bluuebunny/crossref_metadata_2025 huggingface dataset:
Optimizing Cognitive Function in Persons With Chronic Pain
Authors: Baker Katharine S. , Georgiou-Karistianis Nellie , Gibson Stephen J. , Giummarra Melita J.
Published: August 2016

Objectives:

Cognitive functioning is commonly disrupted in people living with chronic pain, yet it is an aspect of pain that is often not routinely assessed in pain management settings, and there is a paucity of research on treatments or strategies to alleviate the problem. The purpose of this review is to outline recent research on cognitive deficits seen in chronic pain, to give an overview of the mechanisms involved, advocate cognitive functioning as an important target for treatment in pain populations, and discuss ways in which it may be assessed and potentially remediated.

Methods:

A narrative review.

Results:

There are several options for remediation, including compensatory, restorative, and neuromodulatory approaches to directly modify cognitive functioning, as well as physical, psychological, and medication optimization methods to target secondary factors (mood, sleep, and medications) that may interfere with cognition.

Discussion:

We highlight the potential to enhance cognitive functions and identify the major gaps in the research literature.
Effects of Different Crystalloid Solutions on Hemodynamics, Peripheral Perfusion, and the Microcirculation in Experimental Abdominal Sepsis
Authors: Orbegozo Diego , Su Fuhong , Santacruz Carlos , He Xinrong , Hosokawa Koji , Creteur Jacques , De Backer Daniel , Vincent Jean-Louis
Published: August 2016

Background

Crystalloid solutions are used to restore intravascular volume in septic patients, but each solution has limitations. The authors compared the effects of three crystalloid solutions on hemodynamics, organ function, microcirculation, and survival in a sepsis model.

Methods

Peritonitis was induced by injection of autologous feces in 21 anesthetized, mechanically ventilated adult sheep. After baseline measurements, animals were randomized to lactated Ringer’s (LR), normal saline (NS), or PlasmaLyte as resuscitation fluid. The sublingual microcirculation was assessed using sidestream dark field videomicroscopy and muscle tissue oxygen saturation with near-infrared spectroscopy.

Results

NS administration was associated with hyperchloremic acidosis. NS-treated animals had lower cardiac index and left ventricular stroke work index than LR-treated animals from 8 h and lower mean arterial pressure than LR-treated animals from 12 h. NS-treated animals had a lower proportion of perfused vessels than LR-treated animals after 12 h (median, 82 [71 to 83] vs. 85 [82 to 89], P = 0.04) and greater heterogeneity of proportion of perfused vessels than PlasmaLyte or LR groups at 18 h. Muscle tissue oxygen saturation was lower at 16 h in the NS group than in the other groups. The survival time of NS-treated animals was shorter than that of the LR group (17 [14 to 20] vs. 26 [23 to 29] h, P < 0.01) but similar to that of the PlasmaLyte group (20 [12 to 28] h, P = 0.74).

Conclusions

In this abdominal sepsis model, resuscitation with NS was associated with hyperchloremic acidosis, greater hemodynamic instability, a more altered microcirculation, and more severe organ dysfunction than with balanced fluids. Survival time was shorter than in the LR group.
Nondepolarizing Neuromuscular Blocking Agents, Reversal, and Risk of Postoperative Pneumonia
Authors: Bulka Catherine M. , Terekhov Maxim A. , Martin Barbara J. , Dmochowski Roger R. , Hayes Rachel M. , Ehrenfeld Jesse M.
Published: August 2016

Background

Residual postoperative paralysis from nondepolarizing neuromuscular blocking agents (NMBAs) is a known problem. This paralysis has been associated with impaired respiratory function, but the clinical significance remains unclear. The aims of this analysis were two-fold: (1) to investigate if intermediate-acting NMBA use during surgery is associated with postoperative pneumonia and (2) to investigate if nonreversal of NMBAs is associated with postoperative pneumonia.

Methods

Surgical cases (n = 13,100) from the Vanderbilt University Medical Center National Surgical Quality Improvement Program database who received general anesthesia were included. The authors compared 1,455 surgical cases who received an intermediate-acting nondepolarizing NMBA to 1,455 propensity score–matched cases who did not and 1,320 surgical cases who received an NMBA and reversal with neostigmine to 1,320 propensity score–matched cases who did not receive reversal. Postoperative pneumonia incidence rate ratios (IRRs) and bootstrapped 95% CIs were calculated.

