bluuebunny/crossref_metadata_2025 huggingface dataset:
Rethinking the Legality of Intervention by Invitation: Toward Neutrality
Authors: Nguyen Quoc Tan Trung
Published: March 2019

The article re-examines one of the most established and classical doctrines in international law, with a massive body of literature—intervention by invitation. The doctrine is straightforward and intuitive, and therefore compelling. Since the use of force or intervention in the domestic affairs of a state is prohibited, the consent of the ‘state’ itself could, naturally, eliminate the wrongfulness of the act. There is contention that the ‘government-preference’ principle of intervention by invitation affords a ‘clear alternative’ to external intervention authorized by the Security Council (‘UNSC’)[ Wippman (1996, Duke Journal of Comparative & International Law, 7, 209)]. Others, however, stressing the momentous nature of current events, believe that ‘democratic legitimacy’ is fundamental. The present author finds both approaches inadequate. In many cases, the complexity of intervention by invitation in both cases is, inevitably, reduced to the issue of recognition: ‘Who can speak for a state?’[We can see such tendency in many works on the topic such as: 2016, Byrne, Journal on the Use of Force and International Law, 3, 97, 100; Wippman (1996, Duke Journal of Comparative & International Law, 7, 217–22; Oppenheim and Lauterpacht, International Law, 7th edition (Longmans Green 1952), 249; or Fox, ‘Intervention by Invitation’ in Weller M (ed), The Oxford Handbook of the Use of Force in International Law (Oxford University Press 2015), 831–35.]. The latter is a highly political question. The law, then, is left undetermined, and actions are explained by the government’s political preferences and its rhetorical appeal to so-called international community values [Falk (ed), The International Law of Civil War (The John Hopkins Press 1971), 28]. Inspired by general neutrality approach, the author will evoke available theoretical principles and state practices to form a theory of the Equality of internal actors, (hereinafter ‘Equality theory’), in the hope of proving the relevance, reliability, consistency and overall superiority of this theory in dealing with the legality of intervention by invitation.
Two pathways for spermatogenesis in Sinanodonta woodiana (Lea, 1834) (Bivalvia: Unionidae)
Authors: Labecka Anna Maria , Domagala Jozef
Published: March 2019

The Chinese pond mussel, Sinanodonta woodiana, an invasive species indigenous to Asia, naturally colonizes new locations as a glochidium that parasitizes fish. Human activity has facilitated a continental-scale spread of S. woodiana in Europe, where it is found in artificial reservoirs and has begun to invade natural habitats. This study aimed to investigate the reproductive activity of males in a female-biased population of S. woodiana that lives in a riverine channel linked to a power plant with a cooling water system in NW Poland. Cells formed during spermatogenesis and morphological changes in reproductive follicles (acini) were analysed over a 2-year period using light microscopy. Typical and atypical spermatogenic pathways were identified. The atypical spermatozoa were released from multinucleated cysts and had significantly shorter heads than typical spermatozoa. Spermatozoa formed in the typical way occurred consistently in all months over the study period, while the atypical spermatozoa were recorded occasionally in the first year of the study and more frequently in the second study. The highest proportion of males with spent gonads was found in late summer and early autumn. Our data show that mussels produce spermatozoa year-round, but that the levels of typical and atypical spermatogenesis varied. The two pathways of spermatogenesis in S. woodiana provide an important insight into potential mechanisms underlying the evolution of doubly uniparental inheritance of mitochondrial DNA, a phenomenon observed in S. woodiana. Additionally, a detailed understanding of the reproductive cycle of this non-native species can help to understand its reproductive potential and predict the likely direction of population change in a newly colonized area. The breeding population of S. woodiana studied by us inhabits a tributary of the Odra River, one of Poland’s largest rivers, and thus poses a threat to the natural environment. Riverine habitats like our study site are local heat islands and the mussels reproducing in them over time may colonize natural waters and expand the range of their distribution.
Most exposed: the endothelium in chronic kidney disease
Authors: Vila Cuenca Marc , Hordijk Peter L , Vervloet Marc G
Published: March 2019

Accumulating evidence indicates that the pathological changes of the endothelium may contribute to the development of cardiovascular complications in chronic kidney disease (CKD). Non-traditional risk factors related to CKD are associated with the incidence of cardiovascular disease, but their role in uraemic endothelial dysfunction has often been disregarded. In this context, soluble α-Klotho and vitamin D are of importance to maintain endothelial integrity, but their concentrations decline in CKD, thereby contributing to the dysfunction of the endothelial lining. These hormonal disturbances are accompanied by an increment of circulating fibroblast growth factor-23 and phosphate, both exacerbating endothelial toxicities. Furthermore, impaired renal function leads to an increment of inflammatory mediators, reactive oxygen species and uraemic toxins that further aggravate the endothelial abnormalities and in turn also inhibit the regeneration of disrupted endothelial lining. Here, we highlight the distinct endothelial alterations mediated by the abovementioned non-traditional risk factors as demonstrated in experimental studies and connect these to pathological changes in CKD patients, which are driven by endothelial disturbances, other than atherosclerosis. In addition, we describe therapeutic strategies that may promote restoration of endothelial abnormalities by modulating imbalanced mineral homoeostasis and attenuate the impact of uraemic retention molecules, inflammatory mediators and reactive oxygen species. A clinical perspective on endothelial dysfunction in CKD may translate into reduced structural and functional abnormalities of the vessel wall in CKD, and ultimately improved cardiovascular disease.
Cerebrovascular Operative Anatomy: An Immersive 3D and Virtual Reality Description
Authors: Hendricks Benjamin K , Hartman Jerome , Cohen-Gadol Aaron A
Published: March 2019

BACKGROUND

The innate detail of the cerebrovasculature is a demonstration of the structural complexity exhibited within the nervous system and highlights the challenges intrinsic to surgically influencing this system. Bridging the knowledge gap between the 2-dimentional learning environment and the 3-dimensional (3D) clinical setting is a challenge requiring experience. Computer graphic technology provides an opportunity for the learner to step into a new era of learning via the use of interactive 3D models and virtual reality.

