bluuebunny/crossref_metadata_2025 huggingface dataset:
Observation of Neointimal Coverage Around the Aneurysm Neck After Stent-Assisted Coil Embolization by Optical Frequency Domain Imaging: Technical Case Report
Authors: Yako Rie , Matsumoto Hiroyuki , Masuo Osamu , Nakao Naoyuki
Published: March 2017

BACKGROUND AND IMPORTANCE: Stent-assisted coil embolization has been established as a treatment option for wide-necked or complex aneurysms. However, concerns have been raised about the incidence of thromboembolic complications, which is higher for coil embolization without stent assistance. Long-term antiplatelet therapy is necessary to prevent acute or delayed ischemic events potentially associated with incomplete stent apposition after treatment with stent-assisted coil embolization. Optical frequency domain imaging (OFDI) provides excellent-resolution images of intraluminal structures, allowing evaluation of the outcomes of stent-assisted procedures in terms of stent apposition and neointimal coverage. We here describe the novel use of OFDI for the observation of intravascular tissue formation after stent-assisted coil embolization.

CLINICAL PRESENTATION: Two patients were treated with stent-assisted coil embolization for unruptured vertebral artery aneurysm. At the 1- or 2-yr follow-up visit, routine angiography followed by OFDI were performed to evaluate neointimal coverage of the stent strut and stent apposition to the vascular wall. OFDI enabled clear visualization of the vessel wall structures and demonstrated complete coverage of the stent struts as well as full stent wall apposition in 1 patient and incomplete coverage near the aneurism neck as well as mallaposition of some struts in the other patient.

CONCLUSION: OFDI represents a feasible modality for the evaluation of intracranial vasculature and the outcomes of stent-assisted coil embolization in terms of intimal healing of aneurysms, stent-vessel interactions, and neointimal coverage of the stent. Such information is helpful in determining the duration of antiplatelet therapy after stent-assisted coil embolization.
Two twin binaries with nearly identical components: KIC 4826439 and KIC 6045264
Authors: Zhang Jia , Qian Sheng-Bang , Wang Shu-Min , Wu Yue , Jiang Lin-Qiao
Published: March 2017

Two twin binaries, KIC 4826439 and KIC 6045264, with very similar component stars were found photometrically based on Kepler eclipsing binary light curves. The absolute parameters of the massive components are 1.156(0.03) M⊙, 1.881(0.02) R⊙, 6065 K for KIC 4826439, and 0.874(0.3) M⊙, 1.206(0.02) R⊙, 6169(30) K for KIC 6045264. The differences between the components are less than two percent for all the parameters. A very low proportion of twin binaries (2/1592 ≈ 0.13%) was found, which does not support the previous findings of excesses of twins on binary mass ratio distribution, but supports a deficiently low proportion of twins. A new method is used to work out the absolute parameters of the two twins without the radial velocities. This method requires the solution of the light curves, the spectra, and the evolutionary isochrones covering the complete stellar parameter space, simultaneously. We also studied their evolution tracks: KIC 4826439 will experience an unstable mass transfer stage followed by an unclear ending, and KIC 6045264 will become a single star via an over-contact phase. It seems highly unlikely that the two twin binaries will produce twin degenerate binaries, although they have quite similar components.
The Economic and Clinical Impact of Sustained Use of a Progressive Mobility Program in a Neuro-ICU*
Authors: Hester Jeannette M. , Guin Peggy R. , Danek Gale D. , Thomas Jaime R. , Titsworth William L. , Reed Richard K. , Vasilopoulos Terrie , Fahy Brenda G.
Published: March 2017

Objective:

To investigate a progressive mobility program in a neurocritical care population with the hypothesis that the benefits and outcomes of the program (e.g., decreased length of stay) would have a significant positive economic impact.

Design:

Retrospective analysis of economic and clinical outcome data before, immediately following, and 2 years after implementation of the Progressive Upright Mobility Protocol Plus program (UF Health Shands Hospital, Gainesville, FL) involving a series of planned movements in a sequential manner with an additional six levels of rehabilitation in the neuro-ICU at UF Health Shands Hospital.

Setting:

Thirty-bed neuro-ICU in an academic medical center.

Patients:

Adult neurologic and neurosurgical patients: 1,118 patients in the pre period, 731 patients in the post period, and 796 patients in the sustained period.

Interventions:

Implementation of Progressive Upright Mobility Protocol Plus.

Measurements and Main Results:

ICU length of stay decreased from 6.5 to 5.8 days in the immediate post period and 5.9 days in the sustained period (F
(2,2641) = 3.1; p = 0.045). Hospital length of stay was reduced from 11.3 ± 14.1 days to 8.6 ± 8.8 post days and 8.8 ± 9.3 days sustained (F
(2,2641) = 13.0; p < 0.001). The impact of the study intervention on ICU length of stay (p = 0.031) and hospital length of stay (p < 0.001) remained after adjustment for age, sex, diagnoses, sedation, and ventilation. Hospital-acquired infections were reduced by 50%. Average total cost per patient after adjusting for inflation was significantly reduced by 16% (post period) and 11% (sustained period) when compared with preintervention (F
(2,2641) = 3.1; p = 0.045). Overall, these differences translated to an approximately $12.0 million reduction in direct costs from February 2011 through the end of 2013.

