bluuebunny/crossref_metadata_2025 huggingface dataset:
Shoulder Complex Mechanics in Adolescent Idiopathic Scoliosis and Their Relation to Patient-perceived Function
Authors: Rapp van Roden Elizabeth A. , Richardson Robert Tyler , Russo Stephanie A. , Rose William C. , Chafetz Ross S. , Gabos Peter G. , Shah Suken A. , Samdani Amer F. , Richards James G.
Published: July 2018

Background:

Proper contribution of the scapulothoracic joint is necessary for adequate shoulder complex function. Associations between trunk shape and abnormal scapular kinematics and subsequent shoulder dysfunction have been established; however, the extent of shoulder dysfunction in adolescent idiopathic scoliosis (AIS) is still poorly understood. The purpose of this study was to perform a comprehensive analysis of scapular kinematics during multiplanar arm motion in patients with AIS and compare kinematics and patient-reported function with that of a typically developing cohort.

Methods:

Typically developing adolescents (n=33) and patients with AIS (n=26) with no history of spine or shoulder surgery were recruited for this study. A 3-dimensional optoelectronic motion capture system was used to analyze scapular kinematics in 4 positions: rest, full abduction, forward reach, and hand to spine. Subjects in each group also completed the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire as a measure of patient-reported function.

Results:

The convex shoulders of the patients with AIS exhibited deficits in scapular upward rotation and posterior tilt in all positions and reduced protraction range of motion during reaching. The AIS group also reported worse patient-perceived shoulder function than the typically developing group; however, this dysfunction was not related to specific scapular kinematic patterns.

Conclusions:

Patients with AIS show alterations in scapular kinematics that are associated with shoulder pathology. Despite displaying an unaffected ability to place the hand in space, the underlying joint mechanics place these adolescents at risk for future pathology. Accordingly, consideration of scapulothoracic and glenohumeral joint function is warranted in the treatment of AIS.

Level of Evidence:

Level III—cross-sectional comparison.
A Comparison of Transphyseal Neck-Head Tunneling and Multiple Epiphyseal Drilling on Femoral Head Healing Following Ischemic Osteonecrosis: An Experimental Investigation in Immature Pigs
Authors: Aruwajoye Olumide O. , Monte Felipe , Kim Audrey , Kim Harry K.W.
Published: July 2018

Background:

Two operative procedures are currently advocated to stimulate the necrotic femoral head healing in children with Legg-Calve-Perthes disease: transphyseal neck-head tunneling (TNHT) and multiple epiphyseal drilling (MED). The purpose of this study was to compare the bone healing and physeal function after treatment with TNHT or MED in a piglet model of ischemic osteonecrosis.

Methods:

Eighteen piglets were induced with osteonecrosis by surgically placing a ligature tightly around the right femoral neck. One week later, the piglets were assigned to 1 of 3 treatment groups (n=6/group): (1) local nonweight bearing only (NWB), (2) TNHT plus NWB, or (3) MED plus NWB. The unoperated left femoral heads were used as normal controls. The animals were euthanized at 8 weeks after osteonecrosis induction. Histologic, histomorphometric, radiographic, microcomputed tomography (CT), and calcein-labeling assessments were performed. Statistical analysis included a 1-way ANOVA.

Results:

Micro-CT analyses showed higher femoral head bone volume in the MED group compared with the TNHT and the NWB groups (P<0.01). The MED group had a higher mean trabecular number (P<0.001) and new bone formation (P=0.001) based on calcein-labeling parameters compared with the TNHT and the NWB groups. In addition, the osteoclast number per bone surface was lower in the MED group compared with the NWB group (P=0.001). Histologic and micro-CT assessments of the proximal femoral physis revealed a larger physeal disruption at the site of physeal drilling in the TNHT group compared with the MED group. However, no significant differences in physeal elongation (P=0.61) and femoral neck length (P=0.31) were observed between the treatment groups.

Conclusions:

MED produced a higher bone volume and stimulated greater bone formation than the TNHT or the NWB alone. Both procedures did not produce a significant physeal growth disturbance during the study period.

Clinical Relevance:

This preclinical study provides evidence that MED produces more favorable bone healing than the TNHT in a large animal model of Legg-Calve-Perthes disease.
Trends in Pediatric ACL Reconstruction From the PHIS Database
Authors: Tepolt Frances A. , Feldman Lanna , Kocher Mininder S.
Published: July 2018

Background:

Previous studies have suggested that anterior cruciate ligament (ACL) reconstruction surgeries are being performed with increased frequency in children and adolescents. The purpose of this study was to evaluate the trend in the frequency of ACL reconstructions normalized by total orthopaedic surgeries at pediatric hospitals nationwide.

Methods:

The Pediatric Health Information System (PHIS) database was queried for patients age 18 years or younger who underwent orthopaedic surgery at any of the PHIS-participating hospitals 2004-2014. The subset of patients who had been treated with ACL reconstruction were identified using Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) procedure codes. The yearly rate was expressed as the number of ACL reconstructions per 1000 orthopaedic surgeries, and a linear model was used to fit the data to illustrate the relative trend.

