bluuebunny/crossref_metadata_2025 huggingface dataset:
Risk Factors for Persistent Cognitive Impairment After Critical Illness, Nested Case-Control Study
Authors: Sakusic Amra , Gajic Ognjen , Singh Tarun D. , O’Horo John C. , Jenkins Gregory , Wilson Gregory A. , Petersen Ronald , Fryer John D. , Kashyap Rahul , Rabinstein Alejandro A.
Published: October 2018

Objectives:

Persistent cognitive impairment after critical illness is an important healthcare problem forecasted to worsen in the near future. However, the epidemiology is insufficiently explored. We aimed to determine potentially modifiable risk factors during ICU hospitalization that play a significant role in developing persistent cognitive impairment.

Design:

An observational case-control study.

Settings:

Mayo Clinic ICUs between July 1, 2004, and November 20, 2015.

Patients:

We conducted a study nested in a large cohort of 98,227 adult critically ill patients. Using previously validated computable phenotypes for dementia and cognitive impairment, we determined the onset of cognitive impairment relative to ICU hospitalization and associated risk factors. The primary endpoint of the study was new and persistent cognitive impairment documented between 3 and 24 months after ICU discharge.

Interventions:

Unadjusted and adjusted analyses were performed to identify potentially modifiable risk factors during ICU hospitalization.

Measurements and Main Results:

Among 21,923 unique patients identified as cognitively impaired (22% of the entire ICU cohort), 2,428 (2.5%) developed incident new and persistent cognitive dysfunction after the index ICU admission. Compared with age- and sex-matched ICU controls (2,401 pairs), cases had higher chronic illness burden (Charlson Comorbidity Index, 6.2 vs 5.1; p < 0.01), and were more likely to have multiple ICU stays (22% vs 14%; p < 0.01). After adjustment for baseline differences, new and persistent cognitive dysfunction was associated with higher frequency of acute brain failure in the ICU, a higher exposure to severe hypotension, hypoxemia, hyperthermia, fluctuations in serum glucose, and treatment with quinolones or vancomycin. Association with sepsis observed in univariate analysis did not persist after adjustment.

Conclusions:

Cognitive dysfunction is highly prevalent in ICU patients. Incident new and persistent cognitive impairment is less common but important, potentially preventable problem after critical illness. Chronic comorbidities and number of ICU stays increase the risk of post-ICU cognitive dysfunction irrespective of age. Modifiable ICU exposures were identified as potential targets for future prevention trials.
Opioid Use After ICU Admission Among Elderly Chronic Opioid Users in Ontario: A Population-Based Cohort Study
Authors: Wang Han Ting , Hill Andrea D. , Gomes Tara , Wijeysundera Duminda N. , Pinto Ruxandra , Scales Damon C. , Fowler Robert , Wunsch Hannah
Published: October 2018

Objectives:

Critical illness is often associated with painful procedures and prolonged opioid infusions, raising the concern that chronic opioid users may be exposed to escalating doses that are continued after hospital discharge. We sought to assess patterns of opioid use after intensive care among elderly patients identified as chronic opioid users prior to hospitalization.

Design:

Population-based cohort study.

Setting:

All adult ICUs in the province of Ontario, Canada.

Participants:

Elderly patients (> 65 yr) admitted to ICUs between April 2002 and March 2015 who also survived to day 180 after hospital discharge, identified as chronic opioid users prior to hospitalization.

Exposure:

Chronic opioid use in the year before hospital admission, as well as a filled opioid prescription with a duration covering the day of hospital admission.

Measurements and Main Results:

The primary outcome was the proportion of patients who filled an opioid prescription with a duration covering day 180 after hospital discharge; secondary outcome was the difference in morphine equivalent daily dosage at day 180 after discharge compared with the amount prescribed prior to hospital admission. Of 496,985 elderly admissions to ICUs, 19,584 (3.9%) were chronic opioid users before hospitalization who also survived to day 180 after hospital discharge. The median daily dose of opioid prescriptions filled before hospital admission was 32.1 mg morphine equivalent (interquartile range, 17.5–75.0 mg morphine equivalent). Among these survivors, 63.3% had at least one opioid prescription filled with a duration covering day 180; 22.0% had filled prescriptions for a higher daily morphine equivalent dose compared with prehospitalization, 19.8% were unchanged, 21.5% had a lower dose, and 36.7% had no prescription filled. The majority of reduction was in prescriptions for codeine and oxycodone.

Conclusions:

Among chronic opioid users, hospitalization with critical illness was not associated with substantial increases in opioids prescribed in the 6 months following hospitalization.
Long-Term Mortality and Hospital Resource Use in ICU Patients With Alcohol-Related Liver Disease*
Authors: Lone Nazir I. , Lee Robert , Walsh Timothy S.
Published: October 2018

Objectives:

Data describing long-term outcomes following ICU for patients with alcohol-related liver disease are scarce. We aimed to report long-term mortality and emergency hospital resource use for patients with alcohol-related liver disease and compare this with two comparator cohorts.

Design:

Retrospective cohort study linking population registry data.

Setting:

All adult general Scottish ICUs (2005–2010) serving 5 million population.

Patients:

ICU patients with alcohol-related liver disease were compared with an unmatched cohort with Acute Physiology and Chronic Health Evaluation defined diagnoses of severe cardiovascular, respiratory, or renal comorbidity and a matched general ICU cohort.

Interventions:

None.

