bluuebunny/crossref_metadata_2025 huggingface dataset:
Remedial Expression
Authors: Stahn Carsten
Published: July 2020

The chapter argues that international criminal justice is more a project of accountability rather than a narrow punitive undertaking. The value of international criminal justice lies not necessarily in the severity of punishment or the infliction of ‘just deserts’ but rather in the publicity of the process, the condemnation of crimes, and the establishment of accountability towards a broader community. Expressive punishment is grounded in retributive-expressive justifications, preventive considerations, and restorative rationales, such as messages about equality of victims and offenders. This approach is able to accommodate a more holistic conception of punishment, including alternative sentences or modes of enforcement. Reparations have an important complementary function to punishment. Like punishment itself, they are an imperfect means to acknowledge responsibility, recognize victimhood, or remedy harm caused through crimes. Rather, they help to restore trust about civility and inspire commitment to a social contract among citizens, aimed at preventing future crimes.
International Criminal Law as Expressivist Justice
Authors: Stahn Carsten
Published: July 2020

This chapter connects expressivism to justice discourse and different dimensions of justice. It claims that expressivism has a more complex role in international criminal justice than publicly admitted. It is a means to reaffirm the purposes and ambitions of the field and to encourage commitment to it, and to enact and perform law. It also provides a more realistic understanding of justice. It views justice not as something ‘objective’ or ‘definitive’ that can be delivered through criminal proceedings, but rather as an intersubjective process that is triggered through messages and communicative relationships: justice is a message.
Aṅgulīyāṅkam and Mantrāṅkam
Authors: Gopalakrishnan Sudha
Published: July 2020

It can be said that Aṅgulīyāṅkam and Mantrāṅkam represent the essential features that distinguish Kūṭiyāṭṭam from the other traditions of performance and challenge the norms of abhinaya prescribed in Nāṭyaśāstra and allied texts. Though these plays are vastly dissimilar in theme, scope, and content, the possible correspondences of these two plays as interpretations-in-performance place them in a complementary relationship to one another. Why and how these two plays established a different path is what the author explores during the course of her article. The sixth act of Śaktibhadras Āścaryacūḍāmaṇi, on which Aṅgulīyāṅkam is based, depicts Hanumān’s encounter with Sītā while she is in Rāvaṇa’s captivity at the Aśoka Garden in Laṅkā. Mantrāṅkam refers to the third act of Bhāsa’s Pratijnāyaugandharāyaṇa. The plot of this act revolves around the strategies devised by the three ministers of the captive King Udayana for releasing their master from imprisonment by King Mahasēna.
Some Remarks on the Āścaryacūḍāmaṇi
Authors: Bansat-Boudon Lyne
Published: July 2020

Lyne Bansat-Boudon gives us a ‘thick description’ of Śaktibhadra’s Āścaryacūḍāmaṇi, from which the act Aṅgulīyāṅkam is taken. She defines powerful thematic emphases and focuses on the special expressivity of this work within the classical tradition and in light of the Nāṭyaśāstra and Abhinavagupta’s commentary. Further, she discovers surprising continuities between structural features discussed by Abhinavagupta and the living performance tradition of Kūṭiyāṭṭam. She further emphasizes that the preparation of the clearing also alludes to the pūrvaraṅga, those semi-ritual and semi-theatrical preliminaries to the performance of dramatic fiction. She concludes by saying that the yogin and the spectator of drama have in common such a ‘recognition’ of the Self (which is none other than their own Self)—a transitory experience for the spectator but one established once and for all for the yogin, who is thus nothing but an ‘emancipated spectator’.
Pracchana Bārhaspatyam
Authors: Nave Orly Hadani
Published: July 2020

This article offers a rich analytical discussion of one of the most amusing of the embedded narratives in Mantrāṅkam—the tale of Iṭṭuṇṇūli and the parrot that eventually outwits her. This story has ancient roots in the Kathā literature but has acquired a peculiarly Keralan character in the process of being integrated into Mantrāṅkam, where it functions as a condensed emblematic statement of the major themes of the play as a whole. Nave has tried to decipher some of the major themes crucial to the project as a whole as they appear in one embedded tale. The play of Mantrāṅkam is considered to be one of the jewels of Kūṭiyāṭṭam. It places an immense strain on the performer and on his memory. It entails a great potential for tension along with enormous effort of the performer.
Reflection and Aruḷ
Authors: Salay Hemdat
Published: July 2020

This essay focuses on the role of Lord Śiva, the deity who is the main subject of the Mattavilāsam, a three-day Kūṭiyāṭṭam masterpiece that also explores the origin of this art form; but also on Śiva as the crypto-identity of Vasantaka, the clown narrator of Mantrāṅkam. Hemdat Salay shows how through the performance of these two texts, the deity is made present in visible form on stage. The call to Śiva is the aruḷ driving the plot and the play, meaning the active and full presence of the deity in his complete, multifaceted, and contradictory form. In this case, the comic and ridiculous nature of the clown fully expresses the always playful deity and enables them to meet and unite.
Mantrāṅkam
Authors: Mucciarelli Elena
Published: July 2020

