bluuebunny/crossref_metadata_2025 huggingface dataset:
Relationship Between Narrative Comments and Ratings for Entry-Level Performance on the Clinical Performance Instrument: A Call to Rethink the Clinical Performance Instrument
Authors: Wetherbee Ellen , Dupre Anne-Marie , Feinn Richard S. , Roush Susan
Published: July 2018

Introduction.

Clinical instructors (CIs) use narratives to qualify anchor points for 18 performance criteria on the Clinical Performance Instrument: Version 2006 (CPI'06) when assessing students' performance during clinical experiences. Directors of Clinical Education (DCE) final narratives and anchor points on the CPI'06 to make sure that the narratives and anchor points are in alignment with each other. CIs and DCEs should have a mutual understanding of the terminology used on the CPI'06. The purpose of this study was to determine the level of agreement (concordance) between raters on whether examples of narratives supported the term, “entry-level performance” (ELP), before and after focus group discussions.

Methods.

Fifty-four CIs discussed the CPI'06 terminology. A pretest/posttest design was used with the intervention being focus group discussions. Participants compared the definition of ELP with sample narratives and agreed, disagreed, or remained undecided about whether the narratives supported ELP. Statistical tests were analyzed to determine participants' concordance about whether the narratives supported ELP. Their rationale to support their decisions was analyzed using qualitative methodology.

Results.

Participants' percent of pairwise agreement about whether the narratives supported ELP for testing conditions were highest for safety (65.2–95.3%) and lowest for professional behaviors (34.4–44.0%). Intraclass correlation for multiple raters using ICC(2,1) model indicated interrater reliability for absolute agreement on each test, across five performance criteria, was fair to poor. Qualitative assessment for participants' rationale about decisions indicated inconsistencies in the interpretation of CPI'06 terminology.

Discussion and Conclusion.

Agreement among professionals about the interpretation of the language used on the CPI'06 to ensure that students graduate with the requisite skills and behaviors is essential. This study indicates that there was a lack of participants' concordance with the interpretation of ELP on the CPI'06.
New Approaches to Respiratory Assist: Bioengineering an Ambulatory, Miniaturized Bioartificial Lung
Authors: Novosel Esther , Borchers Kirsten , Kluger Petra J. , Mantalaris Athanasios , Matheis Georg , Pistolesi Massimo , Schneider Jörg , Wenz Annika , Lelkes Peter I.
Published: July 2018

Although state-of-the-art treatments of respiratory failure clearly have made some progress in terms of survival in patients suffering from severe respiratory system disorders, such as acute respiratory distress syndrome (ARDS), they failed to significantly improve the quality of life in patients with acute or chronic lung failure, including severe acute exacerbations of chronic obstructive pulmonary disease or ARDS as well. Limitations of standard treatment modalities, which largely rely on conventional mechanical ventilation, emphasize the urgent, unmet clinical need for developing novel (bio)artificial respiratory assist devices that provide extracorporeal gas exchange with a focus on direct extracorporeal CO2removal from the blood. In this review, we discuss some of the novel concepts and critical prerequisites for such respiratory lung assist devices that can be used with an adequate safety profile, in the intensive care setting, as well as for long-term domiciliary therapy in patients with chronic ventilatory failure. Specifically, we describe some of the pivotal steps, such as device miniaturization, passivation of the blood-contacting surfaces by chemical surface modifications, or endothelial cell seeding, all of which are required for converting current lung assist devices into ambulatory lung assist device for long-term use in critically ill patients. Finally, we also discuss some of the risks and challenges for the long-term use of ambulatory miniaturized bioartificial lungs.
Outcomes of critical illness: what is meaningful?
Authors: Gajic Ognjen , Ahmad Sumera R. , Wilson Michael E. , Kaufman David A.
Published: July 2018

Purpose of review

In this review, we will discuss efforts and challenges in understanding and developing meaningful outcomes of critical care research, quality improvement and policy, which are patient-centered and goal concordant, rather than mortality alone. We shall discuss different aspects of what could constitute outcomes of critical illness as meaningful to the patients and other stakeholders, including families and providers.

Recent findings

Different outcome pathways after critical illness impact the patients, families and providers in multiple ways. For patients who die, it is important to consider the experience of dying. For the increasing number of survivors of critical illness, challenges of survival have surfaced. The physical, mental and social debility that survivors experience has evolved into the entity called post-ICU syndrome. The importance of prehospital health state trajectory and the need for the outcome of critical care to be aligned with the patients’ goals and preferences have been increasingly recognized.

A theoretical framework is outlined to help understand the impact of critical care interventions on outcomes that are meaningful to patients, families and healthcare providers.
Early Readmission Predicts Increased Mortality in Cirrhosis Patients After Clostridium difficile Infection
Authors: Kruger Andrew J. , Durkin Claire , Mumtaz Khalid , Hinton Alice , Krishna Somashekar G.
Published: July 2018

Goals:

We sought to determine the impact of Clostridium difficile infections (CDI) in cirrhosis by evaluating trends and outcomes of early readmission and mortality.

Background:

The incidence of CDI in cirrhotics is increasing.

Study:

We analyzed the Nationwide Readmissions Database (2011 to 2014) for hospitalized patients with CDI and differentiated them by presence of cirrhosis. Baseline characteristics, surgical rates, and outcomes were collected. The primary outcomes of interest included readmission and mortality rates.