Measurements and Main Results:

Outcomes were 5-year mortality, emergency hospital resource use, and emergency hospital readmission. Multivariable regression was used to identify risk factors and adjust for confounders. Of 47,779 ICU admissions, 2,463 patients with alcohol-related liver disease and 3,590 patients with severe comorbidities were identified; 2,391(97.1%) were matched to a general ICU cohort. The alcohol-related liver disease cohort had greater 5-year mortality than comorbid (79.2% vs 75.3%; p < 0.001) and matched general (79.8% vs 63.3%; p < 0.001) cohorts. High liver Sequential Organ Failure Assessment score and three-organ support were associated with 90% 5-year mortality in alcohol-related liver disease patients. After confounder adjustment, alcohol-related liver disease patients had 31% higher hazard of death (adjusted hazard ratio, 1.31; 95% CI, 1.17–1.47; p < 0.001) and used greater resource than the severe comorbid comparator group. Findings were similar compared with the matched cohort.

Conclusions:

ICU patients with alcohol-related liver disease have higher 5-year mortality and emergency readmission rates than ICU patients with other severe comorbidities and matched general ICU patients. These data can contribute to shared decision-making for alcohol-related liver disease patients.
Extracorporeal CO2 Removal: The Minimally Invasive Approach, Theory, and Practice*
Authors: Duscio Eleonora , Cipulli Francesco , Vasques Francesco , Collino Francesca , Rapetti Francesca , Romitti Federica , Behnemann Tim , Niewenhuys Julia , Tonetti Tommaso , Pasticci Iacopo , Vassalli Francesco , Reupke Verena , Moerer Onnen , Quintel Michael , Gattinoni Luciano
Published: October 2018

Objectives:

Minimally invasive extracorporeal CO2 removal is an accepted supportive treatment in chronic obstructive pulmonary disease patients. Conversely, the potential of such technique in treating acute respiratory distress syndrome patients remains to be investigated. The aim of this study was: 1) to quantify membrane lung CO2 removal (Vco
2ML) under different conditions and 2) to quantify the natural lung CO2 removal (Vco
2NL) and to what extent mechanical ventilation can be reduced while maintaining total expired CO2 (Vco
2tot = Vco
2ML + Vco
2NL) and arterial Pco
2 constant.

Design:

Experimental animal study.

Setting:

Department of Experimental Animal Medicine, University of Göttingen, Germany.

Subjects:

Eight healthy pigs (57.7 ± 5 kg).

Interventions:

The animals were sedated, ventilated, and connected to the artificial lung system (surface 1.8 m2, polymethylpentene membrane, filling volume 125 mL) through a 13F catheter. Vco
2ML was measured under different combinations of inflow Pco
2 (38.9 ± 3.3, 65 ± 5.7, and 89.9 ± 12.9 mm Hg), extracorporeal blood flow (100, 200, 300, and 400 mL/min), and gas flow (4, 6, and 12 L/min). At each setting, we measured Vco
2ML, Vco
2NL, lung mechanics, and blood gases.

Measurements and Main Results:

Vco
2ML increased linearly with extracorporeal blood flow and inflow Pco
2 but was not affected by gas flow. The outflow Pco
2 was similar regardless of inflow Pco
2 and extracorporeal blood flow, suggesting that Vco
2ML was maximally exploited in each experimental condition. Mechanical ventilation could be reduced by up to 80–90% while maintaining a constant Paco
2.

Conclusions:

Minimally invasive extracorporeal CO2 removal removes a relevant amount of CO2 thus allowing mechanical ventilation to be significantly reduced depending on extracorporeal blood flow and inflow Pco
2. Extracorporeal CO2 removal may provide the physiologic prerequisites for controlling ventilator-induced lung injury.
Impact of Mean Arterial Pressure Fluctuation on Mortality in Critically Ill Patients
Authors: Gao Ya , Wang Qinfen , Li Jiamei , Zhang Jingjing , Li Ruohan , Sun Lu , Guo Qi , Xia Yong , Fang Bangjiang , Wang Gang
Published: October 2018

Objective:

The purpose of this study was to investigate the association between mean arterial pressure fluctuations and mortality in critically ill patients admitted to the ICU.

Design:

Retrospective cohort.

Setting:

All adult ICUs at a tertiary care hospital.

Patients:

All adult patients with complete mean arterial pressure records were selected for analysis in the Multiparameter Intelligent Monitoring in Intensive Care II database. Patients in the external cohort were newly recruited adult patients in the Medical Information Mart for Intensive Care III database.

Interventions:

None.

Measurements and Main Results:

The records of 8,242 patients were extracted. Mean arterial pressure fluctuation was calculated as follows: (mean nighttime mean arterial pressure – mean daytime mean arterial pressure)/mean arterial pressure. Patients were divided into two groups according to the degree of mean arterial pressure fluctuation: group A (between –5% and 5%) and group B (<–5% and >5%). The endpoints of this study were ICU and hospital mortality. Patients in group A (n = 4,793) had higher ICU and hospital mortality than those in group B (n = 3,449; 11.1% vs 8.1%, p < 0.001 and 13.8% vs 10.1%, p < 0.001, respectively). After adjusting for other covariates, the mean arterial pressure fluctuations between –5% and 5% were significantly correlated with ICU mortality (odds ratio, 1.296; 95% CI, 1.103–1.521; p = 0.002) and hospital mortality (odds ratio, 1.323; 95% CI, 1.142–1.531; p < 0.001). This relationship remained remarkable in patients with low or high Sequential Organ Failure Assessment scores in the sensitive analysis. Furthermore, external validation on a total of 4,502 individuals revealed that patients in group A still had significantly higher ICU (p < 0.001) and hospital mortality (p < 0.001) than those in group B.