Results:

In total, 470,126 orthopaedic surgeries, including 15,231 ACL reconstructions, were performed for patients 18 years or younger at 27 pediatric hospitals. ACL reconstructions were performed at a yearly rate of 32.4 per 1000 orthopaedic surgeries. Between 2004 and 2014, the number of ACL reconstructions increased 5.7-fold, whereas orthopaedic surgeries increased 1.7-fold; there was a 2.8-fold increase in ACL reconstructions relative to total pediatric orthopaedic surgeries. The 10-year relative fold increase was nearly equivalent across sexes, and the increasing trend in ACL reconstructions relative to orthopaedic surgeries was also seen across age groups.

Conclusions:

The number of ACL reconstructions performed for children and adolescents in pediatric hospitals nationwide markedly increased by nearly 3 times relative to orthopaedic surgeries over a recent 10-year period.

Level of Evidence:

Level IV.
Post Dengue Fever Epidural Abscess With or Without Spondylodiscitis: A Case Series of Eight Patients in a Single Season in a Single Center
Authors: Pillai Suresh S. , Shameer Moidu , Hassan Asif , Parambil Abdurehiman K. , Reddy Sivasankar , Vishnu R Bala , Mohammad Shameem G.
Published: July 2018

Study Design.

A retrospective case series.

Objective.

The aim of this study was to report the immunosuppression and secondary bacterial infection after dengue viral infection and the predilection of these infections in the spine. This can trigger further research in to this fact. The possibility of change in the serotype of dengue virus, which are neurotropic, may be looked into.

Summary of Background Data.

This is the largest case series of epidural abscess with or without spondylodiscitis within 6 weeks following dengue virus infection.

Methods.

We performed a retrospective review of all the eight cases treated for epidural abscess with or without spondylodiscitis within 6 weeks following dengue virus infection in our center during the period of 3 months from June 2017 to August 2017.

Results.

Of the eight cases, three of them were infected with Methicillin Resistant Saphylococcus Aureus and all of them grew the bug in the blood culture. Three of them had Methicillin Sensitive Staphylococcus Aureus (MSSA), one with MSSA septicemia, and one had associated Elizabeth Kingia meningoseptica infection and one patient had positive Acid Fast Bacilli stained in smears. Two patients were infected with pseudomonas. Some patients had multiple site abscess and epidural abscess without spondylodiscitis. Five of them had neurological deficit, which recovered with abscess drainage and antibiotic treatment. The Erythrocyte Sedimentation rate, C-Reactive Protein, and serum ferritin were elevated in these patients.

Conclusion.

This is a large case series of epidural abscess with or without spondylodiscitis within 6 weeks following dengue virus infection. The predilection of dengue virus for the neural tissue should be further investigated. Post dengue immunosuppression also needs further study.

Level of Evidence: 4
Blood Loss Trends and Financial Implications in Adolescent Idiopathic Scoliosis
Authors: Alamanda Vignesh K. , Massengill Danae L. , Rozario Nigel , Moore Charity G. , Scannell Brian , Brighton Brian , Vanderhave Kelly L.
Published: July 2018

Study Design:

This was a retrospective cohort study.

Objective:

The primary goal was to evaluate risk factors related to increased blood loss in adolescent idiopathic surgery (AIS) surgery with the secondary goal being to evaluate the financial implications around the use of intraoperative cell salvage (ICS) and the routine preallocation of autogenous blood products.

Summary of Background Data:

Deformity correction for AIS is a complex procedure and can be associated with significant blood loss.

Methods:

A retrospective cohort study was conducted on consecutive patients between the ages of 10 and 18 years who underwent posterior spinal fusion of 7–12 levels over a 3-year period between January 2013 and December 2015. Demographic information and surgical characteristics were recorded. All patients had a preoperative type and cross of 2 units and ICS was used in all cases. Charges for preoperative type and cross and ICS were also measured. Univariate and multivariable analyses were performed to identify pertinent variables affecting blood loss.

Results:

In total, 134 patients met inclusion criteria. ICS was used in all cases. In total, 51 patients were transfused cell saver blood intraoperatively/postoperatively at the discretion of the surgeon. On average 133 mL were returned to the patient. No complications related to ICS were observed. Multivariable analysis identified male sex, lower body mass index and higher surgical time to be associated with increased blood loss (P<0.05). All 134 patients had a preoperative type and cross, with an average charge to patient of $311. Patients were charged $1037 for intraoperative use of ICS and $242 for centrifugation. Patients who had allogeneic transfusion were charged $1047.

Conclusions:

Several blood conservation strategies, including use of ICS, exist to minimize the consequences of blood loss. Routine use of preoperative type and cross may be avoided except in cases where significant blood loss is anticipated—that is adolescent male individuals, those with a lower body mass index and in whom a longer surgical time is anticipated.
Chronic Longitudinal Instability of the Forearm Treated With a Combination of Ulnar Shortening Osteotomy, Pronator Teres Transfer, and Tightrope Technique
Authors: Nunez Fiesky A. , Evans Peter J.
Published: July 2018

Restoration of longitudinal stability of the forearm continues to pose a difficult challenge for the hand surgeon, and no technique has demonstrated success above others. Longitudinal stability to the forearm is conferred by 3 structures: the radial head, which acts as a primary stabilizer, the interosseous membrane, more specifically, the central band and, the distal radioulnar ligaments which are part of the triangular fibrocartilage complex. A combination of techniques is described in this article to address chronic longitudinal instability of the forearm: (1) ulnar shortening osteotomy to restore ulnar variance, (2) pronator teres transfer was used to reconstruct the central band of the interosseous membrane, and (3) tightrope augmentation was used to prevent elongation during the healing process.
Distinctive Roles and Mechanisms of Human Neutrophil Peptides in Experimental Sepsis and Acute Respiratory Distress Syndrome
Authors: Wu Jianfeng , Han Bing , Fanelli Vito , Wen Xiaoyan , Huang Yongbo , Luo Alice , Ghazarian Mirna , Wang Dingyan , Khang Julie , Morriello Florence , Liaw Patricia C. , Marshall John , Zhong Nanshan , Guan Xiangdong , Slutsky Arthur S. , Li Yimin , Zhang Haibo
Published: July 2018

Objectives:

To examine the effects and mechanisms of human neutrophil peptides in systemic infection and noninfectious inflammatory lung injury.

