bluuebunny/crossref_metadata_2025 huggingface dataset:
Independently measuring cognitive complexity in task design for interlanguage pragmatics development
Authors: Gilabert Roger , Barón Júlia
Published: July 2018

This study examines the effects of task design on interlanguage pragmatics, bringing together task complexity and L2 pragmatic outcomes measured holistically. Fifteen expert judges were asked independently to assess task complexity and to evaluate the pragmatic performance of 60 EFL learners who had written a response to four email messages at 4 different levels of complexity. On the basis of needs analysis, complexity had been manipulated by along the following parameters: +/−frequency of input, +/−familiarity with interlocutor, +/−intentional, +/−causal reasoning, +/−dependency of steps, +/−number of elements, and +/−dual task. In order to validate complexity independently, two techniques were applied. On the one hand, a subjective perception questionnaire evaluating mental effort and difficulty was answered by 15 experienced teachers. On the other hand, subjective judgments on a pragmatic scale by the same teachers followed by retrospective protocol analysis were used in the classification of tasks from simple to complex. Pragmatic outcomes were assessed on a holistic rating scale of pragmatic performance. While descriptive statistical results pointed in the direction of predictions, inferential statistics only confirm a difference between the first level of complexity and the other three. As for the effect of sequence, expert judges did not find the outcomes of the two sequences to differ. Results are discussed in light of task performance, task sequencing, and interlanguage pragmatics development.
The PDR-type ABC transporters AtrA and AtrG are involved in azole drug resistance in Aspergillus oryzae
Authors: Miura Daisuke , Sugiyama Kohei , Ito Atsushi , Ohba-Tanaka Ayumi , Tanaka Mizuki , Shintani Takahiro , Gomi Katsuya
Published: July 2018

For strain improvement of Aspergillus oryzae, development of the transformation system is essential, wherein dominant selectable markers, including drug-resistant genes, are available. However, A. oryzae generally has a relatively high resistance to many antifungal drugs effective against yeasts and other filamentous fungi. In the course of the study, while investigating azole drug resistance in A. oryzae, we isolated a spontaneous mutant that exhibited high resistance to azole fungicides and found that pleiotropic drug resistance (PDR)-type ATP-binding cassette (ABC) transporter genes were upregulated in the mutant; their overexpression in the wild-type strain increased azole drug resistance. While deletion of the gene designated atrG resulted in increased azole susceptibility, double deletion of atrG and another gene (atrA) resulted in further azole hypersensitivity. Overall, these results indicate that the ABC transporters AtrA and AtrG are involved in azole drug resistance in A. oryzae.
Recent Epidemiological Trends in Marijuana Use
Authors: Cottler Linda B. , Okafor Chukwuemeka N.
Published: July 2018

This chapter provides a description of recent epidemiologic trends in marijuana use among U.S. adolescents and adults. Data from large national surveys conducted in the United States on rates of marijuana use have documented various trends in marijuana use. Specifically, the chapter discusses results from the National Survey on Drug Use and Health, Monitoring the Future, Youth Risk Behavior Surveillance System, and the National Monitoring of Adolescent Prescription Stimulant Study. These surveys show that the prevalence of marijuana use has increased for some subgroups in recent years, but rates of cannabis abuse or dependence among adolescents and adults examined have remained relatively steady.
Effects of Adolescent Cannabis Use on Brain Structure and Function
Authors: Schuster Randi Melissa , Gilman Jodi , Evins A. Eden
Published: July 2018

The nature, severity, and persistence of effects of cannabis use on the structure and function of the developing adolescent brain is an active area of research. This chapter will review what is known about these relationships during adolescence (i.e., the time between initiation of sexual maturation and completion of higher-order cognitive development; i.e., ages 10–24). In general, the authors find that cannabis has a negative association with neurocognition beyond acute intoxication and that earlier age of onset of regular cannabis use is associated with worse neurocognitive outcomes. The discussion highlights critical relationships between cannabis and brain development, and underlines areas that are incompletely understood and should be further studied to be adequately informed for this era of rapid policy change regarding cannabis regulation.
Marijuana-Impaired Driving
Authors: DuPont Robert L. , Holmes Erin A. , Talpins Stephen K. , Walsh J. Michael
Published: July 2018

Drug-impaired driving is a serious threat to public safety and health on par with alcohol-impaired driving. Marijuana is the most widely used illicit drug among drivers, including those seriously and fatally injured in crashes. Research confirms that marijuana use can cause significant short- and long-term impairment, putting users and others on the road at risk of crash and injury. There is no consistent relationship between the blood concentration of ∆9-tetrahydrocannabinol, the primary psychoactive component in marijuana, and driving impairment. There is substantial precedent and support for zero tolerance per se laws for drugs for drivers arrested for suspicion of driving under the influence. Administrative license revocation is another tool currently used in alcohol-impaired driving cases that could be useful for removing drug-impaired drivers from the road. Recommendations are provided for drug testing, including using new oral fluid screening technology and further research on and monitoring of marijuana-impaired driving.
Risk Factors for Adolescent Marijuana Use
Authors: Catalano Richard F. , Speaker Elizabeth C. , Skinner Martie L. , Bailey Jennifer A. , Hong Ge , Haggerty Kevin P. , Guttmannova Katarina , Harrop Erin N.
Published: July 2018