OBJECTIVE

To create virtually anatomically accurate cerebrovascular models with superior detail and visual appeal.

METHODS

High-resolution angiographic radiological studies were utilized to create virtual 3D models which were edited for anatomical accuracy and artistry post-processing.

RESULTS

We have created anatomically realistic and detailed 3D virtual models of the cerebrovascular structures including the arterial and venous systems. The relevant surgical anatomy of the bony and brain structures was also included. In addition, these models were used to illustrate the pathoanatomy of a deep vascular malformation to demonstrate the potential of this technology. These models allow user interactivity in the 3D environment for improved understanding of anatomical relationships.

CONCLUSION

Advances in computer graphics have invited a new era of education and experiential learning. The authors have created an immersive virtual 3D model of the cerebrovasculature to augment education, research, and clinical applications.
The dominant origin of diffuse Lyα halos around Lyα emitters explored by spectral energy distribution fitting and clustering analysis
Authors: Kusakabe Haruka , Shimasaku Kazuhiro , Momose Rieko , Ouchi Masami , Nakajima Kimihiko , Hashimoto Takuya , Harikane Yuichi , Silverman John D , Capak Peter L
Published: March 2019

The physical origin of diffuse Lyα halos (LAHs) around star-forming galaxies is still a matter of debate. We present the dependence of LAH luminosity [L(Lyα)H] on the stellar mass (M⋆), star formation rate, color excess [E(B − V)⋆], and dark matter halo mass (Mh) of the parent galaxy for ∼900 Lyα emitters (LAEs) at z ∼ 2 divided into ten subsamples. We calculate L(Lyα)H using the stacked observational relation between L(Lyα)H and central Lyα luminosity of Momose et al. (2016, MNRAS, 457, 2318), which we find agrees with the average trend of VLT/MUSE-detected individual LAEs. We find that our LAEs have relatively high L(Lyα)H despite low M⋆ and Mh, and that L(Lyα)H remains almost unchanged with M⋆ and perhaps with Mh. These results are incompatible with the cold stream (cooling radiation) scenario and the satellite-galaxy star-formation scenario, because the former predicts fainter L(Lyα)H and both predict steeper L(Lyα)H vs. M⋆ slopes. We argue that LAHs are mainly caused by Lyα photons escaping from the main body and then scattering in the circum-galactic medium. This argument is supported by LAH observations of Hα emitters (HAEs). When LAHs are taken into account, the Lyα escape fractions of our LAEs are about ten times higher than those of HAEs with similar M⋆ or E(B − V)⋆, which may partly arise from lower H i gas masses implied from lower Mh at fixed M⋆, or from another Lyα source in the central part.
Systematic study for gas-to-dust ratio of short gamma-ray burst afterglows
Authors: Yoshida Kazuki , Yonetoku Daisuke , Arimoto Makoto , Sawano Tatsuya , Kagawa Yasuaki
Published: March 2019

Extragalactic X-ray absorption and optical extinction are often found in gamma-ray burst (GRB) afterglows, and they could be tracers of both circumburst and host galaxy environments. By performing spectral analyses of the spectral energy distribution of nine short GRB (SGRB) afterglows with a known redshift, we investigated the ratio of the equivalent hydrogen column density to the dust extinction, $N_{\rm H}^{\rm rest}/A_{V}^{\rm rest}$, in the rest frame of each SGRB. We found that the distribution of $N_{\rm H}^{\rm rest}/A_{V}^{\rm rest}$ is systematically smaller than for long GRBs, and is roughly consistent with the gas-to-dust ratio in the Milky Way. This result means that the measured gas-to-dust ratio of SGRBs would originate from the interstellar medium in each host galaxy. This scenario supports the prediction that SGRBs occur in non-star-forming regions in the host galaxies.
A Bioinformatic Analysis of MicroRNAs’ Role in Human Intervertebral Disc Degeneration
Authors: Wang Xue-Qiang , Tu Wen-Zhan , Guo Jia-Bao , Song Ge , Zhang Juan , Chen Chang-Cheng , Chen Pei-Jie
Published: March 2019

Objectives The aim of our study was to ascertain the underlying role of microRNAs (miRNAs) in human intervertebral disc degeneration (IDD).

Design Bioinformatic analysis from multiple databases.

Methods Studies of the association of miRNAs and IDD were identified in multiple electronic databases. All potential studies were assessed by the same inclusion and exclusion criteria. We recorded whether miRNA expression was commonly increased or suppressed in the intervertebral disc tissues and cells of IDD subjects. We used String to identify biological process and cellular component pathways of differentially expressed genes.