Design:

Prospective experimental study.

Setting:

University hospital-based research laboratory.

Subjects:

In vitro human cells and in vivo mouse models.

Interventions:

Wild-type (Friend virus B-type) and conditional leukocyte human neutrophil peptides transgenic mice were subjected to either sepsis induced by cecal ligation and puncture or acute lung injury by intratracheal instillation of hydrochloric acid followed by mechanical ventilation. Using human neutrophil peptides as bait, the basal cell adhesion molecule (CD239) and the purinergic P2Y purinoceptor 6 receptor were identified as the putative human neutrophil peptides receptor complex in human lung epithelial cells.

Measurements and Main Results:

In the cecal ligation and puncture sepsis model, Friend virus B-type mice exhibited higher systemic bacterial load, cytokine production, and lung injury than human neutrophil peptides transgenic mice. Conversely, an increased lung cytokine production was seen in Friend virus B-type mice, which was further enhanced in human neutrophil peptides transgenic mice in response to two-hit lung injury induced by hydrochloric acid and mechanical ventilation. The human neutrophil peptides–mediated inflammatory response was mediated through the basal cell adhesion molecule-P2Y purinoceptor 6 receptor signal pathway in human lung epithelial cells.

Conclusions:

Human neutrophil peptides are critical in host defense against infectious sepsis by their cationic antimicrobial properties but may exacerbate tissue injury when neutrophil-mediated inflammatory responses are excessive in noninfectious lung injury. Targeting the basal cell adhesion molecule/P2Y purinoceptor 6 signaling pathway may serve as a novel approach to attenuate the neutrophil-mediated inflammatory responses and injury while maintaining the antimicrobial function of human neutrophil peptides in critical illness.
Molecular Regulation of Acute Tie2 Suppression in Sepsis
Authors: Thamm Kristina , Schrimpf Claudia , Retzlaff Jennifer , Idowu Temitayo O. , van Meurs Matijs , Zijlstra Jan G. , Ghosh Chandra C. , Zeitvogel Jana , Werfel Thomas A. , Haller Hermann , Parikh Samir M. , David Sascha
Published: July 2018

Objectives:

Tie2 is a tyrosine kinase receptor expressed by endothelial cells that maintains vascular barrier function. We recently reported that diverse critical illnesses acutely decrease Tie2 expression and that experimental Tie2 reduction suffices to recapitulate cardinal features of the septic vasculature. Here we investigated molecular mechanisms driving Tie2 suppression in settings of critical illness.

Design:

Laboratory and animal research, postmortem kidney biopsies from acute kidney injury patients and serum from septic shock patients.

Setting:

Research laboratories and ICU of Hannover Medical School, Harvard Medical School, and University of Groningen.

Patients:

Deceased septic acute kidney injury patients (n = 16) and controls (n = 12) and septic shock patients (n = 57) and controls (n = 22).

Interventions:

Molecular biology assays (Western blot, quantitative polymerase chain reaction) + in vitro models of flow and transendothelial electrical resistance experiments in human umbilical vein endothelial cells; murine cecal ligation and puncture and lipopolysaccharide administration.

Measurements and Main Results:

We observed rapid reduction of both Tie2 messenger RNA and protein in mice following cecal ligation and puncture. In cultured endothelial cells exposed to tumor necrosis factor-α, suppression of Tie2 protein was more severe than Tie2 messenger RNA, suggesting distinct regulatory mechanisms. Evidence of protein-level regulation was found in tumor necrosis factor-α–treated endothelial cells, septic mice, and septic humans, all three of which displayed elevation of the soluble N-terminal fragment of Tie2. The matrix metalloprotease 14 was both necessary and sufficient for N-terminal Tie2 shedding. Since clinical settings of Tie2 suppression are often characterized by shock, we next investigated the effects of laminar flow on Tie2 expression. Compared with absence of flow, laminar flow induced both Tie2 messenger RNA and the expression of GATA binding protein 3. Conversely, septic lungs exhibited reduced GATA binding protein 3, and knockdown of GATA binding protein 3 in flow-exposed endothelial cells reduced Tie2 messenger RNA. Postmortem tissue from septic patients showed a trend toward reduced GATA binding protein 3 expression that was associated with Tie2 messenger RNA levels (p < 0.005).

Conclusions:

Tie2 suppression is a pivotal event in sepsis that may be regulated both by matrix metalloprotease 14–driven Tie2 protein cleavage and GATA binding protein 3–driven flow regulation of Tie2 transcript.
Half-Dose Versus Full-Dose Alteplase for Treatment of Pulmonary Embolism*
Authors: Kiser Tyree H. , Burnham Ellen L. , Clark Brendan , Ho P. Michael , Allen Richard R. , Moss Marc , Vandivier R. William
Published: July 2018

Objectives:

Recent evidence suggests that half-dose thrombolysis for pulmonary embolism may provide similar efficacy with reduced bleeding risk compared with full-dose therapy, but comparative studies are lacking. We aimed to evaluate the effectiveness and safety of half-dose versus full-dose alteplase for treatment of pulmonary embolism.