Marijuana use has been linked to a wide variety of negative consequences, especially for those who initiate use in early adolescence and become daily or regular users as a teenager. If these negative consequences are to be avoided, prevention efforts must focus upstream on childhood and adolescent developmental periods before marijuana use is initiated or has become frequent. Upstream prevention targets factors that predict initiation and escalation of marijuana use, which are often called risk and protective factors. This chapter provides a review of current knowledge about risk and protective factors, with an emphasis on psychosocial variables specific to marijuana, differentiating predictors of marijuana use from predictors of other legal and illegal drugs when possible. The chapter also provides suggestions for future research in light of the rapidly changing legal and community conditions related to access, availability, and norms of marijuana use.
Post-Traumatic Stress Disorder in Adults
Authors: Moshier Samantha J. , Parker-Guilbert Kelly S. , Marx Brian P. , Keane Terence M.
Published: July 2018

Post-traumatic stress disorder (PTSD) was originally conceptualized as a relatively rare response to extraordinary and severe stressors, such as war, violent acts, vehicular or industrial accidents, sexual assault, and other disasters or events that are outside the range of usual human experience. Today, traumatic events and PTSD are viewed as worldwide phenomena that are prevalent and cross all subgroups of the population. This chapter focuses on the assessment of PTSD. It begins with a review of the nature of the disorder, which is followed by a review of clinical assessment instruments designed for the assessment purposes of (a) diagnosis, (b) case conceptualization and treatment planning, and (c) treatment monitoring and evaluation. Recommendations are included for instruments with the greatest scientific support and for assessing PTSD in a clinically sensitive manner.
Alcohol Use Disorder
Authors: Haeny Angela M. , Boness Cassandra L. , McDowell Yoanna E. , Sher Kenneth J.
Published: July 2018

Although extremely heterogeneous across individuals, the general course of alcohol use disorders begins with increasing alcohol involvement during adolescence, peak involvement during late adolescence and early adulthood, and a gradual decrease during adulthood. Four prototypical courses of alcohol involvement have been identified: a non-user/stable low-user course, a chronic or high-user course, a “developmentally limited” course that declines over the lifespan, and a later-onset course that gradually increases over the lifespan. This chapter focuses on the assessment of alcohol use disorders in adults. It begins with a review of the nature of the disorders, which is followed by a review of clinical assessment instruments designed for the assessment purposes of (a) diagnosis, (b) case conceptualization and treatment planning, and (c) treatment monitoring and evaluation. Recommendations are included for instruments with the greatest scientific support and for assessing alcohol use disorders in a clinically sensitive manner.
Session 2: Completing the Closeness Circle and Identifying Parenting Challenges
Authors: Dietz Laura J.
Published: July 2018

Chapter 6 of Family-based Interpersonal Psychotherapy (FB-IPT) for Depressed Preadolescents presents the second session of family-based interpersonal therapy (FB-IPT), in which the therapist outlines the structure for the remainder of the initial phase of treatment (check-in, time with the preadolescent, and time with the parent). The preadolescent rates their feelings using the mood thermometer during the check-in and the therapist helps to link changes in her mood to interpersonal events in the last week. The therapist completes a closeness circle with the preadolescent, a visual mapping of important relationships with family members and friends. When meeting with the parent individually, the therapist helps the parent to identify a challenging aspect of parenting his or her preteen where the limited sick role can be applied.
Sessions 10 and 11: Designing Interpersonal Experiments for Comorbid Anxiety
Authors: Dietz Laura J.
Published: July 2018

Chapter 14 of Family-based Interpersonal Psychotherapy (FB-IPT) for Depressed Preadolescents presents the tenth and eleventh sessions of family-based interpersonal therapy (FB-IPT), in which the therapist introduces interpersonal approach strategies to help socially isolated or avoidant preadolescents increase their interactions peers. Working collaboratively with the preadolescent, the therapist helps identify peers and situations where the preadolescent could initiate a brief interaction and scripts examples of saying hello, asking a question, or giving a compliment. After role-playing, the therapist encourages the preteen to implement this approach in the upcoming week as an “interpersonal experiment,”, with the hope that more frequent initiation with peers will result in more positive moods. The therapist enlists the parent as support for the preadolescent in completing the interpersonal experiment.
Special Topics in FB-IPT
Authors: Dietz Laura J.
Published: July 2018

Chapter 18 of Family-based Interpersonal Psychotherapy (FB-IPT) for Depressed Preadolescents illustrates how to manage certain clinical challenges that are unique to working with preadolescents and when working dyadically with their families. The clinical issues discussed in this chapter include school avoidance, therapy noncompliance, identification of comorbid diagnoses during treatment, suicidality, divorce and custody issues, multiple caregiver involvement in treatment, and parental psychopathology. We will define each challenge and discuss specific adaptations that can be made to address these challenges within the framework of FB-IPT. We will also discuss times when FB-IPT is no longer appropriate and when a preadolescent should be referred to a higher level of care or a different clinical service.
Empirical Evidence for FB-IPT
Authors: Dietz Laura J.
Published: July 2018

Chapter 19 of Family-based Interpersonal Psychotherapy (FB-IPT) for Depressed Preadolescents reviews the results of author-led trials that support family-based interpersonal psychotherapy (FB-IPT) as an efficacious psychotherapy for increasing remission from MDD and decreasing preadolescents’ comorbid anxiety and interpersonal impairment. This chapter also emphasizes that psychotherapy for preadolescents with depression presents an opportunity to reduce family and interpersonal risk factors that may increase the likelihood of recurrent depression in adolescence, and highlights FB-IPT as meeting a need for a developmentally appropriate treatment especially for preadolescents experiencing depression. Future directions for additional research and studies on implementing and disseminating FB-IPT to community-based agencies are also outlined.
Arrhythmogenic mechanisms of obstructive sleep apnea in heart failure patients
Authors: Chadda Karan R , Fazmin Ibrahim T , Ahmad Shiraz , Valli Haseeb , Edling Charlotte E , Huang Christopher L-H , Jeevaratnam Kamalan
Published: July 2018