Results:

Of 366,283 patients hospitalized with CDI, 12,274 (3.4%) had cirrhosis, of which 7741 (63.1%) were decompensated. Among patients with CDI, 30-day readmission rates (33% vs. 24%), index admission mortality (5% vs. 2.5%), and calendar-year mortality (9% vs. 4%) were higher in patients with cirrhosis compared with those without cirrhosis. Recurrent CDI (rCDI) (46%) and cirrhosis-related complications (34.6%) were the most common reasons for readmission. Patients with decompensated cirrhosis were more likely to be readmitted within 30-days than those with compensated cirrhosis [odds ratio (OR), 1.19; 95% confidence interval (CI), 1.03-1.36]. Multivariable analyses revealed that among patients with cirrhosis, index colectomy (OR, 6.50; 95% CI, 1.61-26.24) and decompensation (OR, 3.61; 95% CI, 2.49-5.23) predicted index admission mortality. In addition, 30-day readmission (OR, 3.71; 95% CI, 2.95-4.67) and decompensated cirrhosis (OR, 1.49; 95% CI, 1.17-1.89) independently predicted calendar-year mortality.

Conclusions:

One-third of CDI patients with cirrhosis were readmitted within 30-days, most commonly because of rCDI. The mortality associated with CDI in patients with cirrhosis is high, with decompensation and 30-day readmission heralding a poor prognosis. Reducing rCDI-related readmissions may potentially improve these outcomes.
Optimising emergency weight estimation in underweight and obese children: the accuracy of estimations of total body weight and ideal body weight
Authors: Wells Mike , Goldstein Lara N.
Published: July 2018

Objective

During medical emergencies, underweight and obese children are at a higher risk of weight-estimation errors than ‘average’ children, which may lead to poorer outcomes. In obese children, optimum drug dosing requires a measure of both total body weight (TBW) and ideal body weight (IBW) for appropriate scaling. We evaluated the ability of the Broselow tape, the Mercy method and the PAWPER XL tape to estimate TBW and IBW in obese and underweight children.

Participants and methods

Data for children aged 0–18 years were extracted and pooled from three previous weight-estimation studies. The accuracy of estimation of TBW and IBW by each method was evaluated using percentage of estimations within 10% of target weight (PW10) as the primary outcome measure.

Results

The Broselow tape estimated TBW poorly in obese and underweight children (PW10: 3.9 and 41.4%), but estimated IBW extremely accurately (PW10: 90.6%). The Mercy method estimated TBW accurately in both obese and underweight children (PW10: 74.3 and 76.3%) but did not predict IBW accurately (PW10: 14.3%). The PAWPER XL tape predicted TBW well (PW10: 73.0% in obese children and 74.9% in underweight children) and predicted IBW extremely accurately (PW10: 100%).

Conclusion

The Broselow tape predicted IBW, but not TBW, accurately. The Mercy method estimated TBW very accurately, but not IBW. The PAWPER XL tape estimated both TBW and IBW accurately. The PAWPER XL tape should be considered when choosing a weight-estimation strategy for obese and underweight children.
Quick Sepsis-related Organ Failure Assessment predicts 72-h mortality in patients with suspected infection
Authors: Chen Fu-Cheng , Kung Chia-Te , Cheng Hsien-Hung , Cheng Chi-Yung , Tsai Tsung-Cheng , Hsiao Sheng-Yuan , Su Chih-Min
Published: July 2018

Objective

The aim of this study was to compare quick Sepsis-related Organ Failure Assessment (qSOFA) and Systemic Inflammatory Response Syndrome (SIRS) scores for predicting mortality.

Patients and methods

A single-center, retrospective study of adult patients with suspected infection was conducted. Area under the curve (AUC) and multivariate analyses were used to explore associations between the qSOFA and SIRS scores and mortality.

Results

Of the 69 115 patients enrolled, 1798 died within 72 h and 5640 within 28 days. The qSOFA scores were better than SIRS scores at predicting 72-h mortality (AUC: 0.77 vs. 0.64). However, the discriminatory power of both scores was low in terms of 28-day mortality (AUC: 0.69 vs. 0.60). Patients with qSOFA score of at least 2 had a higher hazard ratio for 72-h mortality than for 28-day mortality (2.64 vs. 1.91).

Conclusion

The qSOFA scores are more accurate than SIRS scores for predicting 72-h mortality and are better at predicting 72-h mortality than 28-day mortality.
Combined petrosal approach
Authors: Polster Sean P. , Horowitz Peleg M. , Awad Issam A. , Gluth Michael B.
Published: July 2018

Purpose of review

The combined petrosal approach to the lateral skull base merges a retrolabyrinthine-presigmoid posterior fossa craniotomy with an adjacent middle fossa craniotomy, which are rendered continuous by division of the tentorium. This is a hearing-preserving approach that affords wide access to the lateral aspect of the clivus, the prepontine space, and the cerebellopontine angle.

Recent findings

This article details the historical development of the combined petrosal approach alongside a description. In particular, the critically relevant anatomy is reviewed, including the course of the vein of Labbé, with a view toward avoiding the known complications associated with this approach. Outcomes for application of this approach as applied for various lesions are also reviewed as portrayed by the current literature.

The combined petrosal approach affords wide access to the lateral skull base in the middle and posterior fossa. The approach and the lesions addressed by this approach involve delicate and sensitive anatomy. We review the evolution of this approach and highlight advancements that have allowed the combined petrosal approach to be a safe addition to the surgeon's armamentarium.
Hepatic Hemosiderosis Contributes to Abnormal Vitamin D-PTH Axis in Thalassemia Major
Authors: Bajoria Rekha , Rekhi Elissa , Almusawy Muhsin , Chatterjee Ratna
Published: July 2018

Objective:

The aim of this study was to evaluate the vitamin D-PTH axis in thalassemia major (TM) in relation to hepatic siderosis liver iron content.