Conclusions:

The reduced mean arterial pressure fluctuation (within –5% and 5%) may be associated with ICU and hospital mortality in critically ill patients.
Estimating the False Positive Rate of Absent Somatosensory Evoked Potentials in Cardiac Arrest Prognostication
Authors: Amorim Edilberto , Ghassemi Mohammad M. , Lee Jong W. , Greer David M. , Kaplan Peter W. , Cole Andrew J. , Cash Sydney S. , Bianchi Matthew T. , Westover M. Brandon
Published: October 2018

Objectives:

Absence of somatosensory evoked potentials is considered a nearly perfect predictor of poor outcome after cardiac arrest. However, reports of good outcomes despite absent somatosensory evoked potentials and high rates of withdrawal of life-sustaining therapies have raised concerns that estimates of the prognostic value of absent somatosensory evoked potentials may be biased by self-fulfilling prophecies. We aimed to develop an unbiased estimate of the false positive rate of absent somatosensory evoked potentials as a predictor of poor outcome after cardiac arrest.

Data Sources:

PubMed.

Study Selection:

We selected 35 studies in cardiac arrest prognostication that reported somatosensory evoked potentials.

Data Extraction:

In each study, we identified rates of withdrawal of life-sustaining therapies and good outcomes despite absent somatosensory evoked potentials. We appraised studies for potential biases using the Quality in Prognosis Studies tool. Using these data, we developed a statistical model to estimate the false positive rate of absent somatosensory evoked potentials adjusted for withdrawal of life-sustaining therapies rate.

Data Synthesis:

Two-thousand one-hundred thirty-three subjects underwent somatosensory evoked potential testing. Five-hundred ninety-four had absent somatosensory evoked potentials; of these, 14 had good functional outcomes. The rate of withdrawal of life-sustaining therapies for subjects with absent somatosensory evoked potential could be estimated in 14 of the 35 studies (mean 80%, median 100%). The false positive rate for absent somatosensory evoked potential in predicting poor neurologic outcome, adjusted for a withdrawal of life-sustaining therapies rate of 80%, is 7.7% (95% CI, 4–13%).

Conclusions:

Absent cortical somatosensory evoked potentials do not infallibly predict poor outcome in patients with coma following cardiac arrest. The chances of survival in subjects with absent somatosensory evoked potentials, though low, may be substantially higher than generally believed.
A Comparison of Mortality From Sepsis in Brazil and England: The Impact of Heterogeneity in General and Sepsis-Specific Patient Characteristics*
Authors: Ranzani Otavio T. , Shankar-Hari Manu , Harrison David A. , Rabello Lígia S. , Salluh Jorge I. F. , Rowan Kathryn M. , Soares Marcio
Published: October 2018

Objectives:

To test whether differences in both general and sepsis-specific patient characteristics explain the observed differences in sepsis mortality between countries, using two national critical care (ICU) databases.

Design:

Cohort study.

Setting:

We analyzed 62 and 164 ICUs in Brazil and England, respectively.

Patients:

Twenty-two–thousand four-hundred twenty-six adult ICU admissions from January 2013 to December 2013.

Interventions:

None.

Measurements and Main Results:

After harmonizing relevant variables, we merged the first ICU episode of adult medical admissions from Brazil (ORganizational CHaractEeriSTics in cRitical cAre study) and England (Intensive Care National Audit & Research Centre Case Mix Programme). Sepsis-3 definition was used, and the primary outcome was hospital mortality. We used multilevel logistic regression models to evaluate the impact of country (Brazil vs England) on mortality, after adjustment for general (age, sex, comorbidities, functional status, admission source, time to admission) and sepsis-specific (site of infection, organ dysfunction type and number) patient characteristics. Of medical ICU admissions, 13.2% (4,505/34,150) in Brazil and 30.7% (17,921/58,316) in England met the sepsis definition. The Brazil cohort was older, had greater prevalence of severe comorbidities and dependency compared with England. Respiratory was the most common infection site in both countries. The most common organ dysfunction was cardiovascular in Brazil (41.2%) and respiratory in England (85.8%). Crude hospital mortality was similar (Brazil 41.4% vs England 39.3%; odds ratio, 1.12 [0.98–1.30]). After adjusting for general patient characteristics, there was an important change in the point-estimate of the odds ratio (0.88 [0.75–1.02]). However, after adjusting for sepsis-specific patient characteristics, the direction of effect reversed again with Brazil having higher risk-adjusted mortality (odds ratio, 1.22 [1.05–1.43]).

Conclusions:

Patients with sepsis admitted to ICUs in Brazil and England have important differences in general and sepsis-specific characteristics, from source of admission to organ dysfunctions. We show that comparing crude mortality from sepsis patients admitted to the ICU between countries, as currently performed, is not reliable and that the adjustment for both general and sepsis-specific patient characteristics is essential for valid international comparisons of mortality amongst sepsis patients admitted to critical care units.
Early Enteral Nutrition Reduces Mortality and Improves Other Key Outcomes in Patients With Major Burn Injury: A Meta-Analysis of Randomized Controlled Trials*
Authors: Pu Hong , Doig Gordon S. , Heighes Philippa T. , Allingstrup Matilde J.
Published: October 2018

Objectives:

To identify, appraise, and synthesize current evidence to determine whether early enteral nutrition alters patient outcomes from major burn injury.

Data Sources:

Medline, Embase, and the China National Knowledge Infrastructure were searched. The close out date was May 1, 2018.

Study Selection:

Early enteral nutrition was defined as a standard formula commenced within 24 hours of injury or admission to ICU or burn unit. Comparators included any form of nutrition support “except” early enteral nutrition. Only randomized controlled trials reporting patient-centered outcomes were eligible for inclusion.

