bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical Relevance of Histopathologic Analysis of HeartMate II Thrombi
Authors: Baumann Kreuziger Lisa , Slaughter Mark S. , Sundareswaran Kartik , Mast Alan E.
Published: February 2018

Left ventricular assist device (LVAD) thrombosis is a devastating complication that occurs in about 10% of patients despite anticoagulation and antiplatelet treatment. How the thrombus initiates and propagates is unknown. We pathologically and immunohistochemically examined 28 thrombi removed from 17 HeartMate II LVADs. Two groups of thrombi were found: those formed in the inlet/outlet and those on the rotor. The four thrombi found at the inlet (three inlet conduit and one inlet tube) and outlet (three at outlet elbow and one outlet graft) appeared similar and were composed of a loose meshwork of fibrin(ogen), von Willebrand factor, leukocytes, and aggregated platelets. The majority of the thrombi (20/28), however, were located on the rotor: nine at the inlet bearing, five on the rotor vanes, and six at the outlet bearing. Laminated thrombi formed around the inlet bearing in rings, an area of blood recirculation. The inner rings of the thrombus had fibrin and von Willebrand factor. Aggregated platelets were found in the outer thrombi rings, but limited evidence of platelets within the laminated thrombi was noted. The presence of distinct rings suggests development of the clot over time. The increased platelets in the outer rings of the inlet bearing thrombi would support further investigation into their role in thrombus growth. Initiating events require further investigation, but the fibrin-rich structure of HeartMate II thrombi suggests that alternative anticoagulation strategies are needed to prevent thrombosis in our LVAD patients.
Vitamin K antagonists and emergencies
Authors: Lapostolle Frédéric , Siguret Virginie , Martin Anne-Céline , Pailleret Claire , Vigué Bernard , Zerbib Yves , Tazarourte Karim
Published: February 2018

The recent emergence of ‘non-VKA’ oral anticoagulants may have led to some forgetting that vitamin K antagonists (VKA) are by far the most widely prescribed oral anticoagulants worldwide. Consequently, we decided to summarize the information available on them. This paper presents the problems facing emergency physicians confronted with patients on VKAs in 10 points, from pharmacological data to emergency management. Vitamin K antagonists remain preferable in many situations including in the elderly, in patients with extreme body weights, severe chronic kidney or liver disease or valvular heart disease, and in patients taking VKAs with well-controlled international normalized ratios (INRs). Given the way VKAs work, a stable anticoagulant state can only be achieved at the earliest 5 days after starting therapy. The induction phase of VKA treatment is associated with the highest risk of bleeding; validated algorithms based on INR values have to be followed. VKA asymptomatic overdoses and ‘non-severe’ hemorrhage are managed by omitting a dose or stopping treatment plus administering vitamin K depending on the INR. Major bleeding is managed using a VKA reversal strategy. A prothrombin complex concentrate infusion plus vitamin K is preferred to rapidly achieve an INR of up to 1.5 and maintain a normal coagulation profile. The INR must be measured 30 min after the infusion. Before an invasive procedure, if an INR of less than 1.5 (<1.3 in neurosurgery) is required, it can be achieved by combining prothrombin complex concentrate and vitamin K. A well-codified strategy is essential for managing patients requiring emergency invasive procedures or presenting bleeding complications.
The Impact of a Health Information Technology–Focused Patient-centered Medical Neighborhood Program Among Medicare Beneficiaries in Primary Care Practices
Authors: Orzol Sean , Keith Rosalind , Hossain Mynti , Barna Michael , Peterson G. Greg , Day Timothy , Gilman Boyd , Blue Laura , Kranker Keith , Stewart Kate A. , Hoag Sheila , Moreno Lorenzo
Published: February 2018

Background:

The Center for Medicare & Medicaid Innovation (CMMI) tests new models of paying for or delivering health care services and expands models that improve health outcomes while lowering medical spending. CMMI gave TransforMED, a national learning and dissemination contractor, a 3-year Health Care Innovation Award (HCIA) to integrate health information technology systems into physician practices. This paper estimates impacts of TransforMED’s HCIA-funded program on patient outcomes and Medicare parts A and B spending.

Research Design:

We compared outcomes for Medicare fee-for-service (FFS) beneficiaries served by 87 treatment practices to outcomes for Medicare FFS beneficiaries served by 286 matched comparison practices, adjusting for differences in outcomes between the 2 groups during a 1-year baseline period. We estimated impacts in 3 evaluation outcome domains: quality-of-care processes, service use, and spending.

Results:

We estimated the program led to a 7.1% reduction in inpatient admissions and a 5.7% decrease in the outpatient emergency department visits. However, there was no evidence of statistically significant effects in outcomes in either the quality-of-care processes or spending domains.

Conclusions:

These results indicate that TransforMED’s program reduced service use for Medicare FFS beneficiaries, but also show that the program did not have statistically significant favorable impacts in the quality-of-care processes or spending domains. These results suggest that providing practices with population health management and cost-reporting software—along with technical assistance for how to use them—can complement practices’ own patient-centered medical home transformation efforts and add meaningfully to their impacts on service use.
Care Experiences Among Medicare Beneficiaries With and Without a Personal Physician
Authors: Martsolf Grant R. , Elliott Marc N. , Haviland Amelia M. , Burkhart Q , Orr Nate , Gaillot Sarah , Saliba Debra
Published: February 2018

Background:

Having a “personal” physician is a critical element to care continuity. Little is known about which older adults are more likely to lack personal physicians and if their care experiences differ from those with a personal physician.