Design and Participants:

In this case-controlled observational study, vitamin D-PTH axis was studied in 158 TM and 84 age and ethnicity-matched healthy nonthalassemic controls attending University College Hospital, London. Patients were classified as 25-hydroxy vitamin D (25-OHD) insufficient and sufficient if the value was less than or greater than 50 nmol/L, respectively. 25-OHD data were evaluated in relation to markers of iron load in TM.

Results:

In TM, 25-OHD insufficiency was 8-fold higher than the control group (odds ratio [OR], 8.1; 95% confidence interval [CI], 4.3-15.0; P<0.001). Similarly, serum PTH (P<0.001), calcium (P<0.001), and phosphate levels (P<0.05) were also significantly lower in TM compared with the controls. In TM, serum ferritin of >2500 μg/L (OR, 5.3; 95% CI, 2.3-12.3; P<0.01), liver iron of >7 mg/g dry weight (OR, 8.8; 95% CI, 3.5-10.3; P<0.001), and serum alanine aminotransferase of >50 IU/L (OR, 9.7; 95% CI, 4.0-23.5; P<0.001) were independent risk factors for low 25-OHD levels.

Conclusions:

Our results suggest that TM had a 8-fold higher risk of 25-OHD insufficiency compared with the controls. This was likely to be associated with hepatic hemosiderosis.
Successful Haploidentical Stem Cell Transplant With Posttransplant Cyclophosphamide for Hemophagocytic Lymphohistiocytosis
Authors: Kohli Shruti , Rastogi Neha , Nivargi Sagar , Thakkar Dhwanee , Katewa Satyendra , Yadav Satya P.
Published: July 2018

Allogeneic hematopoietic stem cell transplant (HSCT) has been known to be a curative therapy for patients with hemophagocytic lymphohistiocytosis (HLH) but donor availability is an issue. Haploidentical HSCT with posttransplant cyclophosphamide (PTCy) has been investigated as a feasible option for various malignant and nonmalignant conditions with reduced incidence of acute graft versus host disease (GVHD) and graft rejection. However, its use has not been described in children with HLH and here we describe 2 boys who underwent successful haploidentical HSCT with PTCy. None had acute GVHD and 1 had limited chronic GVHD. Both are alive and disease-free at follow-up of 912 and 239 days, respectively. Haploidentical HSCT with PTCy is a feasible option for children with HLH lacking a matched sibling donor.
Longitudinal gait assessment in a stiff person syndrome
Authors: Schirinzi Tommaso , Sancesario Andrea , Romano Alberto , Favetta Martina , Gobbi Marina , Valeriani Massimiliano , Bertini Enrico S. , Castelli Enrico , Vasco Gessica , Petrarca Maurizio , Della Bella Gessica
Published: July 2018

Stiff person syndrome (SPS) is an autoimmune disorder with multiple clinical presentations, all characterized by generalized or focal muscular stiffness leading to abnormal postures and movements. To date, no standardized treatments are available; also, the outcome measures are mainly clinical based and unstandardized, limiting the reliability of clinical trials. In this case study, we used the eight-camera motion capture system for gait analysis (GA) to outline the gait features and track the clinical evolution of a young patient with SPS receiving a personalized multimodal therapy. GA was accurate in reflecting clinical changes over a 7-week-long period, thus representing a potential source for objective biomarkers in SPS. Therefore, future studies focusing on either the natural history or the treatment of SPS could adopt GA for reliable outocome measures, confirming this preliminary observation.
Exploring the Associations Between Patient Affect, Self-Care Actions, and Emergency Department Use for Community-Dwelling Adults
Authors: Tzeng Huey-Ming , Pierson James Marcus , Kang Yu , Barker Anne , Yin Chang-Yi
Published: July 2018

Background:

Nurses and other health care providers need to ensure that patients receive care that addresses their specific needs and wants.

Purpose:

This exploratory study examined the associations between patients' self-reported positive and negative affect, the perceived importance of 57 self-care actions, the desire and ability to perform them, and emergency department use in the past 3 months.

Methods:

A secondary analysis from a cross-sectional survey project that surveyed 250 community-dwelling adults living in the southern United States, 2015-2016. Independent t tests and the χ2 test were used.

Results:

Positive affect was associated with positive perceptions of self-care actions and having no emergency department visit. Patients with a more negative affect perceived finding and using services that support their health behaviors as being important and expressed a desire to participate in local health screening or wellness events.

Conclusions:

Patients' perceptions of their self-care actions could lead to better outcomes.
Sexual Harassment in the Work Place: Its Impact on Gynecologic Oncology and Women's Health
Authors: von Gruenigen Vivian E. , Karlan Beth Y.
Published: July 2018

(Abstracted from Gynecol Oncol 2018;149:227–229)

Sexual discrimination, harassment, abuse, and bullying occur in all industries and have for decades. In October of 2017, media and news outlets exposed prominent professionals in the entertainment industry and other settings who took advantage of their status of power and influence to engage in workplace sexual harassment and discrimination.
Minimizing the Risk of Perinatal Human Immunodeficiency Virus Transmission
Authors: Givens Matthew , Dotters-Katz Sarah K. , Stringer Elizabeth , Rahangdale Lisa , Kuller Jeffrey A.
Published: July 2018

Importance

There are approximately 284,500 adolescent and adult women living with human immunodeficiency virus (HIV) in the United States. It is estimated that approximately 8500 of these women give birth annually. While the rate of perinatal transmission in the United States has decreased by more than 90% since the early 1990s, potentially preventable HIV transmission events still occur and cause significant morbidity and mortality.

