bluuebunny/crossref_metadata_2025 huggingface dataset:
The Battleship Potemkin
Authors: Radunović Dušan
Published: April 2020

The Battleship Potemkin (Bronenosets Potёmkin) is Sergei Eisenstein’s second feature film. Produced in 1925 and premiered in January 1926, the film was a watershed moment in the history of Russian and Soviet cinema. In addition, in its home context, Potemkin has asserted that experimental montage is the dominant mode of cinematic storytelling in the Soviet 1920s. Likewise, Potemkin asserted, more vociferously than any other early Soviet film, a specific type of relationship between film/art and state ideology. In the international arena, the worldwide success of the film put the Russian and Soviet cinema on a map for the first time. The triumph of Potemkin announced the advent of the short-lived golden age of early Soviet filmmaking style, hallmarked by the aesthetics of short cuts and fast editing that aimed to challenge the viewers’ perception of the world and posit a revolutionary message. Thematically, the film is set around a historical event, the mutiny on the Imperial Navy armored cruiser Prince Potemkin of Tauris, which took place in June 1905. The events are dramaturgically organized in five parts, emulating, as Eisenstein later recalled, the structure of a classical tragedy (see Eisenstein 2010, cited under Typage Acting). These parts were titled as follows: “Men and Maggots” (Liudi i chervi); “Drama on the Quarter-Deck” (Drama na Tendre); “Appeal from the Dead” (Mertvyi vzyvaet); “Odessa Steps” (Odesskaia lestnitsa); and “Meeting the Squadron” (Vstrecha s eskadroi). Each of the parts is endowed with dramatic function and facilitates a transition to a different mood. The events in Part 1 gradually build narrative tension toward a culmination point in Part 2, and, similarly, the events in Part 3 set the scene for the culmination in Part 4, with Part 5 functioning as an epilogue. A believer in traditional aesthetics and concepts such as organicist whole or golden ratio, Eisenstein argued that dramaturgy of the moving image, facilitated through conflicting montage sequences, can deliver the task of revolutionary art, bringing the viewer into a desired psycho-emotional state that would make one susceptible to the right ideological messages. For all these reasons, the apprehension of Potemkin requires the researcher to acknowledge a number of aspects of the film. Given that Potemkin is a historical film par excellence, the relationship between the fictional narrative, historical period under consideration, and historical time of the making of the film ought to be given due attention. In addition, the production history of Potemkin also matters, as it tells much about the position of the film in the nascent Soviet cinematic “dispositive.” Last, but certainly not least, Potemkin is an artistic tour de force that deploys complex cinematic devices, the understanding of which will be a demanding task as well.
Africa’s International Investment Law Regimes
Authors: Kidane Won
Published: April 2020

Unified by a long history of a subordinate position within the global economic and political hierarchy, African nations have had a remarkably similar reckoning of international investment laws and institutions. Apart from the incidence of geography, the historical experience and existing economic conditions have allowed an integrated treatment of Africa’s investment law regimes in the literature with some success. The existing writings on Africa and international investment law generally attempt to accomplish two principal objectives: (1) situate Africa in the global and regional international investment legal order, and (2) postulate emerging trends in the governance of Africa’s economic relationship beyond its traditional economic partners. Corresponding to the two general areas, writings on Africa’s international investment law tend to focus on Africa’s historical experience with the treatment of foreign investment at the multilateral level and with its traditional economic partners of the Western world. In this regard, the most important source of materials discussed in the literature relating to the substantive rules comes from the more than 135 international investment law cases involving African states in the investor-state arbitrations constituted under the International Centre for the Settlement of Investment Disputes (ICSID). Such discussions are African, however, inasmuch only as they feature treaties and fact patterns originating in Africa. The more recent literature puzzles over Africa’s circumstances in attracting and retaining foreign investment beyond its traditional economic partners in the West such as China and India, and speculates about the suitability of the traditional rules and institutions for the ordering of intra-Africa and other Africa-related South-South economic relations. Significantly, the Africa-specific literature on international investment law is a critique of the existing rules and institutions and the evaluation of emerging trends. Overall, the general literature in the area of international investment law suggests that Africa-related matters are an integral part of the doctrinal underpinnings, the substantive rules, and dispute settlement mechanisms at the global level. Each major work in the area of international investment law generally profiles African treaties and cases as an essential and inextricable part of the existing and emerging global international investment law regime.
The Burden of Bloodstream Infections due to Stenotrophomonas Maltophilia in the United States: A Large, Retrospective Database Study
Authors: Cai Bin , Tillotson Glenn , Benjumea Darrin , Callahan Patrick , Echols Roger
Published: April 2020

Background

Stenotrophomonas maltophilia is an opportunistic pathogen observed in both nosocomial and community-onset infections. S. maltophilia is intrinsically resistant to many currently available broad-spectrum antibiotics and is often not included in antimicrobial resistance surveillance studies or stewardship programs’ guidelines.

Methods

A retrospective cohort study of patients with S. maltophilia bloodstream infection (BSI) in the United States was conducted using the 2010–2015 US Premier Healthcare Database. This study described patient characteristics, infection characteristics, antibiotic treatment, and discharge status.