Design:

A retrospective cohort study comparing outcomes in patients receiving half-dose (50 mg) versus full-dose (100 mg) alteplase for pulmonary embolism. We used propensity score matching and sensitivity analyses to address confounding and hospital-level clustering.

Setting:

Data from 420 hospitals obtained from the Premier Healthcare Database between January 2010 and December 2014.

Subjects:

Adult critically ill patients with acute pulmonary embolism treated with IV alteplase therapy.

Interventions:

None.

Measurements and Main Results:

This study included 3,768 patients: 699 (18.6%) in the half-dose and 3,069 (81.4%) in the full-dose group. At baseline, patients receiving half-dose alteplase required vasopressor therapy (23.3% vs 39.4%; p < 0.01) and invasive ventilation (14.3% vs 28.5%; p < 0.01) less often, compared with full dose. After propensity matching (n = 548 per group), half-dose alteplase was associated with increased treatment escalation (53.8% vs 41.4%; p < 0.01), driven mostly by secondary thrombolysis (25.9% vs 7.3%; p < 0.01) and catheter thrombus fragmentation (14.2% vs 3.8%; p < 0.01). Hospital mortality was similar (13% vs 15%; p = 0.3). There was no difference in cerebral hemorrhage (0.5% vs 0.4%; p = 0.67), gastrointestinal bleeding (1.6% vs 1.6%; p = 0.99), acute blood loss anemia (6.9% vs 4.6%; p = 0.11), use of blood products (p > 0.05 for all), or documented fibrinolytic adverse events (2.6% vs 2.8%; p = 0.82).

Conclusions:

Compared with full-dose alteplase, half-dose was associated with similar mortality and rates of major bleeding. Treatment escalation occurred more often in half-dose–treated patients. These results question whether half-dose alteplase provides similar efficacy with improved safety, and highlights the need for further study before use of half-dose alteplase therapy can be routinely recommended in patients with pulmonary embolism.
Squamoid Eccrine Ductal Carcinoma: An Aggressive Mimicker of Squamous Cell Carcinoma
Authors: Mckissack Sterling S. , Wohltmann Wendi , Dalton Scott R. , Miletta Nathanial R.
Published: July 2018

Squamoid eccrine ductal carcinoma (SEDC) is an uncommon cutaneous adnexal malignancy that has the potential for an aggressive clinical course. The authors present a case of SEDC that resulted in widespread metastases and death. The clinical, histological, and immunohistochemical features of SEDC and several entities on the differential diagnosis are reviewed.
PERIPHERAL RETINAL DRUSEN–LIKE DEPOSITS IN GUCY2C CONGENITAL SECRETORY DIARRHEA SYNDROME
Authors: Cugley Dean , Brislane Nicholas , Guymer Robyn , Carden Susan
Published: July 2018

Purpose:

To report the presence of drusen in infancy, in a patient with Type 1 retinopathy of prematurity and a rare congenital sodium diarrhea secondary to a sporadic GUCY2C mutation.

Methods:

A case report generated by review of clinical course, with imaging of 1 patient and literature review.

Results:

A 1.075-kg infant born at gestation age 27 weeks was admitted to our institution with respiratory distress and secretory diarrhea. During screening for retinopathy of prematurity, peripheral drusen–like subretinal deposits were identified. There were no similar findings in either parent or family history of ocular pathologies. Their distribution is atypical for that seen in other causes of early onset drusen such as autosomal dominant drusen or Sorsby fundus dystrophy. Retinopathy of prematurity was identified, which progressed to Type 1, and was treated with bilateral indirect peripheral retinal photocoagulation at gestational age of 40 weeks. Fluorescein angiography was performed and was consistent with peripheral drusen. Optical coherence tomography of the central macula and an awake electroretinogram at 6 months were normal. Serial examinations confirmed no progression in the drusen-like deposits or in retinopathy of prematurity, with clinically appropriate visual development observed during close follow-up.

Conclusion:

We identify a unique ocular phenotype of retinal drusen–like deposits in an infant with a rare, sporadic GUCY2C mutation.
TREATMENT OF REFRACTORY TUBERCULAR SERPIGINOUS–LIKE CHOROIDITIS WITH INTRAVITREAL METHOTREXATE
Authors: Tsui Edmund , Fern Craig M. , Goldberg Naomi R.
Published: July 2018

Purpose:

To describe a case of tubercular serpiginous–like choroiditis that progressed, despite antitubercular medication, corticosteroids, and immunomodulatory treatment, which ultimately quieted after two intravitreal methotrexate injections.

Methods:

Case report.

Results:

A 35-year-old woman reported a shadow in the left eye for 2 weeks. She presented with tubercular serpiginous–like choroiditis in the right eye 2 years prior. At that time, she was started on antituberculosis therapy but was noncompliant and lost to follow-up. On re-presentation, there was a new active left-eye serpiginous lesion, with repeat positive QuantiFERON gold testing. Four antituberculosis drugs were started, followed by corticosteroids and azathioprine, with continued progression despite aggressive treatment. She was finally given 2 intravitreal methotrexate injections (400 μg/0.1 cc) 1 month apart, with final arrest of lesion extension. The uveitis remained quiet for over 24 months, and the patient was able to discontinue all systemic therapy.