Objective

The aim of this review was to summarize the current data regarding perinatal HIV transmission timing and risk factors, current management recommendations, and implications of timing of transmission on patient management.

Evidence Acquisition

Literature review.

Results

This review reiterates that the risk of perinatal HIV transmission can be reduced to very low levels by following current recommendations for screening for HIV in all pregnant women and properly treating HIV-infected mothers, as well as using evidence-based labor management practices.

Conclusions and Relevance

Familiarity with the pathogenesis of HIV transmission is important for obstetric care providers to appropriately manage HIV-infected women in pregnancy, intrapartum, and the postpartum period.

Target Audience

Obstetricians and gynecologists, family physicians.

Learning Objectives

After completing this activity, the learner should be better able to (1) compare the various modes and risk factors for HIV transmission from mother to fetus, (2) assess current recommendations for HIV screening in pregnancy, and (3) to manage patients in the antepartum, intrapartum, and postpartum periods.
Fetal Major Cardiac Defects and Placental Dysfunction at 11–13 Weeks’ Gestation
Authors: Fantasia I. , Kasapoglu D. , Kasapoglu T. , Syngelaki A. , Akolekar R. , Nicolaides K. H.
Published: July 2018

(Abstracted from Ultrasound Obstet Gynecol 2018;51:194–198)

Major congenital heart defects (CHDs) are those that require invasive interventions within the first year following birth and are often associated with fetal growth restriction (FGR). A recent study on isolated major CHDs found evidence of impaired placental angiogenesis in the absence of impaired placental perfusion and function in pregnancies with fetal CHD.
Trends in Deaths Due to Syphilis, United States, 1968—2015
Authors: Peterman Thomas A. , Kidd Sarah E.
Published: July 2018

Background

Before penicillin, the syphilis case-fatality rate was 10% within 40 years. Late complications, such as cardiovascular syphilis, were still common in the 1950s but now seem quite rare even though some infections likely go undetected. We studied trends in syphilis mortality as an indicator of trends in severe complications of syphilis.

Methods

We assessed underlying cause of death from US death certificates for 1968 to 2015. We examined death trends by type of syphilis (cardiovascular, neuro, congenital, other). We compared trends in deaths with trends in primary and secondary syphilis from national STD surveillance data.

Results

During 1968 to 2015, there were 6498 deaths attributed to syphilis, 4149 males and 2349 females. Annual syphilis deaths decreased from 586 in 1968 to 94 in 1984, then leveled off to between 24 and 46 since 1998. Between 1968 and 2015, the decrease in annual cardiovascular syphilis deaths (from 338 to 3) exceeded the decrease in annual neurosyphilis deaths (from 191 to 33). Congenital syphilis deaths (which do not include stillbirths) generally decreased from 28 to 2 per year. An increase in primary and secondary syphilis among women in the late 1980s was accompanied by a 4-fold increase in congenital syphilis deaths (from 9 in 1986 to 35 in 1990), but there was no subsequent increase in syphilis deaths among women.

Conclusions

Adults now rarely die from syphilis. Increases in infections in the late 1980s did not lead to an increase in adult syphilis deaths. Congenital syphilis deaths still increase when syphilis increases among women.
Treatment of Acute Epididymitis: A Systematic Review and Discussion of the Implications for Treatment Based on Etiology
Authors: Louette Aaron , Krahn Jessica , Caine Vera , Ha Shalane , Lau Tim T. Y. , Singh Ameeta E.
Published: July 2018

A systematic review of studies completed in the last 11 years for the treatment of acute epididymitis identified 1534 records, of which 29 were assessed for eligibility, and only 1 study met the criteria for inclusion. This highlights the need for more prospective studies evaluating treatment regimens for acute epididymitis.
PRAME Expression in Melanocytic Tumors
Authors: Lezcano Cecilia , Jungbluth Achim A. , Nehal Kishwer S. , Hollmann Travis J. , Busam Klaus J.
Published: July 2018

PRAME (PReferentially expressed Antigen in MElanoma) is a melanoma-associated antigen that was isolated by autologous T cells in a melanoma patient. While frequent PRAME mRNA expression is well documented in cutaneous and ocular melanomas, little is known about PRAME protein expression in melanocytic tumors. In this study we examined the immunohistochemical expression of PRAME in 400 melanocytic tumors, including 155 primary and 100 metastatic melanomas, and 145 melanocytic nevi. Diffuse nuclear immunoreactivity for PRAME was found in 87% of metastatic and 83.2% of primary melanomas. Among melanoma subtypes, PRAME was diffusely expressed in 94.4% of acral melanomas, 92.5% of superficial spreading melanomas, 90% of nodular melanomas, 88.6% of lentigo maligna melanomas, and 35% of desmoplastic melanomas. When in situ and nondesmoplastic invasive melanoma components were present, PRAME expression was seen in both. Of the 140 cutaneous melanocytic nevi, 86.4% were completely negative for PRAME. Immunoreactivity for PRAME was seen, albeit usually only in a minor subpopulation of lesional melanocytes, in 13.6% of cutaneous nevi, including dysplastic nevi, common acquired nevi, traumatized/recurrent nevi, and Spitz nevi. Rare isolated junctional melanocytes with immunoreactivity for PRAME were also seen in solar lentigines and benign nonlesional skin. Our results suggest that immunohistochemical analysis for PRAME expression may be useful for diagnostic purposes to support a suspected diagnosis of melanoma. It may also be valuable for margin assessment of a known PRAME-positive melanoma, but its expression in nevi, solar lentigines, and benign nonlesional skin can represent a pitfall and merits further investigations to better assess the potential clinical utility of this marker.
Venoarterial Extracorporeal Membrane Oxygenation Versus Conventional Therapy in Severe Pediatric Septic Shock*
Authors: Oberender Felix , Ganeshalingham Anusha , Fortenberry James D. , Hobson Michael J. , Houmes Robert J. , Morris Kevin P. , Numa Andrew , Hoq Mohammad M. , Donath Susan , Beca John , Butt Warwick
Published: July 2018

Objectives:

The role of venoarterial extracorporeal membrane oxygenation in the treatment of severe pediatric septic shock continues to be intensely debated. Our objective was to determine whether the use of venoarterial extracorporeal membrane oxygenation in severe septic shock was associated with altered patient mortality, morbidity, and/or length of ICU and hospital stay when compared with conventional therapy.