Data Extraction:

The primary outcome was mortality. Gastrointestinal hemorrhage, sepsis, pneumonia, renal failure, and hospital stay were evaluated as secondary outcomes.

Data Synthesis:

Nine-hundred fifty-eight full-text articles were retrieved and screened. Seven randomized controlled trials enrolling 527 participants with major burn injury were included. Compared with all other types of nutrition support, early enteral nutrition significantly reduced mortality (odds ratio, 0.36; 95% CI, 0.18–0.72; p = 0.003; I
2 = 0%). Early enteral nutrition also significantly reduced gastrointestinal hemorrhage (odds ratio, 0.21; 95% CI, 0.09–0.51; p = 0.0005; I
2 = 0%), sepsis (odds ratio, 0.23; 95% CI, 0.11–0.48; p < 0.0001; I
2 = 0%), pneumonia (odds ratio, 0.41; 95% CI, 0.21–0.81; p = 0.01; I
2 = 63%), renal failure (odds ratio, 0.27; 95% CI, 0.09–0.82; p = 0.02; I
2 = 32%), and duration of hospital stay (–15.31 d; 95% CI, –20.43 to –10.20; p < 0.00001; I
2 = 0%).

Conclusions:

The improvements in clinical outcomes demonstrated in this meta-analysis are consistent with the physiologic rationale cited to support clinical recommendations for early enteral nutrition made by major clinical practice guidelines: gut integrity is preserved leading to fewer gastrointestinal hemorrhages, less infectious complications, a reduction in consequent organ failures, and a reduction in the onset of sepsis. The cumulative benefit of these effects improves patient survival and reduces hospital length of stay.
Overview of Link Between Inflammatory Bowel Disease and Cardiovascular Disease
Authors: Nevulis Matthew G. , Baker Colby , Lebovics Edward , Frishman William H.
Published: October 2018

Inflammation has been shown to play an increasingly important role in the pathogenesis of atherosclerosis and in precipitating thrombotic events. Inflammatory bowel disease (IBD) is a systemic inflammatory disorder with a wide range of extraintestinal manifestations including a clinically significant increase in the risk of venous thromboembolism compared to matched controls in several studies. The data for the association between IBD and ischemic heart disease are less clear; multiple population-based studies have shown both positive and negative associations between the 2 conditions. While the systemic inflammation should theoretically increase the risk for cardiovascular disease, inflammatory bowel also potentially provides a cardioprotective effect in several ways. Patients with IBD typically enter the healthcare system at an earlier age and experience a lower incidence of obesity, hypercholesterolemia, and hyperlipidemia. Given the complex interplay among the proatherogenic, prothrombogenic, and cardioprotective effects, IBD should be taken into consideration as a nontraditional risk factor for cardiovascular disease in specific subsets of patients.
Microablative fractional CO2 laser for the genitourinary syndrome of menopause: up to 12-month results
Authors: Athanasiou Stavros , Pitsouni Eleni , Grigoriadis Themos , Zacharakis Dimitris , Falagas Matthew E. , Salvatore Stefano , Protopapas Athanasios , Loutradis Dimitris
Published: October 2018

Objective:

The aim of this study is to assess the efficacy of microablative fractional CO2 laser therapy for genitourinary syndrome of menopause (GSM) management, when three, four, or five laser therapies were applied in a follow-up period of 12 months.

Methods:

Retrospective study evaluating GSM symptoms at baseline, and 1, 3, 6, and 12 months after last laser therapy. Visual analog scale, International Consultation on Incontinence Questionnaires- Female Urinary Tract Symptoms, International Consultation on Incontinence Questionnaires-Urinary Incontinence Short Form, Urogenital Distress Inventory-6, and Female Sexual Function Index were used for assessment of GSM symptoms’ intensity or bothering and parameters of sexual function.

Results:

Overall, 94 women were included (35, 35, and 24 received three, four, and five therapies, respectively). All GSM symptoms improved statistically significantly. Intensity of dyspareunia and dryness decreased from 9 (5-10) (median [minimum-maximum]) and 8 (0-10) at baseline to 0 (0-6) and 0 (0-8), 1 month after last laser therapy (all P < 0.001), respectively. FSFI and frequency of sexual intercourse increased from 10.8 (2-26.9) and 1 (0-8) at baseline to 27.8 (15.2-35.4) and 4 (2-8) 1 month after last laser therapy (all P < 0.001), respectively. The positive laser effect remained unchanged throughout the 12 months of follow-up. The same pattern was followed for symptom-free rates. Four or five laser therapies may be superior in lowering the intensity of GSM symptoms in comparison to three laser therapies, in short and long-term follow-up. Differences between four and five laser therapies were not found.

Conclusions:

Laser therapy may provide significant improvement and/or absence of GSM symptoms up to 12 months follow-up, irrespectively to the number of laser therapies applied. Symptoms intensity 1 month after last laser therapy may be indicative of GSM symptoms intensity at 12 months. One month after third laser therapy is the critical time to decide whether treatment extension should be offered.
Menopausal symptoms in different substages of perimenopause and their relationships with social support and resilience
Authors: Zhao Di , Liu Chunqin , Feng Xiujuan , Hou Fangyan , Xu Xiaofang , Li Ping
Published: October 2018

Objective:

This study is designed to measure the prevalence and severity of menopausal symptoms at different substages of perimenopause, as well as the relationships of these symptoms with social support and resilience in perimenopausal women.

Methods:

A convenience sample of 732 perimenopausal women was recruited from 3 communities of Jinan City, Shandong Province, China, between March 2015 and March 2017. The participants completed the Menopause Rating Scale, the 10-item Connor-Davidson Resilience Scale, the Perceived Social Support Scale, and a questionnaire regarding sociodemographic information.