Results

Patients receiving an NMBA had a higher absolute incidence rate of postoperative pneumonia (9.00 vs. 5.22 per 10,000 person-days at risk), and the IRR was statistically significant (1.79; 95% bootstrapped CI, 1.08 to 3.07). Among surgical cases who received an NMBA, cases who were not reversed were 2.26 times as likely to develop pneumonia after surgery compared to cases who received reversal with neostigmine (IRR, 2.26; 95% bootstrapped CI, 1.65 to 3.03).

Conclusions

Intraoperative use of intermediate nondepolarizing NMBAs is associated with developing pneumonia after surgery. Among patients who receive these agents, nonreversal is associated with an increased risk of postoperative pneumonia.
Cytomegalovirus-Induced Hemophagocytic Lymphohistiocytosis in an Extreme Preterm Infant
Authors: Halliday Matthew , Ross Julie , Southgate W. Michael
Published: August 2016

Background:

Hemophagocytic lymphohistiocytosis (HLH) is a rare disease that can be triggered by cytomegalovirus, a relatively common infectious exposure to neonates. The clinical presentation is common to many acute illnesses seen in extreme premature infants; however, there are key clinical and laboratory findings that can lead to the diagnosis.

Purpose:

We present a case of an extreme premature infant of 25 weeks' gestation who developed cytomegalovirus-induced HLH. Using the current published protocols that are used in pediatric cancer can be adapted for use in a premature infant, which led to remission of HLH and eventual discharge from the neonatal intensive care unit.

Implications for Practice:

There are published treatment protocols used in pediatric oncology that when initiated early can lead to favorable outcomes and remission in even the most fragile neonates.

Implications for Research:

Additional studies are needed on the pharmacokinetics, dosing, and side effects on medications used for treatment of HLH in preterm infants. Additional research is needed to improve the clinician's ability to reach the diagnosis as well as define treatment strategies that provide optimal outcomes.
Mixed-Methods Research in the Discipline of Nursing
Authors: Beck Cheryl Tatano , Harrison Lisa
Published: August 2016

In this review article, we examined the prevalence and characteristics of 294 mixed-methods studies in the discipline of nursing. Creswell and Plano Clark's typology was most frequently used along with concurrent timing. Bivariate statistics was most often the highest level of statistics reported in the results. As for qualitative data analysis, content analysis was most frequently used. The majority of nurse researchers did not specifically address the purpose, paradigm, typology, priority, timing, interaction, or integration of their mixed-methods studies. Strategies are suggested for improving the design, conduct, and reporting of mixed-methods studies in the discipline of nursing.
Nurses' Knowledge About Transgender Patient Care
Authors: Carabez Rebecca M. , Eliason Michele J. , Martinson Marty
Published: August 2016

This study explored practicing nurses' knowledge of the needs of transgender patients. Structured interviews were conducted with 268 nurses in the San Francisco Bay Area. This study focused on the responses to 1 item in the 16-item interview, “Describe health care issues that are particular to transgender patients.” Three themes emerged from the data: discomfort, transition, and harsh consequences of being transgender. These findings revealed nurses' discomfort and lack of knowledge about transgender people and their health care needs. Nursing curricula must challenge the gender binary to better prepare nurses to provide quality care for patients of all genders.
Understanding Influence within the Context of Nursing
Authors: Adams Jeffrey M. , Natarajan Sudha
Published: August 2016

Acquiring influence, and knowing how to use it, is a required competency for nurse leaders, yet the concept of influence and how it works is not well described in the nursing literature. In this article, the authors examine what is known about influence and present an influence model specific to nurse leaders. The Adams Influence Model was developed through an iterative process and is based on a comprehensive review of the influence literature, expert commentary, multiple pilot studies, evaluation of nursing theories, and validation by an external data source. Rather than defining “how to” influence, the model serves as a guide for personal reflection, helping nurse leaders understand and reflect on the influence process and factors, tactics, and strategies they can use when seeking to influence others.
Elbow Kinematics During Gait Improve With Age in Children With Hemiplegic Cerebral Palsy
Authors: Gordon Benjamin L. , Wolff Aviva L. , Daluiski Aaron
Published: August 2016

Background:

Children with hemiplegic cerebral palsy (hCP) exhibit a typical posture of elbow flexion during gait. However, the change in elbow kinematics and symmetry during gait across age span in both hCP and typically developing (TD) children is not well described. The aim of this study was to quantify the change in elbow kinematics and symmetry across age span in hCP children compared with TD children.