Design:

International multicenter, retrospective cohort study using prospectively collected data of children admitted to intensive care with a diagnosis of severe septic shock between the years 2006 and 2014.

Setting:

Tertiary PICUs in Australia, New Zealand, Netherlands, United Kingdom, and United States.

Patients:

Children greater than 30 days old and less than 18 years old.

Interventions:

None.

Measurements and Main Results:

Of 2,452 children with a diagnosis of sepsis or septic shock, 164 patients met the inclusion criteria for severe septic shock. With conventional therapy (n = 120), survival to hospital discharge was 40%. With venoarterial extracorporeal membrane oxygenation (n = 44), survival was 50% (p = 0.25; CI, –0.3 to 0.1). In children who suffered an in-hospital cardiac arrest, survival to hospital discharge was 18% with conventional therapy and 42% with venoarterial extracorporeal membrane oxygenation (Δ = 24%; p = 0.02; CI, 2.5–42%). Survival was significantly higher in patients who received high extracorporeal membrane oxygenation flows of greater than 150 mL/kg/min compared with children who received standard extracorporeal membrane oxygenation flows or no extracorporeal membrane oxygenation (82%, 43%, and 48%; p = 0.03; CI, 0.1–0.7 and p < 0.01; CI, 0.2–0.7, respectively). Lengths of ICU and hospital stay were significantly longer for children who had venoarterial extracorporeal membrane oxygenation.

Conclusions:

The use of venoarterial extracorporeal membrane oxygenation in severe pediatric sepsis is not by itself associated with improved survival. However, venoarterial extracorporeal membrane oxygenation significantly reduces mortality after cardiac arrest due to septic shock. Venoarterial extracorporeal membrane oxygenation flows greater than 150 mL/kg/min are associated with almost twice the survival rate of conventional therapy or standard-flow extracorporeal membrane oxygenation.
Care Coordination in Emergency Departments for Children and Adolescents With Behavioral Health Conditions
Authors: Lynch Sean , Witt Whitney , Ali Mir M. , Teich Judith L. , Mutter Ryan , Gibbons Brent , Walsh Christine
Published: July 2018

Background

Increasing numbers of children are receiving care for behavioral health conditions in emergency departments (EDs). However, studies of mental health–related care coordination between EDs and primary and/or specialty care settings are limited. Such coordination is important because ED care alone may be insufficient for patients' behavioral health needs.

Methods

We analyzed claims during the year 2014 from Truven Health Analytics MarketScan Medicaid and Commercial databases for outpatient services and prescription drugs for youth 2 to 18 years old with continuous enrollment. We applied a standard care coordination measure to insurance claims data in order to examine whether youth received a primary care or specialty follow-up visit within 7 days following an ED visit with a psychiatric diagnosis. We calculated descriptive statistics to evaluate differences in care coordination by enrollees' demographic, insurance, and health-related characteristics. In addition, we constructed a multivariate logistic regression model to detect the factors associated with the receipt of care coordination.

Results

The total percentages of children who received care coordination were 45.8% (Medicaid) and 46.6% (private insurance). Regardless of insurance coverage type, children aged 10 to 14 years had increased odds of care coordination compared with youth aged 15 to 18 years. Children aged 2 to 5 years and males had decreased odds of care coordination.

Conclusions

It is of concern that fewer than half of patients received care coordination following an ED visit. Factors such as behavioral health workforce shortages, wait times for an appointment with a provider, and lack of reimbursement for care coordination may help explain these results.
A Pragmatic Study to Evaluate the Use of a Rapid Diagnostic Test to Detect Group A Streptococcal Pharyngitis in Children With the Aim of Reducing Antibiotic Use in a UK Emergency Department
Authors: Bird Chris , Winzor Gemma , Lemon Katherine , Moffat Alasdair , Newton Tina , Gray Jim
Published: July 2018

Objective

Sore throat is a common presentation to the children's emergency department (ED), and many patients are likely prescribed antibiotics unnecessarily. We aimed to reduce antibiotic prescribing for sore throat in our UK ED through use of an established scoring system combined with a rapid diagnostic test (RDT) to detect group A streptococcal (GAS) pharyngitis.

Methods

AB single-subject and diagnostic accuracy studies were used to measure both antibiotic prescribing rates over time and the performance of the McIsaac clinical score combined with RDT to screen for and treat GAS pharyngitis. All children between the age of 6 months and 16 years with symptoms of sore throat were eligible for inclusion. The study adhered to SQUIRE guidelines.

Results

During 2014 and 2016, antibiotic prescribing rates for 210 children at baseline (median age, 3 years) and 395 children during the intervention (median age, 2 years) were assessed. The baseline prescribing rate was 79%, whereas rates after intervention were 24% and 27%, respectively. The RDT had an acceptable false-negative rate of 7.9%, poor sensitivity of 64.3%, and a negative predictive value of 92.1% when compared with conventional throat culture. A McIsaac score of 3 or more had good sensitivity (92.11%) but very low specificity (12.62%) for predicting GAS infection.

