fat grafting with 2 years of follow-up, and group 2 underwent conservative management for 1 year, then underwent fat grafting with 1 year of follow-up.

Results:

Eighteen subjects (14 women and four men) constituted group 1. Thirteen subjects (nine women and four men) constituted group 2. Group 1 reported the worst pain at baseline and group 2 experienced the worst pain at 6- and 12-month standard-of-care visits; pain for both groups improved immediately following fat grafting and lasted through study follow-up (p < 0.05). Group 1 demonstrated functional improvements at 12, 18, and 24 months postoperatively (p < 0.05), whereas group 2 demonstrated the highest function at 12 months postoperatively (p < 0.05). Pedal fat pad thickness of subjects in group 1 increased postoperatively and returned to baseline thickness at 2 months postoperatively; subjects in group 2 experienced return to baseline thickness at 6 months postoperatively (p < 0.01). Forces and pressures of stance and gait increased over the 2 years of follow-up for group 1 (p < 0.05).

Conclusion:

Pedal fat grafting provides long-lasting improvements in pain and function, and prevents against worsening from conservative management.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, I.
Effects of iPad Video Education on Patient Knowledge, Satisfaction, and Cardiac Rehabilitation Attendance
Authors: Wischer Julie L. , Oermann Marilyn H. , Zadvinskis Inga M. , Kinney Kimberly C.
Published: September 2018

Purpose:

The purpose of this project was to examine the outcomes of using video education as an adjunct to standard discharge education for patients receiving percutaneous coronary intervention. Outcomes included knowledge about heart disease and discharge instructions, satisfaction with the video education, and the percentage of patients with cardiac rehabilitation referrals who attended their first cardiac rehabilitation session.

Methods:

This project analyzed data on 224 participants. A video delivered via an iPad was used to provide adjunct discharge education to patients who underwent percutaneous coronary intervention procedures and were on the 24-hour overnight postrecovery unit. Participants completed a test to gauge knowledge learned. Descriptive statistics, the paired t test, and the Fisher exact test were used to evaluate the efficacy of this education.

Results:

A paired t test showed significant knowledge improvement between the pretest percentage correct (mean = 88.97) and the posttest (mean = 96.62): t = −9.657, df = 223, P < .001. A majority of the patients (86.3%, n = 183) were very satisfied with the video education, and 98.1% (n = 208) stated it improved their knowledge and confidence about caring for their heart disease. Despite these reported improvements, there was no significant increase in cardiac rehabilitation attendance (P = .80).

Conclusion:

Patients of all ages embraced the use of video education on iPads as an adjunct to standard discharge education. Patients felt more confident and informed on discharge about the expectations of caring for their heart disease and the need for cardiac rehabilitation. Despite knowing the benefits of cardiac rehabilitation, it remained an underutilized resource for these patients.
A Multidisciplinary Handoff Process to Standardize the Transfer of Care Between the Intensive Care Unit and the Operating Room
Authors: Karamchandani Kunal , Fitzgerald Karima , Carroll David , Trauger Mary E. , Ciccocioppo Lisa A. , Hess Wendell , Prozesky Jansie , Armen Scott B.
Published: September 2018

Objective:

Critically ill patients are at high risk for adverse events on transfer between intensive care unit and operating room. Patient safety concerns were raised within our institution during such transfers, and absence of a standardized patient handoff process was identified as an area of concern.

Methods:

The current state of the patient transfer processes between the intensive care units (ICUs) and the operating rooms (ORs) was mapped and failure modes were identified. A multidisciplinary team was convened and a standardized handoff process and tool (checklist) was developed. Adherence to the process and care team satisfaction was assessed at the end of a 60-day pilot period.

Results:

The process was successfully implemented hospital-wide covering all adult and pediatric ICUs. We observed a 90% compliance rate with ICU to the OR transfers and 95% compliance rate with transfers from OR to the ICU during the 60-day pilot period. The care team expressed overall satisfaction with the process and identified potential areas of improvement.

Conclusion:

A standardized patient handoff process between the ICU and the ORs can be successfully implemented in a large academic medical center. Universal application of this quality improvement tool can reduce patient harm, improve communication between providers, and enhance patient safety.
Safe Passage: Improving the Transition of Care Between Triage and Labor and Delivery
Authors: Lee Daniel D. , Colwill Alyssa C. , Teel Joseph , Srinivas Sindhu K.
Published: September 2018

Objective:

The multifaceted nature of the transition of care from the triage unit to labor and delivery has historically led to confusion, delays, and errors in care. This study evaluated the effect of standardization of roles and communication on improving this transition.