Methods:

Upper extremity kinematic data were extracted and analyzed from a database for gait studies performed between 2009 and 2015. A total of 35 hCP and 51 TD children between the ages of 4 and 18 (mean age: TD=11.2±0.6, hCP=9.8±0.5) met inclusionary criteria. The groups were further subdivided into 3 age categories: 4 to 7, 8 to 11, 12+ years old. Elbow angles were extracted and peak elbow flexion, overall range of motion during gait, and asymmetry indices were calculated. A 1-way analysis of variance was performed on each group with post hoc Tukey honestly significant difference pairwise comparisons.

Results:

Peak elbow flexion during gait increased with age in TD children (P<0.05) and decreased with age in hCP children on the affected side (P<0.05). There was no change on the less affected side of hCP children. TD children demonstrated significantly less elbow flexion (mean=51.9±2.1 deg.) compared with the affected side in hCP (mean=82.1±3.8 deg.) across all age categories (P<0.05). There was no change in elbow asymmetry index (0=perfect symmetry) across age in either controls or hCP children; however, there were differences between hCP and TD groups in younger age groups (TD=28, hCP=62, P<0.05) that resolved by adolescence (TD=32, hCP=40).

Conclusions:

During gait, hCP children have greater peak elbow flexion on the affected side than do TD children. Peak elbow flexion angle converged between the 2 groups with age, decreasing in hCP children and increasing in TD children. Furthermore, elbow symmetry during gait improves with age in hCP children, approximating symmetry of TD children by adolescence. These findings have implications for both consideration and optimal timing of surgical intervention to improve elbow flexion in children with hCP.

Level of Evidence:

Level III—retrospective case-control study.
Comparison of Motor-Evoked Potentials Versus Somatosensory-Evoked Potentials as Early Indicators of Neural Compromise in Rat Model of Spinal Cord Compression
Authors: Morris Susan H. , Howard Jason J. , El-Hawary Ron
Published: August 2016

Study Design.

Randomized controlled study comparing the efficacy of intraoperative somatosensory-evoked potentials (SSEPs) versus transcranial motor–evoked potentials (TcMEPs) as early indicators of neural compromise and predictors of postoperative function in a rat model of spinal cord compression.

Objective.

To compare the relative efficacy of SSEPs and TcMEPs to detect spinal cord compromise and predict postoperative functional deficit after spinal cord compression.

Summary of Background Data.

There is controversy regarding the efficacy of SSEPs versus TcMEPs to detect intraoperative spinal cord compromise and predict functional outcomes. Previous trials provide some guidance as to the role of each modality in spinal cord monitoring but randomized controlled trials, which are not feasible in humans, are lacking.

Methods.

Twenty-four adult male Wistar rats were evenly divided into three experimental groups and one control group. The experimental groups were determined according to the length of time that 100% TcMEP signal loss was maintained: 0, 5, or 15 minutes. All animals had standardized preoperative functional testing. Spinal cord compromise was initiated utilizing a validated protocol, which involved compression via a balloon catheter introduced into the thoracic sublaminar space. Both SSEPs and TcMEPs were recorded during cord compression for each experimental group. Functional behavioral testing using two validated methods (tilt and modified Tarlov) was repeated 24 hours after termination of spinal cord compression. Post hoc, animals were redistributed into two functional subgroups, noncompromised and compromised, for statistical analysis.

Results.

TcMEPs consistently detected spinal cord compromise either in advance of or at the same time as SSEPs; however, the delay in SSEP response was not significant for cases when compromised postoperative function resulted. Both SSEP and TcMEP amplitude recovery correlated well with postoperative functional scores.

Conclusion.

TcMEPs are more sensitive to spinal cord compromise than SSEPs, but the recovery profiles of both SSEP and TcMEP amplitudes are good predictors of postoperative function.

