bluuebunny/crossref_metadata_2025 huggingface dataset:
Strategies for the management of haemorrhage following pelvic fractures and associated trauma-induced coagulopathy
Authors: Mauffrey C. , Cuellar III D. O. , Pieracci F. , Hak D. J. , Hammerberg E. M. , Stahel P. F. , Burlew C. C. , Moore E. E.
Published: September 2014

Exsanguination is the second most common cause of death in patients who suffer severe trauma. The management of haemodynamically unstable high-energy pelvic injuries remains controversial, as there are no universally accepted guidelines to direct surgeons on the ideal use of pelvic packing or early angio-embolisation. Additionally, the optimal resuscitation strategy, which prevents or halts the progression of the trauma-induced coagulopathy, remains unknown. Although early and aggressive use of blood products in these patients appears to improve survival, over-enthusiastic resuscitative measures may not be the safest strategy.

This paper provides an overview of the classification of pelvic injuries and the current evidence on best-practice management of high-energy pelvic fractures, including resuscitation, transfusion of blood components, monitoring of coagulopathy, and procedural interventions including pre-peritoneal pelvic packing, external fixation and angiographic embolisation.

Cite this article: Bone Joint J 2014; 96-B:1143–54.
Can the use of an evidence-based algorithm for the treatment of intertrochanteric fractures of the hip maintain quality at a reduced cost?
Authors: Egol K. A. , Marcano A. I. , Lewis L. , Tejwani N. C. , McLaurin T. M. , Davidovitch R. I.
Published: September 2014

In March 2012, an algorithm for the treatment of intertrochanteric fractures of the hip was introduced in our academic department of Orthopaedic Surgery. It included the use of specified implants for particular patterns of fracture. In this cohort study, 102 consecutive patients presenting with an intertrochanteric fracture were followed prospectively (post-algorithm group). Another 117 consecutive patients who had been treated immediately prior to the implementation of the algorithm were identified retrospectively as a control group (pre-algorithm group). The total cost of the implants prior to implementation of the algorithm was $357 457 (mean: $3055 (1947 to 4133)); compared with $255 120 (mean: $2501 (1052 to 4133)) after its implementation. There was a trend toward fewer complications in patients who were treated using the algorithm (33% pre- versus 22.5% post-algorithm; p = 0.088). Application of the algorithm to the pre-algorithm group revealed a potential overall cost saving of $70 295.

The implementation of an evidence-based algorithm for the treatment of intertrochanteric fractures reduced costs while maintaining quality of care with a lower rate of complications and re-admissions.

Cite this article: Bone Joint J 2014;96-B:1192–7.
Risco ambiental decorrente de desmatamentos e potencialidades para um desenvolvimento sustentável em espaços de micro zoneamento ecológico amazônico. O caso da Reserva de Alcobaça na região do Lago de Tucuruí – Pará
Authors: Barata Adriana Simone do N.
Published: September 2014

O presente texto refere-se ao resultado de um estudo de caso realizado na Reserva de Desenvolvimento Sustentável – Alcobaça, que se localiza no Estado do Pará – Brasil. Esta reserva foi constituída na sequência da construção da barragem de Tucuruí, cuja albufeira criou numerosas ilhas e zonas marginais ocupadas por populações de pescadores artesanais, coletores, caçadores, caboclos, em área de floresta densa.O foco do estudo voltou-se para a questão dos processos de degradação ambiental de interferência antrópica, no caso os desmatamentos indiscriminados e as suas consequências ambientais. Estes desmatamentos são feitos pela população local para limpeza do solo e ocupação dessas áreas para a agricultura e para habitação, mas também para venda da madeira a madeireiros. Para além do recuo da floresta, esta sofre, também, uma degradação do solo pela diminuição da proteção das árvores. Como os solos são espessos, favorecem o desenvolvimento de voçorocas e rachaduras nos terrenos inclinados.
Riscos ambientais no Litoral: estudo comparativo Brasil-Portugal
Authors: Medeiros Wendson , Cunha Lúcio , Almeida António Campar de
Published: September 2014

O presente trabalho trata os riscos ambientais no Litoral dos territórios da Figueira da Foz (Centro de Portugal) e Areia Branca (Nordeste do Brasil), tendo como principal objetivo identificar e avaliar os riscos ambientais a partir de uma abordagem comparativa, fundamentada em trabalho de campo, interpretação de fotografias aéreas e imagens de satélite, bem como em contactos com as populações das áreas de estudo. Os riscos identificados apresentam magnitudes e expressões diferentes nos dois territórios, apontando para uma necessidade premente de monitorização e de implantação de ações de mitigação do risco, especialmente, no que tange ao planeamento e ordenamento do território.
Riscos associados à exploração mineira. O caso das minas da Panasqueira
Authors: Gonçalves Anselmo Casimiro Ramos
Published: September 2014

Refletir sobre os riscos associados à actividade mineira (externos e internos, riscos para a saúde e acidentes de trabalho) não pode ser visto de modo algum com alarmismo, mas sim como uma atitude de consciencialização daspopulações, das entidades municipais e estatais responsáveis pela gestão do risco, assim como das próprias empresas mineiras.
A evolução da Serra da Malcata – Estudo de Geomorfologia
Authors: Clamote Victor , Salgado Telmo
Published: September 2014