Conclusion:

Intravitreal methotrexate injections halted progression of treatment-refractory tubercular serpiginous–like choroiditis.
Cypass Supraciliary Stent in Eye With Chronic Angle Closure and Postvitrectomy With Silicone Oil
Authors: Hopen Michael L. , Patel Shamil , Gallardo Mark J.
Published: July 2018

Purpose:

To report a case of successful intraocular pressure (IOP) reduction following Cypass supraciliary stent implantation in a postvitrectomized eye filled with silicone oil and chronic angle-closure glaucoma.

Materials and Methods:

This is a case report.

Results:

A 19-year-old female with chronic angle-closure glaucoma underwent combined cataract extraction, goniosynechiolysis and Cypass supraciliary shunt implantation. Patient had a history of proliferative diabetic retinopathy and a tractional retinal detachment, which required pars plana vitretomy and silicone oil implantation, and was subsequently complicated by neovascular glaucoma requiring implantation of an inferior glaucoma drainage device. Approximately 6 months later, the patient’s IOP increased to 36 mm Hg on maximum tolerable medical therapy. The patient underwent combined cataract extraction and Cypass implantation and is now controlled with an IOP of 16 mm Hg on 3 classes of medications 6 months postoperatively.

Conclusions:

Implantation of a Cypass supraciliary shunt can be an effective means for controlling IOP in patients with chronic angle-closure glaucoma in a postvitrectomized eye with silicone oil implantation and failed glaucoma drainage device.
Xen Gel Stent to Resolve Late Hypotony After Glaucoma Drainage Implant Surgery: A Novel Technique
Authors: Välimäki Juha
Published: July 2018

Purpose:

To describe a new surgical method for treating late profound hypotony in 2 patients with glaucoma drainage implant (GDI).

Patients and Methods:

Two patients, an 85-year-old woman and a 44-year-old woman, presented with choroidal effusions secondary related to chronic hypotony after GDI surgery. A novel technique was performed in both cases to narrow the lumen size of the GDI tube. The GDI tube was exposed and ligated temporarily with a polyglactin suture in both cases. The anterior part of the capsule wall was opened. The Xen stent was removed from its injector and pushed through the posterior orifice of the GDI tube. The whole Xen stent was inserted inside the tube to narrow the lumen size of the GDI tube. Once the Xen had been placed inside the tube lumen, a silk suture was tied around the GDI tube to secure the Xen in position. The ligation suture of the GDI tube was removed and suturing of the conjunctiva was performed.

Results:

Before restriction of aqueous flow through the GDI, both patients had an intraocular pressure (IOP) of 2 mm Hg and blurry vison of 20/40 to 20/200. Following the Xen implant insertion, IOP ranged between 8 and 20 mm Hg and choroidal effusions resolved, and visual acuity improved. In both cases, IOP remained stable through 1 year of follow-up and no choroidal effusions or macular folds were noticed.

Conclusions:

A Xen implant placed inside the GDI tube offers an option for the treatment of chronic hypotony in eyes with GDI.
Patient Outcomes Following Micropulse Transscleral Cyclophotocoagulation: Intermediate-term Results
Authors: Yelenskiy Aleksandr , Gillette Thomas B. , Arosemena Analisa , Stern Augustus G. , Garris Winston J. , Young Curt T. , Hoyt Michelle , Worley Nancy , Zurakowski David , Ayyala Ramesh S.
Published: July 2018

Purpose:

To report the safety and efficacy outcomes following micropulse transscleral cyclophotocoagulation (MPTSCPC) procedure in patients with uncontrolled glaucoma.

Materials and Methods:

Longitudinal retrospective cohort, multicenter study. Patients with different types of glaucoma who underwent MPTSCPC with P3 probe between July 2015 and May 2017. Patients were treated by different glaucoma specialists from 5 different locations (Tulane Study Group). Data on preoperative characteristics, surgical procedure(s) performed, and postoperative outcomes were collected and analyzed. Statistical analysis using logistic regression and Kaplan-Meier analysis was performed with Stata software. Intraoperative and postoperative complications, intraocular pressure, visual acuity, need for incisional glaucoma surgery, need for repeat micropulse, and number of topical medications were studied.

Results:

One hundred ninety-seven eyes from 161 patients were included. Median follow-up was 12 months [interquartile range (IQR), 6 to 14]. Glaucoma diagnosis included 141 primary open-angle glaucoma (POAG), 8 neovascular glaucoma, and 12 others. The total success rate was 71%. Two percent (4 patients) developed postoperative cystoid macular edema. Preoperative mean intraocular pressure (SD) was 22±9 and 16±6 mm Hg at last follow-up (P<0.001). Median preoperative logMAR visual acuity (IQR) was 0.4 (0.2 to 1.0) and 0.3 (0.2 to 1.0) at last follow-up (P=0.65, Wilcoxon signed-rank test). Median number (IQR) of topical medications was 3 (1 to 4) preoperative and 2 (1 to 3) at last follow-up (P<0.001). Kaplan-Meier analysis indicated 90% of patients free from repeat MPTSCPC at 12 months. Multivariable logistic regression identified 3 significant independent predictors of total success: diagnosis (P=0.011) (POAG), previous glaucoma surgery (P=0.003), and other concurrent procedures (P=0.013).

