bluuebunny/crossref_metadata_2025 huggingface dataset:
Homelessness and Inpatient Burn Outcomes in the United States
Authors: Kiwanuka Harriet , Maan Zeshaan N , Rochlin Danielle , Curtin Catherine , Karanas Yvonne , Sheckter Clifford C
Published: April 2019

Burn injuries are common in the homeless population. Little is known regarding whether homeless patients experience different outcomes when admitted for burns. We aim to 1) characterize the admitted homeless burn population, and 2) investigate differences in inpatient outcomes between the homeless and non-homeless populations. A retrospective cohort study was performed utilizing the Nationwide Inpatient Sample. Adult patients with complete data for burn characteristics were extracted. Variables included demographic, burn, and facility characteristics. Homelessness was identified with International Classification of Disease 9th edition codes. Outcomes were modeled with regression analysis and included length of stay, total operations, charges, disposition, and Patient Safety Indicators (PSIs). 43,872 encounters were included of which 0.76% were homeless. Homeless encounters were more likely to be male (P < .001) and Medicaid-insured (P < .001). Flame and frostbite injuries were more likely (P < .001), and the mean %TBSA was smaller (15.0 vs 16.8, P < .001). After adjustment, homeless patients had greater lengths of stay (11.5 vs 9.6, P = .046), greater charges ($73,597 vs $66,909, P = .030), fewer operations (P = .016), and three times higher likelihood leaving against medical advice (P = .002). There was no difference in PSIs or mortality. Homeless burn admissions represent a unique cohort that carries a higher comorbidity burden and experiences longer lengths of stay with greater difficulty in disposition. Ironically, these patients accumulate more charges with limited means to pay. Even though no differences were observed in PSIs or mortality, further research is needed to understand how the challenges within this population affect their recovery.
Behaviors Associated with Internet Use in Military Medical Students and Residents
Authors: Schmidt Gerald , Valdez Michelle , Farrell Maureen , Bishop Frank , Klam Warren P , Doan Andrew P
Published: April 2019

Introduction

Problematic use of video games, social media, and Internet-related activities may be associated with sleep deprivation and poor work performance. The Internet Addiction Test was given to military medical and nursing students and housestaff to assess problematic Internet use.

Methods

Medical and nursing students at the Uniformed Services University of the Health Sciences and residents from Naval Medical Center San Diego were contacted via email (n = 1,000) and given a survey that included the Internet Addiction Test (IAT) and questions asking about other specific lifestyle variables. Individuals who received an Internet Addiction Score (IAS) ≥50 were identified as likely experiencing harmful effects of Internet addiction (IA).

Results

Of 399 surveys submitted, 68 were omitted due to gross incompletion or failing to finish the entirety of the IAT. Of the participants included, 205 (61.1%) were male and 125 (37.9%) were female. The mean age was 28.6 years old (S.D. = 5.1 years). In regards to training status, completed surveys were assessed for 94 medical residents, 221 School of Medicine students, and 16 Graduate School of Nursing students. Our survey showed 5.5% of the participants (n = 18) indicated problems with Internet use that are concerning for IA.

Conclusions

The study results indicated that our population showed problematic Internet use in the lower range of global estimates of IA. Rates of IA further decreased between medical students and residents. Multiple lifestyle variables were significantly associated with IA score and may serve as indicators of a higher score. Interestingly, the use of social media during sleeping hours was most significantly associated with increased IAS. This paper discusses IA among military medical and nursing trainees and how problematic Internet use may affect work performance and force readiness.
Changes in Post-traumatic Stress Disorder Service Connection Among Veterans Under Age 55: An 18-Year Ecological Cohort Study
Authors: Murdoch Maureen , Kehle-Forbes Shannon , Spoont Michele , Sayer Nina A , Noorbaloochi Siamak , Arbisi Paul
Published: April 2019

Introduction

Mandatory, age-based re-evaluations for post-traumatic stress disorder (PTSD) service connection contribute substantially to the Veterans Benefits Administration’s work load, accounting for almost 43% of the 168,013 assessments for PTSD disability done in Fiscal Year 2017 alone. The impact of these re-evaluations on Veterans’ disability benefits has not been described.

Materials and Methods

The study is an 18-year, ecological, ambispective cohort of 620 men and 970 women receiving Department of Veterans Affairs PTSD disability benefits. Veterans were representatively sampled within gender; all were eligible for PTSD disability re-evaluations at least once because of age. Outcomes included the percentage whose PTSD service connection was discontinued, reduced, re-instated, or restored. We also examined total disability ratings among those with discontinued or reduced PTSD service connection. Subgroup analyses examined potential predictors of discontinued PTSD service connection, including service era, race/ethnicity, trauma exposure type, and chart diagnoses of PTSD or serious mental illness. Our institution’s Internal Review Board reviewed and approved the study.

Results

Over the 18 years, 32 (5.2%) men and 180 (18.6%) women had their PTSD service connection discontinued; among them, the reinstatement rate was 50% for men and 34.3% for women. Six men (1%) and 23 (2.4%) women had their PTSD disability ratings reduced; ratings were restored for 50.0% of men and 57.1% of women. Overall, Veterans who lost their PTSD service connection tended to maintain or increase their total disability rating. Predictors of discontinued PTSD service connection for men were service after the Vietnam Conflict and not having a Veterans Health Administration chart diagnosis of PTSD; for women, predictors were African American or black race, Hispanic ethnicity, no combat or military sexual assault history, no chart diagnosis of PTSD, and persistent serious mental illness. However, compared to other women who lost their PTSD service connection, African American and Hispanic women, women with no combat or military sexual assault history, and women with persistent serious illness had higher mean total disability ratings. For both men and women who lost their PTSD service connection, those without a PTSD chart diagnosis had lower mean total disability ratings than did their counterparts.