Results

S. maltophilia was the most common carbapenem-resistant, gram-negative pathogen causing BSIs in this database. Of 486 unique patients with S. maltophilia BSI, 44.6% were assessed as community-onset, 95% of cultures were susceptible to trimethoprim-sulfamethoxazole (TMP-SMX), and 84% were susceptible to fluoroquinolones; 39.1% of patients received a potentially effective antibiotic (fluoroquinolone, doxycycline, ceftazidime, minocycline, or TMP-SMX) during the empiric treatment period (≤3 days post–index culture date), whereas 85.8% received a potential effective antibiotics during the definitive treatment period. The most common antibiotic received as definitive treatment was levofloxacin (48.9%). TMP-SMX was used infrequently empirically (10.5%) and in 38.3% during the definitive period. Compared with BSIs caused by other carbapenem-resistant gram-negative pathogens, S. maltophilia BSIs were more likely to be community-onset, and were more likely to be discharged to home and to have a lower mortality rate.

Conclusions

This study demonstrated that patients at risk for S. maltophilia BSI are highly variable and that standard of care is not clearly defined, leading to questions regarding the appropriateness of antibiotic treatment among patients. Further efforts are needed to better recognize and treat S. maltophilia BSI.
Managerial Attributes, Incentives, and Performance
Authors: Coles Jeffrey L , Li Zhichuan (Frank)
Published: April 2020

We examine the relative importance of observed and unobserved firm- and manager-specific heterogeneities in determining executive compensation incentives and firm policy, risk, and performance. First, we decompose executive incentives into time-variant and time-invariant firm and manager components. Manager fixed effects supply 73% (60%) of explained variation in delta (vega). Second, controlling for manager fixed effects alters parameter estimates and corresponding inference on observed firm and manager characteristics. Third, larger CEO delta (vega) fixed effects predict better firm performance (riskier corporate policies and higher firm risk). These results suggest that the delta (vega) fixed effect captures managerial ability (risk aversion). (JEL G3, G32, G34, J24, J31, J33)

Received September 7, 2018; editorial decision February 21, 2020 by Editor Andrew Ellul.
Biomarkers for treatment change and radiographic progression in patients with rheumatoid arthritis in remission: a 5 year follow-up study
Authors: Ramírez Julio , Cuervo Andrea , Celis Raquel , Ruiz-Esquide Virginia , Castellanos-Moreira Raul , Narváez José Antonio , Gómez-Puerta José A , Pablos José L , Sanmartí Raimon , Cañete Juan D
Published: April 2020

Objective

To identify biomarkers of treatment change and radiographic progression in patients with RA under remission.

Patients and methods

RA patients in remission (DAS28-ESR <2.6) were selected and followed up for 5 years. An MRI of the dominant hand and an US assessment of knees/hands and serum levels of inflammation/angiogenesis biomarkers were performed at baseline and at 12th month. Synovial biopsies were obtained in patients with Power Doppler signal. Conventional radiographies of hands/feet were taken at baseline and after 5 years. Radiographic progression was defined as the change in the modified Sharp van der Heijde Score at 5 years >10.47 (small detectable change).

Results

Sixty patients were included, 81.6% were ACPA+ and 45% were taking biological DMARDs. At baseline, 66.6% had Power Doppler signal. After 5 years, 73.3% of patients remained in remission. Change of therapy was performed in 20 patients (33.3%) and was associated with BMI [odds ratio (OR) 1.3, 95% CI: 1, 1.7], lack of biological DMARD therapy (OR 24.7, 95% CI: 2.3, 257.2), first-year progression of MRI erosions (OR 1.2, 95% CI: 1, 1.3) and calprotectin serum levels (OR 2.8, 95% CI: 1, 8.2). Radiographic progression occurred in six (10%) patients. These patients had higher first-year progression of MRI erosions (P =  0.03) and bone oedema (P = 0.04). Among 23 patients undergoing synovial biopsy, mast cell density was independently associated with clinical flares.

Conclusions

One-third of RA patients lost clinical remission and changed therapy throughout the 5 years of follow-up, which was independently associated with BMI, lack of biological DMARDs therapy and first-year progression of MRI erosion score and calprotectin serum levels. Significant radiographic progression was uncommon.
Acute severe malnutrition treatment outcomes in children ages 6–59 months admitted to Singa Hospital, Sudan
Authors: Bilal Jalal Ali , Eltahir Hatim G , Al-Nafeesah Abdullah , Al-Wutayd Osama , Adam Ishag
Published: April 2020

Background

Acute malnutrition threatens the lives of 50.5 million children <5 y of age. Consequences of malnutrition include death, among other short-term sequelae. This study was conducted from April to October 2018 to determine the outcomes of children 6–59 months of age with acute severe malnutrition admitted to Singa Hospital in central Sudan.

Methods

Clinical information for children with a mid-upper arm circumference (MUAC) <115 mm were collected. We measured children's weight and height and calculated weight-for-height z-scores. Treatment was offered according to World Health Organization (WHO) guidelines. Outcomes were recorded as recovered, discharged against medical advice or died.

Results

This study included 376 malnourished children. The median age was 18 months (interquartile range [IQR] 12−24). The male:female ratio was 1:1. Among children with weight-for-height Z-scores of −4 and −3, 103 (27.3%) had oedematous malnutrition. There were 131 (34.8%) children with malaria parasites, 33 (8.7%) with pyuria and 24 (6.3%) with intestinal parasites. The recovery rate was 89.1%. The case fatality rate was 3.7%. Mortality was significantly increased with diarrhoea and dermatoses. There were no significant differences in the median of age (17.5 months [IQR 6−24] vs 18 [6−24], p = 0.595), MUAC (110 mm [IQR 104–111] vs 110 [100–111], p = 0.741) or sex (p = 0.991) between children who died and those who recovered.

