bluuebunny/crossref_metadata_2025 huggingface dataset:
1152. Leveraging Human Factors Engineering to Optimize Low-level Disinfection of Bedside Medical Tools
Authors: Handy Lori , Bezpalko Orysia , Hei Hillary , Ehritz Carly , Townsend Sara , Sammons Julia Shaklee
Published: November 2018

Background

Inadequate cleaning and disinfection of shared medical equipment can lead to healthcare-associated infections and outbreaks. Stethoscopes were identified as the most commonly used piece of shared equipment at our institution, but cleaning practices were inconsistent among providers. We aimed to assess provider attitudes and practices around stethoscope disinfection and to subsequently implement a test of change (TOC) supported by human factors observations to improve cleaning consistency and frequency.

Methods

We conducted an anonymous electronic survey via SurveyMonkey paired with human factors observations in a free-standing children’s hospital. We surveyed physicians, nurses, and advanced practice providers to identify barriers to regular stethoscope cleaning. Quantitative results, human factors observations, and workflow simulations on a single unit were used to design an intervention to standardize low-level disinfection. Small mesh baskets holding alcohol prep pads labeled with brightly colored signage were installed by the exit of each patient room on one trial unit. Following implementation, a postsurvey and direct observations on the unit were conducted.

Results

Of those surveyed healthcare providers who completed the pre-survey (n = 383), 92% believed stethoscopes pose an infection risk to patients. However, only 38% of respondents reported cleaning their stethoscope between patient encounters. The most cited barrier to cleaning was a lack of easily accessible cleaning product (49%). After the unit-based TOC, alcohol from baskets were utilized by 80% of the 25 surveyed providers; 74% reported increased frequency of cleaning due to accessibility. Additionally, the brightly colored signage was a visual cue to disinfect equipment. Increased satisfaction of families reinforced the behavior. Direct observations revealed an increased frequency of cleaning while qualitative interviews elicited increased awareness from staff.

Conclusion

Leveraging human factors engineering to inform the placement and design of easily accessible disinfection supplies correlated with increased frequency of stethoscope cleaning by healthcare providers. Future steps include implementation in all inpatient care areas.

Disclosures

All authors: No reported disclosures.
1158. Needlestick Injuries and Other Potential Exposures to Bloodborne Pathogens Among Police Officers in a City Police Department, 2011–2016
Authors: De Perio Marie , Victory Kerton , Groenewold Matthew
Published: November 2018

Background

The approximately 850,000 police officers nationwide are at risk of bloodborne diseases through needlestick injuries and other exposure incidents because of the nature of their work. In response to a request for a health hazard evaluation, we determined the incidence and circumstances of needlestick injuries and other potential exposures to bloodborne pathogens among police officers at a city department from 2011 to 2016.

Methods

We analyzed data extracted from the city’s centralized human resource database on all needlestick injuries and other potential exposure incidents from January 1, 2011 to December 31, 2016 and characterized their circumstances. We calculated the annual incidence of needlestick injuries using two methods. We ran a Poisson regression model to determine the trend in the annual incidence over time using SAS 9.4.

Results

We identified 13 needlestick injuries and 37 additional potential exposure incidents. Needlestick injuries most commonly occurred during pat-down searches of a suspect and during search of a suspect’s property or vehicle. Nine of 11 source persons with documented test results after a needlestick injury were found to have hepatitis C infection. The annual incidence of needlestick injuries ranged from 0 to 5.07 per 1,000 police officers and from 0 to 2.45 per 10,000 reactive calls for service and did not appear to have a significant trend. Most exposure incidents consisted of spitting incidents, human bites, and other contact with blood. Of 22 source persons with blood drawn, four had hepatitis C infection, two have HIV infection, and one had both. None of the incidents reportedly led to transmission of hepatitis B, hepatitis C, or HIV.

Conclusion

Police officers in this department are at risk for needlestick injuries and other exposures to bloodborne pathogens. We recommended improvements to engineering, administrative, and personal protective equipment controls, including training on safe searching techniques and sharps evidence collection and provision of nitrile gloves.

Disclosures

All authors: No reported disclosures.
1165. Comparing Patient Risk Factors, Sequence Type, and Resistance Loci Identification Approaches for Predicting Antibiotic Resistance in Escherichia coli Bloodstream Infections
Authors: MacFadden Derek , Melano Roberto , Tijet Nathalie , Hanage William P , Daneman Nick
Published: November 2018

Background

To improve the adequacy of empiric antibiotic therapy, an important predictor of clinical outcome, rapid diagnostic tests of antibiotic resistance are increasingly being developed that identify the presence or absence of antibiotic resistance genes/Loci. Few approaches have utilized other sources of predictive information, which could be identified in shorter time periods, including patient epidemiologic risk factors for antibiotic resistance and markers of lineage (e.g., sequence type).

Methods

Using a dataset of 414 Escherichia coli isolated from separate episodes of bacteremia at a single academic institution in Toronto, Canada between 2010 and 2015, we compared the potential predictive ability of three approaches (epidemiologic, sequence type, and gene identification) for classifying antibiotic resistance to three commonly used classes of broad-spectrum antibiotic therapy (third-generation cephalosporins, fluoroquinolones, and aminoglycosides). We used logistic regression models with binary predictor variables to generate model receiver operating characteristic curves. Predictive discrimination was measured using apparent and corrected (bootstrapped) area under the curves (AUCs).