Objective:

The objective of this study was to describe care experiences and characteristics associated with not having a personal physician.

Research Design:

We compare rates of lacking a personal physician across subgroups. Using doubly robust propensity-score–weighted regression, we compare patient experience among beneficiaries with and without a personal physician.

Subjects:

A total of 272,463 nationally representative beneficiaries age 65+ responding to the 2012 Medicare CAHPS survey.

Measures:

Beneficiary characteristics, having a personal physician, 4 patient experience measures.

Results:

Five percent of respondents reported no personal physician. Lacking a personal physician was more common for men, racial/ethnic minorities (eg, 16% of American Indian/Alaska Natives), and the younger and less educated. Those without a personal physician reported substantially poorer experiences on 4 measures (P<0.001); these differences are larger than those observed by key demographic characteristics. Beneficiaries without a personal physician were more than 3 times as likely to have not seen any health care provider in the last 6 months.

Conclusions:

Even with the access provided by Medicare, a small but nontrivial proportion of seniors report having no personal physician. Those without a personal physician report substantially worse patient experiences and lacking a personal physician is more common for some vulnerable groups. This may underlie some previously observed disparities. Efforts should be made to encourage and help seniors without personal physicians to select one.
Hemolysis and immune regulation
Authors: Zhong Hui , Yazdanbakhsh Karina
Published: February 2018

Purpose of review

Hemolytic anemias caused by premature destruction of red blood cells occur in many disorders including hemoglobinopathies, autoimmune conditions, during infection or following reaction to drugs or transfusions. Recent studies which will be reviewed here have uncovered several novel mechanisms by which hemolysis can alter immunological functions and increase the risk of severe complications in hemolytic disorders.

Recent findings

Plasma-free heme can induce the formation of neutrophil extracellular traps (NETs) through reactive oxygen species signaling. Although NETs protect the host against infections, in patients with sickle disease, they are associated with vaso-occlusive crises. Heme may increase host susceptibility to infections by inducing heme oxygenase 1 (HO-1) in immature neutrophils, thereby inhibiting oxidative burst required for clearance of engulfed bacteria. In addition, heme impairs macrophage phagocytosis and microbial clearance through inhibition of cytoskeletal remodeling. Hemolysis can also favor anti-inflammatory immune cell polarization by inhibiting dendritic cell maturation necessary for effector T-cell responses, inducing differentiation of monocytes into red pulp macrophages, important for iron recycling from senescent erythrocytes, and driving regulatory T-cell expansion through modulation of HO-1 expression in nonclassical monocytes.

Hemolysis breakdown products show remarkable effects on the regulation of immune cell differentiation and function.
Debunking the “Myths” of Magnet®
Authors: Graystone Rebecca
Published: February 2018

Rebecca Graystone, the Magnet Program Director, dispels some myths about the Magnet Recognition Program®. Ms Graystone encourages leaders interested in Magnet or those already designated to feel free to access resources including those of the Magnet Program Office.
Electronic Staff Unit Meetings
Authors: Courtney Pamela , Parnell Lisa , Hayden Maria , Johnson Cheryl , Phillips Tracy
Published: February 2018

This article discusses how a group of directors and nursing staff in a rural hospital created an innovative unit meeting model using electronic technology to communicate with staff in a more meaningful manner and still comply with regulatory requirements and 2-way information needs.
Return on Investment for the Baccalaureate-Prepared RN in Ambulatory Care
Authors: Zolotorofe Irene , Fortini Robert , Hash Pam , Daniels Angel , Orsolini Liana , Mazzoccoli Andrea , Gerardi Tina
Published: February 2018

Evidence supports the return on investment for an RN in ambulatory care. Utilizing RNs to their fullest potential in ambulatory practices is essential to effectively manage population health. Bon Secours Health System launched a new role, patient navigator RNs, to ensure seamless transitions of complex patients across care settings, resulting in better patient outcomes and a financial return.
Intraoperative Cervical Treatment Does Not Affect the Prevalence of Vaginal Bleeding 1 Year Postoperatively After Subtotal Hysterectomy: A Register Study From the Swedish National Register for Gynecological Surgery
Authors: Borendal Wodlin Ninnie
Published: February 2018

(Abstracted from Acta Obstet Gynecol Scand 2017;96(12):1430–1437)

A subtotal hysterectomy implies retaining the cervix. Women who undergo this procedure are more likely to present with persistent vaginal bleeding (PVB) after surgery.
Evaluation and Management of Maternal Congenital Heart Disease: A Review
Authors: Hopkins Maeve K. , Goldstein Sarah A. , Ward Cary C. , Kuller Jeffrey A.
Published: February 2018

Objective

Congenital heart defects represent the most common major congenital anomalies. The objective of this review was to define the most common forms of congenital heart disease (CHD) in pregnancy, outline preconception counseling, discuss the associated morbidity and mortality of each lesion, and review current recommendations for management of CHD in pregnancy.

Evidence Acquisition

A MEDLINE search of “congenital heart disease in pregnancy” and specific conditions in pregnancy including “ventricular septal defect,” “atrial septal defect,” “left outflow obstruction,” “right outflow obstruction,” “tetralogy of Fallot,” and “transposition of the great vessels” was performed.

Results

The evidence included in the review contains 18 retrospective studies, 8 meta-analyses or systematic reviews or expert opinions, 5 case reports including surgical case reports, 2 prospective studies, and 2 clinical texts.