The author focuses on a tiny segment of the long performance of Mantrāṅkam, trying to use it as a magnifying glass to read the wide open structure of this work. The aim is to see how in the initial moment of the act, the fixed structure is not respected, and also to account for the apparently unmotivated shift between ritual and theatrical parts. If we are facing a fluid text that has always refused to be concluded, do we need to draw a division between what is theatrical and what is ritual? Are these two terms really of use when we deal with ‘non-discrete’ textual traditions? The author argues that to account for fluidity, we must look at the history of this corpus, which clearly retains traces of an earlier stage in the development of this art form.
The Mantrāṅkam Paribhāṣa from a Historical Linguistics Perspective
Authors: Gamliel Ophira
Published: July 2020

The transliterated text is based on the print version of the paribhāṣa published by P. K. Narayanan Nambiar 1980. The paribhāṣa is designated by the performers as kṛtrima-prākṛta-malayāḷam, an artificial ‘Prakrit-Malayalam’. While it is clearly stylized so as to serve representational concerns, which impact on the interpretations, it involves also dialectical and archaic linguistic features, which impact on the interpretation of the text both diachronically and synchronically. Some features are archaic, some are regional or caste-oriented and some are idiosyncratic. The author takes us through the various features in the paribhāṣa and summarizes by informing us that the dialectical features are possibly used in an attempt to render the character of the jester friendly to Malayalam speakers in the audience, regardless of their command of Sanskrit or of the hand-gesture language. The idiosyncratic features are probably aimed at ridiculing the Sanskrit enthusiast Brahmins in the audience.
Aṅgulīyāṅkam, Rāmāyaṇa-Vēda of the Cākyārs
Authors: Johan Virginie
Published: July 2020

Aṅgulīyāṅkam, the Act of the Ring, is the performance of the sixth act of Śaktibhadra’s Āścaryacūḍāmaṇi according to the Kūṭiyāṭṭam tradition of Kerala. The Cākyār masters consider it as a ‘veda’ for pantomime, and for the traditional Rāmāyaṇa repertoire. They perform it as a kūttu, mono-action, according to their Malayalam acting manual (āṭṭaprakāram) for twelve days in five Kerala temples. On the base of this text and of its performance, this paper shows how the kūttu condenses almost the entire Rāmāyaṇa repertoire of Kūṭiyāṭṭam in a complex, unique and unifying structure, and analyses its epic dramaturgy. Johan underlines how the dramaturgy is based on arresting time either on the multiple levels of the dramatic fiction or on the level of the performance.
Aṅgulīyāṅkam
Authors: Bhadra P.K.M. , Rajneesh B.
Published: July 2020

This chapter is an important contribution because Bhadra and Rajneesh are writing from the viewpoint of performers coming from a traditional background, also capable of presenting Kūṭiyāṭṭam in the ritualistic setup of annual temple performances. They give an explanation of the peculiarities of Aṅgulīyāṅkam in comparison with other plays in Kūṭiyāṭṭam and explain the structure of Aṅgulīyāṅkam according to a typical traditional performance lasting for 12 days. They explain the structure of the Namaskāra segment of Aṅgulīyāṅkam and identify it as the basis of all techniques for non-verbal acting in Kūṭiyāṭṭam. Each and every portion of this act can be elaborated as much as possible by an eminent actor. Thus, this act is recognized as the Veda for acting.
Distinct Conventions in the Staging of Aṅgulīyāṅkam Kūttu
Authors: Chakyar Ammannur Kuttan , Nangiar Aparna
Published: July 2020

By getting trained to perform Aṅgulīyāṅkam, the actor becomes an expert in the acting techniques of Kūṭiyāṭṭam, that is, Aṅgulīyāṅkam includes only two characters: Hanumān and Sītā. Hanumān is the only character that performs the whole play and the text of Sītā will be recited by the Naṅṅyār who plays the cymbals. One of the major technical specialities of this play is that it includes the flashback-technique several times in different contexts and thus the whole story of the Rāmāyaṇa will be enacted on the stage. The authors are experienced performers themselves coming from a traditional Kūṭiyāṭṭam performing family. In their essay they analyse the structure of the play from the perspective of the actors, considering both the ritualistic and the aesthetical issues of the performance.
My Experience of Performing Aṅgulīyāṅkam and Mantrāṅkam
Authors: Chakyar Margi Madhu
Published: July 2020

This chapter gives an important testimony of an experienced actor’s viewpoint and his issues with regard to the performance of Aṅgulīyāṅkam and Mantrāṅkam. In this way, he outlines some peculiarities of this performance such as the unique relation with prabandham that can be seen only in Mantrāṅkam or some techniques of todays Kūṭiyāṭṭam that were not evolved yet (nirvahaṇam, kramadīpika). The special feature of these two acts is the enormous demand they make on the actor to perform both in depth and through a vast range at the same time. Here the aesthetic totality is more important when compared to the newer form of other acts, in which the details of enactment are more clearly visible.
Between Yesterday and Tomorrow
Authors: Desai Ashwin , Vahed Goolam
Published: July 2020

This chapter begins with the promise of the Nelson Mandela presidency which made a commitment to building a ‘rainbow nation’ that would consign racism to the dustbin of history. Against this background, the opening chapter seeks to contextualize firstly the placing of Indians in the South African political economy through the long twentieth century that saw waves of colonialism, segregation and apartheid. It shows how through all these periods Indians were always regarded as outsiders and threatened with repatriation. It was only in 1961 a century after the arrival of the first indentured labourers that Indians were regarded as citizens. The chapter plays close attention to the way in which Indian South Africans reacted to discrimination and their attempts to build alliances with Africans. The chapter then zooms into the present and points to how the post-apartheid period raises in new ways the old chestnuts of diaspora, belonging, and citizenship.
Hindus and Muslims
Authors: Desai Ashwin , Vahed Goolam
Published: July 2020