Conclusions:

Our large longitudinal cohort study has provided evidence that MPTSCPC is a safe and generally effective option in the treatment of POAG up to 12 months.
Importance of a team approach to recommending the human papillomavirus vaccination
Authors: Fontenot Holly B. , Kornides Melanie L. , McRee Annie-Laurie , Gilkey Melissa B.
Published: July 2018

Background and purpose:

Few studies have examined human papillomavirus (HPV) vaccine communication in the context of the health care team.

Methods:

In 2016, the investigators conducted a national, online survey of U.S. parents who reported having discussed HPV vaccination with their adolescent's health care team. Multivariable logistic regression assessed associations between HPV vaccine initiation (≥1 dose) and having: 1) discussed HPV vaccination with multiple team members and 2) received congruent recommendations about HPV vaccination.

Conclusions:

Of the 795 parents in the sample, about half (52%) reported discussing HPV vaccination with multiple team members, including nurse practitioners, nurses, and physicians. Most reported receiving congruent recommendations for (76%) or against (12%) HPV vaccination; few (12%) received mixed recommendations. Parents who discussed HPV vaccination with multiple team members had greater odds of series initiation (odds ratio [OR] = 2.34, 95% CI: 1.61–3.40), whereas those who received mixed versus congruent recommendations for HPV vaccination had lower odds of vaccination (OR = 0.56, 95% CI: 0.33–0.95).

Implications for practice:

Findings suggest that a coordinated team approach to recommendations may encourage HPV vaccination. Nurse practitioners are well positioned to facilitate coordination efforts within their clinical practices.
VAD infection during bridge-to-transplant, unique aspects of treatment and prevention
Authors: Koval Christine
Published: July 2018

Purpose of review

VAD infections remain a frequent complication of VAD care and can markedly affect patient management before and after transplantation. This review highlights the standard-of-care approaches offered by recent guidelines as well as published data that may improve the care for patients with these challenging and often persistent infections.

Recent findings

Prevention and management of VAD infections has become more standardized with updated consensus guidelines published in 2017. Unfortunately, advanced devices have not markedly affected the incidence of VAD infection. Efforts to improve, yet streamline, the prevention of VAD-specific infections are ongoing. However, the data provided in the best of recent publications are rarely effectively comparative. Granular data on management strategies are limited to a few studies. Nevertheless, several publications provide more detailed posttransplant outcomes for patients with pretransplant VAD infections and demonstrate overall excellent posttransplant survival.

Prevention and management of VAD-specific and VAD-related infections are the ongoing work of all VAD programs. Consensus guidelines are a marker of progress for this field. Despite very good posttransplant outcomes for these patients, more granular data are required to understand how such patients arrive successfully to transplantation and how their posttransplant course is affected.
Preparing Clinicians for Transitioning Patients Across Care Settings and Into the Home Through Simulation
Authors: Molloy Margory A. , Cary Michael P. , Brennan-Cook Jill , Cantey Danett S. , Tocchi Christine , Bailey Donald E. , Oermann Marilyn H.
Published: July 2018

Assuring home care staff competencies through simulation has the potential to improve care transitions and clinical outcomes. Recreating a home environment can be used for orientation of home care staff and to meet other learning needs. Lessons learned from the use of simulation in a geriatric nursing course in a prelicensure program can be used to prepare clinicians for transitioning patients across care settings. With simulation, learners can identify challenges in patient safety, pain management, and management of patients' cognitive decline as well as learn how to communicate with patients, family members, and the healthcare team. Simulation, as an interactive pedagogy, provides opportunities for learners to practice assessment, monitoring, and patient care in a controlled, safe, risk-free environment. Following participation in a simulation, learners are given the opportunity to reflect on ways to improve patient care when transitioning from acute to home care settings. Simulations described in this article can be used for orientation of staff to a home healthcare agency because they allow clinicians to hone the skills necessary for patient care in the home. Staff educators can also use simulation to validate staff competencies in caring for patients at home.
Home Healthcare and Hospice
Authors: Fernandes Ritabelle , Osarch Sylvia , Allen Nancy E.
Published: July 2018

The Pacific Islands Geriatric Education Center of the University of Hawaii conducted situational assessments of caregivers, older adults, and healthcare professionals in the Republic of Palau. The findings revealed an urgent need for a solution to the identified crisis of an aging population, increasing chronic diseases and their corresponding impact on caregivers and society. In 2010, the National Healthcare Financing Act was signed into law, becoming Palau's first step in helping residents and workers in Palau pay for medical expenses. This program is referred to as the Health Care Fund and consists of two parts: National Health Insurance and Medical Savings Account. Advocacy and promotion of home healthcare services in Palau was facilitated by the Pacific Islands Geriatric Education Center. Because of these efforts, systems changed to establish home healthcare services and expand the Health Care Fund with a proposed Home Health Insurance Benefit from the National Health Insurance. This is a huge leap forward to improve access to care for older adults and homebound in Palau.
Medication Management in Municipality-Based Healthcare
Authors: Holmqvist Malin , Ekstedt Mirjam , Walter Scott R. , Lehnbom Elin C.
Published: July 2018