Conclusions

The case fatality rate was 3.7% and it was associated with diarrhoea and dermatoses.
A revision of the early neotheropod genusSarcosaurusfrom the Early Jurassic (Hettangian–Sinemurian) of central England
Authors: Ezcurra Martín D , Butler Richard J , Maidment Susannah C R , Sansom Ivan J , Meade Luke E , Radley Jonathan D
Published: April 2020

Neotheropoda represents the main evolutionary radiation of predatory dinosaurs and its oldest records come from Upper Triassic rocks (c. 219 Mya). The Early Jurassic record of Neotheropoda is taxonomically richer and geographically more widespread than that of the Late Triassic. The Lower Jurassic (upper Hettangian–lower Sinemurian) rocks of central England have yielded three neotheropod specimens that have been assigned to two species within the genus Sarcosaurus, S. woodi (type species) and S. andrewsi. These species have received little attention in discussions of the early evolution of Neotheropoda and recently have been considered as nomina dubia. Here, we provide a detailed redescription of one of these specimens (WARMS G667–690) and reassess the taxonomy and phylogenetic relationships of the genus Sarcosaurus. We propose that the three neotheropod specimens from the Early Jurassic of central England represent a single valid species, S. woodi. The second species of the genus, ‘S. andrewsi’, is a subjective junior synonym of the former. A quantitative phylogenetic analysis of early theropods recovered S. woodi as one of the closest sister-taxa to Averostra and provides new information on the sequence of character state transformations in the lead up to the phylogenetic split between Ceratosauria and Tetanurae.
Early Biomarkers of Muscle Atrophy and of Neuromuscular Alterations During 10‐Day Bed Rest
Authors: Narici Marco Vincenzo , Monti Elena , Franchi Martino , Reggiani Carlo , Toniolo Luana , Giacomello Emiliana , Zampieri Sandra , Simunič Bostjan , Pisot Rado
Published: April 2020

Introduction

Disuse atrophy may not only arise from a reduction in mechanical loading but also from muscle denervation and neuromuscular junction damage, triggered by inactivity
[1,
2]. The identification of biomarkers of muscle atrophy and of neuromuscular degeneration is therefore needed for an early detection of neuromuscular alterations induced by inactivity. The aim of this study was to investigate the onset of muscle atrophy and of neuromuscular alterations during a short‐term inactivity period.

Methods

Ten healthy males (aged 23±5 years) participated to a 10‐day bed rest (BR) study, after Ethical approval and informed consent. Blood samples were collected every two days for the assessment of NMJ damage from serum levels of c‐terminal agrin fragment (CAF). Muscle fibre denervation was determined from the expression of neural cell adhesive molecule (N‐CAM) in myofibres obtained from vastus lateralis (VL) muscle biopsies at baseline, 5 and 10 days of BR. Myofibre atrophy was assessed from mean fibre cross‐sectional area (CSA). Whole muscle atrophy was assessed from measurements of muscle architecture (pennation angle and muscle CSA) every two days of BR using ultrasonography. Significance of differences was tested with repeated‐measures Anova, level of significance was set at p<0.05.

Results

Atrophy of whole muscle and of myofibers, represented by decreases of 5.8% in muscle CSA (P<0.0001), 7.3% in pennation angle (P<0.0001), and by a 21% reduction in mean fibre CSA (P<0.01) were detected after 10 days of BR. A 19% increase (p<0.01) in CAF levels was found on BR day 10, together with a 18‐fold increase in N‐CAM positive myofibres. The analysis of myofiber CSA and N‐CAM expression at BR 5 day is in progress.

Conclusions

These findings show a very early onset (within 10 days) of whole muscle and fiber atrophy accompanied by NMJ damage and myofiber denervation in response to chronic inactivity. We suggest that countermeasures against neuromuscular maladaptation to chronic inactivity ought to be implemented as early as possible.

Support or Funding Information

Funding by ASI, MARS‐PRE Project, n. DC‐VUM‐2017‐006, is acknowledged.
The effect of dexmedetomidine on postoperative and intensive care unit delirium: A meta‐analysis of randomized controlled trials
Authors: Jiang Fang , Ye Xiaodong , Cai Yin , Xie Xiang , Wang Lin , Hua Lin-lin , Xia Zhengyuan
Published: April 2020

Background

The present meta‐analysis aimed to assess the efficacy of dexmedetomidine on the occurrence of delirium among critically ill patients in the postoperative and intensive care unit.

Methods

Pubmed, Embase, Cochrane Library (Central), Web of Science and Clinical Trails databases for randomized controlled trials (RCTs) were searched to compare the effect of dexmedetomidine administration in comparison with control group (normal saline or other anesthetic drugs) on the incidence of delirium in adult patients until April 4, 2019. The sensitivity and subgroup analyses were adopted. Statistical analysis was performed with RevMan software version 5.3 and Stata 12.0. The primary endpoint was the incidence of delirium. The secondary outcome included the occurrence of hypotension, hypertension, bradycardia and tachycardia.