The overwhelming majority of Indians who arrived in South Africa were Hindus. There was also a fair smattering of Muslims, especially with the arrival of merchants from the 1870s. This chapter dissects the continuities and changes wrought on these religions especially by global developments and how local religious figures have sought to mediate these developments.
Place, Memory, and Nostalgia
Authors: Desai Ashwin , Vahed Goolam
Published: July 2020

Indians have suffered multiple forms of loss. During the apartheid period, tens of thousands were forcibly removed and located to townships on the outer edge of cities. In recent times these ‘lost’ places are being remembered through the writing of community histories and get-togethers and resurrection of old networks through the use of the internet. This chapter attempts to understand this phenomenon in the context of the emerging literature on nostalgia and remembering.
Classrooms of Mobility
Authors: Desai Ashwin , Vahed Goolam
Published: July 2020

This chapter argues that while the ‘Indian trader’ is ubiquitous in Africa, it was not due to the trading class but that the most significant change in the class patterns and mobility of Indians has been due to the rise of the professional class. Sparked in the 1960s with the expansion of educational opportunities, by the first half of the 1970s Indian men and women were earning degrees in considerable numbers. This chapter discusses the economic impact of this development, especially in the context of the perception that affirmative action measures in the post-apartheid period are strangling this class’s opportunities, both at educational institutions and in the workplace.
The ‘Tyranny of Numbers’
Authors: Desai Ashwin , Vahed Goolam
Published: July 2020

Affirmative action is the most contested policy in post-apartheid South Africa, with most Indians getting the sense that they are the ‘twice-discriminated’, first by the white minority government and now by an African majority government. This chapter examines the different dimensions of the debate, and especially who will be hardest hit amongst Indians, and why this policy requires some re-jigging.
Capital Accumulation in New Times
Authors: Desai Ashwin , Vahed Goolam
Published: July 2020

This chapter examines new trading opportunities created in the post-apartheid period and how the old merchant class have responded to these new times. It includes an important discussion of the impact of recent South Asian migrants and the rise of African organisations and commentators that seek to circumscribe Indian economic opportunity.
After the Rainbow, Dark Clouds?
Authors: Desai Ashwin , Vahed Goolam
Published: July 2020

While its Constitution commits South Africa to a non-racial ethos and there has been no violent explosions between Indians and Africans, tensions in terms of public utterances and a growth of a narrow African nationalism are on the increase. This chapter, which serves as a conclusion, explores these tensions and what the future holds for Afro-Indian relations, and the place of Indians in South Africa.
A Nuclear Paradise
Authors: Kaur Raminder
Published: July 2020

Chapter 2 grounds the study in an exploration of the ecological, material, and social contours of the region. It focuses on the backstories of Kudankulam as the site for a nuclear plant and the spaces of criticality that were generated. The formidable presence of the nuclear plant, visual, material and discursive spawned a range of reactions that spanned from intrigue to ambivalence to resistance. With an overview of ‘hot spots’ in Kanyakumari and Tirunelveli Districts, the prospect of more radioactivity applies not just to the Kudankulam Nuclear Power Plant but also to high levels of background radiation in peninsular India, and the mining of sand for atomic minerals particularly for alternative sources of nuclear fuel by way of thorium. Along the way, we assess the repercussions of new hierarchies with the migrant middle class of nuclear employees and the entrenchment of old ones along caste-communal lines.
Cultures of Dissent
Authors: Kaur Raminder
Published: July 2020

A lens on the people’s struggle around Kudankulam enables a focus on changes in Indian people’s movements over the last four decades in response to the continuing popularity of non-violence, growing environmental awareness and a culture of entitlement for project-affected people in what are called ‘right-to-lives’ movements. The movement against the plant in Kudankulam began in the late 1980s with fishing communities, activists and environmentalists who shared ideas and practices shared from earlier anti-nuclear campaigns in the neighbouring state of Kerala. Due to threats to water supplies and growing disillusion, the movement expanded to include farming and other communities by the 2000s. Whereas in the 1980s, those in the establishment might have taken nuclear concerns seriously and even be converted by them as happened over plans for a nuclear plant in Kerala, by the turn of the century, these anxieties were dismissed out of hand as matters of policy where consumptive rights took precedence over constitutional rights, and where electricity became a herald for the country’s development over and above other concerns.
Full Lives
Authors: Kaur Raminder
Published: July 2020

After a preliminary discussion on how and where opinion, resilience and/or resistance against a nuclear power plant might emerge, Chapter 5 profiles three people—Josef, Savitri and Rajesh—from different walks of life who navigate competing challenges in their lives. It will be made evident that perceptions of risk were the main catalysts in altering the calculus of criticality, and that these risks need be viewed through a socially embedded lens rather than through a focus on the nuclear power plant alone or an abstracted theory of modernity. Nuclear risks did not emanate from the solar plexus of the reactor alone, but in a circuitous fashion, were rerouted through mundane practice—revisited in terms of changes and challenges to peoples’ health, diets, homes, livelihoods, the expense of living, the future of their children, marriage prospects, and worldviews. Significantly, a focus on their lives demonstrates how resistance was fermenting indigenously and not at the behest of outsiders such as non-governmental organisations (NGOs) and foreign funders or agencies as state officials were wont to say.
The Plot Thickens
Authors: Kaur Raminder
Published: July 2020