Results

Using two simple epidemiologic risk factors (prior antibiotic exposure and recent prior Gram-negative susceptibility), modest predictive discrimination was achieved (AUCs 0.65–0.74). Sequence type demonstrated strong discrimination (AUCs 0.84–0.94) across all three antibiotic classes. Epidemiologic risk factors significantly improved sequence-type prediction for cephalosporins and aminoglycosides (P < 0.05). Gene identification approaches provided the highest degree of discrimination (AUCs 0.73–0.99), with no statistically significant benefit of adding epidemiologic predictors.

Conclusion

Rapid identification of sequence type, or other lineage-based classification, could produce excellent discrimination of antibiotic resistance, and may be improved by incorporating readily available epidemiologic predictors.

Disclosures

All authors: No reported disclosures.
LB5. Safety of In Utero Antiretroviral (ARV) Exposure: Neurologic Outcomes in HIV-Exposed, Uninfected Children
Authors: Crowell Claudia S , Williams Paige , Yildirim Cenk , Van Dyke Russell , Smith Renee , Chadwick Ellen G , Seage George , Hazra Rohan
Published: November 2018

Background

Antiretroviral therapy for pregnant women with HIV has dramatically decreased perinatal transmission of HIV, but concerns remain regarding adverse neurologic outcomes from possible mitochondrial dysfunction or other mechanisms in children exposed in utero to antiretroviral (ARV) medications.

Method

We evaluated HIV-exposed uninfected (HEU) children enrolled in the Surveillance Monitoring for ART Toxicities (SMARTT) study, a longitudinal observational cohort study conducted by the Pediatric HIV/AIDS Cohort Study (PHACS) network. The primary outcome of interest was a “neurologic case” (microcephaly, febrile seizures, seizure disorders, ophthalmologic disorders, other neurologic conditions) as determined by clinical review blinded to ARV exposure. Log-binomial regression analysis was used to obtain adjusted relative risks (aRRs) for associations between in utero ARV exposure and neurologic case status, accounting for potential confounders including Hispanic ethnicity, tobacco use during pregnancy, and birth cohort (2011–2014 and 2015–2017 vs. <2011). To account for variable person-time follow-up within the cohort, Poisson regression models for adjusted incidence rate ratios (aIRRs) were also fitted.

Result

Among 3,747 eligible HEU children enrolled in SMARTT (52% male, 68% Black and 31% Hispanic), 237 were diagnosed with neurologic conditions, yielding an event rate of 6.3% (95% CI: 5.6%, 7.2%). Tobacco and alcohol use during pregnancy were common (17% and 8%, respectively). The majority of children had in utero ARV exposure (87%); 60% to PI-based regimens, 16% to NNRTI-based regimens and 7% to PI + NNRTI-based regimens. In adjusted models, there was a trend towards an association between efavirenz exposure (EFV) and neurologic case status (aRR: 1.60, 95% CI: 0.99, 2.58). This association was statistically significant in sensitivity analyses restricted to children enrolled prior to or shortly after birth (aRR: 1.80, 95% CI: 1.06, 3.05), excluding children with confirmed congenital anomalies (aRR: 1.66, 95% CI: 1.02, 2.64), and accounting for person-time follow-up (aIRR: 1.55, 95% CI: 1.00, 2.76).

Conclusion

EFV exposure during pregnancy was associated with a higher risk of neurologic abnormalities in infancy and childhood.

Disclosures

R. Van Dyke, Giliad Sciences: Grant Investigator, Research grant. E. G. Chadwick, Abbott Labs: Shareholder, stock dividends. AbbVie: Shareholder, stock dividends.
LB8. Outbreak of Enterovirus A71 Neurologic Disease in Children—Colorado, 2018
Authors: Messacar Kevin , Burakoff Alexis , Nix William A , Rogers Shannon , Lopez Adriana S , Oberste M Steve , Gerber Susan I , Spence-Davizon Emily , Herlihy Rachel , Dominguez Samuel
Published: November 2018

Background

In May 2018, an outbreak of enterovirus A71 (EV-A71) neurologic disease was detected at Children’s Hospital Colorado (CHCO) prompting a public health investigation. We characterized clinical, laboratory, and radiologic findings during this outbreak.

Methods

A case was defined as meningitis, encephalitis, or acute flaccid myelitis with EV-A71 identified from a biologic specimen in a child examined at CHCO after March 1, 2018. Biologic specimens from children with neurologic disease and EV identified by clinical reverse-transcription polymerase chain reaction (RT-PCR) were typed by VP1 sequencing at CDC.

Results

As of July 20, 2018, 28 cases of EV-A71 neurologic disease were identified. This report describes the clinical, laboratory, and radiologic findings for the first 13 children identified with EV-A71 neurologic disease, for whom complete information is available. The median age was 13 months (range = 10 days–35 months) and 11 (85%) were male. Neurologic presentations included 12 (92%) with meningitis, 9 (69%) with encephalitis, and 3 (23%) with acute flaccid myelitis (AFM). All 13 children had fever and irritability; 3 (23%) had hand, foot, and mouth disease. Neurologic signs included encephalopathy (n = 7, 54%), ataxia (n = 7, 54%), myoclonus (n = 6, 46%), limb weakness (n = 4, 31%), cranial nerve deficits (n = 2, 15%), and seizures (n = 1, 8%). Nine (90%) of 10 children with cerebrospinal fluid (CSF) specimen analyzed had a pleocytosis (>5 white blood cells/uL); 6 of 8 (75%) children who had brain imaging showed abnormalities, with 5 (63%) in the brainstem, 3 (38%) in the cerebellum, and 3 (38%) in the spinal cord. All 13 children had EV-A71 identified in nasopharyngeal, pharyngeal, or fecal specimens; only 2 of 11 (18%) tested had EV identified in CSF. All 13 children were hospitalized and 4 (31%) required intensive care. The 3 (23%) children with AFM had residual limb weakness at time of discharge. All children survived.