Level of Evidence: 2
The Postcardiac Arrest Consult Team: Impact on Hospital Care Processes for Out-of-Hospital Cardiac Arrest Patients*
Authors: Brooks Steven C. , Scales Damon C. , Pinto Ruxandra , Dainty Katie N. , Racz Elizabeth M. , Gaudio Michelle , Amaral Andre C. K. B. , Gray Sara H. , Friedrich Jan O. , Chapman Martin , Dorian Paul , Fam Neil , Fowler Robert A. , Hayes Chris W. , Baker Andrew , Crystal Eugene , Madan Mina , Rubenfeld Gordon , Smith Orla M. , Morrison Laurie J.
Published: August 2016

Objective:

To evaluate whether a Post-Arrest Consult Team improved care and outcomes for patients with out-of-hospital cardiac arrest.

Design:

Prospective cohort study of Post-Arrest Consult Team implementation at two hospitals, with concurrent controls from 27 others.

Setting:

Twenty-nine hospitals within the Strategies for Post-Arrest Care Network of Southern Ontario, Canada.

Patients:

We included comatose adult nontraumatic out-of-hospital cardiac arrest patients surviving more than or equal to 6 hours after emergency department arrival who had no contraindications to targeted temperature management.

Intervention:

The Post-Arrest Consult Team was an advisory consult service to improve 1) targeted temperature management, 2) assessment for percutaneous coronary intervention, 3) electrophysiology assessment, and 4) appropriately delayed neuroprognostication.

Measurements and Main Results:

We used generalized linear mixed models to explore the association between Post-Arrest Consult Team implementation and performance of targeted processes. We included 1,006 patients. The Post-Arrest Consult Team was associated with a significant reduction over time in rates of withdrawal of life-sustaining therapy within 72 hours of emergency department arrival on the basis of predictions of poor neurologic prognosis (ratio of odds ratios, 0.13; 95% CI, 0.02–0.98). Post-Arrest Consult Team was not associated with improved successful targeted temperature management (ratio of odds ratios, 0.91; 95% CI, 0.31–2.65), undergoing angiography (ratio of odds ratios, 1.91; 95% CI, 0.17–21.04), receiving electrophysiology consultation (ratio of odds ratios, 0.93; 95% CI, 0.11–8.16), or functional survival (ratio of odds ratios, 0.75; 95% CI, 0.19–2.94).

Conclusions:

Implementation of a Post-Arrest Consult Team reduced premature withdrawal of life-sustaining therapy but did not improve rates of successful targeted temperature management, coronary angiography, formal electrophysiology assessments, or functional survival for comatose patients after out-of-hospital cardiac arrest.
Peripheral IV Insulin Infusion Infiltration Presenting as “Insulin Resistance”
Authors: Kim Tiffany Y. , Woeber Kenneth A. , MacMaster Heidimarie Windham , Rushakoff Robert J.
Published: August 2016

Objectives:

We present the case of a 66-year-old woman who developed hypoglycemia following the prolonged infiltration of a high dose continuous peripheral IV insulin infusion.

Study Selection:

Case report.

Data Sources and Extraction:

PubMed was searched for relevant literature on exogenous hyperinsulinemic hypoglycemia.

Data Synthesis:

The patient was postlung transplantation and was receiving high doses of glucocorticoids. Despite increasing the peripheral IV insulin rate, hyperglycemia persisted. We discovered that the IV insulin infusion line infiltrated, resulting in a large subcutaneous insulin depot, estimated to be 450 units of regular insulin. She subsequently experienced prolonged hypoglycemia that was managed with concentrated dextrose containing fluids. In our literature search, there were no similar case reports. The literature on insulin overdose, usually from suicide attempts, can help guide the management of iatrogenic hyperinsulinemic hypoglycemia. Important management considerations include anticipated duration of hypoglycemia, supplemental glucose, fluid management, and electrolyte monitoring.

Conclusion:

Peripheral IV insulin infusion infiltration should be considered when patients do not respond to increasing rates of insulin infusion.
Comparing Time-Fixed Mortality Prediction Models and Their Effect on ICU Performance Metrics Using the Simplified Acute Physiology Score 3
Authors: Engerström Lars , Kramer Andrew A. , Nolin Thomas , Sjöberg Folke , Karlström Göran , Fredrikson Mats , Walther Sten M.
Published: August 2016

Objectives:

To examine ICU performance based on the Simplified Acute Physiology Score 3 using 30-day, 90-day, or 180-day mortality as outcome measures and compare results with 30-day mortality as reference.

