bluuebunny/crossref_metadata_2025 huggingface dataset:
The Prognostic Value of Laboratory Markers and Ambulatory Function at Presentation for Post-Treatment Morbidity and Mortality Following Epidural Abscess
Authors: Goh Brian C. , Ferrone Marco L. , Barghi Ameen , Liu Christina Y. , Cronin Patrick K. , Blucher Justin A. , Makhni Melvin C. , Kang James D. , Schoenfeld Andrew J.
Published: February 2020

Study Design.

Retrospective cohort study.

Objective.

To develop a comprehensive understanding of the prognostic value of laboratory markers on morbidity and mortality following epidural abscess.

Summary of Background Data.

Spinal epidural abscess is a serious medical condition with high rates of morbidity. The value of laboratory data in forecasting morbidity and mortality after epidural abscess remains underexplored.

Methods.

We obtained clinical data on patients treated for epidural abscess at two academic centers from 2005 to 2017. Our primary outcome was the development of one or more complications within 90-days of presentation, with mortality a secondary measure. Primary predictors included serum albumin, serum creatinine, platelet–lymphocyte ratio, and ambulatory status at presentation. We used multivariable logistic regression techniques to adjust for confounders. The most parsimonious set of variables influencing both complications and mortality were considered to be clinically significant. These were then examined individually and in combination to assess for synergy along with model-discrimination and calibration. We performed internal validation with a bootstrap procedure using sampling with replacement.

Results.

We included 449 patients in this analysis. Complications were encountered in 164 cases (37%). Mortality within 1-year occurred in 39 patients (9%). Regression testing determined that serum albumin, serum creatinine, and ambulatory status at presentation were clinically important predictors of outcome, with albumin more than 3.5 g/dL, creatinine less than or equal to 1.2 mg/dL, and independent ambulatory function at presentation considered favorable characteristics. Patients with no favorable findings had increased likelihood of 90-day complications (odds ratio [OR] 5.43; 95% confidence intervals [CI] 1.98, 14.93) and 1-year mortality (OR 8.94; 95% CI 2.03, 39.37). Those with one favorable characteristic had greater odds of complications (OR 4.00; 95% CI 2.05, 7.81) and mortality (OR 5.71; 95% CI 1.60, 20.43).

Conclusion.

We developed a nomogram incorporating clinical and laboratory values to prognosticate outcomes after treatment for epidural abscess. The results can be used in shared-decision making and counseling.

Level of Evidence: 3
Do Antifibrinolytic Agents Reduce the Risk of Blood Transfusion in Children Undergoing Spinal Fusion?
Authors: Eisler Lisa D. , Lenke Lawrence G. , Sun Lena S. , Li Guohua , Kim Minjae
Published: February 2020

Study Design.

Retrospective cohort.

Objective.

To evaluate the effectiveness and safety of antifibrinolytic (AF) agents in reducing perioperative blood transfusion in pediatric patients undergoing spinal fusion.

Summary of Background Data.

The potential for AF to decrease bleeding and reduce exposure to allogenic transfusions has led to widespread off-label use in a number of major pediatric surgical procedures. Recent reviews call for improving the body of evidence for their effectiveness and safety in pediatric spinal fusion.

Methods.

Children undergoing spinal fusion were identified in the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) 2016 and 2017 databases. Univariate analyses of patient and perioperative characteristics informed the creation of a propensity score model predicting treatment with AF, followed by 1:1 matching to allow comparison of allogenic red blood cell transfusion rates and secondary outcomes between treated and untreated patients.

Results.

Of 6626 total patients, 5434 (81%) received AF and 1533 (23%) received a blood transfusion. Analysis of data for 1192 propensity score-matched pairs revealed that treatment with AF was associated with a statistically nonsignificant 16% reduction in perioperative transfusion (OR 0.84, 95% confidence interval 0.68–1.05, P = 0.119) and a statistically significant 43% reduction in postoperative transfusion (OR 0.57, 95% confidence interval 0.39–0.81, P = 0.002). No differences in the incidences of postoperative seizure or thrombosis were observed, with overall rates of 7.5 and 22.5 events per 10,000 patients, respectively.

Conclusion.

AF agents appear to reduce postoperative allogenic transfusion in children undergoing spinal fusion surgery. Adverse drug effects such as thromboembolic complications and seizure were extremely rare and warrant continued monitoring, though this is the largest study to date providing evidence for the safety profile of these drugs.

Level of Evidence: 3
The Epidemiology of Back Pain in American Children and Adolescents
Authors: Fabricant Peter D. , Heath Madison R. , Schachne Jonathan M. , Doyle Shevaun M. , Green Daniel W. , Widmann Roger F.
Published: February 2020

Study Design.

Cross-sectional survey.

Objective.

To determine the prevalence of back pain in American children and adolescents, with a focus on anatomic region, duration, severity, and treatment patterns, and to investigate for any predictive variables.

Summary of Background Data.

No study has examined the prevalence of back pain in American children and adolescents in the last 15 years. Because the prevalence of back pain varies greatly by country and year of investigation, previous studies are not generalizable.

Methods.

A United States epidemiologic cross-sectional survey-based investigation was performed in children and adolescents ages 10 and 18 years old, equally split by age and sex, and representing census-weighted distributions of state of residence, race/ethnicity, and health insurance status. Prevalence of back pain was evaluated and described.