Este estudo tem como objetivo fundamental, apresentar uma análise da evolução do relevo da Serra da Malcata sobretudo em termos estruturais. A apresentação deste trabalho justifica-se sobretudo pelo fato da análise desta elevação permanecer uma lacuna nos estudos de Geomorfologia. Deste modo procurámos desenvolver uma explicação da evolução da unidade geomorfológica da Serra da Malcata.Esperamos que a apresentação desta análise possa promover uma fundamentação geomorfológica da evolução da Serra da Malcata, procurando sobretudo lançar importantes elementos de explicação da evolução deste relevo e que os dados agora apresentados possam colmatar de momento o vazio existente nos conhecimentos de geomorfologia relativamente à Serra da Malcata.
Imigração e territórios em mudança. Teoria e prática(s) do modelo de atração-repulsão numa região de baixas densidades
Authors: Castro Fátima Velez de
Published: September 2014

Os estudos pioneiros de Ravenstein (1876, 1889) tiveram um carácter determinante na construção do quadro teórico associado às migrações. Ao desenvolver os princípios do modelo de atração-repulsão, o autor destaca o papel da dinâmica territorial na estruturação do projeto migratório dos indivíduos, cuja decisão de se deslocarem do local de origem para um determinado destino estará relacionada com a percepção positiva ou negativa face a determinados aspetos de ambos os lugares. Significa que, por um lado, os migrantes serão influenciados pela existência de fatores repulsivos existentes no território de partida; por outro, a escolha do território de destino estará condicionada pela existência de fatores atrativos, nomeadamente de cariz económico, laboral e social. Lee (1969) continua o trabalho de Ravenstein, embora lhe faça algumas críticas, considerando a existência de obstáculos intervenientes e de fatores pessoais como aspetos determinantes a considerar na decisão de migrar. Assim, parte-se do princípio que há uma tendência para que os migrantes se desloquem de áreas pouco povoadas para áreas de maior concentração humana; de regiões de baixas densidades para regiões dinâmicas do ponto de vista económico e social; de territórios pobres e pouco desenvolvidos para territórios com um maior nível de desenvolvimento. Porém, coloca-se em causa a linearidade do processo: será que as regiões consideradas repulsivas não podem revelar dinâmicas diferenciadas (neste caso positivas) face a distintas realidades migratórias? Com o objetivo de clarificar a questão, procurar-se-ão discutir os princípios estruturantes do modelo de atraçãorepulsão de Ravenstein, tendo em conta não só a análise crítica de Lee, como também os pressupostos defendidos pelas principais teorias e modelos migratórios, numa perspetiva de complementaridade. Além desta construção teórica, será analisado o estudo de caso de um território português de baixas densidades, com características territoriais potencialmente repulsivas, na sub-região do Alto Alentejo. O interesse de investigação nesta área geográfica está relacionado com o facto de, ao longo da última década, se ter verificado uma renovada dinâmica territorial à escala local, gerada pela presença de grupos de imigrantes que aí residem e trabalham. A partir da compreensão das motivações de deslocação destes indivíduos entre os dois pólos migratórios (origem e destino), tentar-se-á discutir em termos práticos, a validade e as fragilidades do modelo migratório em causa.
O clima como risco, as cidades como sistemas vulneráveis, a saúde como promoção da vida
Authors: Sant´Anna Neto João Lima
Published: September 2014

Este artigo pretende contribuir para a discussão teórica sobre a relação entre o clima e a cidade numa perspectiva geográfica em que se propõe a possibilidade de se considerar o clima urbano como uma construção social. Por não termos a capacidade de lidar com as grandes catástrofes, por variadas limitações, a humanidade optou por resignar-se aceitando a vulnerabilidade diante dos eventos de grande magnitude. As cidades, como espaços produzidos, ao mesmo tempo em que criam oportunidades civilizatórias, também se transformam em armadilha ambiental. Se a cidade é o habitat da modernidade, se os sistemas urbanos são altamente complexos e desiguais e, se a atmosfera urbana é o produto da interação entre as variáveis do clima e as intervenções socioeconômicas, então os diversos grupos sociais não experimentam nem se relacionam com o tempo e o clima urbano da mesma forma. Nesta perspectiva, tem-se que admitir que o clima urbano possa ser interpretado como uma construção social.
Ambiente residencial e obesidade infantil: análise exploratória no distrito de Aveiro
Authors: Lourenço Ana , Gama Augusta , Nogueira Helena , Mourão-Carvalhal Isabel , Ferrão Maria , Rosado Victor , Padez Cristina
Published: September 2014

Na epidemiologia da obesidade, embora recentes investigações no campo da genética revelem a importância dos componentes géneticos na suscetibilidade individual, os fatores ambientais demonstram um efeito mais acentuado. Esta perspetiva socioecológica resulta do brusco aumento da prevalência de excesso de peso e obesidade que ocorreu em todo o mundo, num curto espaço de tempo, sugerindo uma explicação que não é somente, nem fundamentalmente, de índole genética. Este texto tem como propósito avaliar o impacto dos fatores ambientais no índice de massa corporal da população infantil, em idade escolar, residente no distrito de Aveiro. Os resultados obtidos revelaram uma influência significativa da perceção parental dos atributos do ambiente social, nomeadamente a perceção da insegurança da comunidade local, no excesso de peso e obesidade.
Implementação do laboratório ambiental urbano da Figueira da Foz (Portugal)
Authors: Cordeiro A. M. Rochette , Marques David , Ganho Nuno
Published: September 2014