Chapter 6 concentrates on a ‘secret’ public hearing that was held on 6 October 2006 with the Nuclear Power Corporation of India Limited in order to swiftly pass the construction of four more reactors at the plant with as little publicity as possible. It provides an exemplary occasion with which to consider the clash of epistemologies between the nuclear state and local residents. For the authorities, the public hearing was no more than a matter of paper protocol. For members of the public, the occasion was loaded with expectations of genuine consultation, justice, and recompense as a matter of an overdue and urgent entitlement—it being the first ever public hearing on the Kudankulam Nuclear Power Plant. After a look at the sovereignty of the nuclear state through its reliance on science and law, the author casts a lens on the preparations, processes and the aftermath of the public hearing, noting some of the direct, creative, and nuanced challenges to the nuclear state.
Discipline and Deviance
Authors: Kaur Raminder
Published: July 2020

Chapter 7 focuses on the attempt to collate data and create an evidence base to inform an anti-nuclear movement through a survey on radiation readings and proximal health problems. Such endeavours signal a tactic that emerged around the turn of the new millennium in the region—one that draws upon the relevance of data and calls upon a politics of transparency for all public authorities even while nuclear agencies see themselves as off-limits. We learn about what may be described as an ‘indigenous survey’, a statistical methodology that was pursued by local residents to produce data that might challenge state-sanctioned information regarding public health, radiation, and the environment in a region of high background radiation and atomic mineral sandmining. The survey organizers aimed to embolden a space of criticality with supportive facts so as to present themselves as knowledgeable and rational, and thereby enter more forcefully into debate with state officials.
An Unlikely Powerhouse
Authors: Kaur Raminder
Published: July 2020

Chapter 8 hones in on political explosions around the village of Idinthakarai that, from 2011, became the nucleus of the anti-nuclear movement in south India. Living only about a kilometre from the plant, village lives, livelihoods, and environments were irrevocably marred by the prospect of radiation burdens. We consider peoples’ role in jettisoning the People’s Movement Against Nuclear Energy as a force to be reckoned with that reached national and transnational circuits. As they waged non-violence from this village, on the one hand, a ‘university without walls’ was created, and on the other, an ‘open-air jail’ for many of the inhabitants who could not venture out for fear of arrest. Through their fast-track learning at the blunt end of nuclear politics, women rose to the challenge as ‘organic intellectuals’. Despite patriarchal convention, they became expert analysts and spokespersons on several subjects that enabled them to pierce the smokescreens of the nuclear state.
Hobbes
Authors: Irwin Terence
Published: July 2020

Hobbes rejects the view of Suarez and Grotius that human nature is essentially social, and therefore denies that morality is appropriate for human nature in its own right. Morality is good for human beings only in the specific conditions that require collective action for mutual protection and security. In these conditions, but not outside them, the observance of moral principles is in one’s interest. Hobbes justifies morality by its indirect effects, in two stages: (1) Individual moral rules do not refer to their good consequences, but none the less the consequence of general observance of the moral rules as a whole is the preservation of peace and security. (2) The preservation of peace and security for society as a whole is not confined to my security, but none the less my security is a consequence of the peace of society. Hobbes infers that observance of the moral rules is justifiable for me because it is in my interest.
Nietzsche
Authors: Irwin Terence
Published: July 2020

Nietzsche questions the claim—accepted by sentimentalists, rationalists, and Kant—that we have good reasons for accepting moral principles and acting on them. We can see why this claim is open to question if we consider the origins of our moral beliefs and attitudes. They arise from the resentment of inferior people who feel humiliated by the achievements of others. The effect of general observance of moral principles can be seen in the modern democratic spirit, which restrains and penalizes the development of any capacities and talents that tend to make some people superior to others. Belief in the equal moral value of everyone is a consolation for inferior people. When we recognize this psychological basis for our moral outlook, we will be less inclined to suppose that it has any special authority.
Exploring the crystal form landscape
Authors: Bernstein Joel
Published: July 2020

Chapter 3 deals with the theoretical background, the strategies, and the experimental techniques for exploring the crystal for landscape. The various and evolving models for aggregation and nucleation are discussed, followed by the description of thermodynamic (i.e., approximately equilibrium) and kinetic crystallization conditions, followed by the use of thermodynamic information obtained in Chapter 2 for designing crystallization strategies. The various aspects of solid form screens—design, composition, time frame, variables to consider, application of high throughput methods—are discussed, followed by a description of the screen on the specific example of axitinib. The chapter closes with discussions of concomitant polymorphs and disappearing polymorphs.
Surprise Medical Bills: Are We Any Nearer to a Federal Fix?
Authors: Molyneux Jacob
Published: July 2020

The pandemic is shaking up health care delivery and markets. And it's an election year.
Traveling to New York City to Tackle COVID-19
Authors: Szulecki Diane
Published: July 2020