Conclusions

Particularly for men, discontinuing or reducing PTSD service connection in this cohort was rare and often reversed. Regardless of gender, most Veterans with discontinued PTSD service connection did not experience reductions in their overall, total disability rating. Cost-benefit analyses could help determine if mandated, age-based re-evaluations of PTSD service connection are cost-effective.
Transcriptome Analysis of Rlm2-Mediated Host Immunity in the Brassica napus–Leptosphaeria maculans Pathosystem
Authors: Becker Michael G. , Haddadi Parham , Wan Joey , Adam Lorne , Walker Philip , Larkan Nicholas J. , Daayf Fouad , Borhan M. Hossein , Belmonte Mark F.
Published: April 2019

Our study investigated disease resistance in the Brassica napus–Leptosphaeria maculans pathosystem using a combination of laser microdissection, dual RNA sequencing, and physiological validations of large-scale gene sets. The use of laser microdissection improved pathogen detection and identified putative L. maculans effectors and lytic enzymes operative during host colonization. Within 24 h of inoculation, we detected large shifts in gene activity in resistant cotyledons associated with jasmonic acid and calcium signaling pathways that accelerated the plant defense response. Sequencing data were validated through the direct quantification of endogenous jasmonic acid levels. Additionally, resistance against L. maculans was abolished when the calcium chelator EGTA was applied to the inoculation site, providing physiological evidence of the role of calcium in B. napus immunity against L. maculans. We integrated gene expression data with all available information on cis-regulatory elements and transcription factor binding affinities to better understand the gene regulatory networks underpinning plant resistance to hemibiotrophic pathogens. These in silico analyses point to early cellular reprogramming during host immunity that are coordinated by CAMTA, BZIP, and bHLH transcription factors. Together, we provide compelling genetic and physiological evidence into the programming of plant resistance against fungal pathogens.
Association of Marijuana, Mental Health, and Tobacco in Colorado
Authors: Stewart Stephanie B. , Bhatia Devika , Burns Emily K. , Sakai Joseph T. , Martin Laura F. , Levinson Arnold H. , Vaughn Amber M. , Li Yaqiang , James Katherine A.
Published: April 2019

Objectives:

Marijuana's evolving legality may change marijuana use patterns in adults. Co-use of marijuana and tobacco are strongly associated, and populations with mental health disorders are disproportionately likely to use either substance, but neither association has been assessed in the context of legal recreational marijuana. We assessed the associations of tobacco smoking with marijuana use and with mental health disorders in Colorado in 2015.

Methods:

Data came from a population-based survey of adults (n = 8023). Multiple logistic regressions were used with current tobacco smoking as the primary outcome. Past 30-day marijuana use and mental health status were the independent variables of interest. Covariates included age, sex, ethnicity, poverty level, and education.

Results:

Adults who used marijuana in the past 30 days had 3.4 (95% confidence interval [CI] 2.7, 4.2) greater odds of currently smoking tobacco compared to adults who had not recently used marijuana, after adjusting for sociodemographic and economic factors. A mental health disorder was independently associated with tobacco smoking (adjusted odds ratio [OR] 1.7, 95% CI 1.4, 2.1). Prevalence of co-use among adults self-reporting a mental health disorder was significantly higher compared those without a mental health disorder (11.1% vs 4.3%; P < 0.0001).

Conclusions:

This study examined the associations between mental health, marijuana use, and tobacco smoking after the legalization of recreational marijuana in Colorado. Adults using marijuana and/or self-reporting a mental health disorder were more likely to smoke tobacco and should be targeted for cessation interventions.
Outcomes of Second Intention Healing of the Lower Eyelid Margin After Mohs Micrographic Surgery
Authors: Trieu Diane N. , Drosou Anna , White Lucille E. , Goldberg Leonard H.
Published: April 2019

BACKGROUND

Lower eyelid margin defects can be a reconstructive challenge. A possible alternative is second intention healing of the lower eyelid margin.

OBJECTIVE

To determine the cosmetic outcomes and patient satisfaction of second intention healing of the lower eyelid margin after Mohs micrographic surgery (MMS).

MATERIALS AND METHODS

A retrospective chart review was performed on patients who underwent MMS of the lower eyelid margin. Patient information was gathered on age, sex, diagnosis, postoperative size, number of Mohs stages, thickness of defect, and clinical photographs. The preoperative and postoperative photographs were evaluated with a physician assessment scale and patients completed a satisfaction survey.

RESULTS

In all 17 patients (100%), the cosmetic results obtained were considered good to excellent. The objective outcomes were graded as excellent, very good, good, satisfactory, unsatisfactory, and poor. The patient satisfaction survey was divided into excellent, good, satisfied, and unsatisfied. Patient satisfaction ranged from satisfied to excellent. The incidence of complications was low with one report of trichiasis.