Heart failure (HF) affects 23 million people worldwide and results in 300000 annual deaths. It is associated with many comorbidities, such as obstructive sleep apnea (OSA), and risk factors for both conditions overlap. Eleven percent of HF patients have OSA and 7.7% of OSA patients have left ventricular ejection fraction <50% with arrhythmias being a significant comorbidity in HF and OSA patients. Forty percent of HF patients develop atrial fibrillation (AF) and 30%–50% of deaths from cardiac causes in HF patients are from sudden cardiac death. OSA is prevalent in 32%–49% of patients with AF and there is a dose-dependent relationship between OSA severity and resistance to anti-arrhythmic therapies. HF and OSA lead to various downstream arrhythmogenic mechanisms, including metabolic derangement, remodeling, inflammation, and autonomic imbalance. (1) Metabolic derangement and production of reactive oxidative species increase late Na+ currents, decrease outward K+ currents and downregulate connexin-43 and cell-cell coupling. (2) remodeling also features downregulated K+ currents in addition to decreased Na+/K+ ATPase currents, altered Ca2+ homeostasis, and increased density of If current. (3) Chronic inflammation leads to downregulation of both Nav1.5 channels and K+ channels, altered Ca2+ homeostasis and reduced cellular coupling from alterations of connexin expression. (4) Autonomic imbalance causes arrhythmias by evoking triggered activity through increased Ca2+ transients and reduction of excitation wavefront wavelength. Thus, consideration of these multiple pathophysiological pathways (1–4) will enable the development of novel therapeutic strategies that can be targeted against arrhythmias in the context of complex disease, such as the comorbidities of HF and OSA.
New biologics in the treatment of urticaria
Authors: Kocatürk Emek , Zuberbier Torsten
Published: July 2018

Purpose of review

Symptomatic management of chronic spontaneous urticaria (CSU) basically depends on second-generation H1 antihistamines and omalizumab. Omalizumab is a game changer in the management, but still there is a need for new targets and new biologics targeting new pathways in the treatment which will provide long-lasting remission, which will be given orally and which will be cheaper. This review will focus on new biologics that are underway of production or are already under use for different disorders but could be beneficial for the treatment of Chronic urticaria.

Recent findings

In this review, the treatment targets are classified according to the cells which are involved in the pathogenesis of CSU. Those are mast cells/basophils, B cells, T cells and eosinophils. The treatments that are under clinical trials for CSU are anti-IgE treatments such as ligelizumab, molecules targeting intracellular signaling pathways such as spleen tyrosine kinase inhibitors, surface inhibitory molecules such as siglec-8, anti-IL-1s such as canakinumab, Bruton kinase (BTK) inhibitors such as GDC-0853 and anti-IL-5s such as benralizumab and mepolizumab.

The ongoing clinical trials on new targets of treatment hold new hopes not only for a better care of the disease but also a better understanding of the pathomechanisms lying underneath.
Gastric Residual Volumes Versus Abdominal Girth Measurement in Assessment of Feed Tolerance in Preterm Neonates
Authors: Thomas Shemi , Nesargi Saudamini , Roshan Preena , Raju Renjita , Mathew Shiny , P. Sheeja , Rao Suman
Published: July 2018

Background:

Preterm neonates often have feed intolerance that needs to be differentiated from necrotizing enterocolitis. Gastric residual volumes (GRV) are used to assess feed tolerance but with little scientific basis.

Purpose:

To compare prefeed aspiration for GRV and prefeed measurement of abdominal girth (AG) in the time taken to reach full feeds in preterm infants.

Methods:

This was a randomized controlled trial. Infants with a gestational age of 27 to 37 weeks and birth weight of 750 to 2000 g, who required gavage feeds for at least 48 hours, were included. Infants were randomized into 2 groups: infants in the AG group had only prefeed AG measured. Those in the GRV group had prefeed gastric aspiration obtained for the assessment of GRV. The primary outcome was time to reach full enteral feeds at 150 mL/kg/d, tolerated for at least 24 hours. Secondary outcomes were duration of hospital stay, need for parenteral nutrition, episodes of feed intolerance, number of feeds withheld, and sepsis.

Results:

Infants in the AG group reached full feeds earlier than infants in the GRV group (6 vs 9.5 days; P = .04). No significant differences were found between the 2 groups with regard to secondary outcomes.

Implications for Practice:

Our research suggests that measurement of AG without assessment of GRV enables preterm neonates to reach full feeds faster than checking for GRV.

Implications for Research:

Abdominal girth measurement as a marker for feed tolerance needs to be studied in infants less than 750 g and less than 26 weeks of gestation.
Reoperation Rate After Microsurgical Uni- or Bilateral Laminotomy for Lumbar Spinal Stenosis With and Without Low-grade Spondylolisthesis
Authors: Schär Ralph T. , Kiebach Stefanie , Raabe Andreas , Ulrich Christian T.
Published: July 2018

Study Design.

Retrospective single-center cohort study.

Objective.