Results.

In total, 1236 (33.7%) participants reported experiencing back pain within the last year and 325 (8.9%) reported severe back pain within the last year. Prevalence of back pain increased with age and was significantly more common in females, P < 0.001 for both. Treatment for back pain was sought by 505 (40.9%) of the participants with pain, of which physical therapy was the most common. Invasive procedural treatment (e.g., injections, surgery) were rare and comprised only 61 (1.6%) of study participants. In addition, government insurance and lack of insurance coverage was associated with low treatment seeking behavior compared to private insurance users (P = 0.010 and P = 0.006, respectively).

Conclusion.

Despite how commonly it presents, the majority of young patients with back pain do not report procedural treatment such as injections or surgery. However, because many American children and adolescents seek treatment, future research on the etiology, treatment, and prevention of back pain in children and adolescents is essential to reducing a common and financially demanding problem.

Level of Evidence: 4
Ziyuglycoside II exerts antiproliferative and antimetastasis effects on hepatocellular carcinoma cells
Authors: Liao Wanqin , Fan Lixia , Zheng Zhaoguang , Liu Hui , Deng Huizhi , Li Mingchan , Liu Fang , Yang Anping
Published: February 2020

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death worldwide. Phytochemicals are important candidates for developing anticancer agents. Ziyuglycoside II is a major active compound of Sanguisorba officinalis, which exhibits antiproliferation activity in several cancers; however, its action in HCC remains unknown. In this study, we investigated the antitumor activity of ziyuglycoside II against HCC and explored the potential mechanisms. We found that ziyuglycoside II exerts significant inhibitory effects on the viability and clonogenic activity of HCC cells. The proliferation repression mediated by ziyuglycoside II was mainly due to increased apoptosis and reactive oxygen species accumulation, as well as a G0/G1 phase cell-cycle arrest. Additionally, ziyuglycoside II markedly impaired HCC cell migration and invasion, two important steps during metastasis, and these suppressive effects may be attributed to the downregulation of matrix metalloproteinases MMP2 and MMP9 expression. Moreover, ziyuglycoside II blocked the epidermal growth factor receptor/nuclear factor kappa-B (EGFR/NF-kB) signaling, which may contribute to its anticancer activity. Taken together, our findings reveal antiproliferative and antimetastasis activities of ziyuglycoside II in HCC cells, implying that ziyuglycoside II might be a promising candidate for the development of novel anti-HCC drugs.
Anatomical and clinical study of a new mallet fracture classification method
Authors: Yang Yong , Zhang Wei-Guang , Li Zhong-Zhe , Chen Shan-Lin , Tian Wen
Published: February 2020

Background

Mallet fracture is avulsion of the terminal extensor tendon from the base of the distal phalangeal bone with a bony fragment. This study was performed to evaluate the anatomical characteristics of mallet fractures, investigate a new mallet fracture classification system using anatomical and imaging methods, and discuss the treatment schemes for different types of mallet fracture.

Methods

Sixty-four fresh cadaveric fingers were divided into four groups, and models of different types of mallet fracture with distal interphalangeal joint instability were established by dissecting 25%, 50%, 75%, and 100% of the bilateral collateral ligaments. The effect of mallet fractures on the stability of the distal interphalangeal joint was then observed. The lateral radiographs of mallet fractures in 168 patients were analyzed and classified according to the involvement of the joint surface in the fracture, the thickness of fracture, the untreated time after injury, and the complication of distal interphalangeal joint palmar subluxation. Forty-seven patients were surgically treated by reconstruction of extensor tendon insertion, the Ishiguro method, or single Kirschner wire fixation.

Results

The established mallet fracture model showed that the distal interphalangeal joint was stable when the bilateral collateral ligaments were cut off by 25% (t = –0.415, P = 0.684) and significantly unstable when this range was ≥50% (50% transection: t = –6.363, P < 0.001; 75% transection: t = –17.036, P < 0.001; 100% transection: t = –30.977, P < 0.001, respectively). The mallet fractures were divided into Types I, II, and III (fracture involving <20%, 20%–50%, and >50% of the joint surface, respectively). Type II was further divided into Types IIa and IIb according to whether the course of injury was < or ≥2 weeks, respectively. The mean post-operative flexion of the distal interphalangeal joint was 63.4° ± 7.9°, and the mean extension lag was 6.7° ± 4.6°.

Conclusions

The lateral collateral ligament is the main factor that maintains the stability of the distal interphalangeal joint. Classification that combines the involvement of the joint surface in the fracture, the thickness of the fracture, and the untreated time after injury is reasonable and will help to choose an appropriate operational method.
How to Distinguish Best Evidence from Bias: A Basic Guide to Understanding a Systematic Review
Authors: Camargo Cristina Pires , Gemperli Rolf , Rohrich Rod J.
Published: February 2020

A systematic review is a powerful tool to synthesize and show concise and robust evidence for clinical practice. Thus, the inclusion of biased, low-quality studies should be avoided, for otherwise, the resulting systematic review will not reflect the best medical evidence. Because the methodology of systematic review is relatively new, this review aims to present basic rules to guide the reader’s interpretation of a systematic review.
Negative Pressure Wound Therapy Reduces Wound Breakdown and Implant Loss in Prepectoral Breast Reconstruction
Authors: Irwin Gareth W. , Boundouki George , Fakim Bilal , Johnson Richard , Highton Lyndsey , Myers Dave , Searle Richard , Murphy John A.
Published: February 2020

Background:

Single-use negative pressure wound therapy (NPWT) has been shown to encourage wound healing. It is often used when patient factors impair wound healing, or in more complex wounds, such as in implant-based breast reconstruction. We report the findings of a prospective cohort study comparing the use of NPWT with standard dressings in prepectoral breast reconstruction.