A crescente complexidade do subsistema climático urbano torna fundamental que se realize uma monitorização em contínuo do ambiente físico, através da instalação de estações meteorológicas e de qualidade do ar. Conscientes desta realidade, neste artigo, apresentam-se e discutem-se as mais-valias associadas à implementação de um sistema de monitorização ambiental urbano na cidade da Figueira da Foz (Portugal).
Causas de incêndios florestais em Portugal continental. Análise estatística da investigação efetuada no último quindénio (1996 a 2010)
Authors: Lourenço Luciano , Fernandes Sofia , Bento-Gonçalves António , Castro Ana , Nunes Adélia , Vieira António
Published: September 2014

Ao longo dos últimos anos, Portugal não tem conseguido travar os incêndios florestais, tanto no que diz respeito número de ocorrências como no que se refere à dimensão das áreas ardidas, sobretudo durante o período estival, quando dominam temperaturas elevadas e a dessecação dos combustíveis gera um ambiente propício à propagação dos incêndios, cuja ignição, em mais de 90% dos casos, tem origem em atos humanos, negligentes e intencionais.Com o objetivo de melhor compreender a origem destes incêndios florestais, o presente estudo visa analisar as causas responsáveis pela ignição dos incêndios florestais em Portugal e acompanhar o modo como elas foram evoluindo, quer ao longo do tempo, quer em termos da sua distribuição espacial, no período compreendido entre 1996 e 2010.
Grinding California
Authors: Butz Konstantin
Published: September 2014

»Grinding California« provides the first academic analysis of the subculture of skate punk at book-length. It establishes highly critical evaluations of the discourses that influenced early skateboarding and punk cultures. Based on an examination of songs, flyers, magazines, and videos, Konstantin Butz revisits American popular cultures of the 1980s and approaches them from a variety of theoretical and methodological angles. He introduces contemplations of the rebellious potential that can be located within skate punk's material and corporeal contestations of the site-specific locale of suburban Southern California. Theoretical recourses to thinkers such as Gilles Deleuze, Félix Guattari, Jean Baudrillard and Hans Ulrich Gumbrecht are topped off with excerpts from interviews with some of the most influential protagonists of the 1980s skate punk scene.
Konsumkunst
Authors: Blanché Ulrich
Published: September 2014

Der vormalige Young British Artist Damien Hirst und der Street Artist Banksy sind zwei der bekanntesten Vertreter der britischen Gegenwartskunst - ihre Werke im Spannungsfeld von Kunst, Konsum und Popkultur gehören zu den meistbeachtetsten unserer Zeit. Eine systematische Aufarbeitung dieser künstlerischen Positionen und ihrer Bezüge zur Konsumkultur unserer Gegenwart hat jedoch lange auf sich warten lassen. Ulrich Blanché schließt diese Lücke: Er untersucht die Werke der Künstler vor dem Hintergrund der Londoner Kunstszene seit 1980, zeigt Verbindungen zu Duchamp, Warhol oder auch Koons auf und reflektiert die Rolle des Rezipienten, die Bedeutung der »Location« und insbesondere die Bezüge zwischen Kunst, Konsum und Werbung in diesen Werken.
»Aufzeichnungen eines Vielfachen«
Authors: Sanchiño Martínez Roberto
Published: September 2014

Zwei Aspekte des Werkes von Friedrich Nietzsche werden in diesem Buch in Beziehung zueinander gesetzt: seine plurale und dividualistische Subjekt-Konzeption, in der das Subjekt als Vielheit und Dividuum gedacht wird, und seine auf der Ebene von Autorschaft und Schreibweise zu identifizierende selbstreferentielle, literarisch-philosophische Ich-Bezogenheit. Beide Aspekte werden in origineller Lesart auf Nietzsches Poetologie des Selbst, das heißt auf Prozesse der Selbstmodellierung, bezogen. Die so gewonnene Perspektive verbindet die Möglichkeiten der philosophiehistorischen Zugangsweise geschickt mit literatur- und religionswissenschaftlichen Betrachtungsweisen und schöpft daraus innovative Impulse für die Deutung von Werk und Autorschaft Nietzsches.
Die Genese der autonomen Kunst
Authors: Krauss Sebastian W.D.
Published: September 2014

Die Entstehung eines autonomen Kunstsystems ist nicht ohne Ablösung von religiösen und an Schichtung orientierten Erwartungen denkbar. Anhand einer historischen Empirie von Künstlertraktaten zeigt Sebastian W. D. Krauss, auf welche Weise sich im Mittelalter und in der Frühen Neuzeit ein Wissen über Malerei herausbildete, das auf diese Bezüge verzichten konnte. Die wissenssoziologische Analyse folgt hierbei den Reflexionsbemühungen über die Unterscheidung von Kunst und Handwerk sowie dem Wirklichkeitsverhältnis des Bildes, das in diesem Prozess zunehmend auf Imagination und die Kontingenz subjektiven Erlebens verpflichtet wurde.
Home gammaglobulin therapy: a patient survey of intravenous and subcutaneous options in Canada
Authors: Reid Brenda , Pires Linda
Published: September 2014

Introduction: For close to half a century immunoglobulin replacement therapy has been the main therapy for patients unable to produce functioning antibodies. To date, both subcutaneous (SC) and intravenous delivery methods have been successful at effectively and safely replacing immunoglobulin. Home intravenous and SC therapy programs have been established and have gained attention, but the true motivation and frequency of switching from traditional hospital-based treatment to these alternatives remains unknown. This study aims to determine the willingness of patients in Canada to switch to a home-based gammaglobulin treatment program by quantifying related experiences and preferences.