The aim of this study was to analyze the influence of preoperative radiographic parameters on reoperation rates after microsurgical laminotomy for lumbar spinal stenosis (LSS).

Summary of Background Data.

Decompression for symptomatic LSS has shown to be effective. However, the optimal surgical strategy remains a matter of debate, especially with underlying spondylolisthesis.

Methods.

Adult patients with LSS who underwent primary laminotomy without fusion between January 2012 and September 2013 at our institution were included for analysis. Disc height (in mm), facet joint (FJ) orientation (degrees), and grade of spondylolisthesis of all surgical index levels (SILs) were analyzed from preoperative magnetic resonance imaging. Patients were contacted in January 2017 by follow-up phone call (mean follow-up 49 months) regarding lumbar reoperation.

Results.

A total of 161 patients (mean age 68.5 yrs, ±11.3) and 236 SILs were analyzed. Fifty-six patients (34.8%) had low-grade spondylolisthesis involving 60 SILs (25.4%). Twenty-four patients (14.9%) underwent reoperation involving 32 levels. Of latter, 23 SILs (9.7%) had recurrent stenosis (RS) and 9 (3.8%) had adjacent level stenosis. Five patients in total (3.1%) required secondary fusion; all had preexisting spondylolisthesis. SILs with spondylolisthesis had a significantly higher rate of RS requiring reoperation compared with SILs without spondylolisthesis [18.3% (11/60) vs. 6.8% (12/176), P = 0.013]. Disc height and FJ orientation showed no significant difference between patients with and without reoperation, or with and without spondylolisthesis.

Conclusion.

Decompression alone is reasonable for most patients with LSS and stable low-grade spondylolisthesis. The overall reoperation rate and need for secondary fusion were low in our series. However, patients with spondylolisthesis had a higher rate of reoperation for RS after laminotomy without fusion. This must be taken into account for preoperative risk-benefit analysis, tailored surgical decision making and patient counseling.

Level of Evidence: 4
Long-term relative survival from melanoma in Germany 1997–2013
Authors: Brunssen Alicia , Jansen Lina , Eisemann Nora , Waldmann Annika , Weberpals Janick , Kraywinkel Klaus , Eberle Andrea , Holleczek Bernd , Zeissig Sylke R. , Brenner Hermann , Katalinic Alexander
Published: July 2018

Up-to-date melanoma relative survival (RS) estimates and trend analysis facilitate close monitoring of melanoma patients’ prognosis. This study aimed to provide recent 5-year and 10-year RS from melanoma, stratified by prognostic factors, and identify latest survival trends. Data from 12 German cancer registries were analysed. We included patients with primary cutaneous malignant melanoma (ICD-10: C43.X) diagnosed in 1997–2013 who were at least 15 years old. Five-year and 10-year RS were estimated by period analysis. For 10-year RS analyses, we excluded patients who were 75 years of age or older. Analyses were stratified by sex, age, histology, tumour stage, and body site. We included 82 901 patients, of whom 51% were women. The median age at diagnosis was 62 years. Five-year and 10-year RS in 2007–2013 were 92.4 and 90.8%, respectively. RS was higher in women. The prognosis worsened with older age and higher stage. In superficial spreading melanoma and lentigo maligna melanoma, RS was high; it was lower in nodular, acral lentiginous and ‘other’ melanoma. RS was the highest for melanoma on the arms; RS for melanoma on unknown or overlapping sites of the skin was the lowest. Five-year and 10-year RS increased significantly from 2005–2007 and 2008–2010 to 2011–2013, by 3.5 and 3.3 percentage points, respectively. For melanoma of ‘other’ histology, 5-year and 10-year RS increased significantly. Ten-year RS also increased significantly in men with superficial spreading melanoma and T4 melanoma, and in women with T3 melanoma. Melanoma RS improved, especially in certain subgroups. The reasons for improvements need to be investigated further.
Risk factors for sexual dysfunction in BRCA mutation carriers after risk-reducing salpingo-oophorectomy
Authors: Chan Jessica L. , Senapati Suneeta , Johnson Lauren N.C. , DiGiovanni Laura , Voong Chan , Butts Samantha F. , Domchek Susan M.
Published: July 2018

Objective:

The aim of the study was to identify risk factors for sexual dysfunction in BRCA mutation carriers who have undergone risk-reducing salpingo-oophorectomy (RRSO).

Methods:

A cross-sectional study was performed. BRCA1/2 mutation carriers with and without RRSO were surveyed to determine sexual function (Female Sex Function Index [FSFI]), demographics, medical history, sleep quality, depression, and anxiety scores. Characteristics of patients with the lowest quartile of FSFI scores (<14 ± 8.8) were analyzed to identify risk factors for the most severe phenotype.

Results:

In the 804 women surveyed, 764 underwent RRSO. Of the 529 (69%) carriers with completed FSFI questionnaires in the RRSO cohort, sexual dysfunction was reported in 77.3%. Poor sleep (P = 0.002), hot flashes (P = 0.002), lack of current systemic hormone therapy (HT) use (P = 0.002), depression (P < 0.001), and anxiety (P = 0.001) were associated with sexual dysfunction. In adjusted analyses, depression (adjusted odds ratio [aOR] 2.4, 95% CI, 1.4-4.1) and hot flashes (aOR 1.9, 95% CI, 1.2-3.0) remained significantly associated with sexual dysfunction. Depression was also a significant risk factor for the most severe degree of sexual dysfunction (OR 2.1, 95% CI, 1.3-3.5) and had the greatest impact on Arousal and Satisfaction domain scores of the FSFI. Current systemic HT use seemed to decrease the risk for sexual dysfunction (aOR 0.6, 95% CI, 0.4-1.0).