Results We included fifty-seven articles from 1,277 records in this study. This report identified 40 different dysregulated miRNAs in 53 studies, including studies examining cell apoptosis (26 studies, 49.06%), cell proliferation (15 studies, 28.3%), extracellular matrix (ECM) degradation (10 studies, 18.86%), and inflammation (five studies, 9.43%) in IDD patients. Three upregulated miRNAs (miR-19b, miR-32, miR-130b) and three downregulated miRNAs (miR-31, miR-124a, miR-127-5p) were considered common miRNAs in IDD tissues. The top three biological process pathways for upregulated miRNAs were positive regulation of biological process, nervous system development, and negative regulation of biological process, and the top three biological process pathways for downregulated miRNAs were negative regulation of gene expression, intracellular signal transduction, and negative regulation of biological process.

Conclusions This study revealed that miRNAs could be novel targets for preventing IDD and treating patients with IDD by regulating their target genes. These results provide valuable information for medical professionals, IDD patients, and health care policy makers.
How Much Is Needed? Comparison of the Effectiveness of Different Pain Education Dosages in Patients with Fibromyalgia
Authors: Amer-Cuenca Juan J , Pecos-Martín Daniel , Martínez-Merinero Patricia , Lluch Girbés Enrique , Nijs Jo , Meeus Mira , Ferrer Peña Raúl , Fernández-Carnero Josué
Published: March 2019

Objective

To assess the effect of different dosages of pain neuroscience education (PNE) programs on central nociceptive processing in patients with fibromyalgia. Second, to compare the effects of different dosages of PNE programs on numerical pain rating scale (NPRS), disability, and psychological variables.

Design

Single-blind randomized controlled trial.

Setting

Three fibromyalgia centers in Spain (Valencia, Alcorcón, Alcalá de Henares).

Subjects

Seventy-seven patients with fibromyalgia.

Methods

Participants were randomized to four groups of PNE: 1) high-dose PNE (N = 20), 2) low–concentrated dose PNE (N = 20), 3) diluted low-dose PNE (N = 20), and (4) control treatment (N = 17), conducted in two 30–50-minute sessions in groups of four to six participants. Conditioned pain modulation (CPM), temporal summation (TS), and pressure pain thresholds (PPTs) were assessed at baseline and at three-month follow-up. Secondary outcome measures were the Fibromyalgia Impact Questionnaire, Pain Catastrophizing Scale, and Pain Anxiety Symptoms Scale.

Results

There were significant between-group differences for NPRS in favor of the groups receiving high-dose PNE, with a large effect size at three-month follow-up (P < 0.01, η2p = 0.170), but there were no significant differences between groups for the remaining variables (P > 0.05). All groups improved for central nociceptive processing, psychological variables, disability, and pain intensity (NPRS).

Conclusions

In patients with fibromyalgia, higher dosages of PNE produced a larger improvement in pain severity at three-month follow-up than other dosages of PNE and biomedical education. However, PNE was not superior to biomedical education in the central nociceptive processing, disability, or psychological variables in patients with fibromyalgia.
PR3-ANCA-associated vasculitis is associated with a specific motif in the peptide-binding cleft of HLA-DP molecules
Authors: Gregersen Jon Waarst , Erikstrup Christian , Ivarsen Per , Glerup Rie , Krarup Elizabeth , Keller Kresten Krarup , Hansen Ib Tønder , Møller Bjarne Kuno
Published: March 2019

Objectives

This study aimed to characterize the association between HLA alleles and ANCA-associated vasculitis (AAV) in a genetically homogeneous population, and to analyse the contribution of specific HLA molecule amino acid sequences to the risk of AAV.

Methods

We included 187 Danish patients with AAV and 1070 healthy controls. All were HLA typed at two-field resolution. The association of HLA alleles to PR3- or MPO-AAV was analysed. The contribution of the dominant molecular motifs of the HLA-DPB1 molecule to the risk of AAV was investigated by association studies that included specific amino acid sequences of the hypervariable regions in exon 2.

Results

Ninety-four percent of patients with PR3-AAV were carriers of HLA-DPB1*04:01 while all patients with PR3-AAV were carriers of an HLA-DPB1*04 allele, and 85% were homozygous. This was significantly more than in the control group (P < 0.0001). The association was even stronger when HLA-DPB1*04:02 and -DPB1*23:01 were included. HLA-DPB1*04:01, -DPB1*04:02 and -DPB1*23:01 share amino acids in positions 8–9, 69, 76 and 84–87 within the hypervariable regions, but only positions 69 and 84–87 contributed significantly to the disease risk. HLA-DRB1*15 was associated with an increased risk of developing PR3-AAV, while HLA-DRB1*04, -DRB1*07 and -DQB1*03 were associated with a reduced risk of kidney involvement in PR3-AAV. MPO-AAV was only weakly associated with HLA class I alleles.

Conclusion

PR3-AAV is strongly associated with the HLA-DPB1 alleles HLA-DPB1*04:01, -DPB1*04:02 and -DPB1*23:01, which share amino acid sequences crucial for the peptide-binding groove.
Efficacy of the Buzzy Device for Pain Management During Needle-related Procedures
Authors: Ballard Ariane , Khadra Christelle , Adler Samara , Trottier Evelyne D. , Le May Sylvie
Published: March 2019

Objective:

This systematic review and meta-analysis examined the effectiveness of the Buzzy device combining cold and vibration for needle-related procedural pain in children.

Materials and Methods:

Databases search was conducted from inception to December 2017 to identify randomized controlled trials using the Buzzy device for pain management in children undergoing needle-related procedures. Selection of studies, data extraction, and assessment of risk of bias and quality of evidence were independently performed by 2 reviewers. Quantitative and qualitative analyses were conducted.