Conclusion

EV-A71 should be considered when children present with myoclonus, ataxia, or limb weakness in the setting of a febrile illness. Testing of nonsterile sites (respiratory, pharyngeal, or fecal) should be considered when CNS disease associated with EV is suspected and initial CSF testing is negative.

Disclosures

All authors: No reported disclosures.
LB10. Changing Epidemiology of Hepatitis A Virus Infections–– United States, 2007–2017
Authors: Foster Monique , Hofmeister Megan , Yin Shaoman , Weidle Paul
Published: November 2018

Background

Hepatitis A virus (HAV) is primarily spread fecal-orally and causes acute illness including fever, jaundice, and diarrhea. After introduction and widespread use of the hepatitis A vaccine in the United States, infection with HAV decreased and outbreaks typically associated with a common-source were uncommon.

Method

CDC receives reports of hepatitis A infections from states through the National Notifiable Disease Surveillance System (NNDSS) and/or directly to the viral hepatitis outbreak response team. We analyzed NNDSS hepatitis A data for 2007–2016, and a combination of NNDSS data and cases directly reported to the CDC hepatitis A outbreak response team during 2017; excluding 2017 NNDSS data from the four states that directly reported outbreaks to the outbreak response team to eliminate the potential for double-counting cases.

Result

During 2007–2011, a total of 10,619 hepatitis A cases were reported; 521 (5%) were associated with outbreaks. Of the 274 outbreak-associated cases for whom clinical data were reported, 102 (37%) were hospitalized and one (0.3%) died. Of the 407 outbreak-associated cases for whom risk exposure data were reported, 210 (52%) were associated with a common source. Comparatively, during 2012–2017, a total of 11,483 hepatitis A cases were reported; 2,323 (20%) were associated with outbreaks. Of the outbreak-associated cases for whom clinical data were reported, 1,306/2,162 (60%) were hospitalized and 43/2,178 (2%) died. Of the outbreak-associated cases for whom risk exposure data were reported, 379/2,188 (17%) were associated with a common source.

Conclusion

In the United States, outbreaks of hepatitis A infections in the decade prior to 2017 were infrequent and typically associated with a common source. Reported cases associated with hepatitis A outbreaks are increasing, along with concurrent increases in hospitalizations and deaths among persons with outbreak-associated infections. Recent outbreaks indicate a decrease in cases associated with a common-source exposure. Decreasing the susceptible population through adherence to childhood vaccination recommendations and targeted vaccination of recommended at-risk groups can prevent future hepatitis A outbreaks of any transmission pattern.

Disclosures

All authors: No reported disclosures.
First-in-Man Clinical Experience Using a High-Definition 3-Dimensional Exoscope System for Microneurosurgery
Authors: Khalessi Alexander A , Rahme Ralph , Rennert Robert C , Borgas Pia , Steinberg Jeffrey A , White Timothy G , Santiago-Dieppa David R , Boockvar John A , Hatefi Dustin , Pannell J Scott , Levy Michael , Langer David J
Published: November 2018

BACKGROUND

During its development and preclinical assessment, a novel, 3-dimensional (3D), high-definition (4K-HD) exoscope system was formerly shown to provide an immersive surgical experience, while maintaining a portable, low-profile design.

OBJECTIVE

To assess the clinical applicability of this 3D 4K-HD exoscope via first-in-man surgical use.

METHODS

The operative workflow, functionality, and visual haptics of the 3D 4K-HD exoscope were assessed in a variety of microneurosurgical cases at 2 US centers.

RESULTS

Nineteen microneurosurgical procedures in 18 patients were performed exclusively using the 3D 4K-HD exoscope. Pathologies treated included 4 aneurysms, 3 cavernous malformations (1 with intraoperative electrocorticography), 2 arteriovenous malformations, 1 foramen magnum meningioma, 1 convexity meningioma, 1 glioma, 1 occipital cyst, 1 chiari malformation, 1 carotid endarterectomy, 1 subdural hematoma, 1 anterior cervical discectomy and fusion, and 2 lumbar laminectomies. All patients experienced good surgical and clinical outcomes. Similar to preclinical assessments, the 3D 4K-HD exoscope provided an immersive 3D surgical experience for the primary surgeon, assistants, and trainees. The small exoscope frame, large depth of field, and hand/foot pedal controls improved exoscope mobility, decreased need to re-focus, and provided unobstructed operative corridors. Flexible positioning of the camera allows the surgeon's posture to be kept in a neutral position with uncompromised viewing angles.