Conclusions:

Sexual dysfunction is highly prevalent in BRCA mutation carriers after RRSO. Depression seems to be a significant risk factor for sexual dysfunction in this patient population and may be under-recognized and undertreated. Patient and provider education on sexual side effects after surgery and risk factors for sexual dysfunction is necessary to decrease postoperative sexual distress. HT may be associated with improved sexual function after surgery.
Decreasing sleep-related symptoms through increasing physical activity among Asian American midlife women
Authors: Chee Wonshik , Kim Sangmi , Tsai Hsiu-Min , Im Eun-Ok
Published: July 2018

Objective:

The beneficial effects of physical activities on sleep-related symptoms have been reported in the literature, and physical activity has been suggested as an efficient strategy to reduce sleep-related symptoms among midlife women. The effect of Web-based physical activity promotion programs on sleep-related symptoms have, however, rarely been explored, especially among midlife racial/ethnic minority women. The purpose of this pilot study was to test the preliminary efficacy of a WPAPP on self-reported sleep-related symptoms and physical activity of Asian American midlife women.

Methods:

This pilot study was a randomized repeated measures pretest/posttest control group study (14 in an intervention group and 12 in a control group). Multiple instruments were used to measure background characteristics (eg, sociodemographic and health status), sleep-related symptoms and physical activity experiences at pretest, post 1 month, and post 3 months. The data were analyzed using an intent-to-treat linear mixed-model growth curve analysis.

Results:

After adjusting for covariates and random intercept, the intervention group showed a significant decrease in the total numbers of psychological (P = 0.0956) and total sleep-related symptoms (P = 0.0733) at post 1 month. Also, both groups showed a significant increase in physical activity (active living habits) at post 3 months (P = 0.0353).

Conclusions:

The WPAPP is potentially beneficial in decreasing Asian American midlife women's sleep-related symptoms and promoting their lifestyle physical activity.
Successful Pregnancy and Delivery after Autologous Abdominal Wall Reconstruction using Anterolateral-Thigh and Iliotibial-Tract Flap
Authors: Kagaya Yu , Arikawa Masaki , Kobayashi Eisuke , Kawai Akira , Miyamoto Shimpei
Published: July 2018

The surgical management of abdominal wall tumor in women with childbearing potential is a thorny issue. A synthetic mesh is widely used for abdominal wall reconstruction but not necessarily applicable in case of women of childbearing potential because it has been reported to cause severe pain during pregnancy. Autologous reconstruction is usually considered a feasible option for such cases; however, there is no consensus on this approach and almost no evidence to support it. In the present 2 cases, 2 female patients (age, 17 years and 35 years) with abdominal wall desmoid tumor underwent primary radical resection and autologous reconstruction of an abdominal wall defect in the lateral oblique muscle area (defect size, 13 × 5 cm and 8 × 6 cm) using an anterolateral thigh and iliotibial tract flap. The postoperative course was uneventful. Both patients achieved pregnancy and a full-term delivery without complications with the exception of a feeling of mild stretching in the area of the operation. Magnetic resonance imaging and a clinical examination after the delivery revealed no signs of abdominal wall hernia or bulging. Normal pregnancy and full-term delivery could be obtained after abdominal wall resection and autologous reconstruction using an anterolateral thigh + iliotibial tract flap. This reconstructive method is considered to be a versatile option for the management of abdominal wall tumor in women with childbearing potential; however, further evidence should be accumulated on the reconstruction of wider and central abdominal wall defects.
MULTIMODAL IMAGING OF MACULAR CHOROIDAL MACROVESSEL: A REPORT OF TWO CASES
Authors: Dalvin Lauren A. , Pennington Justin D. , Mashayekhi Arman , Shields Carol L.
Published: July 2018

Purpose:

To report two cases of macular choroidal macrovessel with description of multimodal imaging and review of published cases.

Methods:

Medical and imaging records were retrospectively reviewed. A literature review was performed to identify other cases of macular choroidal macrovessel published between 1990 and 2018.

Results:

There were 2 patients referred for evaluation of a potential choroidal tumor, including a 55-year-old white woman with no visual symptoms and a 68-year-old white woman with blurred vision. Funduscopic examination in each case revealed a focal area of choroidal elevation in the temporal foveal area with a single, dilated, slightly tortuous choroidal vessel, estimated to measure 250 μm and 300 μm, respectively, at widest girth, and extending temporally toward the equator with a tapering width. Optical coherence tomography showed an optically hollow choroidal lesion elevating the retinal pigment epithelium with overlying ellipsoid zone mottling. Both cases demonstrate shallow subretinal fluid, sparing the foveola. Fluorescein angiography showed faint staining along the course of the vessel in both cases. Indocyanine green angiography demonstrated clear visualization of the ectatic vessel with early filling and late staining without leakage. Both patients retained visual acuity of 20/25 in the affected eye and did not require treatment.