Conclusions:

An ongoing progressive mobility program in the neurocritical care population has clinical and financial benefits associated with its implementation and should be considered.
Early Lactate Clearance Is Associated With Improved Outcomes in Patients With Postcardiac Arrest Syndrome: A Prospective, Multicenter Observational Study (SOS-KANTO 2012 Study)
Authors: Hayashida Kei , Suzuki Masaru , Yonemoto Naohiro , Hori Shingo , Tamura Tomoyoshi , Sakurai Atsushi , Tahara Yoshio , Nagao Ken , Yaguchi Arino , Morimura Naoto
Published: March 2017

Objectives:

To determine whether early lactate reduction is associated with improved survival and good neurologic outcome in patients with out-of-hospital cardiac arrest.

Design:

Ad hoc data analysis of a prospective, multicenter observational study.

Setting:

Out-of-hospital cardiac arrest patients at 67 emergency hospitals in Kanto, Japan between January 2012 and March 2013.

Patients:

Adult patients with out-of-hospital cardiac arrest admitted to the hospital after successful resuscitation were identified.

Interventions:

Blood lactate concentrations were measured at hospital admission and 6 h after hospital admission. Early lactate clearance was defined as the percent change in lactate level 6 h after a baseline measurement.

Measurements and Main Results:

The 543 patients (mean age, 65 ± 16 yr; 72.6% male) had a mean lactate clearance of 42.4% ± 53.7%. Overall 30-day survival and good neurologic outcome were 47.1% and 27.4%, respectively. The survival proportion increased with increasing lactate clearance (quartile 1, 29.4%; quartile 2, 42.6%; quartile 3, 51.5%; quartile 4, 65.2%; p < 0.001). Multivariate logistic regression analysis showed that lactate clearance quartile was an independent predictor of the 30-day survival and good neurologic outcome. In the Cox proportional hazards model, the frequency of mortality during 30 days was significantly higher for patients with lactate clearance in quartile 1 (hazard ratio, 3.12; 95% CI, 2.14–4.53), quartile 2 (hazard ratio, 2.13; 95% CI, 1.46–3.11), and quartile 3 (hazard ratio, 1.49; 95% CI, 1.01–2.19) than those with lactate clearance in quartile 4. Furthermore, multivariate logistic regression analysis revealed that lactate clearance was a significant predictor of good neurologic outcome at 30 days after hospital admission.

Conclusions:

Effective lactate reduction over the first 6 hours of postcardiac arrest care was associated with survival and good neurologic outcome independently of the initial lactate level.
Outcomes for Children Receiving Noninvasive Ventilation as the First-Line Mode of Mechanical Ventilation at Intensive Care Admission: A Propensity Score-Matched Cohort Study*
Authors: Morris Jenny V. , Ramnarayan Padmanabhan , Parslow Roger C. , Fleming Sarah J.
Published: March 2017

Objectives:

To compare outcomes of children receiving noninvasive ventilation with those receiving invasive ventilation as first-line mode of mechanical ventilation following unplanned intensive care admission.

Design:

Propensity score-matched cohort study analyzing data prospectively collected by the Pediatric Intensive Care Audit Network over 8 years (2007–2014).

Setting:

Thirty-one PICUs in the United Kingdom and Ireland; twenty-one of whom submitted Pediatric Critical Care Minimum Dataset data for the entire study period.

Patients:

Children consecutively admitted to study PICUs. Planned admissions following surgery, unplanned admissions from other hospitals, those on chronic ventilation, and those who did not receive mechanical ventilation on the day of PICU admission were excluded.

Interventions:

Use of noninvasive ventilation, rather than invasive ventilation, as the first-line mode of mechanical ventilation.

Measurements and Main Results:

PICU mortality, length of ventilation, length of PICU stay, and ventilator-free days at day 28. During the study period, there were 151,128 PICU admissions. A total of 15,144 admissions (10%) were eligible for analysis once predefined exclusion criteria were applied: 4,804 (31.7%) received “noninvasive ventilation first,” whereas 10,221 (67.5%) received “invasive ventilation first”; 119 (0.8%) admissions could not be classified. Admitting PICU site explained 6.5% of the variation in first-line mechanical ventilation group (95% CI, 2.0–19.0%). In propensity score-matched analyses, receiving noninvasive ventilation first was associated with a significant reduction in mortality by 3.1% (95% CI, 1.7–4.6%), length of ventilation by 1.6 days (95% CI, 1.0–2.3), and length of PICU stay by 2.1 days (95% CI, 1.3–3.0), as well as an increase in ventilator-free days at day 28 by 3.7 days (95% CI, 3.1–4.3).

Conclusions:

Use of noninvasive ventilation as first-line mode of mechanical ventilation in critically ill children admitted to PICU in an unplanned fashion may be associated with significant clinical benefits. Further high-quality evidence regarding optimal patient selection and timing of initiation of noninvasive ventilation could lead to less variability in clinical care between institutions and improved patient outcomes.
Delayed Second Dose Antibiotics for Patients Admitted From the Emergency Department With Sepsis: Prevalence, Risk Factors, and Outcomes*
Authors: Leisman Daniel , Huang Victor , Zhou Qiuping , Gribben Jeanie , Bianculli Andrea , Bernshteyn Michelle , Ward Mary Frances , Schneider Sandra M.
Published: March 2017

Objective:

1) Determine frequency and magnitude of delays in second antibiotic administration among patients admitted with sepsis; 2) Identify risk factors for these delays; and 3) Exploratory: determine association between delays and patient-centered outcomes (mortality and mechanical ventilation after second dose).

Design:

Retrospective, consecutive sample sepsis cohort over 10 months.

Setting:

Single, tertiary, academic medical center.