Design:

Retrospective cohort study of ICU admissions from 2010 to 2014.

Setting:

Sixty-three Swedish ICUs that submitted data to the Swedish Intensive Care Registry.

Patients:

The development cohort was first admissions to ICU during 2011–2012 (n = 53,546), and the validation cohort was first admissions to ICU during 2013–2014 (n = 57,729).

Interventions:

None.

Measurements and Main Results:

Logistic regression was used to develop predictive models based on a first level recalibration of the original Simplified Acute Physiology Score 3 model but with 30-day, 90-day, or 180-day mortality as measures of outcome. Discrimination and calibration were excellent for the development dataset. Validation in the more recent 2013–2014 database showed good discrimination (C-statistic: 0.85, 0.84, and 0.83 for the 30-, 90-, and 180-d models, respectively), and good calibration (standardized mortality ratio: 0.99, 0.99, and 1.00; Hosmer-Lemeshow goodness of fit H-statistic: 66.4, 63.7, and 81.4 for the 30-, 90-, and 180-d models, respectively). There were modest changes in an ICU’s standardized mortality ratio grouping (< 1.00, not significant, > 1.00) when follow-up was extended from 30 to 90 days and 180 days, respectively; about 11–13% of all ICUs.

Conclusions:

The recalibrated Simplified Acute Physiology Score 3 hospital outcome prediction model performed well on long-term outcomes. Evaluation of ICU performance using standardized mortality ratio was only modestly sensitive to the follow-up time. Our results suggest that 30-day mortality may be a good benchmark of ICU performance. However, the duration of follow-up must balance between what is most relevant for patients, most affected by ICU care, least affected by administrative policies and practically feasible for caregivers.
Double-Stranded RNA Interacts With Toll-Like Receptor 3 in Driving the Acute Inflammatory Response Following Lung Contusion
Authors: Suresh Madathilparambil V. , Thomas Bivin , Machado-Aranda David , Dolgachev Vladislov A. , Kumar Ramakrishnan Sadeesh , Talarico Nicholas , Cavassani Karen , Sherman Matthew A. , Hemmila Mark R. , Kunkel Steven L. , Walter Nils G. , Hogaboam Cory M. , Raghavendran Krishnan
Published: August 2016

Objectives:

Lung contusion is a major risk factor for the development of acute respiratory distress syndrome. We set to determine the role of toll-like receptor 3 and the binding of double-stranded RNA in the pathogenesis of sterile injury following lung contusion.

Design:

Toll-like receptor 3 expression was analyzed in postmortem lung samples from patients with lung contusion. Unilateral lung contusion was induced in toll-like receptor 3 (–/–), TIR-domain-containing adapter-inducing interferon-β (–/–), and wild-type mice. Subsequently, lung injury and inflammation were evaluated. Apoptotic indices, phagocytic activity, and phenotypic characterization of the macrophages were determined. Double-stranded RNA in bronchoalveolar lavage and serum samples following lung contusion was measured. A toll-like receptor 3/double-stranded RNA ligand inhibitor was injected into wild-type mice prior to lung contusion.

Measurements and Main Results:

Toll-like receptor 3 expression was higher in patients and wild-type mice with lung contusion. The degree of lung injury, inflammation, and macrophage apoptosis was reduced in toll-like receptor 3 (–/–), TIR-domain-containing adapter-inducing interferon-β (–/–), and wild-type mice with toll-like receptor 3 antibody neutralization. Alveolar macrophages from toll-like receptor 3 (–/–) mice had a lower early apoptotic index, a predominant M2 phenotype and increased surface translocation of toll-like receptor 3 from the endosome to the surface. When compared with viral activation pathways, lung injury in lung contusion demonstrated increased p38 mitogen-activated protein kinases, extracellular signal-regulated kinase 1/2 phosphorylation with inflammasome activation without a corresponding increase in nuclear factor-κB or type-1 interferon production. Additionally, pretreatment with toll-like receptor 3/double-stranded RNA ligand inhibitor led to a reduction in injury, inflammation, and macrophage apoptosis.