Results:

Of all perimenopausal women surveyed, 76.4% reported menopausal symptoms. The prevalence and severity of menopausal symptoms differed significantly by different substages of perimenopause (all P < 0.001); the severity of menopausal symptoms was the least during the early menopausal transition substage and the most during the early postmenopausal substage. Multivariable-adjusted linear regression showed that family support (β = −0.169 to −0.240, P < 0.001) and resilience (β = −0.140 to −0.202, P < 0.001) were negatively associated with the total and subscale scores of the Menopause Rating Scale, and higher family support and resilience had fewer menopausal symptoms.

Conclusions:

The present findings suggest that menopausal symptoms vary across different substages of perimenopause. Furthermore, higher family support and resilience were significantly associated with fewer menopausal symptoms, which might be helpful for medical staff to identify these symptoms and seek appropriate preventive intervention.
Do Websites Provide What Applicants Need? Plastic Surgery Residency Program Websites Versus Applicant Self-reported Needs
Authors: Chen Vivi W. , Hoang Don , Garner Warren
Published: October 2018

Background:

Plastic surgery residency program websites (PSRWs) remain a major resource for applicants to one of the most competitive specialties in medicine, yet it is unclear how the website content aligns with information applicants need.

Objective:

To evaluate PSRWs and whether they are meeting applicant needs.

Methods:

An anonymous online survey of 2016 plastic and reconstructive surgery applicants evaluated the use of PSRWs and information desired. Two researchers then independently analyzed all 93 PSRWs in the United States to determine whether the websites met the needs of applicants based on a quantitative scoring system.

Results:

Out of 369 total applicants to plastic surgery, the survey was sent to the 189 applicants to University of Southern California, and 87 responded (46% response rate). Ninety-eight percentage of respondents used websites during the application process. For 31%, websites served as the only source of information. Websites were moderately (60%) and only slightly useful (32%). For 22% and 34%, the quality of a website influenced their decision to apply or interview, respectively. Out of the 22 common components between the applicant survey and scoring assessment of websites, there was a significant difference in 17 components (77%) between those rated as “important” by applicants and availability of the corresponding component on websites (P < 0.05). Average (SD) score among websites was 18.7 (5.3) out of 49 maximum points (36.9%). Over 30% of websites displayed broken links or missing or outdated information. Only 19.6% displayed a link to provide website feedback.

Conclusions:

PSRWs commonly include pertinent information that is useful; however, most are lacking components valued by applicants. These findings can help guide the design, content, and improvement of PSRWs to be quality resources for applicants.
Pregnancy following Unilateral Immediate Breast Reconstruction with Titanized Polypropylene Mesh (TiLOOP(R) Bra) without Compromising the Result
Authors: Nolte Elke , Klein Evelyn , Paepke Stefan
Published: October 2018

Immediate breast reconstruction after mastectomy due to cancer or as a prophylactic treatment is widely preferred to avoid psychosocial distress, poor body image, and diminished sexual well-being. An increasing number of women undergoing breast reconstruction are in childbearing age; however, only limited data are available on the cosmetic outcome of patients undergoing implant-based breast reconstruction with a surgical mesh and subsequent pregnancy. This is a case report of a female patient who underwent unilateral implant-based breast reconstruction with a titanized surgical mesh implant (TiLOOP Bra). Twenty-two months after reconstruction, the woman delivered a healthy child. No adverse events occurred. The patient breastfed with the contralateral breast. The cosmetic result and patient-reported outcome was excellent. Pregnancy after breast reconstruction with a synthetic surgical mesh is not contradictory to an excellent cosmetic outcome.
Axillary Reconstruction with a Posterior Circumflex Humeral Artery Perforator Flap as a Salvage Surgery for Axillary Invasion of Advanced Breast Cancer
Authors: Otsuki Yuki , Nuri Takashi , Okada Masashi , Ueda Koichi , Fujioka Hiroya , Kimura Kosei , Iwamoto Mitsuhiko
Published: October 2018

A case of advanced breast carcinoma with large skin invasion that extended from the breast to the axilla and which was reconstructed with a meshed split skin graft for the chest defect and a posterior circumflex humeral artery perforator flap for the axillary area was described. When skin invasion of the breast cancer extends to the axillary area, reconstruction methods of the defect are probably complicated. The purpose of reconstruction is not only to close defects, but also to protect important tissues, such as axillary vessels and the brachial plexus. Moreover, thinner flaps are preferred to prevent a bulky contour. Many reconstruction methods can be used; however, if total mastectomy causes a large tissue defect from the breast to the axilla involving the subscapular artery, and only limited reconstruction is possible, a posterior circumflex humeral artery perforator flap can be an option to reconstruct the axilla.
Meta-analysis and Systematic Review of Skin Graft Donor-site Dressings with Future Guidelines
Authors: Serebrakian Arman T. , Pickrell Brent B. , Varon David E. , Mohamadi Amin , Grinstaff Mark W. , Rodriguez Edward K. , Nazarian Ara , Halvorson Eric G. , Sinha Indranil
Published: October 2018

Background:

Many types of split-thickness skin graft (STSG) donor-site dressings are available with little consensus from the literature on the optimal dressing type. The purpose of this systematic review was to analyze the most recent outcomes regarding moist and nonmoist dressings for STSG donor sites.