Patients:

All patients admitted from the emergency department with sepsis or septic shock (defined: infection, ≥ 2 systemic inflammatory response syndrome criteria, hypoperfusion/organ dysfunction) identified by a prospective quality initiative. Exclusions: less than 18 years old, not receiving initial antibiotics in the emergency department, death before antibiotic redosing, and patient refusing antibiotics.

Interventions:

We determined first-to-second antibiotic time and delay frequency. We considered delay major for first-to-second dose time greater than or equal to 25% of the recommended interval. Factors of interest were demographics, recommended interval length, comorbidities, clinical presentation, location at second dose, initial resuscitative care, and antimicrobial activity mechanism.

Measurements and Main Results:

Of 828 sepsis cases, 272 (33%) had delay greater than or equal to 25%. Delay frequency increased dose dependently with shorter recommended interval: 11 (4%) delays for 24-hour intervals (median time, 18.52 hr); 31 (26%) for 12-hour intervals (median, 10.58 hr); 117 (47%) for 8-hour intervals (median, 9.60 hr); and 113 (72%) for 6-hour intervals (median, 9.55 hr). In multivariable regression, interval length significantly predicted major delay (12 hr: odds ratio, 6.98; CI, 2.33–20.89; 8 hr: odds ratio, 23.70; CI, 8.13–69.11; 6 hr: odds ratio, 71.95; CI, 25.13–206.0). Additional independent risk factors were inpatient boarding in the emergency department (odds ratio, 2.67; CI, 1.74–4.09), initial 3-hour sepsis bundle compliance (odds ratio, 1.57; CI, 1.07–2.30), and older age (odds ratio, 1.16 per 10 yr, CI, 1.01–1.34). In the exploratory multivariable analysis, major delay was associated with increased hospital mortality (odds ratio, 1.61; CI, 1.01–2.57) and mechanical ventilation (odds ratio, 2.44; CI, 1.27–4.69).

Conclusions:

Major second dose delays were common, especially for patients given shorter half-life pharmacotherapies and who boarded in the emergency department. They were paradoxically more frequent for patients receiving compliant initial care. We observed association between major second dose delay and increased mortality, length of stay, and mechanical ventilation requirement.
Controversies in Intrapatient Melanoma BRAFV600E Mutation Status
Authors: Riveiro-Falkenbach Erica , Santos-Briz Angel , Ríos-Martín Juan J. , Rodríguez-Peralto José L.
Published: March 2017

Therapies targeting the BRAF

V600
oncogene have improved the overall and disease-free survival of patients with advanced melanomas. An unresolved issue in clinical practice is the existence (or not) of BRAF

V600
-mutated and BRAF

V600
-nonmutated tumors in individual patients (intrapatient BRAF mutation heterogeneity), which may serve as a mechanism of resistance to BRAF inhibitors or lead to diagnostic problems. Different research groups have reported differing results after analyzing the BRAF mutation statuses of multiple melanoma tumors. Herein, we present a brief revision of the literature on this controversial topic and propose a theory to justify the divergence of the results found in the literature.
Cyclophilin D Modulates the Cardiac Mitochondrial Target of Isoflurane, Sevoflurane, and Desflurane
Authors: Harisseh Rania , Chiari Pascal , Villedieu Camille , Sueur Pauline , Abrial Maryline , Fellahi Jean-Luc , Ovize Michel , Gharib Abdallah
Published: March 2017

Background:

Volatile anesthetics are known to limit myocardial ischemia–reperfusion injuries. Mitochondria were shown to be major contributors to cardioprotection. Cyclophilin D (CypD) is one of the main regulators of mitochondria-induced cell death. We compared the effect of isoflurane, sevoflurane, and desflurane in the presence or absence of CypD, to clarify its role in the mechanism of cardioprotection induced by these anesthetics.

Methods:

Oxidative phosphorylation, mitochondrial membrane potential, and H2O2 production were measured in isolated mitochondria from wild-type (WT) or CypD knockout mice in basal conditions and after hypoxia–reoxygenation in the presence or absence of volatile anesthetics.

Results:

All volatile anesthetics inhibited mitochondrial state 3 of complex I, decreased membrane potential, and increased adenosine diphosphate consumption duration in both WT and CypD knockout mice. However, they differently modified H2O2 production after stimulation by succinate: CypD ablation reduced H2O2 production, isoflurane decreased H2O2 level in WT but not in CypD knockout mice, sevoflurane affected both lines whereas desflurane increased H2O2 production in CypD knockout and had no effect on WT mice.

Conclusions:

This study showed different effects of isoflurane, sevoflurane, and desflurane on mitochondrial functions and highlighted the implication of CypD in the regulation of adenosine diphosphate consumption and complex I–induced radical oxygen species production.
Dacryoadenitis as the Initial Presentation of a Natural Killer T-Cell Lymphoma
Authors: Jiménez-Pérez Juan C. , Jakobiec Frederick A. , Zakka Fouad R. , Yoon Michael K.
Published: March 2017