Results

20 RCTs were finally included in the analysis, with a total of 4,242 adult patients. The results of meta‐analysis showed that dexmedetomidine (odds ratio [OR]=0.47, 95% confidence interval [CI]: 0.35 to 0.64, p < 0.01) could significantly reduce the rate of delirium for the entire patients in the postoperative and intensive care unit when compared with control group. The subgroup analysis indicated that dexmedetomidine reduced the incidence of delirium between groups in cardiac surgery (OR=0.55, 95% CI: 0.30 to 0.98) and non‐cardiac surgery (OR=0.44, 95% CI: 0.31 to 0.64), normal saline (OR=0.47, 95% CI: 0.31 to 0.71) and anesthetic drugs (OR=0.50, 95% CI: 0.30 to 0.81), age ≥ 60 years old (OR=0.50, 95% CI: 0.36 to 0.68) and age < 60 years old (OR=0.34, 95% CI: 0.13 to 0.91), with loading dose (OR=0.38, 95% CI: 0.29 to 0.50) and without loading dose (OR=0.54, 95% CI: 0.44 to 0.67). However, there were no significant difference in delirium among mechanical ventilated patients (OR=0.30, 95% CI: 0.07 to 1.22) and in cardiac surgery patients with age ≥ 60 years old (OR=0.73, 95% CI: 0.44 to 1.22). Additionally, this analysis found that dexmedetomidine administration was associated with an increased incidence of hypertension (OR=0.54, 95% CI: 0.41 to 0.71) and bradycardia (OR=1.59, 95% CI: 1.25 to 2.03), while the incidence of hypotension (OR=0.90, 95% CI: 0.62 to 1.31) and tachycardia (OR=0.73, 95% CI: 0.37 to 1.45) did not differ significantly between dexmedetomidine treated and control groups..

Conclusion

The present limited evidence suggests that dexmedetomidine can reduce the incidence of delirium in the postoperative and intensive care unit except in cardiac surgery patients with age ≥ 60. However, the pooled results should be interpreted with more caution due to significant statistical heterogeneity existed. Therefore, future high‐quality, large RCTs should further verify this findings among this population.
Can detrimental mtDNA mutations be under positive selection in the germline?
Authors: Franco Melissa , Pickett Sarah , Fleischmann Zoe , Khrapko Mark , Annis Sofia , Woods Dori , Markuzon Natalya , Turnbull Doug , Khrapko Konstantin
Published: April 2020

It is conventionally assumed that detrimental mitochondrial DNA (mtDNA) mutations generally are under negative purifying selection in the germline, i.e., that children on average carry a lower burden than mothers. We asked whether, at least for some detrimental mutations, this may not be the case. We chose the infamous 3243G>A mutation, which disrupts mitochondrial function and causes a variety of serious neuromuscular disorders including a severe mitochondrial disease, MELAS. This mutation occurs frequently (detectable in as many as 1 in 500 individuals), and is well studied. To determine whether this mutation is under selection, the mutation level in kids is compared to that in mothers. However, it has been shown that the level of the 3243G>A mutation appears to exponentially decrease with age in blood, where it is commonly measured (~2% per year). This estimation is based on a biologically sensible numerical model that simulates random drift in blood stem cells and removes cells that reach a lethal threshold (Rajasimha, 2008). This model asymptotically converges to an exponential function that describes a decline of 2% heteroplasmy per year. Thus, for fair comparison, kid/mom heteroplasmy ratios need to be corrected for the age difference. With the conventional 2% per year correction, no significant difference between moms and kids could be detected.

There are indications, however, that the change of the 3243G>A level with age may be more complex than simple exponent. It may depend on initial heteroplasmy levels and the age. Indeed, we demonstrate that the 2% model predictions are systematically under‐estimates, and that several predictive models that include heteroplasmy and age as variables ensure better fit of the data and decrease this negative bias. One such model is an adaptation of the original numerical model (Rajasimha, 2008). If its asymptotic behavior is not unconditionally assumed, this model explicitly includes heteroplasmy and age as variables. This non‐asymptotic model produces a better fit and corrects the negative bias.

We reasoned that a negative bias in prediction might have obscured positive selection on 3243G>A in the germline if it existed. To clarify the issue, we used the non‐asymptotic numerical model to predict the children’s heteroplasmy levels at their mothers’ age. Indeed, in preliminary simulations with this improved correction, a statistically significant positive germline selection of 3243G>A was demonstrated. More analysis is needed to confirm this initial result.

We note that, interestingly, if such positive selection of pathogenic mtDNA mutations existed, it might have had an adaptive purpose. Our simulations demonstrate that under realistic conditions, positive selection in the germline may promote removal of detrimental mtDNA mutations at the population level and thus help to evade the dangers of the infamous Muller’s ratchet.
Effect of Angiotensin ll on mouse tracheal reactivity
Authors: Prasad Praveena , Patel Mehaben , Bhavsar Riya , Sheikh Usman , Nahvi Parisa , Ponnoth Dovenia S.
Published: April 2020

Angiotensin II is a hormone peptide that is primarily generated in the lungs and kidneys. However, effects of Ang ll on airway function is not fully understood. We assessed concentration‐responses to Ang II in isolated mouse trachea by using ex‐vivo organ bath experiments. Western blot data showed that mouse trachea expressed AT1 receptors and AT2 receptors. Our data suggested that Ang II induces concentration‐dependent relaxation in methacholine (MCh)‐precontracted tracheal rings (38.95±0.72% at 10μM; n=4). Use of Ang II type 1 (AT1) receptor antagonist losartan blocked this effect resulting in a small contraction of 3.94±2.83%. nNOS inhibitor also completely blunted the Ang II mediated relaxation resulting in a contraction of 5.17±2.05% in the MCh‐precontracted tracheal rings. Novokinin had a minimal effect on the precontracted tissues, suggesting that AT1 receptors played a main role in mediating Ang ll responses. These data suggest that Ang II mediates tracheal relaxation via AT1‐ receptor activation, through a nitric‐oxide dependent mechanism.