Methods:

A multidisciplinary team was assembled to define and standardize roles of team members. A huddle safety board was created as a visual aid to promote closed-loop communication during an admission bedside huddle. The primary metrics collected were duration of time from the admission decision in the triage unit to when the admission huddle was completed on labor and delivery, duration of time from the admission decision in the triage unit to initiation of the plan of care and documented completion of the admission huddle.

Results:

There was a 66-minute reduction in time from the admission decision to the huddle completion between the preintervention and postintervention periods. There was a 93-minute reduction in the time from the admission decision to when the plan of care was initiated between the preintervention and post-intervention periods. The weekly huddle compliance rate improved from 48% to 84% by the postintervention period.

Conclusions:

The implementation of standardized roles and processes facilitating closed-loop communication decreases delays in communication and initiation of care in pregnant women transferred from the triage unit to labor and delivery.
Tomoelastography Paired With T2* Magnetic Resonance Imaging Detects Lupus Nephritis With Normal Renal Function
Authors: Marticorena Garcia Stephan Rodrigo , Grossmann Markus , Bruns Anne , Dürr Michael , Tzschätzsch Heiko , Hamm Bernd , Braun Jürgen , Sack Ingolf , Guo Jing
Published: September 2018

Objectives

The aim of this study was to test multiparametric magnetic resonance imaging including blood oxygen level–dependent (BOLD) imaging by T2* mapping, magnetic resonance elastography (MRE) by tomoelastography, and diffusion-weighted imaging (DWI) for detecting nephropathy in patients with lupus nephritis (LN).

Methods

Forty-one subjects (25 patients with LN and 16 age- and sex-matched healthy volunteers; LN: mean age, 47.3 ± 14.8 years; 22 female subjects; volunteers: mean age, 43.9 ± 11.6 years; 13 female subjects) were prospectively enrolled. The LN group was further divided into subgroups with normal (LN-nRF, GFR > 90 mL/min per 1.73 m2) and compromised renal function (LN-cRF, GFR < 90 mL/min per 1.73 m2). All subjects were examined by multifrequency MRE, BOLD imaging, and DWI, yielding shear wave speed (SWS; in meter per second), T2* relaxation times (in millisecond), and apparent diffusion coefficient (ADC; in millimeter square per second), respectively. Renal subregional analysis was performed for the medulla (ME), inner cortex (CoI), and outer cortex (CoO). Imaging markers were correlated to clinical parameters such as GFR and protein-to-urine creatinine ratio. Cutoffs and area under the receiver operating curve (AUROC) were computed to test diagnostic performances.

Results

Compared with CoI and CoO, LN-nRF predominantly affects ME tissue (SWS: −7%, P < 0.01; T2*: +9%, P < 0.05; ADC: −5%, P = 0.27). Detection of LN-nRF was better with MRE compared with BOLD imaging and DWI (AUROC = 0.81, 0.76, not significant), whereas pairing MRE with T2* further increased diagnostic power (AUROC = 0.91). Disease progression was associated with reduction of SWS also in CoI (LN-nRF, 3.04 ± 0.38 m/s; LN-cRF, 2.60 ± 0.26 m/s; p = 0.013), allowing distinction of LN-nRF from LN-cRF (AUROC = 0.83). Diffusion-weighted imaging was only sensitive to LN-cRF in ME tissue (ADC, –12%; P < 0.05).

Conclusions

Lupus nephritis with normal renal function first arises in MRE and BOLD images within ME tissue, progressing to CoI tissue once renal function becomes impaired and diffusion of tissue water changes.
Bone Sequestration as a Consequence of Esophageal Carcinoma Metastasis Detected by 18F-FDG PET/CT
Authors: Cui Futao , Su Minggang , Chen Chunmeng , Tian Rong
Published: September 2018

A bony sequestrum is a single piece of bone present in an area of osteolysis. It is separated from the surrounding bone and is primarily observed in patients with bone infection. We present our radiographic findings on 18F-FDG PET/CT in a case of esophageal squamous cell carcinoma with a sequestrum in the skull metastasis.
68Ga PET Imaging in Patients With Neuroendocrine Tumors
Authors: Singh Simron , Poon Raymond , Wong Rebecca , Metser Ur
Published: September 2018

Purpose

The aim of this study was to systematically review the literature to assess the role of 68Ga PET imaging in neuroendocrine tumors (NETs).

Materials and Methods

The literature was searched using MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews databases through OVID. Studies comparing PET or PET/CT with conventional imaging in the initial diagnosis, staging and restaging, assessment of treatment response, and routine surveillance of NETs were deemed eligible for inclusion. Risk of bias and applicability concerns were assessed using the Quality Assessment of Diagnostic Accuracy Studies tool.