CONCLUSION

Second intention healing of the lower eyelid margin can produce good cosmetic results and patients are generally satisfied with their outcomes.
Anthropometric and Genetic Factors Associated With the Exposure of Rifampicin and Isoniazid in Mexican Patients With Tuberculosis
Authors: Huerta-García Ana P. , Medellín-Garibay Susanna E. , Salazar-González Raúl A. , Ortiz-Álvarez Arturo , Magaña-Aquino Martín , Rodríguez-Pinal Cristian J. , Portales-Pérez Diana P. , Romano-Moreno Silvia , Milán-Segovia Rosa del Carmen
Published: April 2019

Background:

Tuberculosis (TB) remains a critical infectious, contagious disease worldwide with high prevalence and mortality rate. The directly observed treatment short-course therapy includes rifampicin (RMP) and isoniazid (INH) for at least 6 months. The purposes of this scheme are to interrupt the transmissibility of the Mycobacterium tuberculosis complex and to avoid secondary complications. Low plasma concentrations of these anti-TB drugs have been associated with extended treatment duration, therapeutic failure, and relapse. The determination of anthropometric, genetic, and clinical variables that may affect plasma concentrations of RMP and INH might facilitate the detection of patients at increased risk of therapeutic failure.

Methods:

A prospective observational study was performed in patients with TB diagnosis. A fixed-dose combined formulation was administered following clinical guidelines, and 12 venous blood samples were collected within 24 hours after dose for the quantification of plasma levels of RMP and INH by high-performance liquid chromatography-ultraviolet. The plasma concentrations versus time for each drug in each patient were assessed by a noncompartmental approach to obtain Cmax, and the area under the concentration–time curve to the last observation point (AUC0–24 h) was calculated by the linear trapezoidal rule. Genetic polymorphisms of the enzyme involved in INH metabolism (NAT2) and proteins involved in RMP transport (glycoprotein‐P and OATP1B1) were determined.

Results:

A total of 34 patients aged between 18 and 72 years with the diagnosis of TB were included in the current study. A multivariate analysis was performed to determine the anthropometric and genetic characteristics that modified the Cmax and AUC0–24 h of RMP and INH. Results indicated that RMP Cmax and AUC0–24 h were affected by sex, dose/weight, and single nucleotide polymorphism of MDR1. In addition, age, body mass index, and NAT2 acetylator genotype were shown to determine the Cmax and AUC0–24 h for INH.

Conclusions:

Anthropometric, genetic, and dosage characteristics of Mexican patients with TB are an important source of risk for subtherapeutic plasma concentrations of anti-TB drugs. Factors such as lower-than-recommended RMP dose, male patients with TB, and MDR1 3435 genotype, in addition to age group, body mass index, and INH acetylator phenotype based on NAT2 genotype, should be considered during treatment.
Topical estrogen prescribing patterns for urogenital atrophy among women with breast cancer: results of a national provider survey
Authors: Richter Lee A. , Han Jim , Bradley Sarah , Lynce Filipa C. , Willey Shawna C. , Tefera Eshetu , Pollack Craig E.
Published: April 2019

Objective:

The aim of the study was to evaluate knowledge, attitudes, and practice patterns of physicians prescribing topical estrogen for women with urogenital atrophy and a history of breast cancer.

Methods:

A cross-sectional survey of breast surgeons, urogynecologists, and gynecologists was distributed via their professional societies: the American Society of Breast Surgeons (ASBrS), the American Urogynecologic Society (AUGS), and the Society of Gynecologic Surgeons (SGS). Providers reported level of comfort prescribing vaginal estrogen for urogenital symptoms for women with different categories of breast cancer and current treatment: estrogen receptor (ER) negative, ER positive no longer on endocrine therapy, and ER positive currently on adjuvant endocrine therapy. General knowledge questions assessed agreement on a 5-point Likert scale to statements about vaginal estrogen safety and pharmacology.

Results:

A total of 820 physicians completed the survey: 437 responses from the ASBrS (response rate, 26.7%), 196 from AUGS (15%), and 187 from SGS (44.5%). The majority of physicians (84%), regardless of specialty, felt comfortable prescribing vaginal estrogen to women with a history of ER-negative cancer: 65.7% felt comfortable prescribing for women with ER-positive breast cancer no longer on endocrine therapy; 51.3% for women on an aromatase inhibitor; and 31.4% for women on tamoxifen. Urogynecologists were significantly more comfortable than breast surgeons prescribing vaginal estrogen for the lowest risk patients, whereas breast surgeons had the highest level of comfort for women currently on endocrine therapy.

Conclusions:

This study highlights heterogeneity in practice patterns both within and across specialties. The clinical variation seen in this study suggests providers may benefit from increased knowledge regarding vaginal estrogen.
Reversible alopecia associated with high blood mercury levels and early menopause: a report of two cases
Authors: Peters Jane B. , Warren Michelle P.
Published: April 2019

Objective:

The aim of this study was to report on two women in early menopause with alopecia and high mercury (Hg) levels which reversed with a decrease in toxic levels.

Methods:

Retrospective chart review and case studies in a reproductive endocrinology practice.

Results:

A 43-year-old woman initially evaluated for early menopause later experienced sudden circumscribed hair loss on the scalp. Blood tests indicated elevated Hg levels and further investigation revealed a diet high in tuna. Levels fell with elimination of dietary tuna. Another woman, 39 years old was complaining of severe hot flashes, night sweats, and menstrual irregularity also developed alopecia. Treated unsuccessfully for low testosterone, blood tests indicated high Hg levels and simultaneous hair loss was observed; recommendation to alter diet, including fish intake, was followed by a reversal of alopecia, along with a decrease in blood Hg levels. Literature searches were conducted with a focus on Hg toxicity or poisoning with symptom of alopecia.