Support or Funding Information

Supported by LIU start‐up funds (DSP)
Sexual Dysfunction and Psychopathological Variables Among Tramadol Abusers: An Egyptian Perspective
Authors: Mobasher Maha W. , Hassanin Ahmed M.A. , Elsayed Mohamed A. , Ayoub Doaa R. , El-Makawi Shirin M.
Published: April 2020

Objectives:

The relationship between tramadol and sexual function seems to be controversial, men with premature ejaculation may benefit from taking tramadol off-label. Yet, these patients are rather sensitive to develop other sexual dysfunctions. To date, rather a limited number of studies investigated this issue. In addition, psychological concerns related to sexual functions in these patients had not enough attention. In this paper we present a new approach which will investigate these concerns

Materials and Methods:

Sixty subjects (30 tramadol-dependent men and 30 matched controls). Patients were assessed by the Mini International Neuropsychiatry Interview (MINI) is to assesses the presence of The Diagnostic and Statistical Manual of Mental Disorder, 4th edition disorders, the Addiction Severity Index (ASI), the International Index of Erectile Function (IIEF), and the Sexuality Scale.

Results:

Tramadol patients were found to have significantly decreased different sexual functions in comparison with controls. Sexual depression scores were significantly higher in tramadol patients compared with controls (P=0.020); while sexual-esteem and sexual preoccupation scores were significantly lower in tramadol patients compared with matched controls (P=0.000 and 0.046). In the patient group, the dose of tramadol used per day showed significant negative correlation with erectile function (P=0.04), orgasmic function (P=0.03), and sexual esteem (P=0.04); while the duration of tramadol dependence showed significant negative correlation with erectile function (P=0.04), intercourse satisfaction (P=0.01), overall satisfaction (P=0.00), and significant positive correlation with sexual preoccupation.

Conclusions:

Tramadol patients indeed suffer from different sexual, emotional, occupational dysfunctions, and sexually related psychopathological aspects.
Muscular Tissue Oxygen Saturation and Posthysterectomy Nausea and Vomiting
Authors: Li Gang , Tian Dan-Dan , Wang Xu , Feng Xiaoxian , Zhang Wenyu , Bao Ju , Wang Dong-Xin , Ai Yan-Qiu , Liu Ya , Zhang Mengyuan , Xu Mingjun , Mu Dong-Liang , Zhao Xu , Dai Feng , Yang Jian-Jun , Che Xiangming , Yanez David , Guo Xiangyang , Meng Lingzhong
Published: April 2020

Background

Suboptimal tissue perfusion and oxygenation during surgery may be responsible for postoperative nausea and vomiting in some patients. This trial tested the hypothesis that muscular tissue oxygen saturation–guided intraoperative care reduces postoperative nausea and vomiting.

Methods

This multicenter, pragmatic, patient- and assessor-blinded randomized controlled (1:1 ratio) trial was conducted from September 2018 to June 2019 at six teaching hospitals in four different cities in China. Nonsmoking women, 18 to 65 yr old, and having elective laparoscopic surgery involving hysterectomy (n = 800) were randomly assigned to receive either intraoperative muscular tissue oxygen saturation–guided care or usual care. The goal was to maintain muscular tissue oxygen saturation, measured at flank and on forearm, greater than baseline or 70%, whichever was higher. The primary outcome was 24-h postoperative nausea and vomiting. Secondary outcomes included nausea severity, quality of recovery, and 30-day morbidity and mortality.

Results

Of the 800 randomized patients (median age, 50 yr [range, 27 to 65]), 799 were assessed for the primary outcome. The below-goal muscular tissue oxygen saturation area under the curve was significantly smaller in patients receiving muscular tissue oxygen saturation–guided care (n = 400) than in those receiving usual care (n = 399; flank, 50 vs. 140% · min, P < 0.001; forearm, 53 vs. 245% · min, P < 0.001). The incidences of 24-h postoperative nausea and vomiting were 32% (127 of 400) in the muscular tissue oxygen saturation–guided care group and 36% (142 of 399) in the usual care group, which were not significantly different (risk ratio, 0.89; 95% CI, 0.73 to 1.08; P = 0.251). There were no significant between-group differences for secondary outcomes. No harm was observed throughout the study.

Conclusions

In a relatively young and healthy female patient population, personalized, goal-directed, muscular tissue oxygen saturation–guided intraoperative care is effective in treating decreased muscular tissue oxygen saturation but does not reduce the incidence of 24-h posthysterectomy nausea and vomiting.