Two nurses describe their experiences as visiting workers during the pandemic.
A Message from Frontline Nurses: Let's Keep the Real Enemy in Sight
Authors: Maouyo Rachel , Noon Bridget , Hobilla Barbara , Kim Hojung , Roush Karen
Published: July 2020

Updated several times a week with posts by a wide variety of authors, AJN's blog Off the Charts allows us to provide more timely—and often more personal—perspectives on professional, policy, and clinical issues. Best of the Blog is a regular column to draw the attention of AJN readers to posts we think deserve a wider audience. To read more, please visit: www.ajnoffthecharts.com.
Achieving Gender Equity Is Our Responsibility: Leadership Matters
Authors: Acosta David A. , Lautenberger Diana M. , Castillo-Page Laura , Skorton David J.
Published: July 2020

Across academic medicine, and particularly among faculty and medical school leadership, the status quo is unacceptable when it comes to gender diversity, equity, and inclusion. The Association of American Medical Colleges has launched a bold gender equity initiative, endorsed by its Board of Directors, to implore academic medical institutions to take meaningful and effective actions.

Defining what progress should look like to guide these actions is worth deeper exploration. It is not enough to measure the representation of different genders at various levels of leadership within our institutions. Research and experience we share suggests more must be done, especially for women of diverse racial and ethnic backgrounds. What is needed is a fundamental conversation about privilege, intersectionality across different backgrounds, and progress.

Institutional leaders have a choice to make. Will we make gender equity a top priority system-wide because we recognize that doing so leads to organizational excellence? Do we understand that establishing a robust, comprehensive definition of gender equity and how it is practiced will result in better outcomes for all? And are we ready and able to prioritize and be accountable for efforts that are measurable, with clear definitions of progress; driven and reinforced by leadership directives; inclusive of all, including men as well as women of diverse backgrounds and orientations; and systemic rather than ad-hoc? Implementing such actions requires initiating difficult conversations, making conscious choices, and modeling best practices from leaders who have successfully made gender equity a priority.
Brain Tissue Oxygen Response as Indicator for Cerebral Lactate Levels in Aneurysmal Subarachnoid Hemorrhage Patients
Authors: Hosmann Arthur , Schnackenburg Philipp , Rauscher Steffen , Hopf Andreas , Bohl Isabelle , Engel Adrian , Brugger Jonas , Graf Alexandra , Plöchl Walter , Reinprecht Andrea , Gruber Andreas
Published: July 2020

Background:

Early detection of cerebral ischemia and metabolic crisis is crucial in critically ill subarachnoid hemorrhage (SAH) patients. Variable increases in brain tissue oxygen tension (PbtO2) are observed when the fraction of inspired oxygen (FiO2) is increased to 1.0. The aim of this prospective study was to evaluate whether a 3-minute hyperoxic challenge can identify patients at risk for cerebral ischemia detected by cerebral microdialysis.

Methods:

Twenty consecutive severe SAH patients undergoing continuous cerebral PbtO2 and microdialysis monitoring were included. FiO2 was increased to 1.0 for 3 minutes (the FiO2 challenge) twice a day and PbtO2 responses during the FiO2 challenges were related to cerebral microdialysis–measures, ie, lactate, the lactate-pyruvate ratio, and glycerol. Multivariable linear and logistic regression models were created for each outcome parameter.

Results:

After predefined exclusions, 274 of 400 FiO2 challenges were included in the analysis. Lower absolute increases in PbtO2 (∆PbtO2) during FiO2 challenges were significantly associated with higher cerebral lactate concentration (P<0.001), and patients were at higher risk for ischemic lactate levels >4 mmol/L (odds ratio 0.947; P=0.04). Median (interquartile range) ∆PbtO2 was 7.1 (4.6 to 12.17) mm Hg when cerebral lactate was >4 mmol/L and 10.2 (15.76 to 14.24) mm Hg at normal lactate values (≤4 mmol/L). Median ∆PbtO2 was significantly lower during hypoxic than during hyperglycolytic lactate elevations (4.6 vs. 10.6 mm Hg, respectively; P<0.001). Lactate-pyruvate ratio and glycerol levels were mainly determined by baseline characteristics.

Conclusions:

A 3-minute FiO2 challenge is an easy to perform and feasible bedside diagnostic tool in SAH patients. The absolute increase in PbtO2 during the FiO2 challenge might be a useful surrogate marker to estimate cerebral lactate concentrations and might be used to identify patients at risk for impending ischemia.
Bone Conduction Vibration Vestibular Evoked Myogenic Potential (VEMP) Testing: Reliability in Children, Adolescents, and Young Adults
Authors: Greenwalt Nicole, L. , Patterson Jessie N. , Rodriguez Amanda I. , Fitzpatrick Denis , Gordon Katherine R. , Janky Kristen L.
Published: July 2020

Objectives:

Bone conduction vibration (BCV) vestibular evoked myogenic potentials (VEMP) are clinically desirable in children for multiple reasons. However, no accepted standard exists for stimulus type and the reliability of BCV devices has not been investigated in children. The objective of the current study was to determine which BCV VEMP method (B-71, impulse hammer, or Mini-shaker) yields the highest response rates and reliability in a group of adults, adolescents, and children. It was hypothesized that the Mini-shaker would yield the highest response rates and reliability because it provides frequency specificity, higher output levels without distortion, and the most consistent force output as compared to the impulse hammer and B-71.