Conclusions

Given advances in surgical and medical management, women with a history of congenital cardiac defects are more frequently reaching childbearing age and requiring obstetric care. Many women with CHD can have successful pregnancies, although there are a few conditions that confer significant maternal risk, and pregnancy may even be contraindicated. Appropriate care for women with CHD requires a knowledge of cardiac physiology in pregnancy, the common lesions of CHD, and coordinated care from cardiology and maternal-fetal medicine specialists.

Target Audience

Obstetricians and gynecologists, family physicians.

Learning Objectives

After completing this activity, the learner should be better able to compare pregnancy risks among varying types of the most common maternal CHD; apply criteria of relative and absolute contraindications to pregnancy when performing preconception counseling to women with CHD; interpret for patients and other health providers the prognosis, management, and expectations of pregnancies with women with the most common types of CHD; and select relevant imaging studies, tests, and appropriate consultations and referrals when caring for women with maternal CHD.
Elevated Postmortem Vitreous Sodium and Chloride Level in a Salt Water Drowning Death During Self-Contained Underwater Breathing Apparatus Diving With Diving Mask in Place
Authors: Tse Rexson , Garland Jack , Kesha Kilak , Morrow Paul , Elstub Hannah , Cala Allan , Spark Amy , Stables Simon , Sage Martin
Published: February 2018

Elevation of postmortem vitreous sodium and chloride (PMVSC) levels in salt water drowning (SWD) is hypothesized to result from electrolyte changes in blood from salt water inhalation/ingestion during drowning. After approximately 1 hour after death, electrolytes may diffuse into the vitreous humor via the eye coverings. This hypothesis was based on a study where bovine eyeballs were immersed in salt water. There is no human study that could confirm that SWD would result in an initial elevation of PMVSC with no effects from immersion. We present an SWD during self-contained underwater breathing apparatus diving in which the face mask remained in its correct position while the deceased was underwater. The face mask would have prevented the orbits from being in direct contact with salt water and therefore stopped any effects of immersion on PMVSC. The PMVSC was 294 mmol/L, above control levels, and the reported cut-off of 259 mmol/L for a diagnosis SWD. The elevated PMVSC would unlikely be owing to immersion but SWD. This case report supports the observation that during SWD PMVSC would initially increase from salt water inhalation and ingestion and not from immersion.
Distinct Genomic Copy Number Alterations Distinguish Mucinous Tubular and Spindle Cell Carcinoma of the Kidney From Papillary Renal Cell Carcinoma With Overlapping Histologic Features
Authors: Ren Qinghu , Wang Lu , Al-Ahmadie Hikmat A. , Fine Samson W. , Gopalan Anuradha , Sirintrapun Sahussapont J. , Tickoo Satish K. , Reuter Victor E. , Chen Ying-Bei
Published: February 2018

Mucinous tubular and spindle cell carcinoma (MTSCC) of the kidney is a rare type of renal cell carcinoma that frequently exhibits histologic and immunophenotypic features overlapping with type 1 papillary renal cell carcinoma (PRCC). To clarify molecular attributes that can be used for this difficult differential diagnosis, we sought to delineate the genome-wide copy number alterations in tumors displaying classic histologic features of MTSCC in comparison to the solid variant of type 1 PRCC and indeterminate cases with overlapping histologic features. The study included 11 histologically typical MTSCC, 9 tumors with overlapping features between MTSCC and PRCC, and 6 cases of solid variant of type 1 PRCC. DNA samples extracted from macrodissected or microdissected tumor areas were analyzed for genome-wide copy number alterations using an SNP-array platform suitable for clinical archival material. All cases in the MTSCC group exhibited multiple chromosomal losses, most frequently involving chromosomes 1, 4, 6, 8, 9, 13, 14, 15, and 22, while lacking trisomy 7 or 17. In contrast, cases with overlapping morphologic features of MTSCC and PRCC predominantly showed multiple chromosomal gains, most frequently involving chromosomes 7, 16, 17, and 20, similar to the chromosomal alteration pattern that was seen in the solid variant of type 1 PRCC cases. Morphologic comparison of these molecularly characterized tumors identified histologic features that help to distinguish MTSCC from PRCC, but immunohistochemical profiles of these tumors remained overlapping, including a marker for Hippo-Yes-associated protein signaling. Characteristic patterns of genome-wide copy number alterations strongly support MTSCC and PRCC as distinct entities despite their immunohistochemical and certain morphologic overlap, and help define histologic features useful for the classification of questionable cases.
Significance of T1a and T1b Carcinoma Arising in Mucinous Cystic Neoplasm of Pancreas
Authors: Hui Ling , Rashid Asif , Foo Wai Chin , Katz Matthew H. , Chatterjee Deyali , Wang Hua , Fleming Jason B. , Tamm Eric P. , Wang Huamin
Published: February 2018