The objective of this observational time and motion study was to increase our understanding of how nurses in home healthcare currently distribute their work time with a focus on the medication management process. The research was conducted in four municipalities in the southern part of Sweden. Participants were nurses working in home healthcare. The study measured proportion of time, comparison of proportions of time, proportion of time spent multitasking, and rate of interruptions per hour. Of total observed time, 20.4% was spent on medication management and of these tasks the highest proportion of time was spent on communications and dispensing medications. Nurses in nursing homes spent more time (23.0% vs. 17.4%, p = 0.001) on medication management than nurses in private homes. Nurses spent 47.9% of their time completing tasks with someone else, including patients, but had minimal interaction with prescribers. We observed a rate of 1.2 (95% CI 1.1-1.4) interruptions per hour on average and 30% of all interruptions occurred during medication management tasks. Nurses spent 3.7% of their time multitasking. Interruptions while performing medication-related tasks were common, as well as multitasking. Causes and consequences of the results need to be addressed in order to improve the safety of medication management for patients receiving municipality-based home care.
In Search of an Ideal Closure Method: A Randomized, Controlled Trial of Octyl-2-Cyanoacrylate and Adhesive Mesh versus Subcuticular Suture in Reduction Mammaplasty
Authors: Lee James C. , Ishtihar Sherene , Means Jessica J. , Wu June , Rohde Christine H.
Published: July 2018

Background:

An ideal wound closure system is one that is effective, consistent, and efficient. Recent studies have demonstrated the efficacy of octyl-2-cyanoacrylate and mesh (Dermabond Prineo) in the closure of surgical wounds. This study compared the use of Prineo to use of subcuticular suture closure in reduction mammaplasty.

Methods:

A prospective, randomized, controlled, single-blind study of patients undergoing bilateral reduction mammaplasty was performed. Each breast per patient was randomized to layered closure with Prineo or subcuticular sutures. Incisions were assessed at 2 weeks, 6 weeks, 6 months, and 1 year. Subjects completed the Patient and Observer Scar Assessment Scale for each breast, and two blinded plastic surgeons evaluated scar quality using the Vancouver Scar Scale at each time point.

Results:

Twenty-one patients participated in the study. On average, Prineo closure took 58.38 seconds (2.50 seconds/cm) and subcuticular closure took 444.76 seconds (18.94 seconds/cm). Prineo closure was approximately 6.8 times faster (p < 0.001) than subcuticular closure, saving an average of 6.4 minutes per incision. Vancouver Scar Scale scores were significantly better in patients with Prineo closure at 2 weeks (p = 0.026), although there was no difference in Patient and Observer Scar Assessment Scale and Vancouver Scar Scale scores at all other time points.

Conclusions:

In reduction mammaplasty, Prineo closure results in similar scar quality and lower operative cost without increased complications when compared to subcuticular closure. Prineo is faster than subcuticular closure and represents an effective, consistent, and efficient alternative to subcuticular suture techniques.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, II.
The Influence of Physician Payments on the Method of Breast Reconstruction: A National Claims Analysis
Authors: Sheckter Clifford C. , Panchal Hina J. , Razdan Shantanu N. , Rubin David , Yi Day , Disa Joseph J. , Mehrara Babak , Matros Evan
Published: July 2018

Background:

Flap-based breast reconstruction demands greater operative labor and offers superior patient-reported outcomes compared with implants. However, use of implants continues to outpace flaps, with some suggesting inadequate remuneration as one barrier. This study aims to characterize market variation in the ratio of implants to flaps and assess correlation with physician payments.

Methods:

Using the Blue Health Intelligence database from 2009 to 2013, patients were identified who underwent tissue expander (i.e., implant) or free-flap breast reconstruction. The implant-to-flap ratio and physician payments were assessed using quadratic modeling. Matched bootstrapped samples from the early and late periods generated probability distributions, approximating the odds of surgeons switching reconstructive method.

Results:

A total of 21,259 episodes of breast reconstruction occurred in 122 U.S. markets. The distribution of implant-to-flap ratio varied by market, ranging from the fifth percentile at 1.63 to the ninety-fifth percentile at 43.7 (median, 6.19). Modeling the implant-to-flap ratio versus implant payment showed a more elastic quadratic equation compared with the function for flap-to-implant ratio versus flap payment. Probability modeling demonstrated that switching the reconstructive method from implants to flaps with a 0.75 probability required a $1610 payment increase, whereas switching from flaps to implants at the same certainty occurred at a loss of $960.

Conclusions:

There was a correlation between the ratio of flaps to implants and physician reimbursement by market. Switching from implants to flaps required large surgeon payment increases. Despite a relative value unit schedule over twice as high for flaps, current flap reimbursements do not appear commensurate with physician effort.
Abdominal Panniculectomy: Determining the Impact of Diabetes on Complications and Risk Factors for Adverse Events
Authors: Kantar Rami S. , Rifkin William J. , Wilson Stelios C. , David Joshua A. , Diaz-Siso J. Rodrigo , Levine Jamie P. , Golas Alyssa R. , Ceradini Daniel J.
Published: July 2018

Background:

The prevalence of obesity along with bariatric surgery and massive weight loss requiring panniculectomy is increasing in the United States. The effect of diabetes mellitus on outcomes following panniculectomy remains poorly defined despite its prevalence. This study aims to evaluate the impact of diabetes mellitus on complications following panniculectomy and determine risk factors for adverse events.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients undergoing panniculectomy between 2010 and 2015. Patients were stratified based on diabetes status.