Results:

A total of 9 studies involving 1138 participants aged between 3 and 18 years old were included in the systematic review and 7 were suitable for meta-analysis. The meta-analysis compared the Buzzy device with a no-treatment comparator and the effect of the device was significant in reducing self-report procedural pain (standardized mean difference [SMD]: −1.11; 95% confidence interval [CI]: −1.52 to −0.70; P<0.0001), parent-reported procedural pain (SMD: −0.94; 95% CI: −1.62 to −0.27; P=0.006), observer-report procedural pain (SMD: −1.19; 95% CI: −1.90 to −0.47; P=0.001), observer-reported procedural anxiety (SMD −1.37; 95% CI: −1.77 to −0.96; P<0.00001), and parent-reported procedural anxiety (SMD −1.36; 95% CI: −2.11 to −0.61; P=0.0004). There was no significant difference for the success of the procedure at first attempt and the occurrence of adverse events.

Discussion:

The Buzzy device seems to be a promising intervention for procedural pain management in children. However, the comparative effect is uncertain due to the presence of significant heterogeneity and very low-quality evidence. There is a need to improve the methodological quality and rigor in the design of future trials to conclude to the efficacy of the Buzzy device.
The Association Between Conditioned Pain Modulation and Manipulation-induced Analgesia in People With Lateral Epicondylalgia
Authors: Muhsen Ahmad , Moss Penny , Gibson William , Walker Bruce , Jacques Angela , Schug Stephan , Wright Anthony
Published: March 2019

Objectives:

Conditioned pain modulation (CPM) and manipulation-induced analgesia (MIA) may activate similar neurophysiological mechanisms to mediate their analgesic effects. This study assessed the association between CPM and MIA responses in people with lateral epicondylalgia.

Materials and Methods:

Seventy participants with lateral epicondylalgia were assessed for CPM followed by MIA. A single assessor measured pressure pain thresholds (PPT) before, during, and after cold water immersion (10°C) of the asymptomatic hand and contralateral lateral glide (CLG) mobilization of the neck. For analyses, linear mixed models evaluated differences in CPM and MIA responses. Pearson partial correlations and regression analyses evaluated the association between CPM and MIA PPT.

Results:

There was a significant increase (CPM and MIA, P<0.001) in PPT from baseline during the interventions (CPM mean: 195.84 kPa for elbow and 201.87 kPa for wrist, MIA mean: 123.01 kPa for elbow and 126.06 kPa for wrist) and after the interventions (CPM mean: 126.06 kPa for elbow, 114.24 kPa for wrist, MIA mean: 123.50 kPa for elbow and 122.16 kPa for wrist). There were also significant moderate and positive partial linear correlations (r: 0.40 to 0.54, P<0.001) between CPM and MIA measures, controlling for baseline measures. Regression analyses showed that CPM PPT was a significant predictor of MIA PPT (P<0.001) and the models explained between 73% and 85% of the variance in MIA PPT.

Discussion:

This study showed that CPM and MIA responses were significantly correlated and that the CPM response was a significant predictor of MIA response.
Musculoskeletal Pain in Individuals With Inflammatory Bowel Disease Reflects Three Distinct Profiles
Authors: Falling Carrie , Stebbings Simon , Baxter George D. , Gearry Richard B. , Mani Ramakrishnan
Published: March 2019

Objectives:

Pain affects over 70% of individuals with inflammatory bowel disease (IBD), with abdominal and musculoskeletal pain representing the most common symptoms. Musculoskeletal pain in IBD is reported to be associated with multiple clinical features, however the scope and nature of pain is not well understood. Primary aims were to identify subgroups of musculoskeletal pain in individuals with IBD based on clinical features of pain and assess how these subgroups differ in aspects of demographics, comorbidity, and IBD characteristics.

Methods:

Cross-sectional online survey was performed on adults with IBD. Domains included: demographics, comorbidity, and clinical IBD and pain features. Latent class analysis was used to identify subgroups with similar attributes of: pain (severity, location, interference, and quality), IBD (activity, quality of life, and abdominal pain), and symptoms related to central sensitization. Correlation and regression analyses were used to profile identified subgroups.

Results:

Of 305 included participants, 208 indicated the presence of musculoskeletal pain. Three identified subgroups were characterized as “mixed mechanism,” “central mechanism,” and “regional and remission.” Between subgroup differences included: total comorbidity score (P=0.005), osteoarthritis (P=0.027), osteoporosis (P=0.045), depression (P=0.001), anxiety (P=0.025), and chronic fatigue syndrome (P=0.020). Sex and age were identified as confounders for depression and anxiety.

Conclusions:

Study results suggest multiple mechanisms contributing to pain experiences in IBD, to include central mechanisms. Features related to demographics, extraintestinal manifestations, IBD subtype, and clinical IBD features were not predictors of subgroup membership. However, total comorbidity demonstrated association with pain subgroups in this population.
Nociception-guided versus Standard Care during Remifentanil–Propofol Anesthesia
Authors: Meijer Fleur S. , Martini Chris H. , Broens Suzanne , Boon Martijn , Niesters Marieke , Aarts Leon , Olofsen Erik , van Velzen Monique , Dahan Albert
Published: March 2019

Editor’s Perspective

What We Already Know about This Topic

The nociception level index (Medasense Biometrics Ltd., Ramat Gan, Israel), is a reliable measure of moderate to intense noxious stimulation during anesthesia and surgery

What This Article Tells Us That Is New

In a randomized trial in patients having major abdominal surgery, compared to standard practice, nociception level-guided analgesia resulted in 30% less intraoperative remifentanil consumption

Background

The multidimensional index of nociception, the nociception level, outperforms blood pressure and heart rate in detection of nociceptive events during anesthesia. We hypothesized that nociception level–guided analgesia reduces opioid consumption and suboptimal anesthesia events such as low blood pressure and use of vasoactive medication.