Mucinous cystic neoplasm (MCN) of pancreas is one of the precursor lesions of pancreatic ductal adenocarcinoma. The 5-year disease-specific survival for noninvasive MCNs was 100% and 20% to 60% for those with pancreatic ductal adenocarcinoma arising in a MCN. However, the significance of T1a (≤0.5 cm) and T1b (>0.5 and <1.0 cm) carcinoma arising in MCN as defined by the upcoming American Joint Committee on Cancer, eighth edition is unclear. In this study, we examined 3 cases of MCN with T1a or T1b carcinoma and compared their clinicopathologic characteristics and survival to 46 cases of MCN with low-grade dysplasia (MCN-LGD), 7 cases of MCN with high-grade dysplasia (MCN-HGD), and 7 cases of MCN with advanced invasive carcinoma (T2 or higher T stage). The tumors from all 3 cases were submitted in their entirety in 123, 296, and 200 blocks, respectively. All 3 patients were alive with no recurrence during the follow-up of 20.0, 113.8, and 137.2 months, respectively. Similarly, none of the patients who had MCN with either LGD or HGD had recurrence or died of disease. In contrast, 5 of 7 patients who had MCN with advanced invasive carcinoma had recurrence and later died of disease with a median survival of 22.9 months (P<0.001). Our study showed that MCN with T1a and T1b carcinoma had an excellent prognosis similar to MCNs with LGD or HGD after complete tumor sampling for histologic examination. Our results along with the previous studies suggest that close follow-up, rather than aggressive systemic therapy, may be a better approach for these patients.
Hospital Variation in Risk-Adjusted Pediatric Sepsis Mortality*
Authors: Ames Stefanie G. , Davis Billie S. , Angus Derek C. , Carcillo Joseph A. , Kahn Jeremy M.
Published: February 2018

Objectives:

With continued attention to pediatric sepsis at both the clinical and policy levels, it is important to understand the quality of hospitals in terms of their pediatric sepsis mortality. We sought to develop a method to evaluate hospital pediatric sepsis performance using 30-day risk-adjusted mortality and to assess hospital variation in risk-adjusted sepsis mortality in a large state-wide sample.

Design:

Retrospective cohort study using administrative claims data.

Settings:

Acute care hospitals in the state of Pennsylvania from 2011 to 2013.

Patients:

Patients between the ages of 0–19 years admitted to a hospital with sepsis defined using validated International Classification of Diseases, Ninth revision, Clinical Modification, diagnosis and procedure codes.

Interventions:

None.

Measurements and Main Results:

During the study period, there were 9,013 pediatric sepsis encounters in 153 hospitals. After excluding repeat visits and hospitals with annual patient volumes too small to reliably assess hospital performance, there were 6,468 unique encounters in 24 hospitals. The overall unadjusted mortality rate was 6.5% (range across all hospitals: 1.5–11.9%). The median number of pediatric sepsis cases per hospital was 67 (range across all hospitals: 30–1,858). A hierarchical logistic regression model for 30-day risk-adjusted mortality controlling for patient age, gender, emergency department admission, infection source, presence of organ dysfunction at admission, and presence of chronic complex conditions showed good discrimination (C-statistic = 0.80) and calibration (slope and intercept of calibration plot: 0.95 and –0.01, respectively). The hospital-specific risk-adjusted mortality rates calculated from this model varied minimally, ranging from 6.0% to 7.4%.

Conclusions:

Although a risk-adjustment model for 30-day pediatric sepsis mortality had good performance characteristics, the use of risk-adjusted mortality rates as a hospital quality measure in pediatric sepsis is not useful due to the low volume of cases at most hospitals. Novel metrics to evaluate the quality of pediatric sepsis care are needed.
Cervical Spine Imaging and Injuries in Young Children With Non-Motor Vehicle Crash-Associated Traumatic Brain Injury
Authors: Henry M. Katherine , French Benjamin , Feudtner Chris , Zonfrillo Mark R. , Lindberg Daniel M. , Anderst James D. , Berger Rachel P. , Wood Joanne N.
Published: February 2018

Objectives

The aim of this study was to evaluate cervical magnetic resonance imaging (MRI) and computed tomography (CT) practices and cervical spine injuries among young children with non–motor vehicle crash (MVC)–associated traumatic brain injury (TBI).

Methods

We performed a retrospective study of a stratified, systematic random sample of 328 children younger than 2 years with non-MVC-associated TBI at 4 urban children's hospitals from 2008 to 2012. We defined TBI etiology as accidental, indeterminate, or abuse. We reported the proportion, by etiology, who underwent cervical MRI or CT, and had cervical abnormalities identified.

Results

Of children with non-MVC-associated TBI, 39.4% had abusive head trauma (AHT), 52.2% had accidental TBI, and in 8.4% the etiology was indeterminate. Advanced cervical imaging (CT and/or MRI) was obtained in 19.1% of all children with TBI, with 9.3% undergoing MRI and 11.7% undergoing CT. Cervical MRI or CT was performed in 30.9% of children with AHT, in 11.7% of accidental TBI, and in 10.7% of indeterminate-cause TBI. Among children imaged by MRI or CT, abnormal cervical findings were found in 22.1%, including 31.3% of children with AHT, 7.1% of children with accidental TBI, and 0% of children with indeterminate-cause TBI. Children with more severe head injuries who underwent cervical imaging were more likely to have cervical injuries.

Conclusions

Abusive head trauma victims appear to be at increased risk of cervical injuries. Prospective studies are needed to define the risk of cervical injury in children with TBI concerning for AHT and to inform development of imaging guidelines.
Toll-Like Receptor 4 Signaling Licenses the Cytosolic Transport of Lipopolysaccharide From Bacterial Outer Membrane Vesicles
Authors: Gu Lan , Meng Ran , Tang Yiting , Zhao Kai , Liang Fang , Zhang Rui , Xue Qianqian , Chen Fangping , Xiao Xianzhong , Wang Huadong , Wang Haichao , Billiar Timothy R. , Lu Ben
Published: February 2018