Primary orbital natural killer T-cell lymphoma (NKTCL) is a rare condition with only a few published cases in the literature. Over 1 month, an 81-year-old man developed progressive left periocular inflammation unresponsive to treatment. Clinical examination and imaging studies demonstrated a left lacrimal gland enlargement. Bilateral anterior uveitis and erythematous nontender cutaneous lesions were also found. Biopsies of the skin and lacrimal gland on the back revealed histopathologic and immunohistochemical findings confirming Epstein–Barr virus-positive NKTCL. Metastatic work up disclosed multifocal involvement in the pancreas, stomach, and chest wall. Palliative treatment consisting of nonanthracycline-based chemotherapy and radiation was instituted, but the patient died 5 months after the onset of symptoms. This is the first example of acute dacryoadenitis, and the second of bilateral anterior uveitis, in the setting of NKTCL. Absence of naso-sinus involvement in the current case is rare in NKTCL. Despite treatment, the prognosis remains dismal. Orbital specialists should include NKTCL in the differential diagnosis of lacrimal gland/orbital masses and perform an incisional biopsy if the clinical scenario so dictates.
Chronic pain patients' perspectives of medical cannabis
Authors: Piper Brian J. , Beals Monica L. , Abess Alexander T. , Nichols Stephanie D. , Martin Maurice W. , Cobb Catherine M. , DeKeuster Rebecca M.
Published: March 2017

Medical cannabis (MC) is used for a variety of conditions including chronic pain. The goal of this report was to provide an in-depth qualitative exploration of patient perspectives on the strengths and limitations of MC. Members of MC dispensaries (N = 984) in New England including two-thirds with a history of chronic pain completed an online survey. In response to “How effective is medical cannabis in treating your symptoms or conditions?,” with options of 0% “no relief” to 100% “complete relief,” the average was 74.6% ± 0.6. The average amount spent on MC each year was $3064.47 ± 117.60, median = $2320.23, range = $52.14 to $52,140.00. Open-ended responses were coded into themes and subthemes. Analysis of answers to “What is it that you like most about MC?” (N = 2592 responses) identified 10 themes, including health benefits (36.0% of responses, eg, “Changes perception and experience of my chronic pain.”), the product (14.2%, eg, “Knowing exactly what strain you are getting”), nonhealth benefits (14.1%), general considerations (10.3%), and medications (7.1%). Responses (N = 1678) to “What is it that you like least about MC?” identified 12 themes, including money (28.4%, eg, “The cost is expensive for someone on a fixed income”), effects (21.7%, eg, “The effects on my lungs”), the view of others (11.4%), access (8.2%), and method of administration (7.1%). These findings provide a patient-centered view on the advantages (eg, efficacy in pain treatment, reduced use of other medications) and disadvantages (eg, economic and stigma) of MC.
The long-term reliability of static and dynamic quantitative sensory testing in healthy individuals
Authors: Marcuzzi Anna , Wrigley Paul J. , Dean Catherine M. , Adams Roger , Hush Julia M.
Published: March 2017

Quantitative sensory tests (QSTs) have been increasingly used to investigate alterations in somatosensory function in a wide range of painful conditions. The interpretation of these findings is based on the assumption that the measures are stable and reproducible. To date, reliability of QST has been investigated for short test-retest intervals. The aim of this study was to investigate the long-term reliability of a multimodal QST assessment in healthy people, with testing conducted on 3 occasions over 4 months. Forty-two healthy people were enrolled in the study. Static and dynamic tests were performed, including cold and heat pain threshold (CPT, HPT), mechanical wind-up [wind-up ratio (WUR)], pressure pain threshold (PPT), 2-point discrimination (TPD), and conditioned pain modulation (CPM). Systematic bias, relative reliability and agreement were analysed using repeated measure analysis of variance, intraclass correlation coefficients (ICCs3,1) and SE of the measurement (SEM), respectively. Static QST (CPT, HPT, PPT, and TPD) showed good-to-excellent reliability (ICCs: 0.68-0.90). Dynamic QST (WUR and CPM) showed poor-to-good reliability (ICCs: 0.35-0.61). A significant linear decrease over time was observed for mechanical QST at the back (PPT and TPD) and for CPM (P < 0.01). Static QST were stable over a period of 4 months; however, a small systematic decrease over time has been observed for mechanical QST. Dynamic QST showed considerable variability over time; in particular, CPM using PPT as the test stimulus did not show adequate reliability, suggesting that this test paradigm may be less useful for monitoring individuals over time.
Neuropathic pain-induced enhancement of spontaneous and pain-evoked neuronal activity in the periaqueductal gray that is attenuated by gabapentin
Authors: Samineni Vijay K. , Premkumar Louis S. , Faingold Carl L.
Published: March 2017

Neuropathic pain is a debilitating pathological condition that is poorly understood. Recent evidence suggests that abnormal central processing occurs during the development of neuropathic pain induced by the cancer chemotherapeutic agent, paclitaxel. Yet, it is unclear what role neurons in supraspinal pain network sites, such as the periaqueductal gray, play in altered behavioral sensitivity seen during chronic pain conditions. To elucidate these mechanisms, we studied the spontaneous and thermally evoked firing patterns of ventrolateral periaqueductal gray (vlPAG) neurons in awake-behaving rats treated with paclitaxel to induce neuropathic pain. In the present study, vlPAG neurons in naive rats exhibited either excitatory, inhibitory, or neutral responses to noxious thermal stimuli, as previously observed. However, after development of behavioral hypersensitivity induced by the chemotherapeutic agent, paclitaxel, vlPAG neurons displayed increased neuronal activity and changes in thermal pain-evoked neuronal activity. This involved elevated levels of spontaneous firing and heightened responsiveness to nonnoxious stimuli (allodynia) as well as noxious thermal stimuli (hyperalgesia) as compared with controls. Furthermore, after paclitaxel treatment, only excitatory neuronal responses were observed for both nonnoxious and noxious thermal stimuli. Systemic administration of gabapentin, a nonopioid analgesic, induced significant dose-dependent decreases in the elevated spontaneous and thermally evoked vlPAG neuronal firing to both nonnoxious and noxious thermal stimuli in rats exhibiting neuropathic pain, but not in naive rats. Thus, these results show a strong correlation between behavioral hypersensitivity to thermal stimuli and increased firing of vlPAG neurons in allodynia and hyperalgesia that occur in this neuropathic pain model.
The Role of Forensic Engineering Investigations in Medical Device Reports
Authors: Block Frank E.
Published: March 2017