Methods:

A prospective database of implant-based reconstruction from a single institution was mined to identify patients who underwent prepectoral reconstruction. Patient demographics, operative data, surgical complications, and 90-day outcomes were compared between patients who had NPWT and those who had standard dressings.

Results:

Prepectoral implant-based breast reconstruction was performed on 307 breasts. NPWT dressings were used in 126 cases, with standard dressings used in 181 cases. Wound breakdown occurred in 10 cases after standard dressings versus 1 where NPWT was utilized. Of the standard dressing cases, only 3 implants were salvaged, while 7 cases led to implant loss. The 1 case of wound breakdown in the NPWT cohort settled with conservative measures. The cost of a reconstructive failure was £14,902, and the use of NPWT resulted in a cost savings of £426 per patient.

Conclusions:

The utilization of single-use NPWT reduces the rate of wound breakdown and implant loss in prepectoral implant-based reconstruction. In addition to the significant clinical benefits, this approach is cost-saving compared with standard dressings. These data suggest that prepectoral implant reconstruction should be considered as an indication for the use of NPWT.
Atrial arrhythmias in patients with left ventricular assist devices
Authors: Ozcan Cevher , Deshmukh Amrish
Published: February 2020

Purpose of review

Atrial arrhythmias commonly occur in patients with advanced heart failure with reduced ejection fraction (HFrEF) who require left ventricular assist devices (LVADs) implantation. This review summarizes the current literature regarding the incidence, prevalence, and predictors of atrial arrhythmias in LVAD patients and its impact on the clinical outcomes. Moreover, we review the mechanisms and management strategies of atrial arrhythmias in this population.

Recent findings

Atrial arrhythmias including atrial fibrillation, atrial flutter, and atrial tachycardia are highly prevalent in patients with advanced HFrEF before or after the LVAD implantation. Atrial arrhythmias have a significant impact on overall clinical outcome including survival, heart failure hospitalization, quality of life, thromboembolic events and resource utilization. Atrial fibrillation and other atrial arrhythmias frequently coexist in this population. In patients with atrial arrhythmias and LVAD, anticoagulation and cardiovascular implantable electronic devices should be closely monitored and managed to prevent thromboembolic events or inappropriate shocks. Rhythm and rate control strategies are comparable regarding overall clinical outcomes in this population. LVADs induce favorable atrial remodeling in patients with HFrEF.

Atrial arrhythmias are highly common in LVAD patients and have significant impact on overall clinical outcomes. Further studies are needed to determine optimal management and prevention of atrial arrhythmias in LVAD population.
Dopamine-Related Genes Moderate the Association Between Family Environment and Executive Function Following Pediatric Traumatic Brain Injury: An Exploratory Study
Authors: Smith-Paine Julia , Fisher Allison P. , Wade Shari L. , Zhang Nanhua , Zang Huaiyu , Martin Lisa J. , Yeates Keith Owen , Taylor H. Gerry , Kurowski Brad G.
Published: February 2020

Objective:

This study examined whether carrying dopamine-related “risk” genes—either the dopamine transporter (DAT1) 10-repeat allele or dopamine receptor-4 (DRD4) 7-repeat allele—moderated the association of family environment and executive function (EF) following traumatic brain injury (TBI) in early childhood.

Methods:

Caregivers of children with TBI or orthopedic injury (OI) completed the Behavior Rating Inventory of Executive Function (BRIEF) at postinjury visits. General linear models examined gene by environment interactions as moderators of the effects of TBI on EF at 12 months and 7 years postinjury.

Results:

At 12 months, we did not find any significant gene by environment interactions. At 7 years, we found a significant 3-way interaction among combined carrier status, level of permissive parenting, and injury type. For children exposed to more optimal parenting, carriers of DAT1 and/or DRD4 risk alleles with TBI showed significantly worse parent-reported EF than carriers with OI. In those with less optimal parenting, carriers and noncarriers with TBI, as well as carriers with OI, showed significantly worse parent-reported EF than noncarriers with OI, with medium to large effect sizes.

Conclusions:

The findings highlight the importance of considering polygenetic and environmental factors in future studies of recovery following TBI and other injuries in childhood.
Prevalence of Pseudoexfoliation Glaucoma Risk–associated Variants Within Lysyl Oxidase–like 1 in an Irish Population
Authors: Eivers Sarah B. , Greene Alison G. , Dervan Edward , O’Brien Colm , Wallace Deborah
Published: February 2020

Precis:

High-risk alleles of risk-associated single-nucleotide polymorphisms (SNPs) within the lysyl oxidase-like 1 (LOXL1) gene are associated with pseudoexfoliation in patients recruited from an Irish population.