Conclusion:

Macular choroidal macrovessel is a rare vascular anomaly presenting as a single, dilated, tortuous choroidal vessel, originating in the temporal foveal region and extending temporally to the equator. This finding can simulate a choroidal neoplasm or parasitic track. Optical coherence tomography and indocyanine green angiography have diagnostic value demonstrating the vascular nature of this lesion and delineating the vascular course.
PARACENTRAL ACUTE MIDDLE MACULOPATHY AFTER ENDOVASCULAR COIL EMBOLIZATION
Authors: Nakamura Masaki , Katagiri Satoshi , Hayashi Takaaki , Yoshioka Mayumi , Nakano Tadashi
Published: July 2018

Purpose:

To describe two cases of paracentral acute middle maculopathy (PAMM) that occurred unilaterally after endovascular coil embolization.

Methods:

Medical records including ophthalmic examinations of two PAMM cases were retrospectively reviewed.

Results:

The first case was a 64-year-old woman with hyperlipidemia and chronic sinusitis. The second case was a 49-year-old man with hypertension, hyperlipidemia, tension headache, and vertigo. Both cases exhibited paracentral scotomas just after endovascular coil embolization. Ophthalmoscopy showed multiple faint white-yellow lesions in each affected eye. Optical coherence tomography showed hyper-reflective bands that were mainly observed in the inner nuclear layer and corresponded to the PAMM lesions. Optical coherence tomography angiography revealed variable degrees of abnormal vasculature from slight dilation, decreased visualization, to nonvisualization in the superficial capillary plexuses and similar capillary changes in deep capillary plexuses.

Conclusion:

We described two cases with PAMM that occurred after endovascular coil embolization, which was a new precursor cause of PAMM. Our results demonstrate that optical coherence tomography angiography is especially useful for not only diagnosis, but also for follow-up evaluations in patients with PAMM.
ATYPICAL HEALING IN A CASE WITH RETINAL PIGMENT EPITHELIUM APERTURES
Authors: Molina-Pallete Rodrigo , Andreu-Fenoll Maria , Gallego-Pinazo Roberto , Dolz-Marco Rosa
Published: July 2018

Purpose:

To analyze the multimodal imaging features in a case showing resolution of retinal pigment epithelium (RPE) apertures in association with an avascular pigment epithelium detachment secondary to nonneovascular age-related macular degeneration.

Methods:

Report of a case diagnosed with aperture of the RPE with multimodal imaging long-term follow-up. Color fundus photography, fundus autofluorescence, eye-tracked spectral domain optical coherence tomography (OCT), and OCT angiography findings are discussed.

Results:

A 71-year-old man diagnosed with nonneovascular age-related macular degeneration presented with three different areas of RPE aperture in his right eye. At baseline, best-corrected visual acuity was 20/100 in his right eye. Dilated fundus examination showed three round areas of RPE atrophy, and fundus autofluorescence demonstrated marked hypoautofluorescence in the corresponding areas. The OCT scans showed discontinuities of the RPE band with no evidence of RPE tear. The OCT angiography showed no evidence of abnormal blood flow within the sub-RPE space. Over time, fundus autofluorescence and eye-tracked spectral domain OCT scans demonstrated spontaneous resolution of two of the RPE defects and reduction of the size of the third one, with complete flattening of the pigment epithelium detachment.

Conclusion:

Distinction between RPE tears and apertures is important due to their different etiopathogenic mechanism and prognosis. To the best of our knowledge, this is the first report of a case of complete closure of an RPE aperture. The mechanism of the observed RPE closure remains unknown, and further studies are warranted to better understand the mechanisms of RPE restoration and remodeling.
White Sparse Eyelashes
Authors: Parker James K. , Jacob Sharon E.
Published: July 2018

Teledermatology is a term to describe the provision of dermatologic medical services through telecommunication technology. This is a teledermatology case of white sparse eyelashes.
Cardiovascular disease in Down syndrome
Authors: Versacci Paolo , Di Carlo Duccio , Digilio Maria C. , Marino Bruno
Published: July 2018

Purpose of review

In the last 40 years, with a better understanding of cardiac defects, and with the improved results of cardiac surgery, the life expectancy of persons with Down syndrome has significantly increased. This review article reports on advances in knowledge of cardiac defects and cardiovascular system of persons with trisomy 21.

Recent findings

New insights into the genetics of this syndrome have improved our understanding of the pathogenetic mechanisms of cardiac defects. Recent changes in neonatal prevalence of Down syndrome suggest a growing number of children with cardiac malformations, in particular with simple types of defects. Ethnic and sex differences of the prevalence of specific types of congenital heart disease (CHD) have also been underlined. A recent study confirmed that subclinical morphologic anomalies are present in children with trisomy 21, also in the absence of cardiac defects, representing an internal stigma of Down syndrome. The results of cardiac surgery are significantly improved in terms of immediate and long-term outcomes, but specific treatments are indicated in relation to pulmonary hypertension. Particular aspects of the cardiovascular system have been described, clarifying a reduced sympathetic response to stress but also a ‘protection’ from atherosclerosis and arterial hypertension in these patients.

Continuing dedication to clinical and basic research studies is essential to further improve survival and the quality of life from childhood to adulthood of patients with trisomy 21.
Button battery and magnet ingestions in the pediatric patient
Authors: Bolton Scott M. , Saker Martha , Bass Lee M.
Published: July 2018

Purpose of review

Pediatric foreign body ingestion is a common occurrence that presents a challenge both to pediatric gastroenterologists and primary care providers. Increasing prevalence of smaller, more technologically advanced toys in the household has resulted in an increased exposure to higher voltage batteries and powerful magnets that carry a high incidence of morbidity and mortality. This review highlights the latest findings regarding the patients at risk for button battery and magnet ingestions, the symptoms of presentation, and complications of these objects in contributing to long-standing gastrointestinal injury.