CONCLUSION

The first-in-man clinical experience with the 3D 4K-HD exoscope confirms its excellent optics and ergonomics for the entire operative team, with high workflow adaptability for a variety of microneurosurgical cases. Expanded clinical use of the 3D 4K-HD exoscope is justified.
Amylose-Free (“waxy”) Wheat Colonization by Fusarium spp. and Response to Fusarium Head Blight
Authors: Funnell-Harris Deanna L. , Graybosch Robert A. , O’Neill Patrick M. , Duray Zachary T. , Wegulo Stephen N.
Published: November 2018

Hexaploid waxy wheat (Triticum aestivum L.) has null mutations in Wx genes and grain lacking amylose with increased digestibility and usability for specialty foods. The waxy cultivar Mattern is susceptible to Fusarium head blight (FHB) caused by Fusarium graminearum species complex, which produces the mycotoxin deoxynivalenol (DON). In experiment 1, conducted during low natural FHB, grain from waxy breeding lines, Mattern, and wild-type breeding lines and cultivars were assessed for Fusarium infection and DON concentration. Nine Fusarium species and species complexes were detected from internally infected (disinfested) grain; F. graminearum infections were not different between waxy and wild-type. Surface- and internally infected grain (nondisinfested) had greater numbers of Fusarium isolates across waxy versus wild-type, but F. graminearum-like infections were similar; however, DON levels were higher in waxy. In experiment 2, conducted during a timely epidemic, disease severity, Fusarium-damaged kernels (FDK), and DON were assessed for waxy breeding lines, Mattern, and wild-type cultivars. Disease severity and FDK were not significantly different from wild-type, but DON was higher in waxy than wild-type lines. Across both experiments, waxy breeding lines, Plant Introductions 677876 and 677877, responded similarly to FHB as moderately resistant wild-type cultivar Overland, showing promise for breeding advanced waxy cultivars with reduced FHB susceptibility.
Dynamic Stress Fluoroscopy for Evaluation of the Femoral Neck After Intramedullary Nails: Improved Sensitivity for Identifying Occult Fractures
Authors: Avilucea Frank R. , Joyce David , Mir Hassan R.
Published: November 2018

Objectives:

To report on the use of dynamic stress fluoroscopy (DSF) for detection of occult fractures of the femoral neck associated with femoral shaft fractures. To compare DSF with a fully static imaging protocol in detecting occult femoral neck fractures.

Design:

Multicenter retrospective cohort study.

Setting:

Two urban level I trauma centers.

Participants/Intervention:

A consecutive series of 1273 femoral shaft fractures were included. Inclusion criteria were patients treated with an intramedullary rod (antegrade/retrograde), age ≥18 years, a fine-cut (2 mm) preoperative computed tomography and hip radiographs, intraoperative anteroposterior (AP)/lateral fluoroscopic view of the femoral neck before femoral nailing, and a minimum follow-up of 3 months. Patients were divided into 2 groups based on the technique used to identify the presence of a femoral neck fracture after intramedullary fixation of the femoral shaft: DSF or static intraoperative radiographs.

Main Outcome Measures:

Sensitivity, specificity, positive predictive value, and negative predictive value.

Results:

Both the static imaging protocol and DSF had high specificity (100%; 100%), positive predictive value (100%; 100%), and negative predictive value (99.5%; 99.6%). Sensitivity was poor (73.7%) for the static protocol group versus high (92.3%) for the DSF group.

Conclusions:

Compared with a fully static imaging protocol, DSF is a more sensitive and highly specific technique, enabling intraoperative detection of occult fractures of the femoral neck.

Level of Evidence:

Diagnostic Level III. See Instructions for Authors for complete description of levels of evidence.
Prognostic role of NRAS isoforms in Chinese melanoma patients
Authors: Yan Junya , Xu Longwen , Yu Jiayi , Wu Xiaowen , Dai Jie , Xu Tianxiao , Yu Huan , Guo Jun , Kong Yan
Published: November 2018

Neuroblastoma rat-sarcoma viral oncogene homolog (NRAS) isoforms are expressed in melanoma tumor tissues, which have been described in Caucasian melanoma. However, the status and the clinical significance of NRAS isoforms in the Asian population have not been investigated on a large scale. We examined the expression levels of NRAS isoforms of 140 melanoma samples using quantitative real-time PCR. Furthermore, the relationship of mRNA expression of NRAS isoforms to clinicopathological characteristics and survival of patients was analyzed. Statistical analysis showed that NRAS isoform 2 expression was correlated with melanoma subtypes (P=0.007), and NRAS isoform 4 expression was correlated with tumor thickness (P=0.031) and clinical stage (P=0.006). The median overall survival for patients with high expression of NRAS isoform 3 was significantly shorter than that for patients with low expression of NRAS isoform 3 (P=0.007). In addition, high expression of NRAS isoform 5 was associated with a worse prognosis (P=0.049 and 0.002 for overall survival and disease-free survival, respectively). Multivariate Cox regression analysis showed that high expression levels of NRAS isoform 3 and isoform 5 were independent poor prognostic factors for patients. Our results indicated that the mRNA expressions of NRAS isoform 3 and isoform 5 may be novel indicators of the prognosis of Chinese melanoma patients.
Follicle-stimulating hormone, but not cardiorespiratory fitness, is associated with flow-mediated dilation with advancing menopausal stage
Authors: Serviente Corinna , Witkowski Sarah
Published: November 2018

Objective:

The aim of the study was to evaluate if there are differences in endothelial function before and after acute exercise in women at different menopausal stages with high and low cardiorespiratory fitness.