Outer membrane vesicles (OMVs), released by variety of bacteria, are membrane-enclosed entities enriched in microbial components, toxins, and virulent factors. OMVs could deliver lipopolysaccharide (LPS) into the cytosol of host cells and subsequently activate caspase-11, which critically orchestrates immune responses and mediates septic shock. Although it is known that caspase-11 is activated by intracellular LPS, how OMVs deliver LPS into the cytosol remains largely unknown. Here we show that the activation of toll-like receptor 4 (TLR4), a LPS receptor on the cytoplasmic membrane, licenses macrophages to transport LPS from OMVs into the cytosol through TIR domain-containing adaptor-inducing interferon-β (TRIF). TRIF-mediated cytosolic delivery of LPS from OMVs depends on the production of type 1 interferon and the expression of guanylate-binding proteins (GBPs). Deletion of TRIF or GBPs prevents pyroptosis and lethality induced by OMVs or OMVs-releasing Escherichia coli. Together, these findings provide novel insight into how host coordinates extracellular and intracellular LPS sensing to orchestrate immune responses during gram-negative bacterial infection.
Davydov Procedure for Augmenting Vaginal Length in a Postsurgical Male-to-Female Transgender Patient
Authors: Jalalizadeh Mehrsa , Shobeiri S. Abbas
Published: February 2018

Male-to-female gender reassignment surgery may lead to unsatisfactory vaginal length. No standard approaches are established to treat these patients. We present a case of vaginoplasty using the laparoscopic Davydov technique performed on a male-to-female transgender patient. Our case provides a novel approach to treating this rare condition and introduces Davydov procedure as a potentially effective and safe treatment. Preoperative endovaginal and endoanal 3-dimensional ultrasounds and a pelvic magnetic resonance imaging of the case are presented to provide details of this patient's unique anatomy.
Tourniquet usage in prehospital care and resuscitation of pediatric trauma patients—Pediatric Trauma Society position statement
Authors: Cunningham Aaron , Auerbach Marc , Cicero Mark , Jafri Mubeen
Published: February 2018

BACKGROUND

Recent mass casualty events in the United States have highlighted the need for public preparedness to prevent death from uncontrolled hemorrhage. The Pediatric Trauma Society (PTS) reviewed the literature regarding pediatric tourniquet usage with the aim to provide recommendations about the utility of this adjunct for hemorrhage control in children.

METHODS

Search terms “pediatric” and “tourniquet” were used to query the US National Library of Medicine National Institutes of Health for pertinent literature. Exclusion criteria include not involving children, not involving the use of an extremity tourniquet, primary outcomes not related to hemorrhage control, tourniquet use to prevent snake envenomation, single case reports, and only foreign language formats available. Bibliographies of remaining studies reviewed to identify additional pertinent research. Four physician members of the PTS Guidelines Committee reviewed identified studies.

RESULTS

One hundred thirty-four studies were identified. One hundred twenty-three studies were excluded. Seven additional studies were identified through bibliography review. Eighteen pertinent studies were reviewed. Seven articles evaluated physiologic response to tourniquet use in operating room settings. Six articles were generated from combat experience in conflicts in Afghanistan and Iraq. Four articles discussed technical details of tourniquet usage. One article evaluated the use of tourniquets during the Boston Marathon bombing in 2015.

CONCLUSION

Despite limited data of limited quality regarding their use, the PTS supports the usage of tourniquets in the prehospital setting and during the resuscitation of children suffering from exsanguinating hemorrhage from severe extremity trauma. Expedited, definitive care must be sought, and tourniquet pressure and time should be limited to the least amount possible. The Society supports the ACS “Stop the Bleed” campaign and encourages further investigation of tourniquet use in children.

LEVEL OF EVIDENCE

Guidelines/algorithm study, level IIIa.
Emergency sternal intraosseous access for warm fresh whole blood transfusion in damage control resuscitation
Authors: Bjerkvig Christopher Kalhagen , Fosse Theodor Kaurin , Apelseth Torunn Oveland , Sivertsen Joar , Braathen Hanne , Eliassen Håkon Skogrand , Guttormsen Anne Berit , Cap Andrew P. , Strandenes Geir
Published: February 2018

BACKGROUND

Intraosseous (IO) vascular access is increasingly used as an emergency tool for achieving access to the systemic circulation in critically ill patients. The role of IO transfusion of blood in damage control resuscitation is however questionable due to possible inadequate flow rate and hemolysis. Some experts claim that IO transfusion is contraindicated. In this study, we have challenged this statement by looking at flow rates of autologous fresh whole blood reinfusion and hemolysis using two of the commonly used Food and Drug Administration–approved and Conformité Européenne (CE)-marked sternal needles. Additionally, the success rate of sternal access between the two devices is evaluated.

METHODS

Volunteer professional military personnel, were enrolled prospectively in a nonrandomized observational study design. We collected 450 mL of autologous whole blood from each participant. Participants were divided into the following three groups of 10: Tactically Advanced Lifesaving IO Needle (T.A.L.O.N.) IO, FAST1 IO, and intravenous group. The reinfusion was done by gravity only. Blood sampling was performed before blood collection and 30 minutes after reinfusion. Investigation of hemolysis was performed by measurements of haptoglobin and lactate dehydrogenase. Success rate was evaluated by correct aspiration of bone marrow.

RESULTS

Median reinfusion rate was 46.2 mL/min in the FAST1 group, 32.4 mL/min in the T.A.L.O.N. group, and 74.1 mL/min in the intravenous group. Blood samples from all participants were within normal ranges. There was no statistically significant difference in haptoglobin and lactate dehydrogenase between the groups. In the FAST1 group, 1 (9%) of 11 procedures failed. In the T.A.L.O.N. group, 4 (29%) of 14 procedures failed.