Recent findings

Button batteries may lead to esophageal injury within a few hours. Batteries retained in the esophagus are larger in diameter on average and size is associated with esophageal impaction as well as higher grade esophageal injury. Magnet ingestions, when multiple or with another metallic object, are often initially asymptomatic but may have acute worsening, and therefore warrant close monitoring.

Button battery and magnet ingestions have increased in incidence over the past two decades. Recent literature demonstrates that higher voltage, larger lithium button batteries, and prevalence of high-powered magnets can lead to significant morbidity. High suspicion, early referral, and removal may lead to improved outcomes.
Systems Thinking Education in RN-BSN Programs
Authors: Stalter Ann M. , Jauch Amy
Published: July 2018

Background

Nurses need to take a lead in reducing medical errors. Formal education of systems thinking (ST) can be a catalyst for error prevention.

Problem

Integration of ST in RN-BSN education has not been studied.

Approach

A descriptive, cross-sectional design using survey methods was used.

Outcomes

Deans of accredited RN-BSN programs across the Midwest reported on ST integration across their RN-BSN programs. Gaps in ST integration were identified as (1) a lack of evaluation tools to determine mastery of systems theory, thinking and awareness, and the application of quality and safety competencies for systems-level synthesis and (2) program outcomes emphasizing autonomy of systems-level decisions.

Conclusions

Systems thinking was integrated across curricula among most accredited RN-BSN programs in the Midwest. Recommendations are to integrate systems theory into program outcomes and to develop evaluation tools that validate ST mastery.
Resuscitation With Ringer's Lactate Compared With Normal Saline for Pediatric Diabetic Ketoacidosis
Authors: Bergmann Kelly R. , Abuzzahab M. Jennifer , Nowak Jeffrey , Arms Joe , Cutler Gretchen , Christensen Eric , Finch Mike , Kharbanda Anupam
Published: July 2018

Objective

The aims of this study were to describe the use of Ringer's lactate (LR) or normal saline (NS) for resuscitation among children with diabetic ketoacidosis (DKA) and compare the effect of fluid type on cost, length of stay, and rate of cerebral edema (CE).

Methods

This is a retrospective study of 49,737 children aged 0 to 17 years with DKA between January 1, 2005, and September 30, 2015, using data from the Pediatric Health Information System. Treatment with LR or NS was identified. Our primary outcomes were total adjusted cost and length of stay. Our secondary outcome was CE rate per 1000 episodes.

Results

The majority of patients were treated with NS (n = 43,841 [88%]) compared with LR (n = 1762 [4%]) or both NS and LR (n = 4134 [8%]). Hospital-year–specific practice patterns were used to investigate the effect of fluid type across resuscitation fluid groups. Total adjusted cost was $1160 less (95% confidence interval, −1468 to −852), or −14.2%, for cases with any episode of LR compared with NS only. Length of stay was not different across groups. The rate of cerebral edema per 1000 episodes was 12.7 for cases with any episode of LR compared with 34.6 NS only (difference, −21.9; 95% confidence interval, −30.4 to −13.3).

Conclusions

Ringer's lactate was infrequently used for resuscitation of pediatric DKA patients. However, resuscitation with LR compared with NS was associated with lower total cost and rates of CE. Further investigation using patient-level clinical and laboratory data is needed to evaluate factors that drive cost and risk of CE development with each fluid.
Nonvisualization of Sentinel Lymph Nodes by Lymphoscintigraphy in Primary Cutaneous Melanoma: Incidence, Risk Factors, and a Review of Management Options
Authors: Pavri Sabrina Nicole , Gary Cyril , Martinez Rajendra Sawh , Kim Samuel , Han Dale , Ariyan Stephan , Narayan Deepak
Published: July 2018

Background:

Lymphoscintigraphy is often performed before sentinel lymph node biopsy, especially in areas likely to have multiple or aberrant drainage patterns. This study aims to determine the incidence and characteristics of melanoma patients with negative lymphoscintigraphic findings and to review the management options and surgical recommendations.

Methods:

This is a retrospective study of patients with primary cutaneous melanoma who underwent sentinel lymph node biopsy between 2005 and 2016. Patients with nonvisualized lymph nodes on preoperative lymphoscintigraphy were compared in a 1:4 ratio with a randomly selected unmatched cohort drawn from all melanoma patients who underwent preoperative lymphoscintigraphy within the period of the study. Demographic, clinical, and outcome data were compared between these groups.

Results:

A negative lymphoscintigraphic scan was seen in 2.3 percent of all cases (25 of 1073). In both univariate and multivariate analyses, predictive patient- and tumor-specific factors for negative lymphoscintigraphy included older age and head and neck location. Patients with a nonvisualized sentinel lymph node had significantly worse overall survival compared with patients who had a visualized sentinel lymph node, but there was no difference in melanoma-specific survival. In 16 of the 25 cases (64 percent), at least one sentinel lymph node was found intraoperatively despite the negative lymphoscintigraphic findings.