The complexity of medical devices and their failures has increased dramatically. Understanding device failures from reports submitted to manufacturers and regulatory agencies helps to leverage the lessons learned from previous problems into future successes. User facilities are required to report events when a medical device caused or contributed to patient harm. Unfortunately, reports often do not contain the level of detail required to thoroughly convey the failure event, and this can impede the identification of potentially impactful safety signals. Forensic engineering investigative techniques, when applied, can improve the quality of reports and may contribute to improvements in the design, quality, safety, and effectiveness of medical devices.
Wavelet Transform Features to Hybrid Classifier for Detection of Neurological-Disordered Voices
Authors: Rani K Uma , Holi Maillikarjun S.
Published: March 2017

Neurological problems may lead to speech-related disorders because of improper movements of vocal fold or incomplete closure of glottis. This may alter the acoustic characteristics of voice signal, which may provide valuable clues for diagnosing certain neurological diseases. In this work, the wavelet transform and Mel-frequency cepstral coefficients, which are features of short-time analysis techniques, fused with the time-domain features, and given to a hybrid model designed using Gaussian mixture model (GMM) and support vector machines (SVM). The fusion of features and fusion of different classifiers are carried out to avoid the generation of large feature space, complexity, and delayed results. Linear predictive coded–Mel-frequency cepstral coefficients computed for selected 6-level discrete wavelet transform are given to GMM. The output of which is combined with SVM scores obtained with time-domain features as input and given to another SVM, which makes the decision to classify the data as normal or neurological-disordered voice. It is observed that this hybrid classifier model has shown an improvement with a classification accuracy of 94.3% compared with individual SVM classifier with time-domain features with 81.43% and the GMM-SVM classifier with 85.71%.
Experience With the Use of Single-Use Disposable Bronchoscope in the ICU in a Tertiary Referral Center of Singapore
Authors: Marshall Dominic C. , Dagaonkar Rucha S. , Yeow Chan , Peters Anura T. , Tan Siew Kin , Tai Dessmon Y.H. , Keng Gohs Soon , Lim Albert Y.H. , Ho Benjamin , Lew Sennen J.W. , Abisheganaden John , Verma Akash
Published: March 2017

Background:

Flexible bronchoscopy is performed frequently in intensive care units (ICUs) for various indications using the reusable conventional bronchoscope (CB). Recently, “single-use disposable bronchoscope” (SB) was introduced into the health care industry. The purpose of this study was to compare the utility of SB with CB in ICU.

Methods:

A retrospective review of medical records of patients undergoing flexible bronchoscopy in the ICUs in the year 2015.

Results:

Ninety-three patients undergoing flexible bronchoscopy in the ICU were studied. Eighty-three bronchoscopies were performed using SB in 71 patients, and 24 using CB in 22 patients. The most common indications for using the SB were percutaneous tracheostomy [n=37 (44.6%)] in neuro-ICU, followed by collecting specimens for microbiological evaluation [n=20 (24.1%)] in the medical ICU. Airway inspection [8 (9.6%)], bronchial toilet [8 (9.6%)], hemoptysis [5 (6%)], and intubation [3 (3.6%)] were other indications for which SB was used. Microbiological yield of SB was 70% (14/20) versus 70% (7/10) for CB (P=1.0). The median interval between identification of the need-to-start of the procedure was shorter with SB (10 min) versus CB (66 min, P=0.01), whereas the cost was similar, SGD450 versus SGD472, respectively. In addition, less (3 personnel) were needed to perform bronchoscopy with SB versus 5 with CB with additional resource sparing effect in terms of nursing personnel having to wheel the CB equipment to ICU.

Conclusions:

SB is equivalent in performance to CB in ICU. In addition, the SB may confer clinical, economic, and logistical advantages over the CB.
Applying the PDSA Framework to Examine the Use of the Clinical Nurse Leader to Evaluate Pressure Ulcer Reporting
Authors: Polancich Shea , Coiner Sarah , Barber Rebekah , Poe Terri , Roussel Linda , Williams Kelley , Cumbest Heather , Noles Kristen , Herrero Ashlea , Graham Shannon , Miltner Rebecca
Published: March 2017

The clinical nurse leader (CNL) role has been cited as an effective strategy for improving care at the microsystem level. The purpose of this article is to describe the use of the CNL role in an academic medical center for evaluating pressure ulcer reporting. The Plan-Do-Study-Act cycle was used as the methodological framework for the study. The CNL assessment of pressure ulcers resulted in a 21% to 50% decrease in the number of hospital-acquired pressure ulcers reported in a 3-month time period. The CNL role has potential for improving the validity and reliability of pressure ulcer reporting.
Challenges of Inpatient Glycemic Control
Authors: Gerard Sally O. , Ritchie Josephine
Published: March 2017

Hyperglycemia occurs in more than 30% of hospitalized patients. The condition has been associated with higher mortality and poor outcomes. Systems to effectively treat dysglycemia have been put into place, although many focus on critical care areas. The purpose of this article is to provide an overview of the challenges for glycemic control in non–critical care areas. Standardized order sets, critical pathways, professional education, and collaborative systems can support improved control.
Adult Chest Pain in the Pediatric Emergency Department
Authors: Sacks Jeffrey H. , Flueckiger Peter B. , Spandorfer Philip R. , Mahle William T. , Costello Brian E.
Published: March 2017

Objectives

The American College of Cardiology Foundation/American Heart Association guidelines for acute coronary syndrome (ACS) recommend immediate aspirin (ASA) administration, an electrocardiogram (ECG) in less than 10 minutes, and a door-in to door-out (DIDO) time less than 30 minutes for interfacility transfer. We sought to determine if compliance is hindered when adults with suspected ACS present to pediatric facilities.