Conclusions

Despite poor RDT sensitivity and the McIsaac score's poor specificity in children, their use in combination decreased antibiotic prescribing rates in a children's ED setting.
The Pediatric Disease Spectrum in an Emergency Department at a Tertiary Care Center in Beirut, Lebanon
Authors: El Zahran Tharwat , El Warea Mohammad , Bachir Rana , Hitti Eveline
Published: July 2018

Objective

The aim of this study was to identify the most common diagnoses for pediatric emergency department (ED) visits at a tertiary care center in Lebanon.

Methods

A retrospective chart review of pediatric patients (aged ≤18 years) presenting to the American University of Beirut Medical Center ED during 2010–2011 was completed. The common diagnoses among 5 age groups (<1, 1–4, 5–9, 10–14, and 15–18 years) in 3 categories (all pediatric ED visits, treat and release, admitted visits) were assessed. Diagnoses were classified according to the Clinical Classifications Software. Descriptive statistics and Pearson χ2 test were used.

Results

A total of 12,637 pediatric ED visits were included. The majority (90.2%) were among the treat-and-release group. The mean age for all patients was 7.2 years, 57.1% of whom were males. The top 5 most common diagnoses for all ED visits included fever of unknown origin, external injuries, upper respiratory tract infections, open wounds, and abdominal pain. Cardiac conditions were the most common reason for admission in children younger than 1 year, intestinal infection among 1 to 4 years old, pneumonia among 5 to 9 years old, and appendicitis among 10 to 14 and 15 to 18 years. Seasonal analysis showed fever of unknown origin to be the most common diagnosis across all seasons.

Conclusions

This study is the first to assess pediatric ED visits in a Lebanese setting. The top most common reason was communicable diseases, with fever of unknown origin being the most common reason for all visits, contrary to North America where injury and poisoning are the most common. Noncommunicable diseases (cardiac, pneumonia, gastroenteritis, and appendicitis) were common reasons for admission in different age groups.
Decreased Risk of Delirium With Use of Regional Analgesia in Geriatric Trauma Patients With Multiple Rib Fractures
Authors: O’Connell Kathleen M. , Quistberg D. Alex , Tessler Robert , Robinson Bryce R. H. , Cuschieri Joseph , Maier Ronald V. , Rivara Frederick P. , Vavilala Monica S. , Bhalla Paul I. , Arbabi Saman
Published: July 2018

Objective:

The aim of this study was to examine the risk of delirium in geriatric trauma patients with rib fractures treated with systemic opioids compared with those treated with regional analgesia (RA).

Summary of Background Data:

Delirium is a modifiable complication associated with increased morbidity and mortality. RA may reduce the need for opioid medications, which are associated with delirium in older adults.

Methods:

Cohort study of patients ≥65 years admitted to a regional trauma center from 2011 to 2016. Inclusion factors were ≥ 3 rib fractures, blunt trauma mechanism, and admission to intensive care unit (ICU). Exclusion criteria included head AIS ≥3, spine AIS ≥3, dementia, and death within 24 hours. The primary outcome was delirium positive ICU days, defined using the CAM-ICU assessment. Delirium incident rate ratios (IRRs) and 95% confidence intervals (95% CIs) were estimated using generalized linear mixed models with Poisson distribution and robust standard errors.

Results:

Of the 144 patients included in the study, 27 (19%) received Acute Pain Service consultation and RA and 117 (81%) received opioid-based systemic analgesia. Patients with RA had more severe chest injury than those without. The risk of delirium decreased by 24% per day per patient with use of RA (IRR 0.76, 95% CI 0.61 to 0.96). Individual opioid use, as measured in daily morphine equivalents (MEDs), was significantly reduced after initiation of RA (mean difference −7.62, 95% CI −14.4 to −0.81).

Conclusion:

Although use of RA techniques in geriatric trauma patients with multiple rib fractures was associated with higher MED, opioid use decreased after RA initiation and Acute Pain Service consultation, and the risk of delirium was lower.
Patterns of Initial Opioid Prescribing to Opioid-Naive Patients
Authors: Larach Daniel B. , Waljee Jennifer F. , Hu Hsou-Mei , Lee Jay S. , Nalliah Romesh , Englesbe Michael J. , Brummett Chad M.
Published: July 2018

Objective:

To determine the proportion of initial opioid prescriptions for opioid-naive patients prescribed by surgeons, dentists, and emergency physicians. We hypothesized that the percentage of such prescriptions grew as scrutiny of primary care and pain medicine opioid prescribing increased and guidelines were developed.

Summary of Background Data:

Data regarding the types of care for which opioid-naive patients are provided initial opioid prescriptions are limited.

Methods:

A retrospective cross-sectional study using a nationwide insurance claims dataset to study US adults aged 18 to 64 years. Our primary outcome was a change in opioid prescription share for opioid-naive patients undergoing surgical, emergency, and dental care from 2010 to 2016; we also examined the type and amounts of opioid filled.

Results:

From 87,941,718 analyzed lives, we identified 16,292,018 opioid prescriptions filled by opioid-naive patients. The proportion of prescriptions for patients receiving surgery, emergency, and dental care increased by 15.8% from 2010 to 2016 (P < 0.001), with the greatest increases related to surgical (18.1%) and dental (67.8%) prescribing. In 2016, surgery patients filled 22.0% of initial prescriptions, emergency medicine patients 13.0%, and dental patients 4.2%. Surgical patients’ mean total oral morphine equivalents per prescription increased from 240 mg (SD 509) in 2010 to 403 mg (SD 1369) in 2016 (P < 0.001). Over the study period, surgical patients received the highest proportion of potent opioids (90.2% received hydrocodone or oxycodone).