CONCLUSION

Although preferable, achieving peripheral venous access in the bleeding patient is a major problem. Our findings suggest that fresh whole-blood transfusion through the IO route is safe, reliable, and provide sufficient flow for resuscitation.

LEVEL OF EVIDENCE

Therapeutic/Care management study, level III.
Physician training in critical care in the United States: Update 2018
Authors: Napolitano Lena M. , Rajajee Venkatakrishna , Gunnerson Kyle J. , Maile Michael D. , Quasney Michael , Hyzy Robert C.
Published: February 2018

Critical care fellowship training in the United States differs based on specific specialty and includes medicine, surgery, anesthesiology, pediatrics, emergency medicine, and neurocritical care training pathways. We provide an update regarding the number and growth of US critical care fellowship training programs, on-duty residents and certified diplomates, and review the different critical care physician training pathways available to residents interested in pursuing a fellowship in critical care. Data were obtained from the Accreditation Council for Graduate Medical Education and specialty boards (American Board of Internal Medicine, American Board of Surgery, American Board of Anesthesiology, American Board of Pediatrics American Board of Emergency Medicine) and the United Council for Neurologic Subspecialties for the last 16 years (2001–2017). The number of critical care fellowship training programs has increased 22.6%, with a 49.4% increase in the number of on-duty residents annually, over the last 16 years. This is in contrast to the period of 1995 to 2000 when the number of physicians enrolled in critical care fellowship programs had decreased or remained unchanged. Although more than 80% of intensivists in the US train in internal medicine critical care Accreditation Council for Graduate Medical Education–approved fellowships, there has been a significant increase in the number of residents from surgery, anesthesiology, pediatrics, emergency medicine, and other specialties who complete specialty fellowship training and certification in critical care. Matriculation in neurocritical care fellowships is rapidly rising with 60 programs and over 1,200 neurocritical care diplomates. Critical care is now an increasingly popular fellowship in all specialties. This rapid growth of all critical care specialties highlights the magnitude of the heterogeneity that will exist between intensivists in the future.
Prognosis of diffuse axonal injury with traumatic brain injury
Authors: Humble Stephen S. , Wilson Laura D. , Wang Li , Long Drew A. , Smith Miya A. , Siktberg Jonathan C. , Mirhoseini Mina F. , Bhatia Aashim , Pruthi Sumit , Day Matthew A. , Muehlschlegel Susanne , Patel Mayur B.
Published: February 2018

BACKGROUND

Determine the prognostic impact of magnetic resonance imaging (MRI)-defined diffuse axonal injury (DAI) after traumatic brain injury (TBI) on functional outcomes, quality of life, and 3-year mortality.

METHODS

This retrospective single center cohort included adult trauma patients (age > 17 years) admitted from 2006 to 2012 with TBI. Inclusion criteria were positive head computed tomography with brain MRI within 2 weeks of admission. Exclusion criteria included penetrating TBI or prior neurologic condition. Separate ordinal logistic models assessed DAI's prognostic value for the following scores: (1) hospital-discharge Functional Independence Measure, (2) long-term Glasgow Outcome Scale-Extended, and (3) long-term Quality of Life after Brain Injury-Overall Scale. Cox proportional hazards modeling assessed DAI's prognostic value for 3-year survival. Covariates included age, sex, race, insurance status, Injury Severity Score, admission Glasgow Coma Scale Score, Marshall Head computed tomography Class, clinical DAI on MRI (Y/N), research-level anatomic DAI Grades I-III (I, cortical; II, corpus callosum; III, brainstem), ventilator days, time to follow commands, and time to long-term follow-up (for logistic models).

RESULTS

Eligibility criteria was met by 311 patients, who had a median age of 40 years (interquartile range [IQR], 23–57 years), Injury Severity Score of 29 (IQR, 22–38), intensive care unit stay of 6 days (IQR, 2–11 days), and follow-up of 5 years (IQR, 3–6 years). Clinical DAI was present on 47% of MRIs. Among 300 readable MRIs, 56% of MRIs had anatomic DAI (25% Grade I, 18% Grade II, 13% Grade III). On regression, only clinical (not anatomic) DAI was predictive of a lower Functional Independence Measure score (odds ratio, 2.5; 95% confidence interval, 1.28–4.76], p = 0.007). Neither clinical nor anatomic DAI were related to survival, Glasgow Outcome Scale-Extended, or Quality of Life after Brain Injury-Overall Scale scores.

CONCLUSION

In this longitudinal cohort, clinical evidence of DAI on MRI may only be useful for predicting short-term in-hospital functional outcome. Given no association of DAI and long-term TBI outcomes, providers should be cautious in attributing DAI to future neurologic function, quality of life, and/or survival.

LEVEL OF EVIDENCE

Epidemiological, level III; Therapeutic, level IV.
Evaluation of the management of severe trauma kidney injury and long-term renal function in children
Authors: Overs Camille , Teklali Youssef , Boillot Bernard , Poncet Delphine , Rabattu Pierre-Yves , Robert Yohan , Piolat Christian
Published: February 2018

BACKGROUND

To evaluate the management and long-term renal function with DMSA scintigraphy in pediatric severe traumatic kidney injury grade IV and V at the trauma center of Grenoble Teaching Hospital.