Results

Twenty-two studies met the inclusion criteria. For the initial diagnosis of NETs, PET or PET/CT had a pooled sensitivity of 91% (95% confidence interval [CI], 85%–94%) and a pooled specificity of 94% (95% CI, 86%–98%). In the setting of staging and restaging, the sensitivity of PET or PET/CT for detecting primary and/or metastatic lesions ranged from 78.3% to 100%, whereas specificity ranged from 83% to 100%. Change in management occurred in 45% (95% CI, 36%–55%) of the cases, with majority of the changes involving surgical planning and patient selection for peptide receptor radionuclide therapy.

Conclusions

68Ga PET or PET/CT is recommended for initial diagnosis where conventional testing remained equivocal, for staging of patients with localized primary and/or limited metastasis where definitive surgery is planned, to determine somatostatin receptor status and suitability for peptide receptor radionuclide therapy, and for staging of patients where detection of occult disease will alter treatment options and decision making.
A Case of Radioactivity Concentrated in Orbital Implant in 99mTc-MDP Bone Scan and SPECT/CT
Authors: Cai Min , Feng Guisheng , Zhang Guangwei
Published: September 2018

A 27-year-old woman, who has received a hydroxyapatite orbital implant in the right eye due to a trauma 6 years ago, was newly diagnosis with left breast invasive ductal carcinoma. 99mTc-MDP bone scan showed an increased radiotracer accumulation in the right orbit and SPECT/CT confirmed the focal accumulation at the site of the implant, without any sign of local malignant lesions or orbital infection. Radionuclide imaging could provide certain useful information in diagnosing or differential diagnosing orbital disease.
A New Surgical Method of Correcting Abnormal Cartilage in Mild or Moderate Cryptotia
Authors: Wang Yan , He Zhijuan , Ma Xu , Li Qingchun , Li Ning , Liu Guofeng
Published: September 2018

Objective

This study aimed to introduce a new technique for the correction of mild or moderate types of cryptotia.

Methods

During January 2010 to March 2015, patients with cryptotia deformities came to our hospital and were enrolled in this study. A new surgical method of correction of abnormal cartilage by combining irregular incisions in auricle malformation and directional transplantation of auricular cartilage was designed. The irregular Z shaped flap was designed to correct the skin defects. In the ipsilateral cavum conchae, the auricular cartilage strut was harvested, followed with irregular cartilage incisions and cartilage transplantation.

Results

After correction, the corrected auricles in 3 cases showed natural contour with deep auriculotemporal sulcus and no conspicuous scars. The antihelix folding and backward rotation deformities of the auricular cartilage were corrected, and the morphology of superior and inferior crus of the antihelix was not destroyed. One case appeared necrotic. During 1 year of follow-up, there was no incidence of recurrence or revision.

Conclusions

The combined techniques for correction of abnormal cartilage are simple and easy to operate, and the reconstructed auricles show natural contour without conspicuous scars. The new technique is suitable for correction of mild and moderate cryptotia.
Time to Radiation After Oncoplastic Reduction
Authors: Kapadia Sameer M. , Reitz Alexandra , Hart Alexandra , Broecker Justine , Torres Mylin A. , Carlson Grant W. , Styblo Toncred M. , Losken Albert
Published: September 2018

Background

Partial breast reconstruction with reduction mammaplasty is an accepted option for women with breast cancer who wish to receive breast conserving therapy. With additional surgery and potential postoperative complications, the impact this approach has on the timely initiation of adjuvant radiation therapy has been raised as a concern. The purpose of this study was to determine if any postoperative complications after oncoplastic reduction (OCR) are associated with a delay in time to radiation.

Methods

All patients undergoing OCR with postoperative adjuvant radiation at a single institution between 1997 and 2015 were included in the analysis. Women who received adjuvant chemotherapy or experienced delays in radiation therapy due to nonsurgical reasons were excluded from our analysis. Comparisons were made between the time to radiation for patients with surgical complications and those without.

Results

One hundred eighteen patients were included. Twenty-six (22.0%) experienced a surgical complication. Complications included cellulitis, delayed healing, seroma, wound breakdown, and wound dehiscence. Postoperative complications resulted in a significantly different median time interval for initiation of radiation (74 days vs 54 days, P < 0.001) compared to those without a complication. Among the entire cohort, 5% of patients required a second operative procedure due to complications. (n = 6/118 patients) including hematoma, infection, seroma, open wounds, wound dehiscence, and nipple necrosis. There was no difference in median time to radiation therapy in those with complications who returned to the operating room (73 days) compared to those who did not (74 days, P = 0.692).

Conclusion

Postoperative complications following OCR procedures were associated with an increased time to initiation of adjuvant radiation therapy regardless of whether or not the complication required reoperation. This needs to be taken into consideration when planning these combined procedures with every attempt made to minimize complications through patient selection and surgical technique.