Design:

Participants included 10 child (ages 5 to 10), 11 adolescent (ages 11 to 18), and 11 young adult (ages 23 to 39) normal controls. Cervical VEMP (cVEMP) and ocular VEMP (oVEMP) were measured in response to suprathreshold air-conducted, 500 Hz tone bursts and 3 types of BCV (B-71, impulse hammer, and Mini-shaker) across 2 test sessions to assess reliability.

Results:

For cVEMP, response rates were 100% for all methods in all groups with the exception of the adult group in response to the impulse hammer (95%). For oVEMP, response rates varied by group and BCV method. For cVEMP, reliability was highest in adults using the Mini-shaker, in adolescents using the impulse hammer, and in children using the B-71. For oVEMP, reliability was highest in adults using the Mini-shaker, in adolescents using the Mini-shaker or impulse hammer, and in children using the impulse hammer. Age positively correlated with air-conducted oVEMP amplitude, but not cVEMP amplitude or cVEMP corrected amplitude. Age negatively correlated with all BCV VEMP amplitudes with the exception of cVEMP corrected amplitude in response to the Mini-shaker.

Conclusions:

All BCV methods resulted in consistent cVEMP responses (response rates 95 to 100%) with at least moderate reliability (intraclass correlation coefficient ≥ 0.5) for all groups. Similarly, all BCV methods resulted in consistent oVEMP responses (89 to 100%) with at least moderate reliability (intraclass correlation coefficient ≥ 0.5) except for the B-71 in adults.
An orthopaedist’s review of diabetic foot wounds and osteomyelitis
Authors: DeSanto Matthew R. , Weber Luke V. , Nageeb Emmanuel , Petersen Kyle , Junko Jeffrey
Published: July 2020

As the number of patients with diabetes continues to grow, complications of diabetes have likewise increased. Specifically, diabetic foot ulcers have become a massive burden to both the diabetic patient population and national healthcare systems. Diabetic foot ulcers occur due to nerve damage as a result of extensive hyperglycemia. This nerve damage can allow the progression of ulceration, thus providing a window of opportunity for various pathogens to invade the surrounding tissue. Extensive infection of the ulcer tissue can lead to infection of nearby bone, which may require both surgical and antimicrobial intervention for proper wound healing. The aim of this review was to describe the etiology, pathological progressions, and the advancement of ideologies pertaining to treatment options for diabetic foot ulcers.
Intercalary Allograft Reconstruction of the Proximal Tibia With and Without a Free Fibula Flap in Pediatric Patients
Authors: Misaghi Amirhossein , Jackson Taylor J. , Stans Anthony A. , Shaughnessy William J. , Rose Peter S. , Moran Steven L. , Houdek Matthew T.
Published: July 2020

Background:

Limb salvage of the proximal tibia can be difficult due to the growth potential of and functional demands of the pediatric patients. Multiple reconstruction techniques exist, however, the ideal form of reconstruction is yet to be elucidated. The purpose of the current study is to evaluate outcomes in patients with an intercalary resection of the proximal tibia reconstructed with an allograft with or without a free vascularized fibula flap (FVF).

Methods:

Seventeen pediatric patients (9 males, 8 females) underwent lower extremity limb salvage with the use of intercalary cadaveric allograft at a mean age of 12±4 years. The most common diagnoses were osteosarcoma (n=6) and Ewing sarcoma (n=6). Patients were reconstructed with an allograft alone (n=6) or supplemented with an FVF (n=11).

Results:

All surviving patients had at least 2 years of clinical follow-up, with the mean follow-up of 12±7 years. The mean time to union of the allograft was 11±4 months, with 6 patients requiring additional bone grafting. There was no difference in the need for an additional bone graft (odds ratio=1.14, P=1.0) between patients with an FVF and those without. Four patients underwent an amputation, all with an allograft alone, due to disease recurrence (n=2) and due to infection (n=2). As such, there was a higher 10-year overall limb-salvage rate when the allograft was combined with an FVF compared with an allograft alone (100% vs. 33%, P=0.001). At last follow-up, the mean Mankin and Musculoskeletal Tumor Society rating was 86%, with a higher mean score in patients reconstructed with an FVF (94% vs. 70%, P=0.002).

Conclusion:

Use of an intercalary allograft supplemented with an FVF to reconstruct the proximal tibia provides a durable means of reconstruction with an excellent functional outcome following oncologic proximal tibia resection in a pediatric population.

Level of Evidence:

Level III—therapeutic level.
Association Between the Serum Carnitine Level and Ammonia and Valproic Acid Levels in Patients with Bipolar Disorder
Authors: Yokoyama Saaya , Yasui-Furukori Norio , Nakagami Taku , Miyazaki Kensuke , Ishioka Masamichi , Tarakita Natsumi , Kubo Kazutoshi , Sugawara Norio , Shimoda Kazutaka
Published: July 2020

Purpose:

Valproic acid (VPA) is not only an antiepileptic drug but also a mood stabilizer for patients with bipolar disorder. Long-term VPA therapy can cause carnitine deficiency, which may result in an increase in the blood ammonia level, in patients with epilepsy. However, information about this effect in patients with bipolar disorder is limited. The aim of this study was to investigate the associations between the serum VPA level and the carnitine and ammonia levels in psychiatric adult patients with epilepsy.