Methods: A cohort of 169 patients in Ontario currently on hospital-based intravenous immunoglobulin (IVIG) replacement therapy (referral centers or community hospitals) were sent a 2.5 page survey consisting of 25 questions. Data were collected and statistically analyzed using Fisher, χ2, and McNemar tests, where P < 0.05 was considered statistically significant.

Results: Ninety-one patients responded and most agreed to consider home therapy regardless of the administration route, based on recommendations from an immunologist (IVIG, P = 0.006; SC, P < 0.001). Patients preferred switching to home IVIG rather than to SC (P = 0.01), but their concerns regarding home healthcare costs were more prominent with IVIG (P = 0.01). The main concern with current intravenous therapy was the overall loss of time (P = 0.0001), whereas for home therapy it was the loss of supervision (P = 0.0009) and possible associated costs. Patients considered home treatment more convenient, as it is less time consuming (P = 0.01), and this was perceived as an improvement in quality of life (P = 0.001). It was considered less convenient because it may be unsafe and (or) more expensive.

Conclusion: This survey demonstrates that home intravenous therapy maybe the preferred option for patients with antibody deficiency in Ontario, provided this decision was supported by a specialist in the field, secured supervision was available, and it was not associated with personal expenses.

Statement of novelty: The first study to examine patient willingness to try a new route of gammaglobulin administration at home.
Role of presepsin for the evaluation of sepsis in the emergency department
Authors: Pizzolato Elisa , Ulla Marco , Galluzzo Claudia , Lucchiari Manuela , Manetta Tilde , Lupia Enrico , Mengozzi Giulio , Battista Stefania
Published: September 2014

Sepsis, severe sepsis and septic shock are among the most common conditions handled in the emergency department (ED). According to new Sepsis Guidelines, early diagnosis and treatment are the keys to improve survival. Plasma C-reactive protein (CRP) and procalcitonin (PCT) levels, when associated with documented or suspected infection, are now part of the definitions of sepsis. Blood culture is the gold standard method for detecting microorganisms but it requires too much time for results to be known. Sensitive biomarkers are required for early diagnosis and as indexes of prognosis sepsis. CRP is one of the acute phase proteins synthesized by the liver: it has a great sensitivity but a very poor specificity for bacterial infections. Moreover, the evolution of sepsis does not correlate with CRP plasma changes. In recent years PCT has been widely used for sepsis differential diagnosis, because of its close correlation with infections, but it still retains some limitations and false positivity (such as in multiple trauma and burns). Soluble CD14 subtype (sCD14-ST), also known as presepsin, is a novel and promising biomarker that has been shown to increase significantly in patients with sepsis, in comparison to the healthy population. Studies pointed out the capability of this biomarker for diagnosing sepsis, assessing the severity of the disease and providing a prognostic evaluation of patient outcome. In this mini review we mainly focused on presepsin: we evaluate its diagnostic and prognostic roles in patients presenting to the ED with systemic inflammatory response syndrome (SIRS), suspected sepsis or septic shock.
Geometry of orbit spaces of proper Lie groupoids
Authors: Pflaum Markus J. , Posthuma Hessel , Tang Xiang
Published: September 2014

In this paper, we study geometric properties of quotient spaces of proper
Lie groupoids. First, we construct a natural stratification on such spaces
using an extension of the slice theorem for proper Lie groupoids of
Weinstein and Zung. Next, we show the existence of an appropriate metric on
the groupoid which gives the associated Lie algebroid the structure of a
singular riemannian foliation. With this metric, the orbit space inherits
a natural length space structure whose properties are studied. Moreover,
we show that the orbit space of a proper Lie groupoid can be triangulated.
Finally, we prove a de Rham theorem for the complex of basic differential
forms on a proper Lie groupoid.
Methotrexate-gelonin conjugate – an inhibitor of MCF-7 cells expressing the dihydrofolate receptor
Authors: Badr Mohamed , Kopp Christian , Theison Sandra , Meyer Jennifer , Trommer Wolfgang E.
Published: September 2014

An immunotoxin composed of gelonin, a basic ribosome-inactivating protein, type I of 30 kDa, isolated from the seeds of the Indian plant Gelonium multiflorum and methotrexate (MTX) has been studied as a potential tool of gelonin delivery into the cytoplasm of MTX-responsive cells. On the average, about five molecules of methotrexate were chemically coupled to gelonin via an N-hydroxysuccinimide ester of the drug. The MTX-gelonin conjugate was able to reduce the viability of MCF-7 cells in a dose-dependent manner with ID50 of 10 nm, whereas gelonin or MTX alone showed none or very little effects. Besides its ribosome-inactivating activity, which is about ten-fold lower in an in vitro translation assay (IC50 of 50.5 ng/ml as compared to 4.6 ng/ml), the conjugate also significantly induced direct and oxidative DNA damage as shown by the alkaline comet assay. Hence, MTX-gelonin conjugates are promising candidates for the treatment of MTX-responsive cancers.
Genetic variation within transcriptional regulatory elements and its implications for human disease
Authors: Rada-Iglesias Alvaro
Published: September 2014