Conclusions:

Women of reproductive age frequently seek treatment for what is thought to be hormone-related hair loss especially at menopause. Two women demonstrated a strong temporal correlation to high Hg levels associated with early menopause, which was reversible. The development of alopecia in the setting of mild Hg intoxication has not been reported in the medical literature despite its appearance in the popular press. Measurement of Hg levels should be considered in women with alopecia and its relationship to early menopause is unclear but bears further research.
Evaluation of the Parameter “Mean Impedance” for Representing Eustachian tube Functions During Pressure Increase and Decrease in Pressure Chamber Measurements
Authors: Schwarz David , Jansen Stefanie , Steinhauser Susanne , Meyer Moritz F.
Published: April 2019

Hypothesis:

The hypothesis of the study is that the mean impedance (MI) during compression and decompression provides additional information of the Eustachian tube (ET) function.

Background:

The continuous impedance measurement in a pressure chamber can provide valuable information about the opening function of the ET.

Methods:

Around 55 ear-healthy volunteers were examined in a pressure chamber. These were subjected to a decompression phase and a compression phase. The pressure change was constantly 20 kPa/min. Using evaluation software, the MI could be determined for both ears in each case for the phases of compression and decompression.

Results:

In 49 participants, we could interpret the data successfully. On average, an output value (without pressure changes) of the impedance of 0.58 ±0.11 Pa on the right side and 0.43 ± 0.1 Pa on the left side were measured. During decompression, 0.098 ± 0.05 Pa (right) and 0.087 ± 0.043 Pa (left) could be determined. For compression, values of 0.086 ± 0.044 Pa on the right and 0.079 ± 0.045 Pa on the left were detected. The retest reliability was higher with an intraclass correlation coefficient for the decompression MI of 0.833 than the 0.772 compression MI.

Conclusions:

It is possible to measure MI in healthy subjects during compression and decompression. This value represents a good average in terms of the pressure tolerance of the middle ear. In future, studies will be required to determine whether MI will be a useful parameter in differentiating normal and abnormal ET function.
Global children's surgery: recent advances and future directions
Authors: Ullrich Sarah , Kisa Phyllis , Ozgediz Doruk
Published: April 2019

Purpose of review

Two-thirds of the world's population lacks access to surgical care, many of them being children. This review provides an update on recent advances in global children's surgery.

Recent findings

Surgery is being increasingly recognized as an essential component of global and child health. There is a greater focus on sustainable collaborations between high-income countries (HICs) and low-and-middle-income countries (HICs and LMICs). Recent work provides greater insight into the global disease burden, perioperative outcomes and effective context-specific solutions. Surgery has continued to be identified as a cost-effective intervention in LMICs. There have also been substantial advances in research and advocacy for a number of childhood surgical conditions.

Substantial global disparities persist in the care of childhood surgical conditions. Recent work has provided greater visibility to the challenges and solutions for children's surgery in LMICs. Capacity-building and scale up of children's surgical care, more robust implementation research and ongoing advocacy are needed to increase access to children's surgical care worldwide.
Psychometrics of the SCL-90-R and Development and Testing of Brief Versions SCL-45 and SCL-9 in Infertile Couples
Authors: Martínez-Pampliega Ana , Herrero-Fernández David , Martín Sagrario , Cormenzana Susana
Published: April 2019

Background

Although infertile couples are mentally healthy, dealing with infertility and assisted reproductive technology (ART) treatment is usually associated with psychological distress. It would therefore be useful to have short, multidimensional instruments to be able to identify people who present more intense emotional reactions and follow up their emotional distress throughout the ART.

Objectives

The goals of the study were to analyze the psychometric adequacy of the original 90-item version of the Symptom Checklist (SCL-90) in a sample of Spanish women and their partners undergoing ART, as well as to develop and analyze two brief versions of the SCL-90, given the absence of adequate short versions for this population.

Methods

A cross-sectional design for patients and their partners in the process of ART through in vitro fertilization was used. The two brief scales were obtained, which took into account the levels of variance explained by the items and confirmatory factor analysis.

Results

Two brief instruments were developed. The first, with 45 items (SCL-45-I Infertility), includes nine subdimensions: Somatization, Interpersonal Sensitivity, Obsessive-Compulsive Disorder, Depression, Anxiety, Hostility, Paranoid Ideation, Phobic Anxiety, and Psychoticism. The second instrument contains nine items (SCL-9-I or Global Severity Index [GSI]), one item for each dimension. Both instruments were psychometrically adequate (SCL-45-I: χ2/df = 7.24, RMSEA = .057, 95% CI [.056, .059], CFI = .97, NNFI = .97, SRMR = .049; SCL-9-I: χ2/df = 9.66, RMSEA = .068, 95% CI [.061, .076], CFI = .97, NNFI = .96, SRMR = .035). Measurement invariance analysis by gender was conducted, and the instruments were shown to be suitable for both men and women.

Discussion

The suitability of the SCL-90-R for use in ART was verified, and two valid instruments—useful and easy to use for nurses, psychologists, and other care providers—were developed.
Plasma Cystatin C Associates With HIV-Associated Neurocognitive Disorder but Is a Poor Diagnostic Marker in Antiretroviral Therapy–Treated Individuals
Authors: Kalayjian Robert C. , Robertson Kevin R. , Albert Jeffrey M. , Fichtenbaum Carl J. , Brown Todd T. , Taiwo Babafemi O. ,   for the ACTG 5303 Study Team
Published: April 2019

Objective:

To examine associations between plasma cystatin C and neurocognitive impairment (NCI) and its performance as a diagnostic marker before and during initial antiretroviral therapy (ART).