Methods:

The subjects were 182 consecutive Japanese adult patients (mean age 54.3 ± 19.5 years) diagnosed with bipolar disorder and treated with VPA. The serum VPA level, carnitine fraction, and plasma ammonia level were measured. Furthermore, the free carnitine and acylcarnitine fractions were measured using an enzyme cycling method.

Results:

Sixty-nine patients (38%) had a low free carnitine level. There were significant differences in sex, height, VPA dose, serum VPA level, total carnitine level, acylcarnitine level, and acylcarnitine/free carnitine ratio between patients with a low free carnitine level and those with a normal range of free carnitine. The simple and multiple regression analyses revealed that the VPA dose and the serum VPA level were inversely and significantly correlated with the free carnitine level. The plasma ammonia level was correlated with the VPA dose, serum VPA level, and acylcarnitine level but not with the free carnitine level.

Conclusions:

These findings suggest that carnitine deficiency is associated with the VPA dose and the serum VPA level in patients with bipolar disorder. However, it is unlikely that carnitine deficiency is associated with hyperammonemia in patients with bipolar disorder.
Neurotoxicity Despite a Renal Function-Adjusted Cefepime Regimen: A Case Study
Authors: Engalenc Xavier , Monchaud Caroline , Tafzi Naïma , Woillard Jean-Baptiste
Published: July 2020

An 83-year-old man, presenting decreased renal function (estimated glomerular filtration rate 21 mL/min/1.73 m2), was treated for a bone and joint infection (on a trans-metatarsal right foot amputation) caused by Klebsiella Pneumonia sensitive to cefepime. The starting dose (1 g bid) was based on recommendations for patients presenting severe infections. One week after treatment initiation, the patient developed neurotoxicity, exhibiting extremely high plasma cefepime concentrations. Based on TDM, the dose was reduced by 8 times the original dose. This case report highlights the importance of therapeutic drug monitoring for cefepime, especially in patients presenting altered renal functions, as typical recommendations are estimated for standard patients.
Differences in Theophylline Clearance Between Patients With Chronic Hepatitis and Those With Liver Cirrhosis
Authors: Kurata Yasuo , Muraki Shota , Kashihara Yushi , Hirota Takeshi , Araki Hiroshi , Ieiri Ichiro
Published: July 2020

Background:

Theophylline, a xanthine derivative drug, is used for the treatment of respiratory diseases, such as asthma, and is primarily eliminated by hepatic metabolism. There is marked interindividual variability in theophylline clearance. Therefore, the aim of this study was to evaluate the influence of chronic hepatitis (CH), liver cirrhosis (LC), and other covariates on theophylline clearance by population pharmacokinetic (PPK) analysis.

Methods:

The authors retrospectively obtained 496 trough concentrations of theophylline at steady state from 226 adult patients with bronchial asthma. The liver functions of the patients were classified into 3 categories: normal hepatic function, CH, and LC. The PPK analysis was performed using the NONMEM program. CH, LC, age, smoking status, coadministration of clarithromycin (CAM), and sex were considered as covariates that affected theophylline clearance.

Results:

Theophylline clearance (CL/F per kg) was significantly influenced by CH, LC, smoking, and CAM. The final model of theophylline clearance was as follows: CL/F (L/h·kg−1) = 0.0484 × 1.40SMK × 0.861CAM × 0.889CH × 0.557LC. Smoking is a well-known factor that markedly enhances CL/F through the induction of CYP1A enzymes, whereas CAM has been reported to inhibit CYP3A4. The final model for hepatic function showed that CL/F in CH and LC patients was 0.043 and 0.027 L/h/kg, respectively, and it was lower than that in patients with normal hepatic function. As theophylline clearance depends on intrinsic hepatic clearance, lower CL/F in patients with LC than in those with CH may be due to a decrease in the metabolic enzymatic capability of LC patients.

Conclusions:

Differences exist in theophylline clearance between CH and LC patients as per the PPK analysis.
Impact of Education-based HEART Score Pathway on Coronary Computed Tomography Angiography Utilization and Yield in the Emergency Department
Authors: Shrestha Pragati , Morley Eric J. , Thode Henry C. , Schweitzer Mark E. , Singer Adam J.
Published: July 2020

Objective:

There is a growing consensus to reduce unnecessary testing among low-risk chest pain patients. The objective of this study was to evaluate the impact of implementing an education-based HEART score pathway in the emergency department on coronary computed tomography angiography (CCTA) utilization and yield.

Methods:

A retrospective before and after intervention study was conducted at a single site. Adult emergency department patients undergoing CCTA for suspected acute coronary syndrome were included. Primary outcomes were CCTA utilization and yield. Utilization was defined as the percentage of patients evaluated with CCTA and yield was calculated as the percentage of patients with a diagnosis of obstructive coronary artery disease, defined as ≥50% stenosis in any one coronary artery due to atherosclerosis.

Results:

1540 patients undergoing CCTAs were included. CCTA utilization before and after were 2.2% [95% confidence interval (CI) 2.0–2.3] and 2.0% (95% CI 1.9–2.2), respectively; mean difference 0.1% (95% CI −0.1 to 0.3; P = 0.21). The mean age was 53 years (SD = 11) and females were 52%. Of 1477 patients included in CCTA yield analysis, patients diagnosed with obstructive coronary artery disease before and after were 15.0% (95% CI 12.6–17.7) and 16.2% (95% CI 13.6–19.1), respectively; mean difference 1.2% (95% CI −2.6 to 5.1; P = 0.53).