Methods

Visits to the 2 tertiary care emergency departments of a pediatric healthcare system using an adult chest pain protocol were examined from October 2006 to September 2012. Patients older than 18 years with a diagnosis suggestive of ACS and an initial ECG interpretation were identified. Proportions of patients receiving ASA were calculated as well as median times to ECG and DIDO. Bivariate analysis of ECG and DIDO time and the proportion of the patients receiving ASA was conducted for ECG findings positive and negative for ACS.

Results

One hundred thirteen patients were identified. Aspirin was administered in 69% of eligible cases. Electrocardiogram and DIDO times met recommended intervals in 42% (median, 12 minutes) and 5% (median, 59 minutes) of the patients, respectively. No significant differences between positive (22% of total) and negative (78% of total) ECG findings groups were detected in median DIDO time (57 vs 59 minutes, P = 0.99), time to ECG (14 vs 12 minutes, P = 0.45), or the proportion receiving ASA (84% vs 64%, P = 0.08).

Conclusions

Despite the use of an emergency department protocol, compliance with the American College of Cardiology Foundation/American Heart Association guidelines for adults with suspected ACS remained challenging at this pediatric center. The ECG findings did not seem to impact ASA administration, ECG time, or DIDO time.
The First Use of Pralidoxime in a Child With Rivastigmine Poisoning
Authors: Saz Eylem Ulaş , Yurtseven Ali , Kilinç Mehmet Arda , Sari Ferhat , Ağin Hasan
Published: March 2017

Objective

The aim of this report is to describe the successful use of pralidoxime in a pediatric patient who accidentally ingested 12 mg of rivastigmine and presented to the emergency department with weakness, drowsiness, hyporeactivity to environmental stimuli, and full cholinergic syndrome.

Case

The patient presented to the emergency department 2 hours after a suspected ingestion of rivastigmine. He was sleepy but oriented and cooperative, hypotonic, and hyporeflexic and has a Glasgow Coma Scale score of 13 (E3M6V4). Laboratory tests showed a low plasma cholinesterase levels of 2141 U/L (reference range, 5300–12 900 U/L), hyperglycemia (251 mg/dL), and leukocytosis with neutrophilia (21 900/mL, 75.2% neutrophils).

Conclusions

Only 2 pediatric cases of rivastigmine poisoning have been reported in the literature, and there are no previous reports of using pralidoxime in the management of this poisoning. In the present case, intravenous pralidoxime (30 mg/kg) was administered twice at the fifth and sixth hours of ingestion for nicotinic and central effects. There is reasonable theoretical science to suggest pralidoxime in case of acetylcholinesterase inhibitor toxicity. We conclude that observed clinical improvement in weakness temporally associated with pralidoxime administration. Increased plasma cholinesterase activity after pralidoxime administration also makes it useful in this type of poisoning.
A Giant Pseudoaneurysm Mimicking Retropharyngeal Abscess in a Child
Authors: Gupta Rijuneeta , Patro Sourabha K. , Chauhan Neha , Kumar Ajay
Published: March 2017

Pseudoaneurysms of the cervical internal carotid artery are rare and usually result from trauma, infection, or rarely spontaneously. They harbor potential risk of life-threatening hemorrhage and warrant immediate management. Endovascular treatment in the form of stent placement and coiling is a well established technique for dealing with both intracranial and extracranial pseudoaneurysms. We present a case of a child who presented with fever, neck swelling, dysphagia, and respiratory distress in emergency for which clinical diagnosis of a neck abscess was made. Intubation was not possible because of bulge in the retropharyngeal wall. An elective tracheotomy was planned with imaging of the neck. Imaging and careful planning to avoid incision and drainage in the initial presentation led us to diagnose a pseudoaneurysm and successful management. We present this case to highlight the importance of early recognition and timely meticulous management to avoid serious complications and morbidity in a child.
Effect of Biperiden Treatment in Acute Orofacial and Extremity Dyskinesia With Methylphenidate Therapy
Authors: Arslan Elif Acar , Arslan Erhan , Kilinç Anil , Göksu Özkan
Published: March 2017

Methylphenidate is a stimulant drug commonly prescribed to individuals with attention-deficit/hyperactivity disorder. The suggested underlying mechanism of acute dyskinesias is dopaminergic transmission increase. We describe a 9-year-old boy with a diagnosis of attention-deficit/hyperactivity disorder admitted to emergency clinic with primarily orofacial and extremity dyskinesia after administration of a first dose of 18 mg OROS (osmotic [controlled] release oral) methylphenidate (Concerta). OROS methylphenidate was discontinued, and the patient’s symptoms resolved within 20 minutes after injection of biperiden by intravenous route (0.04 mg/kg). We wish to emphasize that acute orofacial dyskinesia and extremity dyskinesia can be observed during methylphenidate therapy and that biperiden can be successfully used in the treatment of this unpleasant condition. To the best of our knowledge, this is the first report of the use of biperiden therapy in this condition. This case report highlights the importance for physicians of awareness of dyskinesia as a potential adverse effect of methylphenidate therapy and indicates benefit of biperiden therapy.
Prioritizing the Care of Critically Ill Children in South Africa
Authors: Hansoti Bhakti , Hodkinson Peter , Wallis Lee
Published: March 2017

Objective

Childhood mortality remains unacceptably high. In low-resource settings, children with critical illness often present for care. Current triage strategies are time consuming and require trained health care workers. To address this limitation, our team developed a simple subjective tool, SCREEN (Sick Children Require Emergency Evaluation Now), which is easy to administer, to identify critically ill children. This article presents the development of the SCREEN program and evaluates its performance when compared with other commonly implemented triage tools in low-resource settings.