Conclusions:

We conclude that the interaction of double-stranded RNA from injured cells with toll-like receptor 3 drives the acute inflammatory response following lung contusion.
Connecting Professional Practice and Technology at the Bedside
Authors: Gomes Melissa , Hash Pamela , Orsolini Liana , Watkins Aimee , Mazzoccoli Andrea
Published: August 2016

The purpose of this research is to determine the effects of implementing an electronic health record on medical-surgical registered nurses' time spent in direct professional patient-centered nursing activities, attitudes and beliefs related to implementation, and changes in level of nursing engagement after deployment of the electronic health record. Patient-centered activities were categorized using Watson's Caritas Processes and the Relationship-Based Care Delivery System. Methods included use of an Attitudes and Beliefs Assessment Questionnaire, Nursing Engagement Questionnaire, and Rapid Modeling Corporation's personal digital assistants for time and motion data collection. There was a significant difference in normative belief between nurses with less than 15 years' experience and nurses with more than 15 years' experience (t
21 = 2.7, P = .01). While nurses spent less time at the nurses' station, less time charting, significantly more time in patients' rooms and in purposeful interactions, time spent in relationship-based caring behavior categories actually decreased in most categories. Nurses' engagement scores did not significantly increase. These results serve to inform healthcare organizations about potential factors related to electronic health record deployment which create shifts in nursing time spent across care categories and can be used to explore further patient centered care practices.
Lack of effect of ethanol on cocaine prime-induced reinstatement of extinguished cocaine self-administration in rhesus monkeys
Authors: Czoty Paul W.
Published: August 2016

Cocaine and alcohol are commonly co-abused for reasons that are incompletely understood. Laboratory animal studies have suggested that, although the reinforcing effects of low cocaine doses are increased following chronic ethanol (EtOH) consumption, acute EtOH administration does not consistently alter cocaine self-administration. The present study examined whether EtOH influences another abuse-related effect of cocaine: reinstatement of extinguished responding. Rhesus monkeys that had previously consumed EtOH for 8 weeks (2.0 g/kg over 1 h, 5 days/week) self-administered up to 10 injections per day of 0.1 mg/kg cocaine under a fixed-interval 300-s schedule. After responding had been extinguished by substituting saline for cocaine, a pre-session infusion of saline or EtOH (0.5 or 1.0 g/kg, intravenously over 10 min) was followed by a ‘priming’ injection of saline or cocaine (intravenously). Responding was increased significantly by priming injections of cocaine, but not saline. EtOH infusions neither reinstated behavior when administered before a saline prime nor altered the priming effect of cocaine. The inability of EtOH to alter the response-reinstating ability of cocaine provides further evidence for a lack of acute behavioral interactions between cocaine and EtOH.
Plastic Surgery and Suicide: A Clinical Guide for Plastic Surgeons
Authors: Reddy Vikram , Coffey M. Justin
Published: August 2016

Several studies have identified an increased risk of suicide among patient populations which a plastic surgeon may have a high risk of encountering: women undergoing breast augmentation, cosmetic surgery patients, and breast cancer patients. No formal guidelines exist to assist a plastic surgeon when faced with such a patient, and not every plastic surgery team has mental health clinicians that are readily accessible for consultation or referral. The goal of this clinical guide is to offer plastic surgeons a set of practical approaches to manage potentially suicidal patients. In addition, the authors review a screening tool, which can assist surgeons when encountering high-risk patients.
Nipple Reconstruction with the Biodesign Nipple Reconstruction Cylinder: A Prospective Clinical Study
Authors: Collins Brendan , Williams Jeremy Z. , Karu Heather , Hodde Jason P. , Martin Victoria A. , Gurtner Geoffrey C.
Published: August 2016

Background:

Nipple reconstruction is the last stage in cosmetic reconstruction of the breast after mastectomy, but no method produces reliable and consistent aesthetic results. This study examined the use of the Biodesign Nipple Reconstruction Cylinder (NRC) during reconstruction of the nipple after mastectomy.

Methods:

Patients with a history of breast cancer and mastectomy desiring nipple reconstruction were invited to participate. After obtaining consent, unilateral or bilateral nipple reconstruction was performed. Skin flaps were raised, the NRC was placed beneath the flaps as a stent, and the site was protected for up to 4 weeks with a nipple shield. Nipple projection was measured for 12 months after surgery. Patient satisfaction was measured and adverse events were recorded. Follow-up examinations were performed at 1 week, and then at 1, 3, 6, and 12 months after surgery.