Purpose:

SNPs within the LOXL1 gene have been identified as a major risk factor for pseudoexfoliation syndrome (PXF) and pseudoexfoliation glaucoma (PXFG), specifically SNPs within exon 1 and intron 1 regions of the gene. The common haplotype (G-G) of 2 SNPs within exon 1, rs1048661, and rs3825942, is the strongest associated risk factor for PXF in white populations, but is switched in some populations to act as protective or low risk. Herein, a study was undertaken to genotype an Irish population for PXF/PXFG risk-associated SNPs within LOXL1.

Materials and Methods:

Patient cohorts of PXFG, PXF, and controls were recruited and genotyped for risk-associated SNPs within exon 1 (rs1048661 and rs3825942), along with 3 SNPs within intron 1 (rs1550437, rs6495085, and rs6495086) of LOXL1.

Results:

The risk G alleles of rs1048661 and rs3825942 were most prevalent in PXFG patients, and a significant association was found between rs3825942 and pseudoexfoliation (P=0.04). Genotypes of several intron 1 SNPs were found to be present at higher frequencies within the pseudoexfoliation patient cohort (PXF/PXFG) compared with control patients, wherein rs6495085 showed statistical association (P=0.04). The G-G-G haplotype of rs1048661, rs3825942, and rs6495085 was the most prevalent in PXFG patients compared with control patients or patients with PXF alone. Patients with the G-G-G haplotype were more likely to need surgery, suggestive of a more severe form of disease.

Conclusion:

Collectively, these results represent the first study to assess the association of LOXL1 SNPs with PXFG in an Irish population.
Facilitating Patient-Ophthalmologist Dialog: A Call for a Patient-focused Classification of Glaucoma Diagnosis
Authors: Goldberg Ivan , Ritch Robert , Goldmann Nahum
Published: February 2020

We present a recommended patient-oriented glaucoma classification to facilitate patient-ophthalmologist dialog. By improving patients’ understanding of their precise diagnosis, we hope to optimize management outcomes. We invite our colleagues to evolve this classification with us.
Factors Contributing to Symptom Duration and Viral Reduction in Outpatient Children With Respiratory Syncytial Virus Infection
Authors: Utsunomiya Takeshi , Hibino Akinobu , Taniguchi Kiyosu , Nagai Takao , Saito Naruo , Tanabe Ikumi , Odagiri Takashi , Shobugawa Yugo , Kaneko Akira , Saito Reiko ,   for the Japanese HRSV Collaborative Study Group
Published: February 2020

Background:

We investigated the association between age, duration of clinical symptoms and viral shedding in outpatient children infected with respiratory syncytial virus (RSV) in Japan.

Methods:

Outpatients younger than 2 years of age, with suspected RSV infection between 2014 and 2018, were enrolled in the study. Following informed consent, nasal samples were collected at first and second clinic visits (with 0–9 days gap). RSV-A or -B infection and viral load were determined by real-time polymerase chain reaction. Clinical symptoms were recorded at first clinic visit, and fever and symptoms were recorded at home for up to 8 days. Association between clinical symptoms and patient characteristics, such as age, sex and birth weight, were analyzed using ordered logistic regression analysis. The association between viral reduction and estimated shedding period was examined using linear regression analysis.

Results:

Among the 205 cases enrolled in the study, no difference was found in patient characteristics between RSV-A and -B infection. Duration of fever was prolonged with increased age. Duration of rhinorrhea and cough was shorter in females than in males and in groups with birth weight ≥3 kg than in those with <2.5 kg. Daily viral reduction increased and estimated viral elimination period decreased with age.

Conclusions:

Fever duration was found to increase while viral shedding decreased with patient age.
A Piece of the Boardroom Pie—An Interview Study Exploring What Drives Swedish Corporate Boards’ Engagement in Occupational Health and Safety
Authors: Lornudd Caroline , Stenfors Terese , Hasson Henna , Frykman Mandus , Sundberg Carl Johan , Schwarz Ulrica von Thiele
Published: February 2020

Objectives:

To investigate why boards of directors engage in occupational health and safety (OHS) and what influences their level of engagement.

Methods:

Thirty-four board members and chief executive officers at large companies from the manufacturing, construction, trade, and health/social care sectors were interviewed. An inductive thematic analysis was conducted.

Results:

Five drivers organized along a continuum explain why boards engage: legal compliance, untoward events, external expectations/regulations, business drivers, and moral values. Certain factors influence the level of engagement: board's OHS competence, owner's agenda, and competing needs.

Conclusions:

Boards continuously prioritize among multiple foci. If a board's total engagement is likened to a pie, the size of the OHS slice will depend on the drivers, as well as on the influencing factors. We suggest that even boards with many drivers can down-prioritize OHS under certain conditions.
Profiles of BMI and blood pressure in young adults categorized by their components of height
Authors: Zhang Ying-xiu , Wang Shu-rong
Published: February 2020

Background

Body proportion is an important symbol of human biology. The aim of the present study was to examine the association of components of height with BMI and blood pressure (BP) among young adults.

Methods

A total of 4135 college students (2040 males and 2095 females) aged 19–22 years participated in the study. All subjects were classified into four groups (Q1–Q4) according to their quartiles of height, sitting height and leg length, respectively, comparisons of BMI, SBP and DBP among the four groups were made.