Methods:

A comprehensive systematic review was conducted across PubMed/MEDLINE, EMBASE, and Cochrane Library databases to search for comparative studies evaluating different STSG donor-site dressings in adult subjects published between 2008 and 2017. The quality of randomized controlled trials was assessed using the Jadad scale. Data were collected on donor-site pain, rate of epithelialization, infection rate, cosmetic appearance, and cost. Meta-analysis was performed for reported pain scores.

Results:

A total of 41 articles were included comparing 44 dressings. Selected studies included analysis of donor-site pain (36 of 41 articles), rate of epithelialization (38 of 41), infection rate (25 of 41), cosmetic appearance (20 of 41), and cost (10 of 41). Meta-analysis revealed moist dressings result in lower pain (pooled effect size = 1.44). A majority of articles (73%) reported better reepithelialization rates with moist dressings.

Conclusion:

The literature on STSG donor-site dressings has not yet identified an ideal dressing. Although moist dressings provide superior outcomes with regard to pain control and wound healing, there continues to be a lack of standardization. The increasing commercial availability and marketing of novel dressings necessitates the development of standardized research protocols to design better comparison studies and assess true efficacy.
Skin Grafting on 3D Bioprinted Cartilage Constructs In Vivo
Authors: Apelgren Peter , Amoroso Matteo , Säljö Karin , Lindahl Anders , Brantsing Camilla , Stridh Orrhult Linnéa , Gatenholm Paul , Kölby Lars
Published: October 2018

Background:

Three-dimensional (3D) bioprinting of cartilage is a promising new technique. To produce, for example, an auricle with good shape, the printed cartilage needs to be covered with skin that can grow on the surface of the construct. Our primary question was to analyze if an integrated 3D bioprinted cartilage structure is a tissue that can serve as a bed for a full-thickness skin graft.

Methods:

3D bioprinted constructs (10 × 10 × 1.2 mm) were printed using nanofibrillated cellulose/alginate bioink mixed with mesenchymal stem cells and adult chondrocytes and implanted subcutaneously in 21 nude mice.

Results:

After 45 days, a full-thickness skin allograft was transplanted onto the constructs and the grafted construct again enclosed subcutaneously. Group 1 was sacrificed on day 60, whereas group 2, instead, had their skin-bearing construct uncovered on day 60 and were sacrificed on day 75 and the explants were analyzed morphologically. The skin transplants integrated well with the 3D bioprinted constructs. A tight connection between the fibrous, vascularized capsule surrounding the 3D bioprinted constructs and the skin graft were observed. The skin grafts survived the uncovering and exposure to the environment.

Conclusions:

A 3D bioprinted cartilage that has been allowed to integrate in vivo is a sufficient base for a full-thickness skin graft. This finding accentuates the clinical potential of 3D bioprinting for reconstructive purposes.
Prepectoral Hammock and Direct-to-implant Breast Reconstruction in 10 Minutes: A Focus on Technique
Authors: Gunnarsson Gudjon L. , Thomsen Jorn Bo
Published: October 2018

Background:

Breast animation deformity has sparked a reappraisal of the prepectoral implant placement in breast reconstruction. Our approach for direct-to-implant breast reconstruction (DIR) has evolved from a dual plane muscle/mesh coverage to a simple prepectoral hammock covering just the inferolateral part of the implant without the muscle. The aim of this study was to test the procedure in a prospective case series with emphasis on reconstructive outcome.

Methods:

Twenty-seven patients undergoing nipple- or skin-sparing mastectomy without subsequent radiation therapy requesting a primary implant-based reconstruction were included from May 2016 to April 2017. Median age was 46 years (25–67). We registered comorbidities, complications, and long-term results of successful or failed reconstruction.

Results:

Forty-seven DIR in 27 women, 20 bilateral, 7 unilateral. The median body mass index was 24 (17–31). The median time for mastectomy and DIR was 103 minutes (60–150). The inferolateral hammock consisted of Meso Biomatrix (34), Strattice (11), and Vicryl (2). The median implant size was 260 cc (140–345). Four complications (14%), 2 hematomas, 1 seroma, and 1 infection with partial nipple necrosis were all salvaged and reconstruction completed successfully. The median follow-up was 11 months (7–17).

Conclusion:

The prepectoral inferolateral hammock, a swift one-stage procedure with a quick recovery, creates promising results in the presence of an adequate skin flap. The simplicity of the method has made it the authors first choice for DIR.
An Innovative Ventricular Assist Device Strategy as a Bridge-to-Recovery in an Infant with Glenn Physiology
Authors: Boston Umar , Sun John X. , Kumar T. K. Susheel , Knott-Craig Christopher
Published: October 2018

Mechanical circulatory support for infants with single ventricle physiology remains challenging. Utilization of a ventricular assist device (VAD) has potential advantages over extracorporeal circulatory membrane oxygenation. As such, VAD utilization in single ventricle patients with refractory heart failure continues to be explored. Herein, we describe a novel VAD strategy to support an infant with Glenn physiology who presented in cardiogenic shock related to myocardial depression of unknown etiology. This VAD configuration supported the systemic circulation independent of the Glenn circulation. Seven days of VAD support resulted in recovery of myocardial and end-organ function leading to VAD removal. The patient remains alive and free from transplantation 16 months post VAD explantation.
Clinical Outcomes of Impella Microaxial Devices Used to Salvage Cardiogenic Shock as a Bridge to Durable Circulatory Support or Cardiac Transplantation
Authors: Cheng Richard , Tank Rikin , Ramzy Danny , Azarbal Babak , Chung Joshua , Esmailian Fardad , Kobashigawa Jon A. , Moriguchi Jaime D. , Arabia Francisco A.
Published: October 2018