Conclusions:

Initial opioid prescribing attributable to surgical and dental care is increasing relative to primary and chronic pain care. Evidence-based guideline development for surgical and dental prescribing is warranted in order to curb iatrogenic opioid morbidity and mortality.
The Accuracy of Low-dose Computed Tomography Protocol in Patients With Suspected Acute Appendicitis
Authors: Sippola Suvi , Virtanen Johanna , Tammilehto Ville , Grönroos Juha , Hurme Saija , Niiniviita Hannele , Lietzen Elina , Salminen Paulina
Published: July 2018

Objective:

To compare diagnostic accuracy of contrast enhanced low-dose computed tomography (CT) accomplished in the OPTICAP trial phantom phase to standard CT in patients with suspected acute appendicitis.

Background:

Increasing use of CT as the gold standard in diagnosing acute appendicitis has raised concerns regarding radiation exposure. Unenhanced low-dose CT protocols have shown similar diagnostic accuracy with standard CT for diagnosing appendicitis. To our knowledge, there are no other trials in which the same patient with suspected acute appendicitis underwent both standard and low-dose CT allowing interpatient comparison.

Methods:

OPTICAP is an interpatient protocol sequence randomized noninferiority single-center trial performed at Turku University Hospital between November, 2015 and August, 2016. Sixty patients with suspected acute appendicitis and body mass index <30 kg/m2 were enrolled to undergo both standard and low-dose contrast enhanced CT scans, which were categorized as normal, uncomplicated or complicated appendicitis by 2 radiologists in blinded manner. All patients with CT confirmed appendicitis underwent appendectomy to obtain histopathology.

Results:

The low-dose protocol was not inferior to standard protocol in terms of diagnostic accuracy; 79% [95% confidence interval (CI) 66%–89%) accurate diagnosis in low-dose and 80% (95% CI 67%–90%) in standard CT by primary radiologist. Accuracy to categorize appendicitis severity was 79% for both protocols. The mean radiation dose of low-dose CT was significantly lower compared with standard CT (3.33 and 4.44 mSv, respectively).

Conclusion:

Diagnostic accuracy of contrast enhanced low-dose CT was not inferior to standard CT in diagnosing acute appendicitis or distinguishing between uncomplicated and complicated acute appendicitis in patients with a high likelihood of acute appendicitis. Low-dose CT enabled significant radiation dose reduction.
Importance of the coronary circulation for cardiac and metabolic performance in rainbow trout (Oncorhynchus mykiss)
Authors: Ekström Andreas , Axelsson Michael , Gräns Albin , Brijs Jeroen , Sandblom Erik
Published: July 2018

Cardiac oxygenation is achieved via both coronary arterial and luminal venous oxygen supply routes in many fish species. However, the relative importance of these supplies for cardiac and aerobic metabolic performance is not fully understood. Here, we investigated how coronary artery ligation in rainbow trout (Oncorhynchus mykiss), implanted with heart rate loggers, affected cardiorespiratory performancein vivo. While coronary ligation significantly elevated resting heart rate, the standard metabolic rate was unchanged compared to sham-treated controls. However, coronary ligation reduced the maximum metabolic rate while heart rate remained unchanged following enforced exercise. Thus, coronary ligation reduced metabolic and heart rate scopes by 29% and 74%, respectively. Our findings highlight the importance of coronary oxygen supply for overall cardiorespiratory performance in salmonid fish, and suggest that pathological conditions that impair coronary flow (e.g. coronary arteriosclerosis) constrain the ability of fish to cope with metabolically demanding challenges such as spawning migrations and environmental warming.
Precipitation is the main factor affecting the variation of foliar nitrogen isotope composition in two leguminous shrub species of northwestern China
Authors: Ma Fei , Xu Ting-Ting , Li Ming , Liu Ji-Li , Sun Zhao-Jun
Published: July 2018

An increase in foliar nitrogen isotope composition (δ
15
N) with decreasing precipitation has been shown to occur widely in non-N
2
-fixing plant species. However, similar patterns have not been identified in N
2
-fixing species. Here, we tested the relationships of foliar δ
15
N with local environmental factors and leaf properties in two leguminous shrub species (
Caragana korshinskii
and
Caragana liouana
) sampled from 30 populations. Results indicated that the mean annual precipitation (MAP) primarily accounted for the variation of foliar δ
15
N in the two species. Further analysis revealed strong negative correlations between foliar δ
15
N and MAP within and across species. These results suggest that the foliar δ
15
N of leguminous shrub species also shift along precipitation gradients, which augments our understanding of the relationships between foliar δ
15
N and climatic factors.
Systems protobiology: origin of life in lipid catalytic networks
Authors: Lancet Doron , Zidovetzki Raphael , Markovitch Omer
Published: July 2018