Common human pathologies have a complicated etiology involving both genetic and environmental risk factors. Moreover, the genetic basis of these disorders is also complex, with multiple and weak genetic variants contributing to disease susceptibility. In addition, most of these risk genetic variants occur outside genes, within the vast non-coding human genomic space. In this review I first illustrate how large-scale genomic studies aimed at mapping cis-regulatory elements in the human genome are facilitating the identification of disease-causative non-coding genetic variation. I then discuss some of the challenges that remain to be solved before the pathological consequences of non-coding genetic variation can be fully appreciated. Ultimately, revealing the genetics of human complex disease can be a critical step towards more personalized and effective diagnosis and treatments.
Titin: central player of hypertrophic signaling and sarcomeric protein quality control
Authors: Kötter Sebastian , Andresen Christian , Krüger Martina
Published: September 2014

The giant sarcomeric protein titin has multiple important functions in striated muscle cells. Due to its gigantic size, its central position in the sarcomere and its elastic I-band domains, titin is a scaffold protein that is important for sarcomere assembly, and serves as a molecular spring that defines myofilament distensibility. This review focuses on the emerging role of titin in mechanosensing and hypertrophic signaling, and further highlights recent evidence that links titin to sarcomeric protein turnover.
The epigenetic tracks of aging
Authors: Weidner Carola Ingrid , Wagner Wolfgang
Published: September 2014

Aging is associated with the deterioration of biological functions, which is either caused by accumulation of random defects or mediated by a controlled process. This article provides an overview of age-associated epigenetic alterations in the histone code, DNA-methylation (DNAm) pattern, and chromatin structure. In particular, age-related DNAm changes are highly reproducible at specific sites in the genome. The DNAm level at few CpGs facilitates estimation of chronological age and there is evidence that such predictions are indicative for biological age. Overall, aging appears to be associated with a tightly regulated epigenetic process, but the underlying mechanism remains to be elucidated.
The role of the Mpv17 protein mutations of which cause mitochondrial DNA depletion syndrome (MDDS): lessons from homologs in different species
Authors: Löllgen Stefanie , Weiher Hans
Published: September 2014

Mitochondrial DNA depletion syndromes (MDDS) are severe pediatric diseases with diverse clinical manifestations. Gene mutations that underlie MDDS have been associated with alterations in the mitochondrial DNA (mtDNA) replication machinery or in mitochondrial deoxyribonucleoside triphosphate pools. However, the nuclear gene MPV17, whose mutated forms are associated with hepatocerebral MDDS in humans, plays a so-far unknown role in mtDNA maintenance. A high degree of conservation has been determined between MPV17 and its mouse (Mpv17), zebrafish (tra) and yeast (SYM1) homologs, respectively, whereby mutants in these cause very different phenotypes. While dysfunction in this gene in humans causes fatal liver disease, kidney pathology is induced in mice. Moreover, in zebrafish inactivation of the Mpv17 homolog was detected as a viable dyscolouration mutant. Knock out of the yeast ortholog results in a temperature-sensitive metabolic growth phenotype. Detailed analyses on common denominators between these different phenotypes strengthen the hypothesis that the Mpv17 protein forms a channel in the inner mitochondrial membrane, allowing small molecules – in vertebrates probably nucleotides, and in yeast probably intermediates of the tricarboxylic acid cycle – to pass. Moreover, a function modifying the pathologic manifestations of MPV17-related disease in mice has been identified. This signaling pathway remarkably involves the non-mitochondrial catalytic subunit of DNA-dependent protein kinase (PRKDC), important in double-strand break repair resistance against reactive oxygen-induced genotoxic stress.
Surgical Strategy for Moderate Ischemic Mitral Valve Regurgitation: Repair or Ignore?
Authors: Diken Adem İ , Altıntaş Garip , Yalçınkaya Adnan , Lafçı Gökhan , Hanedan Onur , Çağlı Kerim
Published: September 2014

Background: Ischemic heart disease is a significant complication of atherosclerosis. Myocardial infarction after the development of coronary artery disease can lead to a number of serious complications, including ischemic mitral regurgitation (IMR). Currently there is no consensus regarding the preferred therapeutic modality for moderately severe IMR. In this study, the postoperative outcome of concomitant coronary artery bypass (CABG) and mitral valve repair was compared with that of CABG alone in two groups of patients with moderately severe IMR.

Methods: A total of 84 patients who underwent operations for coronary artery disease and moderately severe IMR were included in the study. Preoperative demographic and clinical characteristics were recorded at the time of admission. The severity of mitral regurgitation was graded using transthoracic echocardiography and left ventriculography.

Results: Significant postoperative improvements were observed in ejection fraction and systolic diameter compared to preoperative values (P = .006 and P = .020 respectively, in the intervention group, P = .001 and P = .001 respectively, in the control group). The decrease in pulmonary artery pressure (PAP) was significant only in the intervention group (P = .001). There was a significantly marked reduction in the severity of IMR in the intervention group compared to control.

Conclusion: Surgical repair of the mitral valve in conjunction with CABG for moderately severe IMR appears to be more effective than isolated CABG for certain outcome parameters, including decreased severity of mitral regurgitation and decreased pulmonary artery pressure.
Echocardiographic Assessment and Guidance in Minimally Invasive Surgical Device Closure of Perimembranous Ventricular Septal Defects
Authors: Yang Yifeng , Gao Lei , Xu Xinhua , Zhao Tianli , Yang Jinfu , Gao Zibo , Yin Ni , Xiong Lian , Xie Li , Huang Can , Jin Wancun , Wu Qin
Published: September 2014

Background: The primary aim of this study was to explore the safety and feasibility of minimally invasive surgical device closure of perimembranous ventricular septal defects (PMVSDs) in children using echocardiography for preoperative assessment and intraoperative guidance.