Temporary mechanical circulatory support (MCS) can be a bridge to decision for patients in severe cardiogenic shock who may be eligible for durable support or transplantation. Outcomes with Impella microaxial devices for salvage of severe shock in the end-stage heart failure population are not well described. Patients who underwent Impella placement as a bridge to decision, durable MCS, or transplantation were included. Eighty Impella devices (2.5 [1.3%], CP [53.8%], and 5.0 [45.0%]) were placed in 64 patients. Implant age was 56.2 ± 12.5 years. Mean duration of assisted support was 13.2 ± 15.1 days, and median duration per device was 7 days (interquartile range: 3–14). A total of 48.4% were in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS 1) shock at implant, 51.6% in profile 2. Recent cardiopulmonary resuscitation (CPR) (26.7%), ventilator use (67.2%), and extracorporeal membrane oxygenation (ECMO) use (26.7%) were frequent. Forty four of sixty four (68.8%) survived to next therapy: durable MCS (40.9%), heart transplant (OHT) (36.4%), and recovery (22.7%). Overall 30 and 60 day survival were 67.2% and 65.6%, respectively. Thirty and 60 day survival conditional on having survived to next therapy were 94.1% and 91.2%, respectively. Survivors were less likely to be on ventilators (p = 0.049) or continuous renal replacement therapy (p < 0.001) but were otherwise not different from nonsurvivors by age, sex, INTERMACS profile, CPR, prevalence of ischemic cardiomyopathy, among other characteristics. Sixteen patients were directly bridged to heart transplantation, and all were alive at long-term follow-up. Impella devices can be used to salvage patients in severe heart failure as a bridge to decision, durable MCS, or transplantation. Baseline demographics are not predictive of survival. Their use for this indication is increasing and further investigations are warranted.
Marked Practice Variation in Antithrombotic Care with the Berlin Heart EXCOR Pediatric Ventricular Assist Device
Authors: May Lindsay J. , Lorts Angela , VanderPluym Christina , Conway Jennifer , Massicotte M. Patricia , Millar Morgan M. , Steiner Marie E. , Rosenthal David N.
Published: October 2018

Management of antithrombotic therapy (ATT) for pediatric ventricular assist devices is challenging, and the Berlin EXCOR remains the only Food and Drug Administration (FDA)-approved option. Among those on the EXCOR, 28% have neurologic complications and major bleeding occurs in 50%. The Edmonton Protocol was developed to guide ATT, but the adverse event rate remains high, leading most centers to make modifications. The objective of this study is to characterize antithrombotic practice variation among North American pediatric ventricular assist device programs, in order to guide future research. In this descriptive cross-sectional study, a survey assessing antithrombotic (AT) practices was distributed by Berlin Heart Inc. to centers that implanted ≥1 EXCOR between January 2012 and January 2016. Practices were compared at high- versus low-volume centers. High volume was defined as ≥14 implants in this period. Seventeen of 38 centers (44.7%) participated; 4 were high volume. At half of all centers (9/17), ≤2 clinicians managed all AT decisions. Although 47.1% (8/17) followed the protocol “extremely/very closely,” only 5.9% (1/17) felt it to be “very effective.” Most centers (10/15; 66.7%) deviated in ≥2 protocol aspects. Over half modified either recommended antiplatelet agents (5/15) or anticoagulants (4/15). Adjunct medication use was highly variable. Most (11/17; 64.7%) deviated from protocol in either timing or type of AT lab monitoring. Despite widespread use of Thromboelastography (TEG)/Platelet Mapping (PM), concerns of inaccuracy were common. Most high-volume centers (3/4; 75%) abandoned TEG/PM as a primary tool. These practice variation analyses have identified areas in ATT that are amenable to care standardization and further research. Systematic study of optimal AT medication dosing and monitoring is needed.
Role of the von Willebrand factor and the VITRO score as predictors for variceal bleeding in patients with hepatitis C-related cirrhosis
Authors: Ibrahim Elsaed H. , Marzouk Salah A. , Zeid Ahmed E. , Lashen Sameh A. , Taher Tarek M.
Published: October 2018

Background

Noninvasive methods have been established to detect clinically significant portal hypertension in liver cirrhosis with variable limitations. The von Willebrand factor (vEF) has been found to increase in liver cirrhosis.

Aim

The aim of this study was to explore the vEF and VITRO (von Willebrand factor antigen/platelet ratio) score in the prediction of variceal bleeding in patients with portal hypertension.

Materials and methods

Fifty patients with hepatitis C-related liver cirrhosis (25 patients with variceal bleeding and 25 without variceal bleeding) as well as 80 healthy controls were included. Laboratory investigations and upper gastrointestinal endoscopy were performed in all patients. Serum vEF was measured in the patient and the control group. The VITRO score was calculated.

Results

The mean levels of the vEF antigen and the VITRO score were higher in patients with variceal bleeding compared with patients without variceal bleeding and controls (P<0.001). At levels of at least 100.1 ng/ml and at least 0.732, the vEF and the VITRO score could predict variceal bleeding with a sensitivity and a specificity of 92 and 99.9% for the vEF and 80 and 68% for the VITRO score (area under the curve=0.982 and 0.843), respectively. Levels of vEF were correlated positively with esophageal varices grade.