Methods:

Multivariable logistic regression and generalized estimating equations examined associations with NCI, determined by neuropsychological measurements, in participants of a 48-week randomized clinical trial of initial ART. Receiver operator characteristic curves examined diagnostic models of NCI.

Results:

Cystatin C was associated with NCI before ART [odds ratio (OR) 3.4 (95% CI: 1.2 to 9.4) for each 2-fold increase in baseline levels] and during 48 weeks of ART, in models that excluded baseline measurements [OR 3.0 (1.2 to 7.8) for each 2-fold increase in time-updated levels]. The strength of association increased with more severe impairment using HIV-associated neurocognitive disorder criteria [OR 2.2 (0.8 to 6.0) with asymptomatic NCI and OR 4.0 (1.5 to 11.0) with mild neurocognitive disorder or HIV-associated dementia vs. no impairment, for each 2-fold increase in time-updated levels] or by global development score [OR 2.6 (1.1 to 6.3) with mild impairment and OR 4.6 (1.1 to 18.9) with moderate or severe impairment vs. no impairment]. Cystatin C performed poorly as a diagnostic marker for NCI, however, with an area under the receiver operator characteristic curve of 0.58 at baseline and 0.54 at week 48.

Conclusions:

Higher plasma cystatin C levels were significantly associated with NCI, but these levels did not seem to be useful as a diagnostic marker for this condition.
Risk and Predictors of Esophageal and Stomach Cancers in HIV-Infected Veterans: A Matched Cohort Study
Authors: Thrift Aaron P. , Kramer Jennifer R. , Hartman Christine M. , Royse Kathryn , Richardson Peter , Dong Yongquan , Raychaudhury Suchismita , Desiderio Roxanne , Sanchez Dina , Anandasabapathy Sharmila , White Donna L. , Chiao Elizabeth Y.
Published: April 2019

Background:

To evaluate the risks of esophageal and stomach carcinomas in people living with HIV (PLWH) compared with the general population and risk factors for these cancers in PLWH.

Setting:

Retrospective cohort study in the Veterans Health Administration.

Methods:

We compared incidence rates for esophageal and stomach cancers in 44,075 HIV-infected male veterans with those in a matched HIV-uninfected cohort (N = 157,705; 4:1 matched on age and HIV-index date). We used Cox regression models to estimate Hazard ratios (HRs) and 95% confidence intervals (CIs) for associations with HIV infection and for cancer risk factors in PLWH.

Results:

In unadjusted models, HIV infection was associated with increased risks of esophageal squamous cell carcinoma (ESCC; HR, 2.21; 95% CI: 1.47 to 3.13) and gastric cardia cancer (HR, 1.69; 95% CI: 1.00 to 2.85) but associated with lower risk of esophageal adenocarcinoma (EAC; HR, 0.48; 95% CI: 0.31 to 0.74). After adjusting for age, race/ethnicity, smoking and alcohol use, HIV infection remained statistically significantly associated with elevated risk for ESCC [adjusted hazard ratio (aHR), 1.58; 95% CI: 1.02 to 2.47], especially among HIV-infected patients with CD4 count ≤200 (aHR, 2.20; 95% CI: 1.35 to 3.60). HIV infection was not associated with risks of EAC (aHR, 0.82; 95% CI: 0.53 to 1.26), gastric cardia (aHR, 0.80; 95% CI: 0.33 to 1.94), or noncardia (aHR, 1.06; 95% CI: 0.61 to 1.84) cancers. Risk factors for these cancers in HIV-infected patients were otherwise similar to those in general population (eg, Helicobacter pylori for gastric noncardia cancer).

Conclusion:

HIV-infected individuals with low CD4 count are at highest risk for ESCC, but HIV infection was not independently associated with EAC or gastric cancer after adjusting for confounders.
The Impact of Blast Implosions and Bullet Injury on Maxillary Air Sinus
Authors: Al-Quisi Ahmed Fadhel , Al-Anee Auday M. , Mohammed Abbas Sabah
Published: April 2019

Background:

Successive waves and generations of terrorists attacked the Iraqis in the years following the fall of the regime in Iraq in 2003, after the US invasion of the country under the pretext of weapons of mass destruction. Hence, the Iraqi people enrolled in ongoing war with these armed groups which led to massive casualties due to blasts and missile injuries.

Mechanism of blasts injury can be classified into primary, secondary, tertiary, and quaternary. While bullet injuries can be classified into low and high-energy injuries, the type and severity of the injury will influence the type of management, together with facilities available in the authors’ hospitals.

In this study the authors aim to compare between the effects of blast implosions and penetrating missiles on the maxillofacial air containing cavities, specifically the maxillary sinuses.

Patients and methods:

Twenty-eight patients (26 male patients [92.85%] and 2 [7.14%] female patients) with maxillary sinus wall fractures were admitted to the authors’ maxillofacial surgery Department in the Hospital of specialized surgeries/Baghdad Medical city from July 2014 to November 2016.

Results:

Seventy-six percent of the total bullet injuries affect the left side of the face, while shell injuries tend to affect the right side of the face by 60% than the left side.