Methods: We enrolled 942 children diagnosed with PMVSDs from April 2010 to October 2013. All children underwent full evaluation by transthoracic echocardiography (TTE) and multiplane transesophageal echocardiography (MTEE) to determine the sizes, types and spatial positions of defects and their proximity to the adjacent tissues. The PMVSDs were surgically occluded using MTEE for guidance.

Results: Eight hundred eighty-nine (94.37%) of 942 children underwent successful closure of PMVSDs. Symmetric devices were used in 741 children (including 38 A4B2 occluders) and asymmetric devices were used in the other 148. All patients received follow-ups at regular intervals after successful occlusion. The occluders remained firmly in place. No noticeable residual shunt or valvular regurgitation was discovered, with the exception of one child whose original mild aortic regurgitation progressed to moderate by the 18 month follow-up. Overall there were no significant arrhythmias with the exception of 3 children, all of whom experienced postsurgical acute attacks of Adams-Stokes syndrome.

Conclusions: Minimally invasive surgical device closure of PMVSDs is safe and feasible. TTE and MTEE play vital roles in all stages of treatment of PMVSDs.
Trends in Hospitalizations and Resource Utilization for Pediatric Pertussis
Authors: Lopez Michelle A. , Cruz Andrea T. , Kowalkowski Marc A. , Raphael Jean L.
Published: September 2014

Background and Objective:

Pertussis is a serious and preventable childhood illness often necessitating hospitalization. The objective was to describe national trends in pediatric pertussis hospitalizations and resource utilization and factors associated with increased length of stay (LOS).

Methods:

This was a cross-sectional analysis of the 1997 to 2009 Healthcare Cost and Utilization Project Kids’ Inpatient Databases. We examined pediatric hospitalizations of children (0–18 years) with a diagnosis of pertussis. Primary outcomes were hospitalizations, LOS, and charges. Weighted linear regression was used to evaluate trends in resource utilization. Multivariate logistic regression was used to determine factors associated with prolonged LOS.

Results:

Infants 0 to 6 months old accounted for nearly 90% of pediatric pertussis hospitalizations. Hospitalizations in public payers increased from 50% in 1997 to 67.4% in 2009 (P < .01). Among children with complex chronic conditions (CCCs), pertussis hospitalizations increased from 9.4% in 1997 to 16.8% in 2009 (P < .01). Mean LOS for pediatric pertussis hospitalizations decreased from 5.40 days in 1997 to 5.28 days in 2009 (P < .01), whereas those for children with CCCs increased from 8.86 days in 1997 to 9.25 days in 2009 (P < .01). Mean adjusted charges for pediatric pertussis hospitalizations rose from $14 520 in 1997 to $22 278 in 2009 (P < .01). For all study years, neonates and children with CCCs had greater odds of prolonged LOS.

Conclusions:

Young infants and publicly insured patients account for a disproportionate number of pertussis-related hospitalizations. Patients with CCCs are increasingly contributing to hospitalizations and resource utilization attributable to pertussis. As new vaccine recommendations are implemented, targeted interventions are warranted to increase preventive efforts in these vulnerable populations.
Factors Associated With Readmission in Late-Preterm Infants: A Matched Case-Control Study
Authors: Moyer Laurel B. , Goyal Neera K. , Meinzen-Derr Jareen , Ward Laura P. , Rust Christina L. , Wexelblatt Scott L. , Greenberg James M.
Published: September 2014

Objective:

The goal of this study was to evaluate risk factors for readmission among late-preterm (34–36 weeks’ gestation) infants in clinical practice.

Methods:

This was a retrospective, matched case-control study of late-preterm infants receiving care across 8 regional hospitals in 2009 in the United States. Those readmitted within 28 days of birth were matched to non-readmitted infants at a ratio of 1:3 according to birth hospital, birth month, and gestational age. Step-wise modeling with likelihood ratio tests were used to develop a multivariable logistic regression model. A subgroup analysis of hyperbilirubinemia readmissions was also performed.

Results:

Of 1861 late-preterm infants delivered during the study period, 67 (3.6%) were readmitted within 28 days of birth. These were matched to 201 control infants, for a final sample of 268 infants. In multivariable regression, each additional day in length of stay was associated with a significantly reduced odds ratio (OR) for readmission (0.57, P = .004); however, for those infants delivered vaginally, there was no significant association between length of stay and readmission (adjusted OR: 1.08, P = .16). A stronger inverse relationship was observed in subgroup analysis for hyperbilirubinemia readmissions, with the adjusted OR associated with increased length of stay 0.40 (P = .002) for infants born by cesarean delivery but 1.14 (P = .27) for those delivered vaginally.