Conclusion

Serum vEF level and the VITRO score are potential noninvasive biomarkers for the prediction and risk stratification of variceal bleeding in hepatitis C-related liver cirrhosis.
The clinical impact of glucose-6-phosphate dehydrogenase deficiency in patients with sickle cell disease
Authors: Karafin Matthew S. , Fu Xiaoyun , D’Alessandro Angelo , Thomas Tiffany , Hod Eldad A. , Zimring James C. , Field Joshua J. , Francis Richard O.
Published: October 2018

Purpose of review

Glucose-6-phosphate dehydrogenase (G6PD) deficiency and sickle cell disease (SCD) cause hemolysis, often occurring in individuals of African descent. These disorders co-occur frequently, and possibly interact, altering clinical outcomes in SCD. However, epidemiological investigations of SCD with G6PD deficiency have produced variable results. This contribution reviews the available data about the interaction of G6PD deficiency and SCD.

Recent findings

Overall, G6PD deficiency contributes few, if any, effects to laboratory values and clinical outcomes in SCD patients, but may impact transfusion efficacy. This observation is most likely because of the relatively increased G6PD activity in the young red blood cell (RBC) population seen in SCD patients with or without G6PD deficiency. In addition, G6PD deficiency possibly interacts with other genetic modifiers, such as α thalassemia, hemoglobin F levels and SCD haplotype.

Although G6PD deficiency is relatively common, it does not appear to clinically impact patients with SCD. Nonetheless, it is important to evaluate G6PD status in patients with SCD to avoid the use of medications that may cause hemolysis. Future studies evaluating the clinical impact of transfusions from G6PD-deficient RBC donors would be of the greatest benefit to the current literature.
Chlamydia, Gonorrhea, and Human Immunodeficiency Virus Infection Among Transgender Women and Transgender Men Attending Clinics that Provide Sexually Transmitted Disease Services in Six US Cities: Results From the Sexually Transmitted Disease Surveillance Network
Authors: Pitasi Marc A. , Kerani Roxanne P. , Kohn Robert , Murphy Ryan D. , Pathela Preeti , Schumacher Christina M. , Tabidze Irina , Llata Eloisa
Published: October 2018

Background

Transgender women and transgender men are disproportionately affected by human immunodeficiency virus (HIV) infection and may be vulnerable to other sexually transmitted diseases (STDs), but the lack of surveillance data inclusive of gender identity hinders prevention and intervention strategies.

Methods

We analyzed data from 506 transgender women (1045 total visits) and 120 transgender men (209 total visits) who attended 26 publicly funded clinics that provide STD services in 6 US cities during a 3.5-year observation period. We used clinical and laboratory data to examine the proportion of transgender women and transgender men who tested positive for urogenital and extragenital chlamydial or gonococcal infections and who self-reported or tested positive for HIV infection during the observation period.

Results

Of the transgender women tested, 13.1% tested positive for chlamydia and 12.6% tested positive for gonorrhea at 1 or more anatomic sites, and 14.2% were HIV-infected. Of transgender men tested, 7.7% and 10.5% tested positive for chlamydia and gonorrhea at 1 or more anatomic sites, and 8.3% were HIV-infected. Most transgender women (86.0% and 80.9%, respectively) and more than a quarter of transgender men (28.6% and 28.6%, respectively) with an extragenital chlamydial or gonococcal infection had a negative urogenital test at the same visit.

Conclusions

Publicly funded clinics providing STD services are likely an important source of STD care for transgender persons. More data are needed to understand the most effective screening approaches for urogenital, rectal, and pharyngeal Chlamydia trachomatis and Neisseria gonorrhoeae infections in transgender populations.
Delayed Death Due to Saddle Pulmonary Thromboembolus in Child With Nephrotic Syndrome Induced by Focal Segmental Glomerulosclerosis
Authors: Guenther Rory A. , Kemp Walter L.
Published: October 2018

While the characteristic features of nephrotic syndrome (ie, proteinuria, hypoalbuminemia, peripheral edema, and hyperlipidemia) are well known, the association of nephrotic syndrome and the risk of thromboembolic events is not as often appreciated and may be overlooked. This report describes a 10-year-old boy with focal segmental glomerulosclerosis who died following a saddle pulmonary thromboembolus, with near-complete occlusion of the left and right pulmonary arteries. The gross appearance of the thrombus suggested organization and histologic changes within the wall of the pulmonary artery indicated a period of at least 3 or more hours to a few days since the event occurred. Pulmonary thromboemboli in children are rare, and the number of cases in the medical literature discussing the occurrence of pulmonary thromboemboli in the background of renal disease in children is relatively small, and none apparently clearly describe saddle thromboemboli with a delay from time of occurrence until death. This case report serves as a good reminder for forensic pathologists to consider renal disease as an underlying etiology for pulmonary thromboembolus and how histologic features of the pulmonary artery may help determine a time frame for the event.
Diagnostic Criteria for Commotio Cordis Caused by Violent Attack
Authors: Lupariello Francesco , Curti Serena Maria , Di Vella Giancarlo
Published: October 2018

The diagnosis of lethal commotio cordis (CC) is really complex. The forensic pathologist's task is even more relevant when he/she has to explain a CC diagnosis caused by an assault in a trial. The purpose of this study was to analyze the literature on lethal CC as a result of violent attacks and identify relevant parameters that may help in the diagnosis. A review of the relevant articles was performed. Fifty-two cases of CC caused by violent attacks were identified. The collected data allowed to confirm the following literature's criteria for CC diagnosis in case of assaults: witnessed occurrence of a blunt, nonpenetrating blow to the chest preceding cardiovascular collapse; absence of structural damage to the sternum, ribs, or heart itself; and absence of any underlying cardiovascular abnormalities (such as other causes of sudden death). Regarding the assessment of the third criterion, the authors suggest that the pathologist should always specify the scientific autopsy guidelines that he/she used to differentiate CC from the other causes of sudden death. In addition, the authors highlight the importance of a multidisciplinary approach for a correct interpretation of clinical, autopsy, and laboratory findings.