Direct maxillary sinus injuries constitute 76.9% of the injuries caused by bullets, while it constitutes only 40% of shell injuries.

Conclusion:

Bullet injuries are associated with more severe comminuted fractures in addition to involvement of multiple neighboring bones and this may lead to extensive bone loss, while postoperative complications and infection are more common with improvised explosive devices injuries.
Surgical Management of the Nose in Relation With the Fronto-Orbital Area to Change and Feminize the Eyes’ Expression
Authors: Di Maggio Marcelo Ruben , Nazar Anchorena Joaquin , Dobarro Juan Cruz
Published: April 2019

Gender affirmation surgeries in male-to-female transition patients include breast augmentation, genital construction, and facial feminization. Facial features serve an integral role in identifying an individual's gender, with certain characteristics perceived as feminine or masculine.

The nose, as the centerpiece of the middle third of the face, is an important component of facial attractiveness and gender identity. Thus, reduction rhinoplasty is a mainstay of the facial feature remodeling (FFRS) and facial feminization surgery (FFS).

The authors usually divide the surgery planning in 2 steps, obviously depending on each patient needs, but generally speaking, the authors do the upper part of the head in one stage and the mandible and face lift in another.

If the patient only requires frontal bone surgery and softening of the orbital rims, the authors always perform the nose surgery in this stage. If a mandible reduction is needed, combined with a face-lift, the authors do it in another procedure, usually separated between 7 to 10 days from the other surgery. In these cases, the authors begin with the lower part of the face on the first stage and then, the frontal bone and rhinoplasty on the second.

The fronto naso-orbital complex is one of the main facial areas that determine the identification of facial gender, the nose plays a crucial role in FFS of the middle third. The main goal of rhinoplasty in FFRS is to change masculine nasal features to feminine ones by performing dorsal reduction, tip refinement, and narrowing the nasal bones, most often using an external approach and cartilaginous grafts to provide good tip support and long-term stability. Lip-lift and frontonasal recontouring can be technically complementary to rhinoplasties associated with facial features remodeling and feminization.
Staged Treatment of Chest Wall Radiation-Induced Ulcer With Negative Pressure Wound Therapy and Latissimus Dorsi Myocutaneous Flap Transplantation
Authors: Li Xiuqi , Zhang Fan , Liu Xujin , Cao Zilong , Liu Pei , Xia Lin , Du Min
Published: April 2019

Chest wall ulcer induced by postmastectomy radiation therapy (PRMT) remains challenging for plastic surgeons because of the reduced blood supply, fibrosis, and impaired cellular potential in the irradiated area. In this study, chest wall ulcer was treated with negative pressure wound therapy (NPWT) and the latissimus dorsi myocutaneous (LDM) flap reconstruction in 2 stages. A retrospective study was performed on consecutive patients with chronic radiation-induced ulcers in chest wall from June 2012 to June 2017. Surgical debridement and NPWT were performed in the first stage and the chest wall reconstructed by the LDM flap transplantation after extensive debridement in the second stage. There were 10 female patients with chest wall ulcers with a mean age of 60.3 years. The average duration of the ulcers was 21.2 months and the ulcers varied from 1 × 2 to 5 × 7 cm2. Histological examination denied any recurrent breast cancer or radiation-related malignancy. Negative pressure wound therapy was applied with 100 to 125 mm Hg negative pressure during a period of 5 to 7 days in the first stage. The LDM flap varied from 11 × 15 to 15 × 20 cm2. The mean follow-up was 25.9 months. All the flaps survived well with satisfactory appearance and there was no donor-site morbidity or ulcer recurrence during the follow-up period. The staged treatment of the chest wall radiation ulcer incorporated the benefits of NPWT and LDM flap. It is beneficial in increasing the blood and nutrient supply to the irradiated tissue, enhancing the debridement and promoting tissue healing, thus improving the flap survival and decreasing the ulcer recurrence.
Acute Inflammation in Traumatic Brain Injury and Polytrauma Patients Using Network Analysis
Authors: Rowland Bradley , Savarraj Jude P.J. , Karri Jay , Zhang Xu , Cardenas Jessica , Choi H. Alex , Holcomb John B. , Wade Charles E.
Published: April 2019

Introduction:

Traumatic brain injury (TBI) is associated with secondary injury to the central nervous system (CNS) via inflammatory mechanisms. The combination of polytrauma and TBI further exacerbates the inflammatory response to injury; however, combined injury phenomena have not been thoroughly studied. In this study, we examined the inflammatory differences between patients with TBI versus patients with polytrauma, but no TBI (polytrauma). We hypothesize that patients with TBI have a heightened early inflammatory response compared with polytrauma.

Methods:

We conducted a single-center retrospective study of a cohort of patients with polytrauma, who were enrolled in the PROPPR study. These patients had blood samples prospectively collected at eight time points in the first 3 days of admission. Using radiological data to determine TBI, our polytrauma cohort was dichotomized into TBI (n = 30) or polytrauma (n = 54). Inflammatory biomarkers were measured using ELISA. Data across time were compared for TBI versus polytrauma groups using Wilcoxon rank-sum test. Network analysis techniques were used to systematically characterize the inflammatory responses at admission.

Results:

Patients with TBI (51.6%) had a higher 30-day mortality compared with polytrauma (16.9%) (P <0.001). Expression levels of IL6, IL8, and CCL2 were elevated from the 2-h through 24-h time points, becoming significant at the 6-h time point (IL6, IL8, and CCL2; P <0.05) (Fig. 2). CSF3 showed a similar pattern, but did not attain significance. TBI and polytrauma networks underwent diverging trends from admission to the 6-h time point.