Conclusions:

Infants born via cesarean delivery with longer length of hospital stay have a decreased risk for readmission. As hospitals implement protocols to standardize length of stay, mode of delivery may be a useful factor to identify late-preterm infants at higher risk for readmission.
The Pediatric Inpatient Family Care Conference: A Proposed Structure Toward Shared Decision-Making
Authors: Fox David , Brittan Mark , Stille Chris
Published: September 2014

Over the past decade, there has been a steady increase in the medical complexity of patients on the pediatric inpatient service while at the same time, there are few data to show that families are satisfied with communication of complex issues. Family care conferences are defined as an opportunity outside of rounds to meet and discuss treatment decisions and options. They offer a potential pathway for psychosocial support and facilitated communication. The lack of consensus about the structure of these conferences impedes our ability to research patient, family, and provider outcomes related to communication. The goal of the present article was to describe a structure for family care conferences in the pediatric inpatient setting with a literature-based description of each phase of the conference. The theoretical framework for the structure is that patient and family engagement can improve communication and ultimately health care quality. This proposed model offers guidance to providers and researchers whose goal is to improve communication on the inpatient service.
Predictors of Long Length of Stay in Infants Hospitalized With Urinary Tract Infection
Authors: McMullen Janet A. , Mahant Sanjay , DeGroot Julie M. , Stephens Derek , Parkin Patricia C.
Published: September 2014

Objective:

Urinary tract infection (UTI) is the most common serious bacterial infection in infants. To use resources optimally, factors contributing to costs through length of stay (LOS) must be identified. This study sought to identify clinical and health system factors associated with long LOS in infants with UTI.

Methods:

Using a case–control design, we included infants <6 months old hospitalized with UTI. Cases had LOS ≥96 hours; controls had LOS <96 hours. Clinical and health system variables were extracted from medical records. Cases and controls were compared by using comparative statistics and multiple logistic regression analysis.

Results:

Cases (n = 71) and controls (n = 71) did not differ by gender; cases were more likely to be younger (4.2 vs 7.1 weeks, P = .04), born preterm (13% vs 3%, P = .03), have known genitourinary disease (17% vs 4%, P = .01), an ultrasound (85% vs 68%, P = .02) or voiding cystourethrogram (VCUG) (61% vs 34%, P = .001) ordered, longer wait for VCUG (53 vs 27 hours, P = .002), consult requested (54% vs 10%, P < .001), and longer duration of intravenous (IV) antibiotics (125 vs 62 hours, P < .001). Multiple logistic regression demonstrated that cases were more likely to be premature (odds ratio [OR] 7.6), have known genitourinary disease (OR 7.3), and have VCUG ordered in the hospital (OR 4.5).

Conclusions:

Infants who are older, are born full term, have no genitourinary disease, receive shorter courses of IV antibiotics, and do not have a VCUG ordered have shorter stays and may be eligible for a short-stay unit. Earlier transition to oral antibiotics and delayed ordering of a VCUG may decrease LOS.
Educational Perspectives: Bundling NRP: A Comprehensive Maternal Neonatal Resuscitation Program
Authors: Arafeh Julie
Published: September 2014

Obstetric and neonatal care providers will rarely be required to carry out simultaneous maternal and neonatal resuscitation. However, if this event occurs, a perfect performance of basic life support, advanced cardiac life support with considerations for pregnancy, and neonatal resuscitation guidelines will afford the woman and her child the best chance for survival. Training for rare events with such high stakes is challenging. It is time to consider moving from a traditional life-support training format to one that is bundled with all of the life-support programs required for a specific unit. Organizing resuscitation training so that care providers from a specific unit train together allows them time to practice key nontechnical skills as a team. Team building in this manner supports the adoption of the cognitive, technical, and nontechnical skills required for this difficult event.
Improving Developmental Screening Documentation and Referral Completion
Authors: Talmi Ayelet , Bunik Maya , Asherin Ryan , Rannie Michael , Watlington Tyler , Beaty Brenda , Berman Stephen
Published: September 2014

BACKGROUND AND OBJECTIVES:

Screening, early identification, and referral improves outcomes for young children at risk for developmental delays. Effective developmental screening processes should include efforts to ensure referral completion and documentation of evaluation results and service eligibility in the child’s medical record. Our objectives were to improve provider documentation of actions taken after an abnormal developmental screening result and increase Early Intervention (State Part C) referrals.

METHODS:

Various strategies including an electronic medical record template, monthly clinical informatics reporting, and a phone follow-up after an abnormal screening result were implemented to enhance provider documentation of screening results and improve referral actions and outcomes.

RESULTS:

Of the children eligible for screening (n = 3023), 2610 (86%) were screened, with 382 (15%) scoring in the abnormal range. With phone follow-up, 50% of the abnormal screenings were referred to community resources, including 43% to Early Intervention (EI), in contrast to 20% community referrals and 13% EI referrals with the screening template only (P < .0001). Provider documentation of EI outcomes increased when screening templates and follow-up calls were implemented together (31%) as compared with using the screening template alone (15%).

CONCLUSIONS:

Enhanced documentation of developmental screening efforts using screening templates and clinical informatics reporting in combination with phone follow-up after an abnormal screening result improved developmental screening outcomes, including referral rates, completed evaluations, and provider documentation of EI services. Such strategies can be effectively used in pediatric primary care settings to improve screening processes and ensure that young children access appropriate services.
Cardio-Facio-Cutaneous Syndrome: Clinical Features, Diagnosis, and Management Guidelines
Authors: Pierpont Mary Ella M. , Magoulas Pilar L. , Adi Saleh , Kavamura Maria Ines , Neri Giovanni , Noonan Jacqueline , Pierpont Elizabeth I. , Reinker Kent , Roberts Amy E. , Shankar Suma , Sullivan Joseph , Wolford Melinda , Conger Brenda , Santa Cruz Molly , Rauen Katherine A.
Published: September 2014