Methods

In this single-blinded randomized study, 80 American Society of Anesthesiologists class I–III adult patients of either sex, scheduled for major abdominal procedures under remifentanil/propofol anesthesia by target-controlled infusion, were included. During the procedure nociception level, noninvasive blood pressure, and heart rate were monitored. Patients were randomized to receive standard clinical care or nociception level–guided analgesia. In the nociception level–guided group, remifentanil concentration was reduced when index values were less than 10 or increased when values were above 25 for at least 1 min, in steps of 0.5 to 1.0 ng/ml. Propofol was titrated to bispectral index values between 45 and 55. The primary outcomes of the study were remifentanil and propofol consumption and inadequate anesthesia events.

Results

Compared with standard care, remifentanil administration was reduced in nociception level–guided patients from (mean ± SD) 0.119 ± 0.033 to 0.086 ± 0.032 μg · kg-1 · min-1 (mean difference, 0.039 μg · kg-1 · min-1; 95% CI, 0.025–0.052 μg · kg-1 · min-1; P < 0.001). Among nociception level–guided patients, 2 of 40 (5%) experienced a hypotensive event (mean arterial pressure values less than 55 mm Hg) versus 11 of 40 (28%) patients in the control group (relative risk, 0.271; 95% CI, 0.08–0.77; P = 0.006). In the nociception level–guided group, 16 of 40 (40%) patients received vasoactive medication versus 25 of 40 (63%) patients in the standard care group (relative risk, 0.64; 95% CI, 0.40–0.99; P = 0.044).

Conclusions

Nociception level-guided analgesia during major abdominal surgery resulted in 30% less remifentanil consumption.
Implementation of Clinical Practice Guidelines in the Health Care Setting
Authors: Beauchemin Melissa , Cohn Elizabeth , Shelton Rachel C.
Published: March 2019

The literature is replete with clinical practice guidelines (CPGs) and evidence supporting them. Translating guidelines into practice, however, is often challenging. We conducted a concept analysis to define the concept of “implementation of CPGs in health care settings.” We utilized Walker and Avant's methodology to define the concept of “implementation of CPGs in health care settings.” This included a focused review of the literature, defining the relevant attributes, defining implementation, case examples, and antecedents and potential consequences from implementation of CPGs in health care settings. The concept “implementation” is complex, with numerous frameworks, facilitators, and barriers to implementation described in the literature. The existing literature supports our definition of implementation of CPGs in a health care setting as a process of changing practice in health care while utilizing the best level of evidence that is available in the published literature. These include 7 attributes necessary for effective implementation. Implementation of CPGs in health care settings requires an ongoing iterative process that considers these attributes and is inclusive to administrators, clinicians, and patients to ensure guidelines are understood, accepted, implemented, and evaluated for continued adoption of best practices. Ongoing efforts inclusive at all steps of implementation across multiple levels are needed to effectively change practice.
Middle third clavicular fractures fixed with precontoured locking compression plate or reconstruction plate: comparison of outcomes and complications
Authors: Kariya Ankur D. , Jain Pramod A. , Patond Kisan
Published: March 2019

Background:

Fractures of the clavicle account for 2.6% to 4% of all fractures. Operative management of displaced fractures of the midshaft clavicle is preferred due to better outcomes. Various plates are used for fixation of these fractures, which include reconstruction plates, dynamic compression plates, and precontoured locking plates. Very few studies have documented whether the proposed benefits of precontoured plates are realized in a clinical setting. In this study, we compared the outcomes and complications of displaced midshaft clavicular fractures fixed using precontoured and reconstruction plates.

Methods:

Patients with Robinson Type 2B fractures of the clavicle treated using reconstruction plates (46 patients) or precontoured plates (68 patients) were included in the study. Parameters such as duration of surgery, functional outcome at 6 mo, and occurrence of complications, such as nonunion, infection, hardware prominence, and overall reoperation rates, were compared between the two groups.

Results:

There was no significant difference in functional outcomes between the reconstruction plate group and precontoured plate group (Constant score: 85.23 vs. 86.75, respectively). However significantly higher rate of hardware prominence (32.6% vs. 7.3%, respectively), implant removal (15.2% vs. 2.9%, respectively), and reoperation (19.5% vs. 4.4%, respectively) was found with reconstruction plates compared to precontoured plates.

Conclusions:

The treatment of displaced midshaft clavicular fractures with either reconstruction plates or precontoured plates offers a return to excellent shoulder function. However, a significant decrease in duration of surgery, hardware prominence, and reoperation rate was seen with precontoured plates.
Vitamin D hypovitaminosis and efficacy of supplementation in spine surgery patients
Authors: Lindley Emily M. , Perry James , Patel Manishi , Noshchenko Andriy , Bond Amy , Burger Evalina L. , Cain Christopher M.J. , Patel Vikas V.
Published: March 2019

Background:

Although there is evidence that hypovitaminosis D is present in many otherwise healthy adults, there is little information on supplementation in patients undergoing spine surgery. Thus, the purpose of this study was to determine the prevalence of preoperative hypovitaminosis D in spine surgery patients and evaluate the efficacy of postoperative vitamin D supplement regimens.