Conclusion:

Patients with TBI demonstrated upregulations in proinflammatory cytokines IL6, IL8, and CCL2. Utilizing informatics methods, we were able to identify temporal differences in network trends, as well as uncharacterized cytokines and chemokines in TBI. These data suggest TBI induces a distinct inflammatory response and pathologically heightened inflammatory response in the presence of polytrauma and may propagate worsened patient outcomes including mortality.
Comparison of male and female victims of intimate partner homicide and bidirectionality—an analysis of the national violent death reporting system
Authors: Velopulos Catherine G. , Carmichael Heather , Zakrison Tanya L. , Crandall Marie
Published: April 2019

BACKGROUND

Intimate partner violence (IPV) is a public health crisis, affecting at least 1:4 women and 1:9 men. A recent multicenter trial on universal screening in trauma patients showed similar rates of positive screens between men and women. Few studies have explored the bidirectional violence in opposite-sex or same-sex relationships. Our goal was to estimate prevalence and risk factors for the most severe manifestation of IPV: intimate partner homicide.

METHODS

This is a 2003–2015 retrospective review of the National Violent Death Reporting System, a Centers for Disease Control and Prevention database of surveillance data. Deaths were coded IPV if the primary relationship between the suspect and victim fell into the categories of current partner or ex-partner. Bivariable and multivariable analysis examined differences between groups for factors and circumstances.

RESULTS

A total of 6,131 persons in opposite-sex relationships and 181 in same-sex relationships were murdered as a result of IPV. Women and Black men were disproportionately affected, and alcohol and preceding arguments were a factor in a higher proportion of male victims. Abuse preceded homicide in many women with almost half of male suspects attempting or committing suicide at the time of intimate partner homicide. Women were more likely than men to use a stabbing instrument, although firearms were still the most common means for each group. In 46.5% of homicides of women, the male suspect attempted suicide (p < 0.001). Bidirectionality was highest in male victims of female perpetrators and in same-sex pairings regardless of sex of the victim.

CONCLUSION

Homicide caused by IPV is a significant public health crisis for both men and women, with women and Black men at particular risk. Firearms are the most commonly used weapon for homicide in both sexes, and mental illness is not a common risk factor. A staggering proportion of these homicides involve suicide of the suspect, suggesting that each potential incident has two victims to target for prevention and intervention. Interventional programs to prevent such bidirectional mortality are urgently needed.

LEVEL OF EVIDENCE

Retrospective secondary data analysis, level III.
Noninvasive diagnostics for extremity compartment syndrome following traumatic injury: A state-of-the-art review
Authors: Walters Thomas J. , Kottke Melissa A. , Hargens Alan R. , Ryan Kathy L.
Published: April 2019

Acute compartment syndrome (ACS) is a serious medical condition that can occur following traumatic injury to an extremity. If left undiagnosed, ACS can eventuate in amputation of the limb or even death. Because of this, fasciotomy to release the pressure within the muscle and restore tissue perfusion is often performed upon suspicion of ACS, as the sequelae to fasciotomy are less severe than those associated with not performing the fasciotomy. Currently, the “gold standard” of diagnosis is based on clinical assessment of such symptoms as pain out of proportion to the injury, obvious high pressure and swelling, pain on passive stretch of the muscles in the affected compartment, and deficits in sensory and/ormotor functions. Diagnosis is often confirmed using invasive measurements of intramuscular pressure (IMP); however, controversy exists as to how direct IMP measurement should be accomplished and threshold pressures for accurate diagnosis. Because of this and the attendant issues with invasive measurements, investigators have been searching over the last 25 years for a noninvasive means to quantitatively measure IMP or perfusion to the limb. The purpose of this review is to summarize the current state of the art of noninvasive devices that could potentially be used to diagnose ACS accurately and objectively. To do this, we divide the discussion into those medical devices that primarily measure mechanical surrogates of IMP (e.g., tissue hardness or myofascial displacement) and those that primarily measure indices of tissue perfusion (e.g., tissue oxygen saturation via near-infraredspectroscopy). While near-infrared spectroscopy-basedtechnologies have shown the most promise, whether such technologies will be of diagnostic benefit await the completion of ongoing clinical trials.

LEVEL OF EVIDENCE

Systematic Review, level II.
Effect of damage control laparotomy on major abdominal complications and lengths of stay: A propensity score matching and Bayesian analysis
Authors: Harvin John A. , Sharpe John P. , Croce Martin A. , Goodman Michael D. , Pritts Timothy A. , Dauer Elizabeth D. , Moran Benjamin J. , Rodriguez Rachel D. , Zarzaur Ben L. , Kreiner Laura A. , Claridge Jeffrey A. , Holcomb John B.
Published: April 2019

BACKGROUND

In patients for whom surgical equipoise exists for damage control laparotomy (DCL) and definitive laparotomy (DEF), the effect of DCL and its associated resource utilization are unknown. We hypothesized that DEF would be associated with fewer abdominal complications and less resource utilization.