Results

BMI is positively associated with sitting height and inversely associated with leg length, and the BP level is associated with sitting height rather than leg length. BMI and BP level of young adults are also associated with their body proportion, subjects with high sitting height ratio (SHR = sitting height/height × 100) had higher BMI and BP level, and more likely to have overweight/obesity and high BP.

Conclusion

BMI and BP level of young adults are associated with their components of height, young adults with longer sitting height and higher SHR should be given special attention in the prevention of hypertension in their future lives.
Congenital dermoid inclusion cyst over the anterior fontanel in Chinese children
Authors: Cao Lirong , Wang Yizheng , Zhao Linsheng , Hu Xiaoli , Cai Chunquan
Published: February 2020

Congenital dermoid inclusion cyst (CDIC) over the anterior fontanel is a rare and benign tumor. This study reports nine Chinese cases (three females and six males) with CDIC over the anterior fontanel. The clinical manifestations and imaging were analyzed retrospectively. Surgical resection was undertaken in all cases. The diagnosis of CDIC over the anterior fontanel was confirmed by histological examination. The cysts were all noticed soon after birth and enlarged gradually. They were soft, nontender with a sessile base without inflammatory signs and breaking. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed soft tissue mass over the anterior fontanel without intracranial extensions. The histopathological examination displayed stratified squamous epithelium with skin appendages. There were no complications or recurrence after operation during a follow-up for one year. CDIC over the anterior fontanel is a benign tumor. Imaging is recommended preoperatively to aid differential diagnosis. The main management is total excision with good prognosis
Investigation of pulmonary embolism in patients with chest pain in the emergency department: a retrospective multicenter study
Authors: Lefevre-Scelles Antoine , Jeanmaire Paul , Freund Yonathan , Joly Luc-Marie , Phillipon Anne-Laure , Roussel Melanie
Published: February 2020

Introduction:

Chest pain is a common main complaint in the emergency department. Among its associated differential diagnoses, pulmonary embolism remains a key concern for the clinician. There are no clear recommendations on which patients should have a formal workup for pulmonary embolism diagnosis. The objective of this study was to determine the proportion of patients with chest pain who were investigated for pulmonary embolism diagnosis and to determine the clinical profile of these patients.

Methods:

This was a retrospective multicenter study conducted in three French Emergency Departments. We included all patients who presented to these centers for chest pain during a 2-month period. The primary outcome was the initiation of pulmonary embolism workup. We also aimed to find factors associated with this outcome.

Results:

We included 881 patients with a main complaint of chest pain. Mean age was 50 years and 481 (56%) were men. A total of 263 patients (30%, 95% confidence interval 27–33%) had a formal pulmonary embolism workup, and pulmonary embolism was ultimately diagnosed in 7 cases (prevalence of 2.6%, 95% confidence interval 1.1–5.3%). Five factors were identified as independently associated with a workup for pulmonary embolism diagnosis: female sex, young age, no ischemic heart disease, recent flight and associated dyspnea.

Conclusion:

Among patients presenting to emergency department with chest pain, 30% had a workup for pulmonary embolism. We report five clinical variables independently associated with a higher probability of pulmonary embolism workup in our sample.
Liver transplantation for alcoholic hepatitis: update
Authors: Yanny Beshoy , Boutros Sandra , Saleh Fatima , Saab Sammy
Published: February 2020

Purpose of review

Alcoholic liver disease continues to be a major public health concern in the United States and around the world. Alcoholic liver disease remains the third most common indication for liver transplantation in the United States. Mortality has been reported in up to 30–50% of patients with severe alcoholic hepatitis. Liver transplantation can be lifesaving for patients with alcoholic hepatitis. Liver transplantation for alcoholic liver disease was traditionally only considered in patients who have achieved 6 months of abstinence. The majority of patients with severe alcoholic hepatitis who fail medical therapy will not live long enough to meet this requirement. The purpose of this review is to provide an update from the most recent peer reviewed articles regarding early liver transplantation of alcoholic hepatitis.

Recent findings

This review shows that liver transplantation offers the best survival benefit to patients with alcoholic hepatitis. Selection criteria is a key component for a successful transplant. No change in 1-year graft survival between patients who have 6 months sobriety vs. those transplanted prior to 6 months abstinence. Liver transplantation is limited by very narrow selection criteria and limited long-term data.

Liver transplantation offers the best survival benefit to patients with alcoholic hepatitis. Selection criteria of patients has evolved and have become more permissive and the period of sobriety has become less important in the evaluation of process. However, long-term outcomes continue to lack in the literature. On the basis of previous studies, patients with longer pretransplant abstinence, disease process insight, older age at the time of transplant, the presence of social support that lives with the patient in the same dwelling place were noted to have lower rates of return to alcohol use after liver transplantation.
Lineage Assignment in Acute Leukemia: A Challenging Case in a Pediatric Patient
Authors: Turcotte Karine , Lowas Stefanie , Patel Sachit A. , Perry Deborah A. , Amador Catalina , Pirruccello Samuel J. , Fu Kai
Published: February 2020