Methods:

Per standard of care, serum 25-hydroxyvitamin D levels were regularly drawn preoperatively and at 6 mo postoperatively; patients with hypovitaminosis D were prescribed a 3-month supplementation regimen based on their level of deficiency: 2000 IU/day, 50,000 IU/wk, or both 50,000 IU/wk and 2000 IU/day. For this analysis, we retrospectively reviewed charts of patients who had spine surgery to identify those with preoperative vitamin D levels. Rates of hypovitaminosis D were compared before and after treatment with supplementation.

Results:

Of 853 patients with preoperative serum vitamin D levels, 505 (59.2%) had hypovitaminosis D (<30 ng/mL). The rate of insufficiency (20-29 ng/mL) was 31.5%, and the rate of deficiency was 27.7%. At 6 mo postoperatively, the mean serum vitamin D level of patients with hypovitaminosis D increased from 19.7 ng/mL to 30.0 ng/mL (P<0.001). However, only 42.6% of patients achieved sufficiency at 6 mo. There were no differences in improvements between the supplementation regimens.

Conclusions:

Hypovitaminosis D is common among patients undergoing spine surgery. Patients should be tested preoperatively and prescribed a supplementation for at least 3 mo postoperatively. Serum levels should be checked regularly postoperatively, especially in deficient patients, to determine if further treatment is needed.
Data Mining for Adverse Drug Events
Authors: Thorlton Janet , Catlin Ann Christine
Published: March 2019

Emerging technologies and big data influence the role of nurses, calling for new ways of thinking and teaching. Innovative educational methods are needed to prepare students for providing evidence-based care in today's complex healthcare environment. Active learning methods appeal to tech-savvy, self-directed learners who desire instant results during the learning process. The aim of this pretest/posttest study was to evaluate the impact of active learning methods on student attitudes and feelings, using the Grasha-Riechmann Student Learning Style Scale. Results were used to tailor active learning interventions using Twitter and Federal Adverse Event Reporting System data, for a research and evidence-based practice nursing course. Participants (N = 126) evaluated tweets describing adverse drug events and their concordance with federal reporting system data. Paired-samples t test results revealed significant differences (P < .05) between pretest/posttest for five of the six learning style preferences. Active learning methods resulted in high levels of student engagement and satisfaction. Data mining as an active learning intervention is popular with learners and offers a quick, valuable way to reveal real-world adverse drug event experiences while introducing basic research principles.
Are Serum Metal Ion Levels a Concern at Mid-term Followup of Revision Knee Arthroplasty With a Metal-on-metal Hinge Design?
Authors: Klasan Antonio , Meine Esko , Fuchs-Winkelmann Susanne , Efe Turgay , Boettner Friedrich , Heyse Thomas Jan
Published: March 2019

Background

Elevated serum levels of chromium and cobalt ions in metal-on-metal (MoM) bearing surfaces is a well-known phenomenon in THA. However, few studies have addressed this issue in complex primary and revision knee arthroplasty using a MoM hinged mechanism, and no study, to our knowledge, has investigated knees with MoM hinges in patients without megaprostheses (tumor prostheses).

Questions/purposes

We analyzed a series of patients who received MoM hinged revision knee prostheses and asked: (1) What are the serum metal ion levels at short-term followup? (2) Is there any correlation between metal ion levels and the Knee Society Score (KSS) at this followup?

Methods

Between 2013 and 2017, we performed 198 revision knee arthroplasties, of which 32 (17.7%) were performed with a latest-generation MoM hinge knee design. In addition, three complex primary TKAs utilizing the same design were included in this study. The device features a metal-on-polyethylene bearing with a MoM hinge. During that period, our general indications for using a hinge were single-stage and two-stage revision surgeries, revisions with large bone defects, and primary TKA with > 20° mechanical malalignment or collateral ligament insufficiency. Of the 35 patients who received this device, 23 patients (65% of the overall group who received this implant; 11 males, 12 females) were available for followup at a median of 28 months (range, 13-61 months), and the remaining 12 (35%) patients were lost to followup. Our rationale for reporting before the more typical 2-year minimum was the finding of elevated serum ion levels with unclear clinical significance. Median age at the time of surgery was 68 years (range, 52-84 years). None of the patients included in the study had other implants with MoM bearings. Serum ion levels of chromium (III) and cobalt were assessed using mass spectrometry. Ion levels > 5 ppb were considered elevated. Clinical outcome was assessed using the original KSS.

Results

Median chromium serum level was 6.3 ppb (range, 0.6–31.9 ppb) and median cobalt serum level was 10.5 (range, 1.0–47.5 ppb). Of the 23 patients, 16 had elevated serum ion levels. There was a moderate correlation between KSS and both chromium (p = 0.029, r = 0.445) and cobalt (p = 0.012, r = 0.502) levels.

Conclusions

Elevated metal ion levels and radiolucent lines are common after surgery with this MoM hinge design at short-term followup, and we believe this finding is of great concern. Although no patient has yet been revised, these patients will be closely monitored. We recommend that serum ion analysis become a routine part of followup after any hinge TKA in an attempt to better understand the potential consequences of this phenomenon.