Methods:

Participants were healthy high-fit premenopausal (n = 11), perimenopausal (n = 12), and postmenopausal women (n = 13) and low-fit perimenopausal (n = 7) and postmenopausal women (n = 8). Brachial artery flow-mediated dilation (FMD) was measured before and after acute moderate intensity exercise. FMD was calculated as (Diameterpeak−Diameterbaseline)/ Diameterbaseline) × 100. Differences between high-fit women and between high- and low-fit perimenopausal and postmenopausal women were assessed with repeated-measure ANOVAs. Relations with FMD were assessed with Pearson correlations.

Results:

FMD was reduced with progressive menopausal stage in high-fit women (P = 0.005) and was lower in perimenopausal compared to postmenopausal women (P = 0.047). FMD was lower in high-fit compared to low-fit women (P = 0.006) and there was no relation between FMD and VO2peak (P > 0.05). There was an inverse relation between FMD and follicle-stimulating hormone (P < 0.05), but not estradiol (P > 0.05).

Conclusions:

These data suggest that endothelial function is lower with progressive menopausal stage in women with high cardiorespiratory fitness; that FMD is lower in women with higher cardiorespiratory fitness; and that FSH, but not estradiol, is associated with FMD.
ICD-10 Coding Will Challenge Researchers
Authors: Mainor Alexander J. , Morden Nancy E. , Smith Jeremy , Tomlin Stephanie , Skinner Jonathan
Published: November 2018

Background:

The October 1, 2015 US health care diagnosis and procedure codes update, from the 9th to 10th version of the International Classification of Diseases (ICD), abruptly changed the structure, number, and diversity of codes in health care administrative data. Translation from ICD-9 to ICD-10 risks introducing artificial changes in claims-based measures of health and health services.

Objective:

Using published ICD-9 and ICD-10 definitions and translation software, we explored discontinuity in common diagnoses to quantify measurement changes introduced by the upgrade.

Design:

Using 100% Medicare inpatient data, 2012–2015, we calculated the quarterly frequency of condition-specific diagnoses on hospital discharge records. Years 2012–2014 provided baseline frequencies and historic, annual fourth-quarter changes. We compared these to fourth quarter of 2015, the first months after ICD-10 adoption, using Centers for Medicare and Medicaid Services Chronic Conditions Data Warehouse (CCW) ICD-9 and ICD-10 definitions and other commonly used definitions sets.

Results:

Discontinuities of recorded CCW-defined conditions in fourth quarter of 2015 varied widely. For example, compared with diagnosis appearance in 2014 fourth quarter, in 2015 we saw a sudden 3.2% increase in chronic lung disease and a 1.8% decrease in depression; frequency of acute myocardial infarction was stable. Using published software to translate Charlson-Deyo and Elixhauser conditions yielded discontinuities ranging from −8.9% to +10.9%.

Conclusions:

ICD-9 to ICD-10 translations do not always align, producing discontinuity over time. This may compromise ICD-based measurements and risk-adjustment. To address the challenge, we propose a public resource for researchers to share discovered discontinuities introduced by ICD-10 adoption and the solutions they develop.
Assessing Infrastructure to Care for Pediatric Patients in the Prehospital Setting
Authors: Ely Michael , Edgerton Elizabeth A. , Telford Russell , Page Kent , Hemingway Craig , Vernon Donald , Olson Lenora M.
Published: November 2018

Objectives

Pediatric patients represent a small proportion of emergency medical services (EMS) calls, challenging providers in maintaining skills in treating children. Having structural capacity to appropriately diagnose and treat pediatric patients is critical. Our study measured the availability of off-line and on-line medical direction and recommended pediatric equipment at EMS agencies.

Methods

A Web-based survey was sent to EMS agencies in 2010 and 2013, and results were analyzed to determine availability of medical direction and equipment.

Results

Approximately 5000 agencies in 32 states responded, representing over 80% response. Availability of off-line medical direction increased between years (78% in 2010 to 85% in 2013), was lower for basic life support (BLS) (63% and 72%) than advanced life support (ALS) agencies (90% and 93%), and was generally higher in urban than rural or frontier locations. On-line medical direction was consistently available (90% both years) with slight increases for BLS agencies (87% to 90%) and slightly greater availability for urban and rural compared with frontier agencies. The majority of agencies carried most recommended equipment; however, less than one third of agencies reported carrying all equipment. Agencies with off-line medical direction, on-line medical direction, and with both off-line and on-line medical direction were respectively 1.69, 1.31, and 2.21 times more likely to report carrying all recommended equipment.

Conclusions

Basic structural capacity exists in EMS for treating children, with improvements seen over time. However, gaps remain, particularly for BLS and nonurban agencies. Continuous attention to infrastructure is necessary, and the recent development of national performance measures should further promote quality emergency care for all children.
Evaluating for Racial Differences in Pain Management of Long-Bone Fractures in a Pediatric Rural Population
Authors: Liao Lucia , Reyes Lilia
Published: November 2018

Objectives

The aim of this study was to determine if a racial disparity exists in the administration of an analgesic, time to receiving analgesic, and type of analgesic administered to children with long-bone fractures. Prior studies have reported the existence of racial disparity but were mostly in adult and urban populations.

Methods

This is a retrospective chart review of 727 pediatric patients (aged 2–17 years) with International Classification of Diseases, Ninth Revision (or 10th revision) codes for long-one fractures in an emergency department that cares for a suburban and rural population between January 2013 and January 2016. Logistic regression was used to estimate the odds ratio of receiving no analgesic versus receiving an analgesic and receiving a nonopioid versus opioid drug. Linear regression analysis was performed to study the relationship between race and time to receive the analgesic, after adjusting for sex, age, insurance type, and mechanism of injury.