Cardio-facio-cutaneous syndrome (CFC) is one of the RASopathies that bears many clinical features in common with the other syndromes in this group, most notably Noonan syndrome and Costello syndrome. CFC is genetically heterogeneous and caused by gene mutations in the Ras/mitogen-activated protein kinase pathway. The major features of CFC include characteristic craniofacial dysmorphology, congenital heart disease, dermatologic abnormalities, growth retardation, and intellectual disability. It is essential that this condition be differentiated from other RASopathies, as a correct diagnosis is important for appropriate medical management and determining recurrence risk. Children and adults with CFC require multidisciplinary care from specialists, and the need for comprehensive management has been apparent to families and health care professionals caring for affected individuals. To address this need, CFC International, a nonprofit family support organization that provides a forum for information, support, and facilitation of research in basic medical and social issues affecting individuals with CFC, organized a consensus conference. Experts in multiple medical specialties provided clinical management guidelines for pediatricians and other care providers. These guidelines will assist in an accurate diagnosis of individuals with CFC, provide best practice recommendations, and facilitate long-term medical care.
Rapid Regression of Left Ventricular Outflow Tract Rhabdomyoma After Sirolimus Therapy
Authors: Breathnach Colm , Pears Jane , Franklin Orla , Webb David , McMahon Colin J.
Published: September 2014

The neonatal presentation of cardiac rhabdomyomas varies in severity from severe outflow tract obstruction to minimal cardiac dysfunction. The natural history for these lesions is spontaneous regression in the majority of cases. We describe a newborn boy with severe left ventricular outflow tract obstruction secondary to a large rhabdomyoma. The tumor infiltrated the paraaortic area and extended around the origin of the right coronary artery, making surgical resection challenging. Oral sirolimus therapy resulted in a rapid regression of the tumor and alleviation of outflow tract obstruction within 1 month of treatment. This is the first report of sirolimus therapy in alleviating critical left ventricular outflow tract obstruction in this condition.
Immunologic Effects of Hydroxyurea in Sickle Cell Anemia
Authors: Lederman Howard M. , Connolly Margaret A. , Kalpatthi Ram , Ware Russell E. , Wang Winfred C. , Luchtman-Jones Lori , Waclawiw Myron , Goldsmith Jonathan C. , Swift Andrea , Casella James F.
Published: September 2014

BACKGROUND AND OBJECTIVE:

Susceptibility to encapsulated bacteria is well known in sickle cell disease (SCD). Hydroxyurea use is common in adults and children with SCD, but little is known about hydroxyurea’s effects on immune function in SCD. Because hydroxyurea inhibits ribonucleotide reductase, causing cell cycle arrest at the G1–S interface, we postulated that hydroxyurea might delay transition from naive to memory T cells, with inhibition of immunologic maturation and vaccine responses.

METHODS:

T-cell subsets, naive and memory T cells, and antibody responses to pneumococcal and measles, mumps, and rubella vaccines were measured among participants in a multicenter, randomized, double-blind, placebo-controlled trial of hydroxyurea in infants and young children with SCD (BABY HUG).

RESULTS:

Compared with placebo, hydroxyurea treatment resulted in significantly lower total lymphocyte, CD4, and memory T-cell counts; however, these numbers were still within the range of historical healthy controls. Antibody responses to pneumococcal vaccination were not affected, but a delay in achieving protective measles antibody levels occurred in the hydroxyurea group. Antibody levels to measles, mumps, and rubella showed no differences between groups at exit, indicating that effective immunization can be achieved despite hydroxyurea use.

CONCLUSIONS:

Hydroxyurea does not appear to have significant deleterious effects on the immune function of infants and children with SCD. Additional assessments of lymphocyte parameters of hydroxyurea-treated children may be warranted. No changes in current immunization schedules are recommended; however, for endemic disease or epidemics, adherence to accelerated immunization schedules for the measles, mumps, and rubella vaccine should be reinforced.
Infant Feeding Practices and Reported Food Allergies at 6 Years of Age
Authors: Luccioli Stefano , Zhang Yuanting , Verrill Linda , Ramos-Valle Moraima , Kwegyir-Afful Ernest
Published: September 2014

OBJECTIVE:

The goal of this study was to identify the frequency of physician-diagnosed food allergies among 6-year-old US children and study the impact of exclusive breastfeeding and complementary food introduction on this frequency.

METHODS:

Data were analyzed from children who participated in the Infant Feeding Practices Study II Year 6 Follow-Up Study (Y6FU). Children with probable food allergy (pFA) were defined as children with report of physician-diagnosed food allergy at age 6 years. Subgroups of pFA included children who were not diagnosed before 1 year of age (new pFA) and those with atopic risk factors (high risk).

RESULTS:

Prevalence of total pFA in the Y6FU was 6.34%. The majority of these children had new pFA and high-risk factors. Higher maternal education, higher family income, family history of food allergy, and reported eczema before 1 year of age were significantly associated with higher odds of total or new pFA. Exclusive breastfeeding duration and timing of complementary food introduction were not significantly associated with total pFA. However, exclusive breastfeeding of ≥4 months compared with no breastfeeding was marginally associated with lower odds of new pFA (adjusted odds ratio: 0.51; P = .07); this effect was not observed with high-risk children.

CONCLUSIONS:

Analysis of infant and maternal variables in the Y6FU cohort of US children revealed that socioeconomic and atopic factors were the main predictors of pFA at age 6 years. Exclusive breastfeeding of ≥4 months may have a preventive effect on development of pFA after 1 year of age in non high-risk children.