We report a case of a 2-year-old girl who was diagnosed with natural killer cell acute lymphoblastic leukemia and treated with an acute lymphoblastic leukemia chemotherapy regimen. Two months posttherapy, the disease relapsed with a myeloid immunophenotype. Complete response was then achieved with acute myeloid leukemia therapy followed by unrelated donor umbilical cord allogenic stem cell transplant. Retrospectively, reanalysis of the diagnostic specimen showed minimal myeloperoxidase expression that was called negative by conventional single parameter linear gating but better appreciated on histogram overlays. This case illustrates that even low levels of myeloperoxidase expression should be considered significant in lineage assignment in acute leukemia.
Mixed Langerhans Cell Histiocytosis and Erdheim-Chester Disease in a Girl: A Rare and Puzzling Diagnosis
Authors: Ocak Suheyla , Bayramoglu Zuhal , Tugcu Deniz , Karaman Serap , Unuvar Aysegul , Karakas Zeynep
Published: February 2020

Objective:

The objective of this study was to report the case of a girl diagnosed as suffering from multisystem, BRAF V600E–positive refractory Langerhans cell histiocytosis (LCH) and coexistent Erdheim-Chester disease (ECD) with perirenal, intracranial involvement and the dramatic response to clofarabine treatment.

Observations:

Histiocytoses are rare diseases with a broad clinical spectrum. Recent evidence supports a molecular and clinical overlap between LCH and ECD, and mixed LCH/ECD is now a separate entity. However, only a few pediatric cases of mixed disease have been reported in the literature.

Conclusions:

In a child with refractory, multisystem histiocytosis and atypical presentations, mixed LCH/ECD should be suspected in the differential diagnosis.
Investigation of the effect of task-orientated rehabilitation program on motor skills of children with childhood cancer: a randomized-controlled trial
Authors: Şahin Sedef , Akel Burcu Semin , Huri Meral , Akyüz Canan
Published: February 2020

Problems have been reported in the execution and development of motor skills and its treatment as a cause of cancer in children. The purpose of this study was to examine the effect of the task-orientated rehabilitation program (ToRP) on motor skills of children with childhood cancer. Following the consort guideline, 93 children (49 males and 44 females) with pediatric cancer were randomized to either study (n = 52; 12.35 ± 3.43 years) or control (n = 41; 11.89 ± 3.56 years) groups. The study group received ToRP, and the control group received a home-based therapeutic strategies program for 20 sessions. Motor skill outcomes were assessed with Bruininks-Oseretsky Test of Motor Proficiency, Short Form (BOTMP-SF) by assessor who was blind to group allocation and interventions. The groups were homogenous in terms of demographic characteristics and motor skills. The study group showed a significant increase in both gross and fine motor skills (P values for all subtests: P < 0.001), whereas running speed, bilateral coordination, strength, response speed and visual motor control did not show significant improvement with the control group (P > 0.05). The ToRP appears to provide beneficial effects in improving motor skills at the early stages of rehabilitation for children with childhood cancer.
Impact of an Immersive Virtual Reality Curriculum on Medical Students’ Clinical Assessment of Infants With Respiratory Distress*
Authors: Zackoff Matthew W. , Real Francis J. , Sahay Rashmi D. , Fei Lin , Guiot Amy , Lehmann Corinne , Tegtmeyer Ken , Klein Melissa
Published: February 2020

Objective:

To determine whether exposure to an immersive virtual reality curriculum on pediatric respiratory distress improves medical students’ recognition of impending respiratory failure.

Design:

Randomized, controlled, prospective study conducted from July 2017 to June 2018. Evaluators blinded to student groupings.

Setting:

Academic, free-standing children’s hospital.

Participants:

All third-year medical students (n = 168) were eligible. The standard curriculum was delivered to all students during their pediatric rotation with optional inclusion of research data per Institutional Review Board review. A randomized selection of students was exposed to the virtual reality curriculum.

Intervention:

All students received standard training on respiratory distress through didactics and high-fidelity mannequin simulation. Intervention students underwent an additional 30-minute immersive virtual reality curriculum, experienced through an OculusRift headset, with three simulations of an infant with 1) no distress, 2) respiratory distress, and 3) impending respiratory failure.

Measurements and Main Results:

The impact of the virtual reality curriculum on recognition/interpretation of key examination findings, assignment of an appropriate respiratory status assessment, and recognition of the need for escalation of care for patients in impending respiratory failure was assessed via a free response clinical assessment of video vignettes at the end of the pediatric rotation. Responses were scored on standardized rubrics by physician experts. All eligible students participated (78 intervention and 90 control). Significant differences between intervention and control were demonstrated for consideration/interpretation of mental status (p < 0.01), assignment of the appropriate respiratory status assessment (p < 0.01), and recognition of a need for escalation of care (p = 0.0004).