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New
A simple approach for determining tendon limb length in open Achilles lengthening: technical note
Authors: Makarewich Christopher A. , Swarup Ishaan , Davidson Richard S.
Published: April 2020

Estimating the appropriate tendon length and associated skin incision needed to achieve a plantigrade foot without compromising function are essential steps in open Achilles tendon lengthening. Here we describe a technique using basic surgical instruments referencing anatomic landmarks without the need for radiographs. The center of ankle rotation in the sagittal plane is found referencing the tip of the medial malleolus. This point is translated to the plantar surface of the foot, and a straight instrument in line with the foot is used to make a mark at the posterior calcaneal fat pad. The straight instrument is then rotated (representing the plantar surface of the foot) as if dorsiflexing the ankle along the axis of the transposed tibiotalar joint from a plantar-flexed position to the desired final position and a second mark is made at the posterior heel. The distance between the marks is measured, representing the amount of Achilles lengthening required. The skin incision and tendon limb lengths area a sum of the operative correction and the amount of desired tendon overlap, typically 2 cm of tendon overlap is optimal to allow for suture fixation, ensure tendon healing, and maintain the integrity of the repair. A Z-type lengthening is then performed using this tendon limb length. This technique allows an accurate and simple approach to lengthening the Achilles tendon. In this way the ideal tendon limb length is selected to optimize function while minimizing incision length, associated wound complications, inadequate lengthening, and overlengthening. Level of evidence: Technical note, Level V.
The Reemergence of Ketamine for Treatment in Critically Ill Adults
Authors: Hurth Kimberly P. , Jaworski Anthony , Thomas Kristen B. , Kirsch William B. , Rudoni Michael A. , Wohlfarth Kevin M.
Published: April 2020

Objectives:

To assess the evidence and discuss the risks and clinical relevance of ketamine for the treatment of various disease states impacting the adult critically ill population.

Data Sources:

A literature review was performed using PubMed evaluating primary literature published until August 2018.

Study Selection:

Case reports, observational studies (cohort, case-control), and randomized controlled trials involving patients 18 years and older in a nonperioperative setting using either IV or intramuscular ketamine were included for analysis. Uses of ketamine discussed focused on critically ill patients in the ICU and emergency department settings.

Data Extraction:

Included studies were evaluated for dosing, outcomes, and adverse effects of ketamine. For each study, the design, population, intervention, investigated outcomes, and results were assessed.

Data Synthesis:

The evidence was organized according to use of ketamine, which included pain, sedation, status asthmaticus, alcohol withdrawal syndrome, status epilepticus, and acute behavioral psychologic disturbances. Evaluation of the evidence was based on the included primary literature along with any related guideline recommendations.

Conclusions:

Ketamine has suggested potential benefit in several disease states impacting critically ill patients including pain, alcohol withdrawal syndrome, status epilepticus, and acute agitation. Further supporting evidence is needed to validate its use in the setting of critical illness.
Policies for Mandatory Ethics Consultations at U.S. Academic Teaching Hospitals: A Multisite Survey Study*
Authors: Neal Jonathan B. , Pearlman Robert A. , White Douglas B. , Tolchin Benjamin , Sheth Kevin N. , Bernat James L. , Hwang David Y.
Published: April 2020

Objectives:

To determine the number of top-ranked U.S. academic institutions that require ethics consultation for specific adult clinical circumstances (e.g., family requests for potentially inappropriate treatment) and to detail those circumstances and the specific clinical scenarios for which consultations are mandated.

Design:

Cross-sectional survey study, conducted online or over the phone between July 2016 and October 2017.

Setting:

We identified the top 50 research medical schools through the 2016 U.S. News and World Report rankings. The primary teaching hospital for each medical school was included.

Subjects:

The chair/director of each hospital’s adult clinical ethics committee, or a suitable alternate representative familiar with ethics consultation services, was identified for study recruitment.

Interventions:

None.

Measurements and Main Results:

A representative from the adult ethics consultation service at each of the 50 target hospitals was identified. Thirty-six of 50 sites (72%) consented to participate in the study, and 18 (50%) reported having at least one current mandatory consultation policy. Of the 17 sites that completed the survey and listed their triggers for mandatory ethics consultations, 20 trigger scenarios were provided, with three sites listing two distinct clinical situations. The majority of these triggers addressed family requests for potentially inappropriate treatment (9/20, 45%) or medical decision-making for unrepresented patients lacking decision-making capacity (7/20, 35%). Other triggers included organ donation after circulatory death, initiation of extracorporeal membrane oxygenation, denial of valve replacement in patients with subacute bacterial endocarditis, and posthumous donation of sperm. Twelve (67%) of the 18 sites with mandatory policies reported that their protocol(s) was formally documented in writing.

Conclusions:

Among top-ranked academic medical centers, the existence and content of official policies regarding situations that mandate ethics consultations are variable. This finding suggests that, despite recent critical care consensus guidelines recommending institutional review as standard practice in particular scenarios, formal adoption of such policies has yet to become widespread and uniform.
Economic Implications of Chinese Diagnosis-Related Group–Based Payment Systems for Critically Ill Patients in ICUs
Authors: Meng Zhaolin , Ma Yanan , Song Suhang , Li Ye , Wang Dan , Si Yafei , Sun Ruochen , Zhang Ruochen , Xue Hao , Jing Limei , Wu Huazhang
Published: April 2020

Objectives:

To evaluate the economic implications of payments based on Chinese diagnosis-related groups for critically ill patients in ICUs in terms of total hospital expenditure, out-of-pocket payments, and length of stay.

Design:

A pre-post comparison of patient cohorts admitted to ICUs 1 year before and 1 year after Chinese diagnosis-related group reform was undertaken. Demographic characteristics, clinical data, and medical expenditures were collated from a health insurance database.