METHODS

In 2016, six US Level I trauma centers performed a yearlong, prospective, quality improvement project with the primary aim to safely decrease the use of DCL. From this cohort of patients undergoing emergent trauma laparotomy, those who underwent DCL but were judged by majority faculty vote at each center to have been candidates for potential DEF (pDEF) were prospectively identified. These pDEF patients were matched 1:1 using propensity scoring to the DEF patients. The primary outcome was the incidence of major abdominal complications (MAC). Deaths within 5 days were excluded. Outcomes were assessed using both Bayesian generalized linear modeling and negative binomial regression.

RESULTS

Eight hundred seventy-two total patients were enrolled, 639 (73%) DEF and 209 (24%) DCL. Of the 209 DCLs, 44 survived 5 days and were judged to be patients who could have safely been closed at the primary laparotomy. Thirty-nine pDEF patients were matched to 39 DEF patients. There were no differences in demographics, mechanism of injury, Injury Severity Score, prehospital/emergency department/operating room vital signs, laboratory values, resuscitation, or procedures performed during laparotomy. There was no difference in MAC between the two groups (31% DEF vs. 21% pDEF, relative risk 0.99, 95% credible interval 0.60–1.54, posterior probability 56%). Definitive laparotomy was associated with a 72%, 77%, and 72% posterior probability of more hospital-free, intensive care unit-free, and ventilator-free days, respectively.

CONCLUSION

In patients for whom surgeons have equipoise for DCL versus definitive surgery, definitive abdominal closure was associated with a similar probability of MAC, but a high probability of fewer hospital-free, intensive care unit-free, and ventilator-free days.

LEVEL OF EVIDENCE

Therapeutic/care management, level III.
Development of clinical tracheostomy score to identify cervical spinal cord injury patients requiring prolonged ventilator support
Authors: Scantling Dane , Granche Janeway , Williamson John , Gracely Edward , Thosani Darshak , McCracken Brendan
Published: April 2019

BACKGROUND

Cervical spinal cord injuries often necessitate ventilator support (VS). Prolonged endotracheal tube use has conveyed substantial morbidity in prospective study. Tracheostomy is recommended if VS is anticipated to be 7 days or longer, which defines prolonged ventilation (PV). Identifying these patients on arrival and before tracheostomy need is readily evident could prevent morbidity while lowering hospital costs. We aimed to create a tracheostomy score (trach score) to identify patients requiring PV and who could benefit from immediate tracheostomy.

METHODS

A review of patients with cervical spine fractures and cervical spinal cord injuries from 2005 to 2017 from the Pennsylvania Trauma Outcome Study database was performed. Patients were excluded for missing data, no use of VS or death in less than 7 days. Patients were selected for a training set or validation set by state identification number. We used automated forward stepwise selection to select a logistic model. Significant continuous variables were dichotomized to create a simplified screening score (trach score) and this was applied to the validation set.

RESULTS

Needing ventilation for 7 or more days was positively associated with higher Injury Severity Scores having a complete or anterior injury, and having a motor cord injury from C1 to C4. Application of the logistic model to the validation data produced a receiver operating characteristic curve with area under the curve of 0.7712, with 95% confidence limit (CL) of 0.6943 to 0.8481. The validation receiver operating characteristic curve was statistically better than chance using a contrast test with χ2 with p value less than 0.01. In the validation set, a trach score of 0 correlated to 33% needing PV, a score of 1 with 67% needing PV, 2 with 85%, and 3 with 98%.

CONCLUSION

Use of the trach score identified the majority of patients requiring prolonged VS in our study. An early tracheostomy protocol using predictive modeling could aid in reduction of intensive care unit length of stay and improving ventilator weaning in these patients. External verification of this predictive tool and of an early tracheostomy protocol is needed.

LEVEL OF EVIDENCE

This work is a retrospective prognostic cohort study and meets evidence Level III criteria.
Escalation of mortality and resource utilization in emergency general surgery transfer patients
Authors: Keeven David D. , Davenport Daniel L. , Bernard Andrew C.
Published: April 2019

BACKGROUND

Emergency general surgery (EGS) patients require greater resources and have increased rates of morbidity and mortality. Previous work has shown mortality differences in colectomy patients between direct admissions and transfers patients based on source, including emergency department, inpatient, and nursing home transfers. We hypothesize that patient transfer status negatively effects morbidity, mortality, and resource utilization in a mixed population of EGS patients.

METHODS

Data were obtained for patients undergoing EGS using public files from the American College of Surgeons National Surgery Quality Improvement Program for the years 2014 through 2016. We analyzed risk factors and 30-day outcomes by transfer status on frequently performed procedures using χ2 analysis and multivariable logistic regression. Significance was set at p < 0.001 for the bivariate analyses and p < 0.05 for the multivariable analyses.

RESULTS

A total of 167,636 procedures were identified. Transferred patients had increased clinical risk, operative complexity, and poorer outcomes. Fewer transfers were initiated for less technically sophisticated cases such as laparoscopic appendectomy and cholecystectomy, whereas more complex acute open cases were more often transferred. Transfer patients required longer operations and more transfusions and experienced more complications likely to require an intensive care unit stay. Transfer patients returned to the operating room more often, had higher rates of readmission, and greater 30-day mortality. These effects remained after adjusting for procedure group, secondary procedures, age, sex, and American Society of Anesthesiologists class.

CONCLUSION

Our study demonstrates significant increases in mortality, morbidity, and resource utilization in EGS transfer patients who were not attributable to case mix, demographics, and comorbid status alone. These data point to potential financial and quality assessment challenges for tertiary referral centers.

LEVEL OF EVIDENCE

Prognostic, level III; therapeutic, level IV.