Results:

Review of the database identified 7035 eligible patients who underwent panniculectomy, of which 770 (10.9 percent) were diabetic. Multivariate regression showed that diabetes mellitus was a significant risk factor for wound dehiscence (OR, 1.92; 95 percent CI, 1.41 to 3.15; p = 0.02). Obesity was a significant risk factor for superficial (OR, 2.78; 95 percent CI, 1.53 to 3.69; p < 0.001) and deep (OR, 1.52; 95 percent CI, 1.38 to 3.97; p = 0.01) incisional surgical-site infection. Smokers were also at an increased risk for superficial (OR, 1.42; 95 percent CI, 1.19 to 1.75; p = 0.03) and deep (OR, 1.63; 95 percent CI, 1.31 to 2.22; p = 0.02) incisional surgical-site infection.

Conclusions:

Diabetes mellitus is an independent risk factor for wound dehiscence following panniculectomy. Obesity and smoking were significant risk factors for superficial and deep incisional surgical-site infection. These results underscore the importance of preoperative risk factor evaluation in patients undergoing panniculectomy for safe outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, II.
Micro-RNA–Regulated Proangiogenic Signaling in Arteriovenous Loops in Patients with Combined Vascular and Soft-Tissue Reconstructions: Revisiting the Nutrient Flap Concept
Authors: Henn Dominic , Abu-Halima Masood , Falkner Florian , Wermke Dominik , Meme Lilian G. , Kühner Clemens , Keller Andreas , Kneser Ulrich , Meese Eckart , Schmidt Volker J.
Published: July 2018

Background:

The placement of arteriovenous loops can enable microvascular anastomoses of free flaps when recipient vessels are scarce. In animal models, elevated fluid shear stress in arteriovenous loops promotes neoangiogenesis. Anecdotal reports in patients indicate that vein grafts used in free flap reconstructions of ischemic lower extremities are able to induce capillary formation. However, flow-stimulated angiogenesis has never been systematically investigated in humans, and it is unclear whether shear stress alters proangiogenic signaling pathways within the vascular wall of human arteriovenous loops.

Methods:

Eight patients with lower extremity soft-tissue defects underwent two-stage reconstruction with arteriovenous loop placement, and free flap anastomoses to the loops 10 to 14 days later. Micro-RNA (miRNA) and gene expression profiles were determined in tissue samples harvested from vein grafts of arteriovenous loops by microarray analysis and quantitative real-time polymerase chain reaction. Samples from untreated veins served as controls.

Results:

A strong deregulation of miRNA and gene expression was detected in arteriovenous loops, showing an overexpression of angiopoietic cytokines, oxygenation-associated genes, vascular growth factors, and connexin-43. The authors discovered inverse correlations along with validated and bioinformatically predicted interactions between angiogenesis-regulating genes and miRNAs in arteriovenous loops.

Conclusions:

The authors’ findings demonstrate that elevated shear stress triggers proangiogenic signaling pathways in human venous tissue, indicating that arteriovenous loops may have the ability to induce neoangiogenesis in humans. The authors’ data corroborate the nutrient flap hypothesis and provide a molecular background for arteriovenous loop–based tissue engineering with potential clinical applications for soft-tissue defect reconstruction.
Abdominoplasty with Circumferential Liposuction: A Review of 1000 Consecutive Cases
Authors: Sozer Sadri Ozan , Basaran Karaca , Alim Hasan
Published: July 2018

Background:

The authors present the technique called “abdominoplasty with concurrent circumferential liposuction,” where the whole trunk is addressed as a single aesthetic unit.

Methods:

Between January of 2008 and June of 2016, abdominoplasty with circumferential liposuction was performed in 1000 patients (984 women and 16 men) by the senior author. Patients had a mean body mass index of 27.5 kg/m2 (range, 18.1 to 34.5 5 kg/m2). Liposuction was performed circumferentially and the abdominal flap was detached up to the costal margins. Simultaneous fat grafting was also performed if required. Outcomes and complications were documented.

Results:

Traditional abdominoplasty incisions were used in 359 patients, whereas extended incisions were used in 641 patients. The mean duration of follow-up was 27 months (range, 12 days to 61 months), and the mean duration of surgery was 154 minutes (range, 109 to 260 minutes). The mean amount of simultaneously aspired supernatant lipoaspirate was 1940 cc (range, 1700 to 4580 cc). Simultaneous gluteal fat grafting was performed in 34 percent. None of the patients had any skin necrosis. The most common complication was seroma (19 percent).

Conclusions:

In abdominoplasty, the entire central body should be considered as a single unit. Circumferential widespread liposuction with standard undermining of the abdominal flap up to the costal margins is safe and yields superior aesthetic outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Peer support for people with advanced cancer: a systematically constructed scoping review of quantitative and qualitative evidence
Authors: Walshe Catherine , Roberts Diane
Published: July 2018

Purpose of review

The number of people living with advanced cancer is increasing, and appropriate support to this population is essential. Peer support is increasingly advocated as a component of care, but little is known about how to provide this in the context of advanced cancer. This review describes the experience and impact of different forms of peer support for people with advanced cancer.

Recent findings

Data from 22 articles were reviewed, primarily descriptive studies. They describe three forms of peer support (one-to-one, group, and online), reaching primarily those who are women, middle-aged, and well educated. Only two studies focused on support to people with advanced cancer, but those with advanced cancer were frequent users of all forms of peer support. Benefits of peer support were described, but no data were presented to allow a determination of the best form of support for people with advanced cancer.

Practitioners can be assured that peer support is likely to be beneficial and provide care that complements that of clinicians. However, there is a need for a comprehensive programme of high-quality evaluative research of peer support for people with advanced cancer.