Setting:

Twenty-two public hospitals in Sanming, Southern China.

Patients:

All patients admitted to ICUs from January 1, 2017, to December 31, 2018.

Intervention:

The implementation of Chinese diagnosis-related group–based payments on January 1, 2018.

Measurements and Main Results:

Economic variables (total expenditures, out-of-pocket payments, and length of stay) were calculated for each patient from the day of hospital admission to the day of hospital discharge. Adjusted mean out-of-pocket payment estimates were 29.46% (p < 0.001) lower following reform. Adjusted mean out-of-pocket payments fell by 41.32% for patients in neonatal ICU, whereas there were no significant decreases in out-of-pocket payments for patients in PICU and adult ICU. Furthermore, adjusted mean out-of-pocket payments decreased by 55.74% in secondary hospitals, but there was no significant change in tertiary hospitals after Chinese diagnosis-related group reform. No significant changes were found in total expenditures and length of stay.

Conclusions:

Chinese diagnosis-related group policy provided an opportunity for critically ill patients in ICUs to achieve at least short-term financial benefits in reducing out-of-pocket payments, without affecting the total expenditures and length of stay. Chinese diagnosis-related group–based payment significantly relieved financial burdens for patients with lower illness severities, such as patients in neonatal ICU. The results of this study can offer significant insights for policymakers in reducing the financial burden on critically ill patients, both in China and in other countries with similar systems.
Potential for Lung Recruitment and Ventilation-Perfusion Mismatch in Patients With the Acute Respiratory Distress Syndrome From Coronavirus Disease 2019*
Authors: Mauri Tommaso , Spinelli Elena , Scotti Eleonora , Colussi Giulia , Basile Maria Cristina , Crotti Stefania , Tubiolo Daniela , Tagliabue Paola , Zanella Alberto , Grasselli Giacomo , Pesenti Antonio
Published: April 2020

Objectives:

Severe cases of coronavirus disease 2019 develop the acute respiratory distress syndrome, requiring admission to the ICU. This study aimed to describe specific pathophysiological characteristics of acute respiratory distress syndrome from coronavirus disease 2019.

Design:

Prospective crossover physiologic study.

Setting:

ICU of a university-affiliated hospital from northern Italy dedicated to care of patients with confirmed diagnosis of coronavirus disease 2019.

Patients:

Ten intubated patients with acute respiratory distress syndrome and confirmed diagnosis of coronavirus disease 2019.

Interventions:

We performed a two-step positive end-expiratory pressure trial with change of 10 cm H2O in random order.

Measurements and Main Results:

At each positive end-expiratory pressure level, we assessed arterial blood gases, respiratory mechanics, ventilation inhomogeneity, and potential for lung recruitment by electrical impedance tomography. Potential for lung recruitment was assessed by the recently described recruitment to inflation ratio. In a subgroup of seven paralyzed patients, we also measured ventilation-perfusion mismatch at lower positive end-expiratory pressure by electrical impedance tomography. At higher positive end-expiratory pressure, respiratory mechanics did not change significantly: compliance remained relatively high with low driving pressure. Oxygenation and ventilation inhomogeneity improved but arterial co
2 increased despite unchanged respiratory rate and tidal volume. The recruitment to inflation ratio presented median value higher than previously reported in acute respiratory distress syndrome patients but with large variability (median, 0.79 [0.53–1.08]; range, 0.16–1.40). The Fio
2 needed to obtain viable oxygenation at lower positive end-expiratory pressure was significantly correlated with the recruitment to inflation ratio (r = 0.603; p = 0.05). The ventilation-perfusion mismatch was elevated (median, 34% [32–45%] of lung units) and, in six out of seven patients, ventilated nonperfused units represented a much larger proportion than perfused nonventilated ones.

Conclusions:

In patients with acute respiratory distress syndrome from coronavirus disease 2019, potential for lung recruitment presents large variability, while elevated dead space fraction may be a specific pathophysiological trait. These findings may guide selection of personalized mechanical ventilation settings.
Patterns and Outcomes of Diagnosis Disclosure to Youth with Autism Spectrum Disorder
Authors: Kiely Bridget , Adesman Andrew , Rapoport Eli , Gutman Alyson
Published: April 2020

Objective:

Although the benefits of diagnosis disclosure have been recognized for a number of pediatric medical conditions, there is a paucity of research about the process by which youth with autism spectrum disorder (ASD) are informed about their diagnosis. The aim of this study was to systematically characterize the antecedents, correlates, and outcomes of diagnosis disclosure to youth with ASD.

Methods:

In this cross-sectional study, parents and guardians of youth with ASD (ages 8–25) completed a detailed online questionnaire about their experiences with diagnosis disclosure. The perceived impact of disclosure on affected youth was also assessed.

Results:

Five hundred seventy-five parents of youth with ASD (mean age: 14 years) completed the questionnaire, of whom 81% reported their affected child had been told that he or she had ASD. Most youth who had been told about their diagnosis (86%) were currently aware that they had ASD, according to the parent report. Youth awareness of the diagnosis was reported to be associated with improved self-advocacy skills (60%), enhanced self-awareness of personal strengths (69%) and weaknesses (68%), and other benefits. Youth who had sought information about ASD from support groups and other individuals with ASD had better outcomes regarding self-esteem [adjusted odds ratio = 2.73, 95% confidence interval: (1.34, 3.98)] and acceptance of the diagnosis (p = 0.001) than those who exclusively learned about ASD from other sources.