Conclusions:

Older patients with head and neck melanomas are more likely to experience nodal nonvisualization on lymphoscintigraphy. In patients who have nodal nonvisualization, the surgeon should attempt sentinel lymph node biopsy at the time of excision of the primary lesion because a sentinel lymph node can still be found in a majority of cases, and it offers prognostic information.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, II.
Anatomical Basis of the Gastroepiploic Vascularized Lymph Node Transfer: A Radiographic Evaluation Using Computed Tomographic Angiography
Authors: Howell Anna C. , Gould Daniel J. , Mayfield Cory , Samakar Kamran , Hassani Cameron , Patel Ketan M.
Published: July 2018

Background:

The omentum, nourished by the gastroepiploic vessels, has gained popularity as an option for vascularized lymph node transfer. The anatomy of the gastroepiploic vessels, omentum, and lymph nodes has not been investigated. The purpose of this article is to describe the right gastroepiploic artery and related structures by using computed tomographic angiography.

Methods:

A retrospective analysis was conducted on 34 patients who underwent computed tomographic angiography. Statistical models were applied to identify right gastroepiploic artery and lymph node anatomical characteristics.

Results:

The right gastroepiploic artery was identified in 33 of 34 patients. It was found to have a diameter of 2.49 ± 0.66 mm at its origin. The gastroduodenal artery length before right gastroepiploic artery takeoff was 3.09 ± 1.31 cm. Twenty-five patients had lymph nodes in the right gastroepiploic artery lymphosome. There were 2.7 ± 2.12 lymph nodes identified per patient. The distance from the right gastroepiploic artery origin to the most proximal lymph node was 3.99 ± 2.21 cm. The distance from the gastroepiploic artery origin to the third lymph node was 9.12 ± 5.06 cm. Each lymph node was within 7.00 ± 6.2 mm of the right gastroepiploic artery.

Conclusions:

When using the right gastroepiploic artery donor site for vascularized lymph node transfer, the plastic surgeon should anticipate using a pedicle length of 4 cm, a total flap length of 9 cm, and 3 cm of surrounding tissue to obtain at least three lymph nodes for transfer. Computed tomographic angiography is an effective imaging modality that can be used for patient-specific surgical navigation before vascularized lymph node transfer.
Sphenoid Dysplasia in Neurofibromatosis: Patterns of Presentation and Outcomes of Treatment
Authors: Naran Sanjay , Swanson Jordan W. , Ligh Cassandra A. , Shubinets Val , Taylor Jesse A. , Bartlett Scott P.
Published: July 2018

Background:

Sphenoid wing dysplasia in patients with neurofibromatosis type 1 may result in challenging and significant changes, including ultimately vision loss. The authors describe the radiographic patterns of sphenoid dysmorphology with time and age, and the impact of surgical intervention on preservation of vision.

Methods:

A retrospective study was performed at a single pediatric hospital, identifying subjects with neurofibromatosis type 1. Records were reviewed in their entirety for each subject, with attention to ophthalmologic evaluation. Radiographic images were digitally analyzed and scored for sphenoid transformations on a grade of 0 to 3.

Results:

Fifty-two subjects were identified. On initial imaging, 42.31 percent had a normal sphenoid (grade 0), 32.69 percent had an abnormal contour (grade 1), 11.54 percent had thinning (grade 2), and 13.46 percent had a gross defect (grade 3). Among the 45 subjects with serial imaging, 55.56 percent demonstrated progression of the deformity of at least one grade. Deformity progression correlated with length of imaging interval. Enucleation was noted to occur more often in subjects with a gross sphenoid defect (p < 0.0001). Of subjects identified as having a gross sphenoid defect, 26.7 percent were managed using orbitosphenoid reconstruction with titanium mesh and cranial bone graft, and 33.3 percent were managed with soft-tissue debulking and canthopexy only. Vision was more likely to be preserved with early orbitosphenoid reconstruction (p < 0.05).

Conclusions:

Sphenoid dysplasia is a progressive disease. Loss of vision is associated with a gross defect, and appears to be better preserved with early orbitosphenoid reconstruction with titanium mesh and cranial bone graft.
Comparison of Pediatric Intercalary Allograft Reconstructions with and without a Free Vascularized Fibula
Authors: Houdek Matthew T. , Rose Peter S. , Milbrandt Todd A. , Stans Anthony A. , Moran Steven L. , Sim Franklin H.
Published: July 2018

Background:

Lower extremity intercalary allograft reconstruction has traditionally been used to facilitate limb salvage. Combining the allograft with a free vascularized fibula graft has been described; however, there is a paucity of data comparing the outcome of these reconstructions.

Methods:

Twenty-nine pediatric patients (15 boys and 14 girls) underwent lower extremity limb salvage with the use of intercalary cadaveric allograft at a mean age of 12 years. The most common diagnosis was osteosarcoma (n = 18). Patients underwent reconstruction with an allograft alone (n = 11) or supplemented with a free vascularized fibula graft (n = 18).

Results:

The mean time to union of the allograft was 11 months, with 10 patients requiring additional bone grafting. There was no difference in the need for an additional bone graft (OR, 0.87; p = 1.0) between patients with a free vascularized fibula graft and those without. The allograft was revised in three patients because of fracture (n = 2) and fracture and infection (n = 1). In all of these patients, the allograft was not supplemented with a free vascularized fibula graft (p < 0.001). Five patients underwent an amputation, most commonly for disease recurrence. At last follow-up, the mean Mankin and Musculoskeletal Tumor Society rating was 90 percent, with 19 patients (66 percent) who achieved a “good” or “excellent” outcome according to the Mankin score.

Conclusion:

Use of an intercalary allograft to reconstruct a lower extremity provides a durable means of reconstruction; however, supplementation with a free vascularized fibula graft reduces the risk of allograft revision.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.