Conclusions:

Exposure to an immersive virtual reality curriculum led to improvement in objective competence at the assessment of respiratory distress and recognition of the need for escalation of care for patients with signs of impending respiratory failure. This study represents a novel application of immersive virtual reality and suggests that it may be effective for clinical assessment training.
Carpal Tunnel Release without a Tourniquet: A Systematic Review and Meta-Analysis
Authors: Olaiya Oluwatobi R. , Alagabi Awwal M. , Mbuagbaw Lawrence , McRae Mark H.
Published: February 2020

Background:

Open carpal tunnel release is commonly performed with the use of a tourniquet. The combination of local anesthetic and epinephrine with a pneumatic tourniquet helps provide clear visualization during decompression of the median nerve. There has been a rapid expansion of literature challenging the use of tourniquets in open carpal tunnel release. Consequently, the local anesthesia/no tourniquet approach has become increasingly popular. The authors evaluated the outcomes of awake open carpal tunnel release with and without a tourniquet.

Methods:

The authors attempted to identify all relevant studies, regardless of language or publication status. A systematic database search for relevant studies was conducted in MEDLINE, EMBASE, EBSCO, and CENTRAL. Included studies compared patients undergoing awake open carpal tunnel release with and without an arm or forearm tourniquet.

Results:

Eight studies evaluating 765 patients and 866 hands were included. Open carpal tunnel release with the wide awake, local anesthesia, no tourniquet approach resulted in a 2.14 point reduction on the visual analog scale (95% CI, 1.30 to 2.98; p < 0.001). The procedure was 1.82 minutes faster with the use of a tourniquet (95% CI, –3.26 to –0.39; p = 0.01). There were no significant differences between groups in intraoperative blood loss, surgeon perceived difficulty, and complications.

Conclusion:

This systematic review found that tourniquet use causes significantly more pain with no significant clinical benefit as compared with using a wide awake, no tourniquet approach in carpal tunnel decompression.
Recent Developments Are Changing Extensor Tendon Management
Authors: Merritt Wyndell H. , Wong Alison L. , Lalonde Donald H.
Published: February 2020

Learning Objectives:

After reviewing this article, the participant should be able to: 1. Start early protected movement at 3 to 5 days after surgery with relative motion extension splinting for zone 5 extensor tendon lacerations over the hand. 2. Allow patients to resume regular activities much sooner than the conventional 3 to 4 weeks of splinting after extensor tendon repair. 3. Improve the rehabilitation of boutonniere deformities with relative motion splinting.

This article focuses on surgery and rehabilitation of extensor tendon injuries from the proximal interphalangeal joint (boutonniere) to the wrist. Relative motion flexion and extension splinting and wide awake, local anesthesia, no tourniquet surgery have revolutionized the management of these lesions, with early protected movement, sooner return to regular activities, and improved rehabilitation. This article explains and illustrates these new advances in extensor tendon management.
Correction of the Topographic Relationship between the Depressor Septi Nasi and Incisivus Labii Superioris: Application to Cosmetic Surgery on the Lip and Nose
Authors: Kikuta Shogo , Iwanaga Joe , Watanabe Koichi , Kusukawa Jingo , Tubbs R. Shane
Published: February 2020

Background:

The depressor septi nasi is a facial muscle with many different descriptions of its anatomy. Therefore, the aim of this study was to clarify the relationship of the depressor septi nasi, incisivus labii superioris, and surrounding structures.

Methods:

Twenty sides from 10 fresh-frozen cadaveric heads were used in this study. The depressor septi nasi and incisivus labii superioris were dissected intraorally and extraorally, and the relationship with surrounding structures was observed.

Results:

Eighteen of 20 sides had a depressor septi nasi. When present, the depressor septi nasi originated from the orbicularis oris above the central incisor and the medial portion of the inferior part of the incisivus labii superioris and inserted into the base of the medial crus of the major alar cartilage and nasal septum. These three muscles were three-dimensionally fused at the insertion point of the depressor septi nasi. There was no specimen where the depressor septi nasi originated directly from the maxilla. The depressor septi nasi runs obliquely from the nasal septum and the base of the medial crus of the major alar cartilage to the orbicularis oris and inferior part of the incisivus labii superioris.

Conclusion:

A better understanding of the depressor septi nasi, incisivus labii superioris, and surrounding structures might be important during various surgical techniques, especially rhinoplasty.
Quantifying the Crisis: Opioid-Related Adverse Events in Outpatient Ambulatory Plastic Surgery
Authors: Crystal Dustin T. , Blankensteijn Louise L. , Ibrahim Ahmed M. S. , Brownstein Gary M. , Reed Lawrence S. , Watts David C. , Lin Samuel J.
Published: February 2020

Background:

The United States is currently in the midst of an opioid epidemic precipitated, in part, by the excessive outpatient supply of opioid pain medications. Accordingly, this epidemic has necessitated evaluation of practice and prescription patterns among surgical specialties. The purpose of this study was to quantify opioid-related adverse events in ambulatory plastic surgery.

Methods:

A retrospective review of 43,074 patient profiles captured from 2001 to 2018 within an American Association for Accreditation of Ambulatory Surgery Facilities quality improvement database was conducted. Free-text search terms related to opioids and overdose were used to identify opioid-related adverse events. Extracted profiles included information submitted by accredited ambulatory surgery facilities and their respective surgeons. Descriptive statistics were used to quantify opioid-related adverse events.

Results:

Among our cohort, 28 plastic surgery patients were identified as having an opioid-related adverse event. Overall, there were three fatal and 12 nonfatal opioid-related overdoses, nine perioperative opioid-related adverse events, and four cases of opioid-related hypersensitivities or complications secondary to opioid tolerance. Of the nonfatal cases evaluated in the hospital (n = 17), 16 patients required admission, with an average 3.3 ± 1.7 days’ hospital length of stay.