Level of Evidence

Level IV, therapeutic study.
Polymethylmethacrylate Collagen Gel–Injectable Dermal Filler for Full Face Atrophic Acne Scar Correction
Authors: Joseph John H. , Shamban Ava , Eaton Laura , Lehman Alayne , Cohen Steven , Spencer James , Bruce Suzanne , Grimes Pearl , Tedaldi Ruth , Callender Valerie , Werschler Phillip
Published: March 2019

BACKGROUND/OBJECTIVES

This trial evaluated the effectiveness and safety of Bellafill for full-face acne scar treatment.

PATIENTS AND METHODS

In this open-label, nonrandomized, multicenter pilot study investigating the use of polymethylmethacrylate for full-face atrophic acne scar correction, 42 adult subjects with a mean age of 43 years were treated and assessed for safety and effectiveness at Months 4 and 7. There were no hypersensitivity reactions to pretreatment skin testing or during scar treatments.

RESULTS

At 4 and 7 months after initial treatment, 92% and 95% of subjects, respectively, were responders with ≥1-point improvement on the 5-point Acne Scar Assessment Scale. Subjects reported very high levels of improvement on the Global Aesthetic Improvement Scale (GAIS), with 95% of subjects reporting “improved or better” at 4 months and 90% at 7 months. The outcome of the physician GAIS was also high with 92% of patients classified as “improved or better” at 4 months and 97% at 7 months. There were only 2 device-related adverse events, both mild events related to Bellafill skin test (bruising, ecchymosis). There were no serious adverse events in response to the treatment product in this short-term follow-up study.

CONCLUSION

Polymethylmethacrylate is effective for treating full-face acne scarring. Clinicaltrials.gov #NCT02642627.
Histologic Characterization of Polymethylmethacrylate Dermal Filler Biostimulatory Properties in Human Skin
Authors: Ronan Stephen J. , Eaton Laura , Lehman Alayne , Pilcher Brian , Erickson Christof P.
Published: March 2019

BACKGROUND

Little literature exits on the mechanism of action of implanted polymethylmethacrylate (PMMA) filler.

OBJECTIVE

To characterize PMMA-induced dermal extracellular matrix production in the skin.

MATERIALS AND METHODS

Single-center, open-label prospective study in healthy volunteers undergoing removal of redundant skin was injected intradermally and subdermally with PMMA dermal filler (Bellafill). Punch biopsies were harvested over a time course and evaluated for the deposition of collagen-3 and procollagen-1, proteoglycans and elastin using immunohistochemistry. Blinded histopathologic readings were performed by a dermatopathologist to characterize the nature of the dermal extracellular matrix findings.

RESULTS

Normal inflammatory infiltrate was exhibited at all timepoints after PMMA injection with an influx of fibroblasts and new vasculature. Tissue proteoglycans were noted within the injectate beginning at Week 1 and persisted through the study end point. Increased collagen Type 3 was evident following the first week after injection, peaked at Month 2 and diminished through Months 3 through 6. Procollagen-1 was noted at Month 1 and continued to increase in intensity and organization through the study end point (6 months). Elastin staining was inconclusive. Polymethylmethacrylate microspheres remained within the initial injection area and became encapsulated within new collagen fibers. The growth and pattern of new connective tissue mimicked a normal wound healing response.

CONCLUSION

Polymethylmethacrylate-collagen gel filler stimulates collagen-3 and procollagen-1 when injected into human skin. This combination of neocollagenesis followed by microencapsulation of PMMA microspheres in the new tissue provides for long-lasting results.
Linear No-threshold (LNT) vs. Hormesis: Paradigms, Assumptions, and Mathematical Conventions that Bias the Conclusions in Favor of LNT and Against hormesis
Authors: Sacks Bill , Meyerson Gregory
Published: March 2019

The linear no-threshold assumption misunderstands the complex multiphasic biological response to ionizing radiation, focusing solely on the initial physical radiogenic damage. This misunderstanding is enabled (masked and amplified) by a number of mathematical approaches that bias results in favor of linear no-threshold and away from alternatives, like hormesis, that take biological response into account. Here we explore a number of these mathematical approaches in some detail, including the use of frequentist rather than Bayesian statistical rules and methods. We argue that a Bayesian approach cuts through an epidemiological stalemate, in part because it enables a better understanding of the concept of plausibility, which in turn properly rests on empirical evidence of actual physical and biological mechanisms. Misuse of the concept of plausibility has sometimes been used to justify the mathematically simple and convenient linearity-without-a-threshold assumption, in particular with the everywhere-positive slope that is central to linear no-threshold and its variants. Linear no-threshold’s dominance in the area of dose regulation further rests on a misapplication of the precautionary principle, which only holds when a putative caution has positive effects that outweigh the negative unintended consequences. In this case the negative consequences far outweigh the presumed hazards.
Factors Influencing Primary Care Follow-Up After Pediatric Mild Traumatic Brain Injury
Authors: Currie Dustin , Snedden Traci , Pierpoint Lauren , Comstock R. Dawn , Grubenhoff Joseph A.
Published: March 2019

Objective:

To identify socioeconomic, demographic, and caregiver factors associated with children attending primary care provider (PCP) follow-up after emergency department (ED) evaluation for mild traumatic brain injury (mTBI).

Setting:

Pediatric trauma center ED.

Participants:

Children 8 to 18 years of age sustaining mTBI less than 48 hours prior to an ED visit. Mean age of the 183 participants was 12 years with no significant differences between those who attended follow-up and those who did not in race, ethnicity, insurance provider, or PCP office setting.