Results

Of the 727 children, 27% of them did not receive analgesics regardless of race. 27% (164/605) of white children, 25% (8/31) of African American children, and 24% (12/49) of Hispanic children did not receive analgesics. African Americans are 12% more likely (odds ratio [OR], 1.12; 95% confidence interval [CI], 0.48–2.61) to receive an analgesic compared with whites, and Hispanics are 22% more likely (OR, 1.22; 95% CI, 0.60–2.45) to receive an analgesic than whites. African Americans are 26% less likely (OR, 0.74; 95% CI, 0.31–1.75) to receive an opioid versus a nonopioid compared with whites, and Hispanics are 92% more likely (OR, 1.92; 95% CI, 0.91–4.17). Mean wait time across all races was 69 minutes, with no statistical difference between groups.

Conclusions

This study showed no statistical significance in the receipt or type of analgesic or wait time for pediatric long-bone fractures between race in a major academic level 1 trauma children's hospital, despite previous literature citing otherwise. This study augments to the few studies conducted in a rural setting. It is also one of the few studies that analyzed pain management in a large pediatric population as well as used waiting time to receive analgesic as an outcome measure. Overall, we found a mean wait time of 69 minutes for analgesic administration regardless of race, suggesting the need for more prompt pain management across all races for the management of long-bone fracture in the pediatric population.
Challenges of Clinical Management of Adolescent and Young Adults With Bone and Soft Tissue Sarcoma
Authors: Ferrari Andrea , Gasparini Patrizia , Gill Jonathan , Gorlick Richard
Published: November 2018

Clinical management of adolescents and young adults with bone and soft tissue sarcomas is quite challenging, mainly because of different chemotherapy approaches adopted by pediatric and adult oncologists and tumor-associated factors related to this peculiar age group. Overcoming these barriers is essential for adolescent and young adult patients, whose survival and long-term physical effects are worse than their pediatric counterparts. Nowadays, constant efforts from international collaborations between pediatric and adult oncologists of sarcoma groups have optioned in converging toward a common therapeutic strategy, while improving quality of treatment, as well as research advances dedicated to this at-risk age group of patients with sarcomas.
Modifiable Risk Factors for the Development of Breast Cancer in Young Women
Authors: Cathcart-Rake Elizabeth J. , Ruddy Kathryn J. , Johnson Rebecca H.
Published: November 2018

Introduction

Breast cancer is the most common malignancy among adolescents and young adults (AYAs) women aged 15 to 39 years at diagnosis. An improved understanding of modifiable factors that mitigate the risks of the development of breast cancer may allow for future strategies to reduce the incidence of AYA breast cancer.

Method

A literature review was conducted to report upon associations between modifiable lifestyle factors and breast cancer risk.

Results

Higher levels of physical activity, lower red meat intake, and higher intake of plants appear to decrease the risk of developing AYA breast cancer, whereas associations between obesity and AYA breast cancer risk were less straightforward.

Conclusions

Further research, ideally in large prospective trials, is needed to truly understand modifiable risk factors for the development of AYA breast cancer.
Dynamics and Challenges of Clinical Trials in Adolescents and Young Adults With Cancer
Authors: Fern Lorna A. , Bleyer Archie
Published: November 2018

Inclusion in cancer clinical trials is considered the optimal standard of care, offering improved patient experience and progressive survival gains for subsequent generations of patients. Adolescent and young adult (AYA) patients are underrepresented in cancer research; consequently, improvements in outcomes for AYAs lag behind their pediatric and adult counterparts. Despite international evidence of underrepresentation in research, systematically tested interventions to improve recruitment for AYAs do not exist, and recruitment rates for AYAs continue to be lower than those for children. We review recruitment of AYAs into trials and discuss barriers and facilitators.
Establishing a Culture of Patient Safety, Quality, and Service in Plastic Surgery: Integrating the Fractal Model
Authors: Manahan Michele A. , Aston Jeffrey W. , Bello Ricardo J. , Siotos Charalampos , Demski Renee , Cooney Carisa M. , Pronovost Peter J. , Rosson Gedge D.
Published: November 2018

Problem

There are obstacles to effective nationwide implementation of a culture of patient safety. Plastic surgery faces unique challenges in this area because quality measures are not as well-established as in other fields. Plastic surgery may also require emphasis on patient-reported outcomes as a quality-of-life specialty with distinct concomitant analytical methods.

Approach

We devised a dynamic framework, based on our 3-year experience using a Comprehensive Unit-Based Safety Program—a formal quality improvement committee structure, literature review, and work from The Johns Hopkins Armstrong Institute for Patient Safety and Quality. This framework is specific and exportable to the field of plastic surgery. Monthly patient safety, quality, and service committee meetings encourage multilevel participation in a bottom-up fashion, while connecting with other departments and entities in Johns Hopkins Medicine. Our model focuses our work in the following four domains: (1) safety, (2) external measures, (3) patient experience, and (4) value. Our framework identifies and communicates clear goals, creates necessary infrastructure, identifies opportunities and needs, uses robust performance to develop and implement interventions, and includes analytics to track improvement plans and results.