METHODS

This is a single-center observational retrospective study between 2004 and 2014. All children younger than 15 years and managed at the Grenoble teaching Hospital for a severe trauma kidney injury grade IV or V were included. The trauma grade was radiologically diagnosed on arrival at hospital, using the classification of the American Association for Surgery of Trauma. The management followed the algorithm in effect in the establishment. The assessment of the renal function was performed by a DMSA scintigraphy after at least 6 months from the injury.

RESULTS

Twenty-one children were managed for a severe renal trauma (16 IV and 5 V). The diagnosis was initially made by an ultrasonography (eight cases) or a computed tomography scan (13 cases). A child with a severe renal trauma IV underwent nephrectomy on day 6 of the trauma. Eleven children needed a therapeutic procedure (three embolizations, four double J stents, one arterial stent, one peritoneal lavage for a splenic hemoperitoneum, four pleural drainages). A DMSA scintigraphy was performed in 15 patients to assess the function of the injured kidney: 11 of 16 severe renal trauma IV with an average of 39.4%, and 17% in 4 of 5 severe renal trauma V analyzed.

CONCLUSION

Among the 21 children managed for a severe kidney trauma injury IV or V, 11 required a therapeutic procedure, one of them a nephrectomy. The DMSA scintigraphy performed after at least 6 months from the trauma found an injured renal function at 39.4% in 11 of 16 severe renal trauma IV analyzed, and 17% in 4 of 5 severe renal trauma V analyzed, which confirms the currently conservative management.

LEVEL OF EVIDENCE

Type of study: original article, retrospective observational study, level IV.
Uncertainty in multispectral lidar signals caused by incidence angle effects
Authors: Kaasalainen Sanna , Åkerblom Markku , Nevalainen Olli , Hakala Teemu , Kaasalainen Mikko
Published: February 2018

Multispectral terrestrial laser scanning (TLS) is an emerging technology. Several manufacturers already offer commercial dual or three wavelength airborne laser scanners, while multispectral TLS is still carried out mainly with research instruments. Many of these research efforts have focused on the study of vegetation. The aim of this paper is to study the uncertainty of the measurement of spectral indices of vegetation with multispectral lidar. Using two spectral indices as examples, we find that the uncertainty is due to systematic errors caused by the wavelength dependency of laser incidence angle effects. This finding is empirical, and the error cannot be removed by modelling or instrument modification. The discovery and study of these effects has been enabled by hyperspectral and multispectral TLS, and it has become a subject of active research within the past few years. We summarize the most recent studies on multi-wavelength incidence angle effects and present new results on the effect of specular reflection from the leaf surface, and the surface structure, which have been suggested to play a key role. We also discuss the consequences to the measurement of spectral indices with multispectral TLS, and a possible correction scheme using a synthetic laser footprint.
Comparing terrestrial laser scanning and unmanned aerial vehicle structure from motion to assess top of canopy structure in tropical forests
Authors: Roşca Sabina , Suomalainen Juha , Bartholomeus Harm , Herold Martin
Published: February 2018

Terrestrial laser scanning (TLS) and unmanned aerial vehicles (UAVs) equipped with digital cameras have attracted much attention from the forestry community as potential tools for forest inventories and forest monitoring. This research fills a knowledge gap about the viability and dissimilarities of using these technologies for measuring the top of canopy structure in tropical forests. In an empirical study with data acquired in a Guyanese tropical forest, we assessed the differences between top of canopy models (TCMs) derived from TLS measurements and from UAV imagery, processed using structure from motion. Firstly, canopy gaps lead to differences in TCMs derived from TLS and UAVs. UAV TCMs overestimate canopy height in gap areas and often fail to represent smaller gaps altogether. Secondly, it was demonstrated that forest change caused by logging can be detected by both TLS and UAV TCMs, although it is better depicted by the TLS. Thirdly, this research shows that both TLS and UAV TCMs are sensitive to the small variations in sensor positions during data collection. TCMs rendered from UAV data acquired over the same area at different moments are more similar (RMSE 0.11–0.63 m for tree height, and 0.14–3.05 m for gap areas) than those rendered from TLS data (RMSE 0.21–1.21 m for trees, and 1.02–2.48 m for gaps). This study provides support for a more informed decision for choosing between TLS and UAV TCMs to assess top of canopy in a tropical forest by advancing our understanding on: (i) how these technologies capture the top of the canopy, (ii) why their ability to reproduce the same model varies over repeated surveying sessions and (iii) general considerations such as the area coverage, costs, fieldwork time and processing requirements needed.
Close-range laser scanning in forests: towards physically based semantics across scales
Authors: Morsdorf F. , Kükenbrink D. , Schneider F. D. , Abegg M. , Schaepman M. E.
Published: February 2018

Laser scanning with its unique measurement concept holds the potential to revolutionize the way we assess and quantify three-dimensional vegetation structure. Modern laser systems used at close range, be it on terrestrial, mobile or unmanned aerial platforms, provide dense and accurate three-dimensional data whose information just waits to be harvested. However, the transformation of such data to information is not as straightforward as for airborne and space-borne approaches, where typically empirical models are built using ground truth of target variables. Simpler variables, such as diameter at breast height, can be readily derived and validated. More complex variables, e.g. leaf area index, need a thorough understanding and consideration of the physical particularities of the measurement process and semantic labelling of the point cloud. Quantified structural models provide a framework for such labelling by deriving stem and branch architecture, a basis for many of the more complex structural variables. The physical information of the laser scanning process is still underused and we show how it could play a vital role in conjunction with three-dimensional radiative transfer models to shape the information retrieval methods of the future. Using such a combined forward and physically based approach will make methods robust and transferable. In addition, it avoids replacing observer bias from field inventories with instrument bias from different laser instruments. Still, an intensive dialogue with the users of the derived information is mandatory to potentially re-design structural concepts and variables so that they profit most of the rich data that close-range laser scanning provides.
The Sibship Index can’t discriminates Half-Sibs from Full-Sibs; a new algorithm, including maternal genotype, can do it
Authors: Cardillo Giuseppe
Published: February 2018