Methods

We measured the sensitivity and specificity of SCREEN, to identify critically ill children, compared with 4 other previously validated triage tools: the Integrated Management of Childhood Illnesses, the Pediatric Early Warning, the Pediatric South African Triage Scale, and the World Health Organization Emergency Triage Treatment Tool.

Findings

SCREEN has high sensitivity (100%–98.73%; P < 0.001) and specificity (64.41%–50.71%; P < 0.001) when compared with other validated triage tools.

Conclusions

The SCREEN tool may offer a simple and effective method to identify critically ill children in low-resource environments.
Enterocolitis in a Child With Hirschsprung Disease
Authors: Guillaume Alexander W.D. , Miller Andrew C. , Nguyen Michael C.
Published: March 2017

Hirschsprung disease is a congenital abnormality that can be surgically corrected. However, Hirschsprung-associated enterocolitis can be a life-threatening sequela. Very little has been published in the emergency medicine literature about the risk of enterocolitis and shock in patients with a history of Hirschsprung disease. We describe the case of a 6-month-old male infant with a history of multiple surgeries for Hirschsprung disease who presented to the emergency department with a seemingly benign viral gastrointestinal illness. His stable condition led him to be discharged. However, 4 days later, he returned to the emergency department with severe diarrhea and was subsequently admitted to the pediatric intensive care unit for the management of enterocolitis and shock. With this case report, we aim to raise emergency physicians’ awareness of the serious and possibly fatal complications of Hirschsprung disease. We argue that this single element of a patient’s medical history can alter the management of seemingly simple viral gastrointestinal illnesses; rather than be discharged, such a patient requires surgical consultation and possibly admission for close monitoring and treatment.
Predictors and Impact of Self-Reported Suboptimal Effort on Estimates of Prevalence of HIV-Associated Neurocognitive Disorders
Authors: Levine Andrew J. , Martin Eileen , Sacktor Ned , Munro Cynthia , Becker James ,   for the Multicenter AIDS Cohort Study-Neuropsychology Working Group
Published: March 2017

Background:

Prevalence estimates of HIV-associated neurocognitive disorders (HAND) may be inflated. Estimates are determined via cohort studies in which participants may apply suboptimal effort on neurocognitive testing, thereby inflating estimates. Additionally, fluctuating HAND severity over time may be related to inconsistent effort. To address these hypotheses, we characterized effort in the Multicenter AIDS Cohort Study.

Methods:

After neurocognitive testing, 935 participants (525 HIV− and 410 HIV+) completed the visual analog effort scale (VAES), rating their effort from 0% to 100%. Those with <100% then indicated the reason(s) for suboptimal effort. K-means cluster analysis established 3 groups: high (mean = 97%), moderate (79%), and low effort (51%). Rates of HAND and other characteristics were compared between the groups. Linear regression examined the predictors of VAES score. Data from 57 participants who completed the VAES at 2 visits were analyzed to characterize the longitudinal relationship between effort and HAND severity.

Results:

Fifty-two percent of participants reported suboptimal effort (<100%), with no difference between serostatus groups. Common reasons included “tired” (43%) and “distracted” (36%). The lowest effort group had greater asymptomatic neurocognitive impairment and minor neurocognitive disorder diagnosis (25% and 33%) as compared with the moderate (23% and 15%) and the high (12% and 9%) effort groups. Predictors of suboptimal effort were self-reported memory impairment, African American race, and cocaine use. Change in effort between baseline and follow-up correlated with change in HAND severity.

Conclusions:

Suboptimal effort seems to inflate estimated HAND prevalence and explain fluctuation of severity over time. A simple modification of study protocols to optimize effort is indicated by the results.
Economic Costs and Health-Related Quality of Life Outcomes of HIV Treatment After Self- and Facility-Based HIV Testing in a Cluster Randomized Trial
Authors: Maheswaran Hendramoorthy , Petrou Stavros , MacPherson Peter , Kumwenda Felistas , Lalloo David G. , Corbett Elizabeth L. , Clarke Aileen
Published: March 2017

Background:

The scale-up of HIV self-testing (HIVST) in Africa is recommended, but little is known about how this novel approach influences economic outcomes following subsequent antiretroviral treatment (ART) compared with established facility-based HIV testing and counseling (HTC) approaches.

Setting:

HIV clinics in Blantyre, Malawi.

Methods:

Consecutive HIV-positive participants, diagnosed by HIVST or facility-based HTC as part of a community cluster-randomized trial (ISRCTN02004005), were followed from initial assessment for ART until 1-year postinitiation. Healthcare resource use was prospectively measured, and primary costing studies undertaken to estimate total health provider costs. Participants were interviewed to establish direct nonmedical and indirect costs over the first year of ART. Costs were adjusted to 2014 US$ and INT$. Health-related quality of life was measured using the EuroQol EQ-5D at each clinic visit. Multivariable analyses estimated predictors of economic outcomes.