Outcomes

We have gradually implemented this quality improvement structure into the Johns Hopkins Department of Plastic and Reconstructive Surgery successfully since 2012. Outcomes have improved in externally reported measures of patient safety, quality, and service. We have demonstrated exemplary National Surgical Quality Improvement Program performance for morbidity, return to operating room, and readmission rates. Patient satisfaction surveys show improvement related to the high-level patient experience.
Transoral Robotic Surgery With Transoral Retropharyngeal Lymph Node Dissection in Patients With Tonsillar Cancer: Anatomical Points, Surgical Techniques, and Clinical Usefulness
Authors: Park Young Min , Cha Dongchul , Koh Yoon Woo , Choi Eun Chang , Kim Se-Heon
Published: November 2018

Objective:

The purpose of this study was to evaluate the clinical usefulness of TORS and transoral robotic retropharyngeal lymph node (RPLN) dissection in tonsillar cancer patients with suspicious RPLN metastasis.

Methods:

From April 2008 to March 2014, 71 patients with tonsillar cancer underwent transoral robotic surgery and standard neck dissection at the Yonsei Head and Neck Cancer Center.

Results:

Three patients underwent transoral robotic ropharyngectomy with transoral robotic RPLN dissection because of suspicious RPLN metastasis. The mean age of the patients was 42 years (range, 31–50 years). There were no cases of wound infection or serious complications related to wound healing. Mild nasal regurgitation was observed during an oral diet immediately after surgery, but all patients spontaneously resolved without surgical treatment. There was no significant bleeding due to great vessel injury during surgery or swallowing difficulty due to cranial nerve IX injury.

Conclusion:

Although the oncologic stability and usefulness of this technique should be confirmed based on large-scale research, RPLN can be easily accessed and resected through our approach with less morbidity compared to the conventional surgical approach. In addition, because RPLN metastasis can be performed pathologically based on obtained specimens, it will be helpful to explore whether to perform adjuvant radiation.
Induced and endogenous acoustic oscillations in granular faults
Authors: de Arcangelis L. , Lippiello E. , Pica Ciamarra M. , Sarracino A.
Published: November 2018

The frictional properties of disordered systems are affected by external perturbations. These perturbations usually weaken the system by reducing the macroscopic friction coefficient. This friction reduction is of particular interest in the case of disordered systems composed of granular particles confined between two plates, as this is a simple model of seismic fault. Indeed, in the geophysical context frictional weakening could explain the unexpected weakness of some faults, as well as earthquake remote triggering. In this manuscript, we review recent results concerning the response of confined granular systems to external perturbations, considering the different mechanisms by which the perturbation could weaken a system, the relevance of the frictional reduction to earthquakes, as well as discussing the intriguing scenario whereby the weakening is not monotonic in the perturbation frequency, so that a re-entrant transition is observed, as the system first enters a fluidized state and then returns to a frictional state.

This article is part of the theme issue ‘Statistical physics of fracture and earthquakes’.
Effect of disorder on the spatial structure of damage in slowly compressed porous rocks
Authors: Kun Ferenc , Pál Gergő , Varga Imre , Main Ian G.
Published: November 2018

Faults and damage zone properties control a range of important phenomena, from the hydraulic properties of underground reservoirs to the physics of earthquakes on a larger scale. Here, we investigate the effect of disorder of porous rocks on the spatial structure of damage emerging under compression. Model rock samples are numerically generated by sedimenting particles where the amount of disorder is controlled by the particle size distribution. To obtain damage bands with a sufficiently large length along axis, we performed simulations of ‘Brazilian’-type compression tests of cylindrical samples. As failure is approached, damage localization leads to the formation of two conjugate shear bands. The orientation angle of bands to the loading direction increases with disorder, implying a decrease in the internal coefficient of friction. The width of the damage band scales as a power law of the degree of disorder. Inside the damage band, the sample is crushed into a large number of pieces with a power law mass distribution. The shape of fragments undergoes a crossover at a disorder-dependent size from the isotropy of small pieces to the anisotropic flattened form of the large ones. The results provide important constraints in understanding the role of disorder in geological fractures.

This article is part of the theme issue ‘Statistical physics of fracture and earthquakes’.
Statistical physics models for aftershocks and induced seismicity
Authors: Luginbuhl Molly , Rundle John B. , Turcotte Donald L.
Published: November 2018

A standard approach to quantifying the seismic hazard is the relative intensity (RI) method. It is assumed that the rate of seismicity is constant in time and the rate of occurrence of small earthquakes is extrapolated to large earthquakes using Gutenberg–Richter scaling. We introduce nowcasting to extend RI forecasting to time-dependent seismicity, for example, during an aftershock sequence. Nowcasting uses ‘natural time’; in seismicity natural time is the event count of small earthquakes. The event count for small earthquakes is extrapolated to larger earthquakes using Gutenberg–Richter scaling. We first review the concepts of natural time and nowcasting and then illustrate seismic nowcasting with three examples. We first consider the aftershock sequence of the 2004 Parkfield earthquake on the San Andreas fault in California. Some earthquakes have higher rates of aftershock activity than other earthquakes of the same magnitude. Our approach allows the determination of the rate in real time during the aftershock sequence. We also consider two examples of induced earthquakes. Large injections of waste water from petroleum extraction have generated high rates of induced seismicity in Oklahoma. The extraction of natural gas from the Groningen gas field in The Netherlands has also generated very damaging earthquakes. In order to reduce the seismic activity, rates of injection and withdrawal have been reduced in these two cases. We show how nowcasting can be used to assess the success of these efforts.