Sibship DNA testing is conducted in order to determine if two subjects share one or both biological parents: Full-sibs have both parents in common, whereas Half-sibs have one parent in common, either the mother or the father. When an alleged father is not available for a paternity test, sibship testing is one way to determine family relationships. Results of a sibship test have also been accepted as proof in Social Security benefit and other inheritance claims. To analyze the possibility that the siblings share two common parents versus only one common parent, the ratio of the full sibship index versus half sibship index is computed: a sibship index less than 1, provides genetic evidence which does not favor a full-sibling relationship. In this paper we will demonstrate that the actually used Sibship Index is unable to distinguish Full-sibs from Half-Sibs and the only way to distinguish them is to use a new Index including the genotype of the Mother, that, usually, is the known common parent.

Highlights

Usually used Sibship Index (SI) greatly overestimates likelihood ratios;

Rising up the number of investigated STR, all Half-Sibs are declared Full-Sibs;

The only way to avoid this overestimate is to use a Sibship Index Corrected by the common parent genotype, that usually is the mother (SICMG); all likelihood ratio formulas can be reconducted to five scenarios;

For both SI and SICMG there is a better cut-off than 1 to discriminate Half-Sibs: this cut-off is computed for all commercial available forensic STR kit.
A stainless-steel mortar, pestle and sleeve design for the efficient fragmentation of ancient bone
Authors: Gondek Agata T , Boessenkool Sanne , Star Bastiaan
Published: February 2018

Ancient DNA (aDNA) bone extraction protocols routinely require the fragmentation of larger bone pieces into smaller pieces or powder prior to DNA extraction. To achieve this goal, different types of equipment such as oscillating ball mills, freezer mills, mortar and pestle, or drills can be used. Although all these approaches are suitable, practical drawbacks are associated with each method. Here, we present the design for a stainless-steel mortar and pestle, with a removable sleeve to contain bone material. The tool readily comes apart for ease of cleaning and its simplicity allows university workshops equipped with a lathe, boring tools and milling machine to make these components at local expense. We find that this design allows for the controlled fragmentation of ancient bone and that it significantly improves our sample throughput. We recommend this design as a useful, economical addition to existing laboratory equipment for the efficient handling of ancient bone.
Evidence of a common causal relationship between body mass index and inflammatory skin disease: a Mendelian Randomization study
Authors: Budu-Aggrey Ashley , Brumpton Ben , Tyrrell Jess , Watkins Sarah , Modalsli Ellen H , Celis-Morales Carlos , Ferguson Lyn D , Vie Gunnhild Åberge , Palmer Tom , Fritsche Lars G , Løset Mari , Nielsen Jonas Bille , Zhou Wei , Tsoi Lam C , Wood Andrew R , Jones Samuel E , Beaumont Robin , Saunes Marit , Romundstad Pål Richard , Siebert Stefan , McInnes Iain B , Elder James T , Smith George Davey , Frayling Timothy M , Åsvold Bjørn Olav , Brown Sara J , Sattar Naveed , Paternoster Lavinia
Published: February 2018

Objective

Psoriasis and eczema are common inflammatory skin diseases that have been reported to be associated with obesity. However, causality has not yet been established. We aimed to investigate the possible causal relationship between body mass index (BMI) and psoriasis or eczema.

Methods

Following a review of published epidemiological evidence of the association between obesity and either psoriasis or eczema, Mendelian Randomization (MR) was used to test for a causal relationship between BMI and these inflammatory skin conditions. We used a genetic instrument comprising 97 single nucleotide polymorphisms (SNPs) associated with BMI. One-sample MR was conducted using individual-level data (401,508 individuals) from the UK Biobank and the Nord-Trøndelag Health Study (HUNT), Norway. Two-sample MR was performed with summary-level data (731,021 individuals) from published BMI, psoriasis and eczema GWAS. The one-sample and two-sample MR estimates were meta-analysed using a fixed effect model. To explore the reverse causal direction, MR analysis with genetic instruments comprising variants from recent genome-wide analyses for psoriasis and eczema were used to test if inflammatory skin disease has a causal effect on BMI.

Results

Published observational data show an association of greater BMI with both psoriasis and eczema case status. The observational associations were confirmed in UK Biobank and HUNT datasets. MR analyses provide evidence that higher BMI causally increases the odds of psoriasis (by 53% per 5 units higher BMI; OR= 1.09 (1.06 to 1.12) per 1 kg/m2; P=4.67×10-9) and eczema (by 8% per 5 units higher BMI; OR=1.02 (1.00 to 1.03) per 1 kg/m2; P=0.09). When investigating causality in the opposite direction, MR estimates provide little evidence for an effect of either psoriasis or eczema influencing BMI.

Conclusion

Our study, using genetic variants as instrumental variables for BMI, shows that higher BMI leads to a higher risk of inflammatory skin disease. The causal relationship was stronger for psoriasis than eczema. Therapies and life-style interventions aimed at controlling BMI or targeting the mechanisms linking obesity with skin inflammation may offer an opportunity for the prevention or treatment of these common skin diseases.