Design:

Thirty-day longitudinal cohort study.

Main Measures:

Insurance type, PCP practice setting, and a caregiver attitudes survey regarding mTBI recovery and management (5 questions each scored on a 5-point Likert scale). The primary outcome was attending a PCP follow-up visit within 1 month of injury.

Results:

Females were more likely than males to attend PCP follow-up (adjusted odds ratio: 2.27 [95% confidence interval: 1.00-5.18]). Increasing scores on the caregiver attitudes survey indicating greater concerns about recovery were significantly associated with attending PCP follow-up (adjusted odds ratio: 1.12 per unit increase in composite score [95% confidence interval: 1.02-1.23]). No other socioeconomic, demographic, or injury characteristics were associated with attending PCP follow-up.

Conclusions:

The ED counseling regarding PCP follow-up of mTBI should stress the importance of follow-up care to monitor recovery and identify presence of lingering symptoms.
Acceptance of Rehabilitation Technology in Adults With Moderate to Severe Traumatic Brain Injury, Their Caregivers, and Healthcare Professionals: A Systematic Review
Authors: Vaezipour Atiyeh , Whelan Brooke-Mai , Wall Kylie , Theodoros Deborah
Published: March 2019

Background:

Moderate to severe traumatic brain injuries (TBIs) commonly result in persistent physical, cognitive, and/or emotional deficits that require long-term rehabilitation. Technology-enabled rehabilitation provides an innovative alternative to traditional intervention models. End-user acceptance of these interventions, however, is a critical factor in determining the effective implementation and acceptance of these technologies.

Objective:

To systematically review the literature to identify methods and measures used to evaluate user acceptance relating to rehabilitation technologies for adults with moderate to severe TBI, their caregivers, and healthcare professionals.

Methods:

Six key databases including Medline, Embase, CINAHL, Cochrane, Scopus, and Web of Science were searched using the relevant search terms.

Results:

From a yield of 2059 studies, 13 studies met the eligibility criteria. The review revealed limited research that formally evaluated user acceptance in relation to rehabilitation technologies designed for adults with TBI. Furthermore, where such evaluations were conducted, comprehensive research designs incorporating theoretical frameworks of technology acceptance were sparse. Importantly, a range of technologies and recommendations that positively influenced user acceptance were identified. Future directions for research in this area include the use of theory-driven research designs to enhance our understanding of technology acceptance, to support the development of rehabilitation technologies that maximize functional outcomes for individuals with TBI.
Limited Prediction of Performance Validity Using Embedded Validity Scales of the Neurobehavioral Symptom Inventory in an mTBI Veteran Sample
Authors: Menatti Andrew R. R. , Melinder Meredith R. D. , Warren Stacie L.
Published: March 2019

Objective:

To test embedded symptom validity scales of the Neurobehavioral Symptom Inventory (NSI) as predictors of performance validity.

Setting:

A Veterans Affairs Level II TBI/Polytrauma outpatient care unit in the Midwestern United States.

Participants:

Veterans with a history of mild traumatic brain injury undergoing neuropsychological assessment as part of their routine care within the TBI/Polytrauma clinic.

Design:

Retrospective analysis of the existing clinical data.

Main Measures:

The NSI, the b Test, Test of Memory Malingering, Reliable Digit Span, California Verbal Learning Test-II Forced Choice.

Results:

Embedded NSI validity scales were positively correlated with number of performance validity test failures. Participants identified as invalid responders scored higher on embedded NSI validity scales than participants identified as valid responders. Using receiver operating characteristic analysis, the embedded NSI validity scales showed poor sensitivity and specificity for invalid responding using previously published cutoff scores. Only 1 scale differentiated valid from invalid responders better than chance.

Conclusion:

The embedded NSI validity scales' usefulness in predicting invalid neuropsychological performance validity was limited in this sample. Continued measurement of both symptom and performance validity in clinical settings involving traumatic brain injury treatment is recommended, as the present results support the existing research suggesting symptom validity tests and performance validity tests tap into related but ultimately distinct constructs.
Cognitive Reserve Protects Against Memory Decrements Associated With Neuropathology in Traumatic Brain Injury
Authors: Krch Denise , Frank Lea E. , Chiaravalloti Nancy D. , Vakil Eli , DeLuca John
Published: March 2019

Objective:

To evaluate whether cognitive reserve (CR) moderates the relationship between neuropathology and cognitive outcomes after traumatic brain injury (TBI).

Setting:

Outpatient research organization.

Participants:

Patients with complicated mild (n = 8), moderate (n = 9), and severe (n = 44) TBI.

Design:

Prospective, cross-sectional study.

Main Measures:

Cognitive reserve was estimated using a test of word reading (Wechsler Test of Adult Reading). Diffusion tensor imaging (functional anisotropy) was used to quantify neuropathology. Neuropsychological test scores were submitted to principal components analyses to create cognitive composites for memory, attention, executive function, and processing speed domains.

Results:

At lower levels of neuropathology, people with higher CR exhibited better memory than those with lower CR. This benefit diminished as neuropathology increased and disappeared at the highest levels of neuropathology. Cognitive reserve ceased exerting a protective effect at premorbid intelligence levels below average.

Conclusion:

Cognitive reserve may differentially protect some cognitive domains against neuropathology relative to others. A clinical cutoff below which CR is no longer protective, together with a possible neuropathology ceiling effect, may be instructive for prognostication and clinical decision-making in cognitive rehabilitation.