This article is part of the theme issue ‘Statistical physics of fracture and earthquakes’.
Unhealthy Yet Avoidable – How Cognitive Bias Modification Alters Behavioral And Brain Responses To Food Cues In Obesity
Authors: Nora Mehl , Filip Morys , Arno Villringer , Annette Horstmann
Published: November 2018

Objective

Obesity is associated with automatically approaching problematic stimuli, such as unhealthy food. Cognitive bias modification (CBM) could beneficially impact on problematic approach behavior. However, it is unclear which mechanisms are targeted by CBM in obesity: Candidate mechanisms include (1) altering reward value of food stimuli or (2) strengthening inhibitory abilities.

Methods

33 obese people completed either CBM or sham training during fMRI scanning. CBM consisted of an implicit training to approach healthy and avoid unhealthy foods.

Results

At baseline, approach tendencies towards food were present in all participants. Avoiding vs. approaching food was associated with higher activity in the right angular gyrus (rAG). CBM resulted in a diminished approach bias towards unhealthy food, decreased activation in the rAG, and increased activation in the anterior cingulate cortex. Relatedly, functional connectivity between the rAG and right superior frontal gyrus increased. Analysis of brain connectivity during rest revealed training-related connectivity changes of the inferior frontal gyrus and bilateral middle frontal gyri.

Conclusion

Taken together, CBM strengthens avoidance tendencies when faced with unhealthy foods and alters activity in brain regions underpinning behavioral inhibition.
Using DeepLabCut for 3D markerless pose estimation across species and behaviors
Authors: Nath Tanmay , Mathis Alexander , Chen An Chi , Patel Amir , Bethge Matthias , Mathis Mackenzie Weygandt
Published: November 2018

Noninvasive behavioral tracking of animals during experiments is crucial to many scientific pursuits. Extracting the poses of animals without using markers is often essential for measuring behavioral effects in biomechanics, genetics, ethology & neuroscience. Yet, extracting detailed poses without markers in dynamically changing backgrounds has been challenging. We recently introduced an open source toolbox called DeepLabCut that builds on a state-of-the-art human pose estimation algorithm to allow a user to train a deep neural network using limited training data to precisely track user-defined features that matches human labeling accuracy. Here, with this paper we provide an updated toolbox that is self contained within a Python package that includes new features such as graphical user interfaces and active-learning based network refinement. Lastly, we provide a step-by-step guide for using DeepLabCut.
Positive linkage between bacterial social traits reveals that homogeneous rather than specialized behavioral repertoires prevail in natural Pseudomonas communities
Authors: Kramer Jos , López Carrasco Miguel Ángel , Kümmerli Rolf
Published: November 2018

Bacteria frequently cooperate by sharing secreted metabolites such as enzymes and siderophores. The expression of different ‘public good’ traits can be interdependent, and studies on laboratory systems have shown that such trait linkage affects eco-evolutionary dynamics within bacterial communities. Here, we examine whether linkage among social traits occurs in natural Pseudomonas communities by examining investment levels and correlations between five public goods: biosurfactants, biofilm components, proteases, pyoverdines, and toxic compounds. Our phenotypic assays involving 315 isolates from soil and freshwater communities revealed that their social trait expression profiles varied dramatically, and that correlations between traits were frequent, exclusively positive, and sometimes habitat-specific. Our results indicate that Pseudomonas communities are dominated by isolates lying on a continuum between a ‘social’ type producing multiple public goods, and an ‘asocial’ type showing low investment into social traits. This segregation into different social types could reflect local adaptation to different microhabitats, or emerge from competition between different (social) strategies. Moreover, our results show that isolates with specialized trait repertoires are rare, suggesting limited scope for the mutual exchange of different public goods between isolates. Overall, our work indicates that complex interdependencies among social traits influence the evolution of microbial lifestyles in nature.
The Set1 complex is dimeric and acts with Jhd2 demethylation to convey symmetrical H3K4 trimethylation
Authors: Choudhury Rupam , Singh Sukhdeep , Arumugam Senthil , Roguev Assen , Stewart A. Francis
Published: November 2018

Epigenetic modifications can maintain or alter the inherent symmetry of the nucleosome however the mechanisms that deposit and/or propagate symmetry or asymmetry are not understood. Here we report that yeast Set1C/COMPASS is dimeric and consequently symmetrically trimethylates histone 3 lysine 4 (H3K4me3) on promoter nucleosomes. Mutation of the dimer interface to make Set1C monomeric abolished H3K4me3 on most promoters. The most active promoters, particularly those involved in the oxidative phase of the yeast metabolic cycle, displayed H3K4me2, which is normally excluded from active promoters, and a subset of these also displayed H3K4me3. In wild-type yeast, deletion of the sole H3K4 demethylase, Jhd2, has no effect. However in monomeric Set1C yeast, Jhd2 deletion increased H3K4me3 levels on the H3K4me2 promoters. Notably, the association of Set1C with the elongating polymerase was not perturbed by monomerisation. These results imply that symmetrical H3K4 methylation is an embedded consequence of Set1C dimerism and that Jhd2 demethylates asymmetric H3K4me3. Consequently, rather than methylation and demethylation acting in opposition as logic would suggest, a dimeric methyltransferase and monomeric demethylase co-operate to eliminate asymmetry and focus symmetrical H3K4me3 onto selected nucleosomes. This presents a new paradigm for the establishment of epigenetic detail.