Conclusion:

Given the numerous potential benefits of diagnosis disclosure, there is a need for physicians and other professionals to support parents in educating youth with ASD about their diagnosis.
More than a View: School Landscape Features Are Associated with Improved Student Adjustment
Authors: Sajady Mollika , Gower Amy L. , McCullough Michael , Jordan Cathy
Published: April 2020

Objective:

Research indicates that natural features surrounding schools are associated with better academic achievement, enhanced focus, and reduced stress in students. However, few studies have examined the associations between school landscape elements and anxiety, depression, and behavioral concerns in students. The purpose of this study was to determine whether greenery and impervious surfaces surrounding schools are associated with student internalizing and externalizing problems.

Method:

Fifth-grade students (n = 21,378) reported internalizing and externalizing behaviors on the 2016 Minnesota Student Survey, an anonymous school-based survey administered statewide. Geographic information system landscape data were available for 268 schools in metropolitan areas. We calculated the percentages of tree canopy, grass and shrub cover, and impervious surfaces within 300- and 500-m radius areas around each school building. Multilevel regression models evaluated the associations between student-level internalizing and externalizing behaviors and school-level landscape percentages, controlling for sex, race, and free/reduced-price lunch.

Results:

Students attending metropolitan schools with a higher percentage of impervious surfaces were more likely to report externalizing behaviors and marginally more internalizing symptoms than students in schools with a lower percentage of impervious surfaces. Higher percentages of tree canopy and grass and shrub cover surrounding schools were not associated with internalizing or externalizing behaviors.

Conclusion:

Increased impervious surfaces around schools in metropolitan areas were related to increased student externalizing behaviors. Further studies are necessary to understand the significance of the built environment, types of greenery, impact of greenery on student adjustment in nonmetropolitan settings, and varying areas surrounding schools. These results could inform initiatives to improve school landscapes.
Two Non-gadolinium–based, Innovative Approaches to Preoperative Lymphangiography
Authors: Lee Christine U. , Glockner James F. , Hesley Gina K. , Brinkman Nathan J. , Tran Nho V.
Published: April 2020

Most magnetic resonance lymphangiography techniques employ intravenous gadolinium-based contrast agents, which carry a US Food and Drug Administration warning about gadolinium retention in the body when used intravenously. Because of this, there may be reluctance to perform intradermal injections of gadolinium-based contrast agents in patients with obstructed lymphatic drainage due to concerns about gadolinium retention in the skin and soft tissues and potential-related toxicity. The aim of this study was to show proof of concept of 2 preoperative lymphangiographic techniques that do not use gadolinium-based contrast agents. One technique used contrast-enhanced ultrasound with intradermal injections of microbubbles (Lumason) in a patient with stage 3, nonpitting left upper extremity edema. Another technique used magnetic resonance imaging with intradermal injections of 0.03 mg/mL or 0.003% ferumoxytol (Feraheme) in a patient with stage 3, nonpitting right lower extremity edema. Both contrast-enhanced ultrasound with microbubbles and magnetic resonance lymphangiogram with ferumoxytol were able to identify candidates for lymphovenous bypass surgery. These candidates were not identified by conventional indocyanine green injections. The authors conclude that (1) low-dose ferumoxytol is a potentially effective non-gadolinium–based contrast alternative to gadolinium-based contrast agent in magnetic resonance lymphangiography and (2) contrast-enhanced ultrasound can identify candidate lymphatic vessels for anastomosis.
Systematic review and meta-analysis: monopolar hemostatic forceps with soft coagulation in the treatment of peptic ulcer bleeding
Authors: Kamal Faisal , Khan Muhammad Ali , Tariq Raseen , Ismail Mohammad K. , Tombazzi Claudio , Howden Colin W.
Published: April 2020

Monopolar hemostatic forceps with soft coagulation (MHFSC) have been compared with hemoclips, heater probe, and argon plasma coagulation (APC) for the treatment of peptic ulcer bleeding. In this systematic review and meta-analysis, we compared MHFSC with other modalities in the treatment of peptic ulcer bleeding. We reviewed MEDLINE, Embase, Scopus, Cochrane, Web of Science, and Scopus from inception to 7 January 2019 to identify studies comparing MHFSC with other modalities for peptic ulcer bleeding. The primary outcome of interest was achievement of initial hemostasis. Secondary outcomes were rebleeding, adverse events, procedure time, and length of hospital stay. Data were analyzed using a random effects model and summarized as pooled odds ratio (OR) with 95% confidence interval (CI). Heterogeneity was assessed by I
2 statistic. We included five randomized controlled trials and one observational study comprising 693 patients with endoscopically confirmed actively bleeding ulcers (spurting or oozing) or nonbleeding visible vessel. MHFSC was superior to other modalities in achieving initial hemostasis (OR 0.25; 95% CI 0.08–0.81; I
2 = 67%) and prevention of rebleeding (OR 0.28; 95% CI 0.09–0.86; I
2 = 46%). Rates of adverse events were similar between MHFSC and other modalities. Procedure times were shorter with MHFSC (mean difference −4.15 min; 95% CI −4.83 to −3.47; I
2 = 59%). Length of hospital stay was also shorter with MHFSC. MHFSC appears to be more effective than other modalities for achievement of initial hemostasis and reduction of rebleeding among patients with peptic ulcer bleeding.