Conclusions:

There was no significant change in the CCTA utilization or yield after the implementation of an education-based HEART pathway in a large academic center. Our findings suggest adopting a more comprehensive approach for deploying such evidence-based protocols to increase institutional compliance.
A longitudinal examination of the interpersonal fear avoidance model of pain: the role of intolerance of uncertainty
Authors: Neville Alexandra , Kopala-Sibley Daniel C. , Soltani Sabine , Asmundson Gordon J.G. , Jordan Abbie , Carleton R. Nicholas , Yeates Keith Owen , Schulte Fiona , Noel Melanie
Published: July 2020

Youth with chronic pain and their parents face uncertainty regarding their diagnosis, treatment, and prognosis. Given the uncertain nature of chronic pain and high comorbidity of anxiety among youth, intolerance of uncertainty (IU) may be critical to the experience of pediatric chronic pain. This study longitudinally examined major tenets of the Interpersonal Fear Avoidance Model of Pain and included parent and youth IU as key factors in the model. Participants included 152 youth with chronic pain (Mage = 14.23 years; 72% female) and their parents (93% female). At baseline, parents and youth reported on their IU and catastrophic thinking about youth pain; youth reported on their fear of pain, pain intensity, and pain interference; and parents reported on their protective responses to child pain. Youth reported on their pain interference 3 months later. Cross-lagged panel models, controlling for baseline pain interference, showed that greater parent IU predicted greater parent pain catastrophizing, which, in turn, predicted greater parent protectiveness, greater youth fear of pain, and subsequently greater youth 3-month pain interference. Youth IU had a significant indirect effect on 3-month pain interference through youth pain catastrophizing and fear of pain. The results suggest that parent and youth IU contribute to increases in youth pain interference over time through increased pain catastrophizing, parent protectiveness, and youth fear of pain. Thus, parent and youth IU play important roles as risk factors in the maintenance of pediatric chronic pain over time and may be important targets for intervention.
Netrin-1 receptor DCC is required for the contralateral topography of lamina I anterolateral system neurons
Authors: Bourojeni Farin B. , Zeilhofer Hanns Ulrich , Kania Artur
Published: July 2020

Anterolateral system (AS) neurons relay nociceptive information from the spinal cord to the brain, protecting the body from harm by evoking a variety of behaviours and autonomic responses. The developmental programs that guide the connectivity of AS neurons remain poorly understood. Spinofugal axons cross the spinal midline in response to Netrin-1 signalling through its receptor deleted in colorectal carcinoma (DCC); however, the relevance of this canonical pathway to AS neuron development has only been demonstrated recently. Here, we disrupted Netrin-1:DCC signalling developmentally in AS neurons and assessed the consequences on the path finding of the different classes of spinofugal neurons. Many lamina I AS neurons normally innervate the lateral parabrachial nucleus and periaqueductal gray on the contralateral side. The loss of DCC in the developing spinal cord resulted in increased frequency of ipsilateral projection of spinoparabrachial and spinoperiaqueductal gray neurons. Given that contralateral spinofugal projections are largely associated with somatotopic representation of the body, changes in the laterality of AS spinofugal projections may contribute to reduced precision in pain localization observed in mice and humans carrying Dcc mutations.
Activation of the Notch signaling pathway in the anterior cingulate cortex is involved in the pathological process of neuropathic pain
Authors: Duan Haifeng , Shen Fengyan , Li Li , Tu Zhiyi , Chen Ping , Chen Pei , Wang Zhiru , Liang Weimin , Wang Yingwei
Published: July 2020

Plastic changes in the anterior cingulate cortex (ACC) are critical in pain hypersensitivity caused by peripheral nerves injury. The Notch signaling pathway has been shown to regulate synaptic differentiation and transmission. Therefore, this study was to investigate the function of the Notch signaling pathway in the ACC during nociceptive transmission induced by neuropathic pain. We adopted Western blotting, N-[N-(3,5-difluorophenacetyl)-l-alanyl]-S-phenylglycine t-butyl ester (DAPT) microinjections, RNA interference targeting Notch1, Hairy and enhancer of split (Hes) 1 or Hes5, electrophysiological recordings, and behavioral tests to verify the link between Notch signaling in ACC and neuropathic pain with adult male Sprague-Dawley rats. Levels of the Notch intracellular domain were increased in ACC on day 7 after chronic constriction injury surgery or spared nerve injury. Meanwhile, the mRNA level of the downstream effector of Notch signaling Hes1 was increased, whereas the level of Hes5 mRNA did not change. Microinjection of DAPT, a γ-secretase (a key enzyme involved in Notch pathway) inhibitor, into ACC significantly reversed neuropathic pain behaviors. Intra-ACC injection of short hairpin RNA-Notch reduced Notch intracellular domain expression and decreased the potentiation of synaptic transmission in the ACC. Moreover, pain perceptions were also alleviated in rats subjected to chronic constriction injury or spared nerve injury. This process was mainly mediated by the downstream effector Hes1, but not Hes5. Based on these results, the activation of the Notch/Hes1 signaling pathway in the ACC participates in the development of neuropathic pain, indicating that the Notch pathway may be a new therapeutic target for treating chronic pain.