Results:

Of 325 participants attending HIV clinics for assessment for ART, 265 were identified through facility-based HTC, and 60 through HIVST; 168/265 (69.2%) and 36/60 (60.0%), respectively, met national ART eligibility criteria and initiated treatment. The mean total health provider assessment costs for ART initiation were US$22.79 (SE: 0.56) and US$19.92 (SE: 0.77) for facility-based HTC and HIVST participants, respectively, and was US$2.87 (bootstrap 95% CI: US$1.01 to US$4.73) lower for the HIVST group. The mean total health provider costs for the first year of ART were US$168.65 (SE: 2.02) and US$164.66 (SE: 4.21) for facility-based HTC and HIVST participants, respectively, and comparable between the 2 groups (bootstrap 95% CI: −US$12.38 to US$4.39). EQ-5D utility scores immediately before and one year after ART initiation were comparable between the 2 groups. EQ-5D utility scores 1 year after ART initiation had increased by 0.129 (SE: 0.011) and 0.139 (SE: 0.027) for facility-based HTC and HIVST participants, respectively.

Conclusions:

Once HIV self-testers are linked into HIV services, their economic outcomes are comparable to those linking to services after facility-based HTC.
Higher Body Mass Index Is Associated With Greater Proportions of Effector CD8+ T Cells Expressing CD57 in Women Living With HIV
Authors: Reid Michael J. A. , Baxi Sanjiv M. , Sheira Lila A. , Landay Alan L. , Frongillo Edward A. , Adedimeji Adebola , Cohen Mardge H. , Wentz Eryka , Gustafson Deborah R. , Merenstein Daniel , Hunt Peter W. , Tien Phyllis C. , Weiser Sheri D. ,   for the Women's Interagency HIV Study (WIHS)
Published: March 2017

Background:

A low proportion of CD28−CD8+ T cells that express CD57 is associated with increased mortality in HIV infection. The effect of increasing body mass index (BMI) changes in the proportion of CD57+CD28−CD8+ T cells among HIV-infected individuals on antiretroviral therapy is unknown.

Setting:

In a US cohort of HIV-infected women, we evaluated associations of BMI and waist circumference with 3 distinct CD8+ T cell phenotypes: % CD28−CD57+CD8+ T cells, % CD57+ of CD28−CD8+ T cells, and % CD28− of all CD8+ T cells.

Methods:

Multivariable linear regression analysis was used to estimate beta coefficients for each of 3 T-cell phenotypes. Covariates included HIV parameters (current and nadir CD4, current viral load), demographics (age, race, income, and study site), and lifestyle (tobacco and alcohol use) factors.

Results:

Of 225 participants, the median age was 46 years and 50% were obese (BMI >30 m2/kg). Greater BMI and waist circumference were both associated with higher % CD28−CD57+CD8+ T cells and % CD57+ of all CD28−CD8+ T cells in multivariable analysis, including adjustment for HIV viral load (all P < 0.05). The association between greater BMI and the overall proportion of CD28− CD8+ cells in fully adjusted models (0.078, 95% confidence interval: −0.053 to 0.209) was not significant.

Conclusions:

In this analysis, greater BMI and waist circumference are associated with greater expression of CD57 on CD28−CD8+ T cells and a greater proportion of CD57+CD28− CD8+ T cells. These findings may indicate that increasing BMI is immunologically protective in HIV-infected women. Future research is needed to understand the prognostic importance of these associations on clinical outcomes.
Brief Report: IL-1β Levels Are Associated With Chronic Multisite Pain in People Living With HIV
Authors: Merlin Jessica S. , Westfall Andrew O. , Heath Sonya L. , Goodin Burel R. , Stewart Jesse C. , Sorge Robert E. , Younger Jarred
Published: March 2017

Background:

The pathophysiology of chronic pain experienced by people living with HIV (PLWH) in the current antiretroviral treatment era is poorly understood. We sought to investigate the relationship between inflammation and chronic pain in PLWH. We hypothesized that, among PLWH who have undetectable HIV viral loads, those with chronic multisite pain (CMP) would have higher levels of circulating pain-related inflammatory markers than those without chronic pain.

Setting:

This study was conducted at the University of Alabama at Birmingham's Center for AIDS Research Network of Integrated Clinical System site.

Methods:

We compared inflammatory markers in 70 PLWH with CMP and 70 PLWH without chronic pain. Custom multiplex human inflammatory assays were completed on banked plasma specimens to measure cytokines commonly associated with chronic inflammatory pain: interleukin 1β (IL-1β), eotaxin, IL-15, IL-6, tumor necrosis factor α, and leptin. Logistic regression models were built using group status (CMP vs no pain) as the outcome variable, with each cytokine as independent variables and age, sex, substance use, and prescribed opioid medications as covariates.

Results:

Participants were mostly men (71%); 53% were 50 years or older. The most common sites of pain were low back (86%), hands/feet (81%), and knee (66%). Median CD4+ T-cell count was 676 cells per milliliter. IL-1β was significantly higher in the CMP group than in the individuals without chronic pain (odds ratio: 1.35, 95% confidence interval: 1.01 to 1.82, P < 0.05). Eotaxin, IL-15, IL-6, tumor necrosis factor α, and leptin were not significantly different between groups.

Conclusions:

We found that PLWH who also have CMP have significantly higher levels of IL-1β than PLWH who do not have any pain. Future work on the role of IL-1β on chronic pain pathogenesis in this population may inform novel approaches to chronic pain management.