Life is that which replicates and evolves, but there is no consensus on how life emerged. We advocate a systems protobiology view, whereby the first replicators were assemblies of spontaneously accreting, heterogeneous and mostly non-canonical amphiphiles. This view is substantiated by rigorous chemical kinetics simulations of the graded autocatalysis replication domain (GARD) model, based on the notion that the replication or reproduction of compositional information predated that of sequence information. GARD reveals the emergence of privileged non-equilibrium assemblies (composomes), which portray catalysis-based homeostatic (concentration-preserving) growth. Such a process, along with occasional assembly fission, embodies cell-like reproduction. GARD pre-RNA evolution is evidenced in the selection of different composomes within a sparse fitness landscape, in response to environmental chemical changes. These observations refute claims that GARD assemblies (or other mutually catalytic networks in the metabolism first scenario) cannot evolve. Composomes represent both a genotype and a selectable phenotype, anteceding present-day biology in which the two are mostly separated. Detailed GARD analyses show attractor-like transitions from random assemblies to self-organized composomes, with negative entropy change, thus establishing composomes as dissipative systems—hallmarks of life. We show a preliminary new version of our model, metabolic GARD (M-GARD), in which lipid covalent modifications are orchestrated by non-enzymatic lipid catalysts, themselves compositionally reproduced. M-GARD fills the gap of the lack of true metabolism in basic GARD, and is rewardingly supported by a published experimental instance of a lipid-based mutually catalytic network. Anticipating near-future far-reaching progress of molecular dynamics, M-GARD is slated to quantitatively depict elaborate protocells, with orchestrated reproduction of both lipid bilayer and lumenal content. Finally, a GARD analysis in a whole-planet context offers the potential for estimating the probability of life's emergence. The invigorated GARD scrutiny presented in this review enhances the validity of autocatalytic sets as abona fideearly evolution scenario and provides essential infrastructure for a paradigm shift towards a systems protobiology view of life's origin.
A centriolar FGR1 oncogene partner-like protein required for paraflagellar rod assembly, but not axoneme assembly in African trypanosomes
Authors: Harmer Jane , Towers Katie , Addison Max , Vaughan Sue , Ginger Michael L. , McKean Paul G.
Published: July 2018

Proteins of the FGR1 oncogene partner (or FOP) family are found at microtubule organizing centres (MTOCs) including, in flagellate eukaryotes, the centriole or flagellar basal body from which the axoneme extends. We report conservation of FOP family proteins,
Tb
FOPL and
Tb
OFD1, in the evolutionarily divergent sleeping sickness parasite
Trypanosoma brucei
, showing (in contrast with mammalian cells, where FOP is essential for flagellum assembly) depletion of a trypanosome FOP homologue,
Tb
FOPL, affects neither axoneme nor flagellum elongation. Instead,
Tb
FOPL depletion causes catastrophic failure in assembly of a lineage-specific, extra-axonemal structure, the paraflagellar rod (PFR). That depletion of centriolar
Tb
FOPL causes failure in PFR assembly is surprising because PFR nucleation commences approximately 2 µm distal from the basal body. When over-expressed with a C-terminal myc-epitope,
Tb
FOPL was also observed at mitotic spindle poles. Little is known about bi-polar spindle assembly during closed trypanosome mitosis, but indication of a possible additional MTOC function for
Tb
FOPL parallels MTOC localization of FOP-like protein TONNEAU1 in acentriolar plants. More generally, our functional analysis of
Tb
FOPL emphasizes significant differences in evolutionary cell biology trajectories of FOP-family proteins. We discuss how at the molecular level FOP homologues may contribute to flagellum assembly and function in diverse flagellates.
Somatic ERK activation during transit amplification is essential for maintaining the synchrony of germline divisions in
Drosophila
testis
Authors: Gupta Samir , Varshney Bhavana , Chatterjee Shambhabi , Ray Krishanu
Published: July 2018

Transit amplification (TA) of progenitor cells maintains tissue homeostasis by balancing proliferation and differentiation. In
Drosophila
testis, the germline proliferation is tightly regulated by factors present in both the germline and the neighbouring somatic cyst cells (SCCs). Although the exact mechanism is unclear, the epidermal growth factor receptor (EGFR) activation in SCCs has been reported to control spermatogonial divisions within a cyst, through downstream activations of Rac1-dependent pathways. Here, we report that somatic activation of the mitogen-activated protein kinase (Rolled/ERK) downstream of EGFR is required to synchronize the mitotic divisions and regulate the transition to meiosis. The process operates independently of the Bag-of-marble activity in the germline. Also, the integrity of the somatic cyst enclosure is inessential for this purpose. Together, these results suggest that synchronization of germ-cell divisions through somatic activation of distinct ERK-downstream targets independently regulates TA and subsequent differentiation of neighbouring germline cells.
Loss of
runx1
function results in B cell immunodeficiency but not T cell in adult zebrafish
Authors: Chi Yali , Huang Zhibin , Chen Qi , Xiong Xiaojie , Chen Kemin , Xu Jin , Zhang Yiyue , Zhang Wenqing
Published: July 2018

Transcription factor RUNX1 holds an integral role in multiple-lineage haematopoiesis and is implicated as a cofactor in V(D)J rearrangements during lymphocyte development.
Runx1
deficiencies resulted in immaturity and reduction of lymphocytes in mice. In this study, we found that

runx1
W84X/W84X

mutation led to the reduction and disordering of B cells, as well as the failure of V(D)J rearrangements in B cells but not T cells, resulting in antibody-inadequate-mediated immunodeficiency in adult zebrafish. By contrast, T cell development was not affected. The decreased number of B cells mainly results from excessive apoptosis in immature B cells. Disrupted B cell development results in

runx1
W84X/W84X

mutants displaying a similar phenotype to common variable immunodeficiency—a primary immunodeficiency disease primarily characterized by frequent susceptibility to infection and deficient immune response, with marked reduction of antibody production of IgG, IgA and/or IgM. Our studies demonstrated an evolutionarily conserved function of
runx1
in maturation and differentiation of B cells in adult zebrafish, which will serve as a valuable model for the study of immune deficiency diseases and their treatments.