Conclusions:

Opioid-related adverse events are notable occurrences in ambulatory plastic surgery. Several adverse events may have been prevented had different diligent medication prescription practices been performed. Currently, there is more advocacy supporting sparing opioid medications when possible through multimodal anesthetic techniques, education of patients on the risks and harms of opioid use and misuse, and the development of societal guidance regarding ambulatory surgery prescription practices.
Comparative Effectiveness Analysis of Complex Lower Extremity Reconstruction: Outcomes and Costs for Biologically Based, Local Tissue Rearrangement, and Free Flap Reconstruction
Authors: Kozak Geoffrey M. , Hsu Jesse Y. , Broach Robyn B. , Shakir Sameer , Calvert Catherine , Stranix John. T , Messa Charles , Levin L. Scott , Serletti Joseph M. , Kovach Stephen J. , Fischer John P.
Published: February 2020

Background:

Various surgical techniques exist for lower extremity reconstruction, but limited high-quality data exist to inform treatment strategies. Using multi-institutional data and rigorous matching, the authors evaluated the effectiveness and cost of three common surgical reconstructive modalities.

Methods:

All adult subjects with lower extremity wounds who received bilayer wound matrix, local tissue rearrangement, or free flap reconstruction were retrospectively reviewed (from 2010 to 2017). Cohorts’ comorbidities and wound characteristics were balanced. Graft success at 180 days was the primary outcome; readmissions, reoperations, and costs were secondary outcomes.

Results:

Five hundred one subjects (166 matrix, 190 rearrangement, and 145 free flap patients) were evaluated. Matched subjects (n= 312; 104/group) were analyzed. Reconstruction success at 180 days for matrix, local tissue rearrangement, and free flaps was 69.2 percent, 91.3 percent, and 93.3 percent (p <0.001), and total costs per subject were $34,877, $35,220, and $53,492 (p <0.001), respectively. Median length of stay was at least 2 days longer for free flaps (p <0.0001). Readmissions and reoperations were greater for free flaps. Local tissue rearrangement, if achievable, provided success at low cost. Free flaps were effective with large, traumatic wounds but at higher costs and longer length of stay. Matrices successfully treated older, obese patients without exposed bone.

Conclusions:

Lower extremity reconstruction can be performed effectively using multiple modalities with varying degrees of success and costs. Local tissue rearrangement and free flaps demonstrate success rates greater than 90 percent. Bilayer wound matrix-based reconstruction effectively treats a distinct patient population.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Effectiveness of Switching to Darunavir/Cobicistat in Virologically Suppressed HIV-Positive Patients Receiving Ritonavir-Boosted Protease Inhibitor–Based Regimen: The “STORE” Study
Authors: Gori Andrea , Antinori Andrea , Vergori Alessandra , Cossu Maria Vittoria , Menzaghi Barbara , Sterrantino Gaetana , Rusconi Stefano , Cattelan Anna Maria , Castelli Francesco , Gianotti Nicola , Orofino Giancarlo , Ripamonti Diego , Savinelli Stefano , Manzillo Elio , Santantonio Teresa Antonia , Celesia Benedetto Maurizio , Cauda Roberto , Maserati Renato , d'Arminio Monforte Antonella , Stingone Christof , Bonora Stefano , Uglietti Alessia , Termini Roberta , Rucci Francesco , Mancusi Daniela
Published: February 2020

Objective:

This study investigates the effectiveness and tolerability of switching to a darunavir/cobicistat (DRV/c)-based antiretroviral regimen from a ritonavir-boosted protease inhibitor (PI/r)-based regimen in virologically suppressed HIV-positive patients. DRV trough values were also investigated.

Setting:

Prospective, multicenter, single-country, noninterventional cohort study.

Methods:

This study included patients on a PI/r-based ART for at least 12 months having plasma HIV-1 RNA <50 copies/mL since at least 6 months. The primary endpoint, defined as HIV-1 RNA <50 copies/mL, was measured at 48 ± 6 weeks from baseline. A secondary analysis was performed using the time to loss of virological response algorithm. Biochemical parameters, including DRV trough samples, were collected as per clinical practice and measured using high-performance liquid chromatography.

Results:

Of 336 patients enrolled, 282 completed the study: 70.8% had plasma HIV-1 RNA <50 copies/mL at 48 weeks; using the time to loss of virological response algorithm, 82.7% maintained virological suppression. Virological failure was observed in 6 patients (1.8%). Adverse event–related discontinuations were 4.5%. After 48 weeks, we found a significant improvement in both triglycerides (median, 130 to 113.5 mg/dL, P = 0.0254) and high-density lipoprotein cholesterol (48 to 49 mg/dL, P < 0.0001) but no change in other biomarkers. DRV trough concentrations in 56 subjects showed a median value of 2862.5 (1469.5–4439) ng/mL, higher in women than in men (4221 vs. 2634 ng/mL, P = 0.046).

Conclusions:

In stable HIV-1 positive virologically suppressed patients, the switch to DRV/c-based ART was beneficial in terms of low rates of virological failure and adverse events due to its high tolerability and improvement in triglycerides.