Results:

Eighty-two nipple reconstructions were performed in 50 patients. Related postoperative adverse events were minor, but reported in 8 reconstructions (9.8%) representing 7 patients (14.0%). Average projection at 6 and 12 months was 4.1 ± 1.6 mm and 3.8 ± 1.5 mm, respectively, compared with 10.5 ± 2.2 mm 1 week after surgery. Of patients completing the satisfaction questionnaire at 12 months, 70/75 (93.3%) of reconstructions were rated “pleased” or “very pleased” with the overall outcome. Overall, 45/46 (97.8%) patients would recommend nipple reconstruction to other women.

Conclusions:

The Biodesign NRC offers a safe alternative to nipple reconstruction, resulting in stable projection and a high level of patient satisfaction for 12 months after placement.
Physiological Responses to Arm Activity in Individuals With Chronic Obstructive Pulmonary Disease Compared With Healthy Controls
Authors: Lima Vanessa Pereira , Iamonti Vinicius C. , Velloso Marcelo , Janaudis-Ferreira Tania
Published: August 2016

PURPOSE:

The mechanisms underlying physiological limitations during arm activity in individuals with chronic obstructive pulmonary disease (COPD) are unknown. The objective of this systematic review was to describe cardiorespiratory responses, symptoms, chest wall kinematics, muscle activity, and lung volumes during arm activity in individuals with COPD relative to the responses of healthy controls.

METHODS:

Original research articles that compared cardiorespiratory responses, symptoms, muscle activity, chest wall kinematics, and lung function during arm activity between individuals with COPD and healthy controls were identified after searches of 5 electronic databases and reference lists of pertinent articles. Two reviewers performed the electronic and manual searches with 1 screening title and abstracts. Two investigators screened the full texts to determine eligibility for inclusion. One reviewer performed the data extraction and tabulation using a standardized form with a second reviewer double-checking the data extracted.

RESULTS:

Of the 54 full-text articles assessed for eligibility, 6 met the inclusion criteria. Reduced cardiorespiratory responses during peak arm exercise in individuals with COPD compared with healthy controls were evident. Compared with healthy controls, individuals with COPD had increased dyspnea and hyperinflation during peak arm exercise. Increased effort of the trapezius muscle during arm activities was also found in persons with COPD compared with healthy controls.

CONCLUSIONS:

There is limited evidence describing physiological responses during arm activity in individuals with COPD. Findings of this systematic review suggest that individuals with COPD have decreased cardiorespiratory responses during peak arm exercise compared with controls but increased dyspnea, hyperinflation, and arm muscle effort.
BRANCH RETINAL ARTERY OCCLUSION ASSOCIATED WITH PARACENTRAL ACUTE MIDDLE MACULOPATHY IN A PATIENT WITH LIVEDO RETICULARIS
Authors: Baciu Paul , Nofar Candice M. , Spaulding Justin , Gao Hua
Published: August 2016

Purpose:

To report the occurrence of a branch retinal artery occlusion with paracentral acute middle maculopathy in an otherwise healthy young man with a history of livedo reticularis (LR).

Methods:

Retrospective case report.

Patients:

A 21-year-old man with a history of LR being treated with pentoxifylline developed an acute branch retinal artery occlusion with initial best-corrected visual acuity at presentation of 20/80.

Results:

A thorough diagnostic work up was negative for potential causes of branch retinal artery occlusion or LR. The patient was continued on pentoxifylline and started on aspirin 81 mg daily. At five-month follow-up, vision had improved to 20/25. Optical coherence tomography testing showed a hyperreflective band in the inner nuclear layer and outer plexiform layers in the affected eye that ultimately thinned, consistent with paracentral acute middle maculopathy.

Conclusion:

To our knowledge, this is the first case of branch retinal artery occlusion occurring in a patient with a history of LR. This could potentially be an early manifestation of Sneddon syndrome, a rare entity characterized by LR and cerebrovascular disease, which has been previously associated with central retinal artery occlusions.
Presumed Furosemide-associated Bilateral Angle-Closure Glaucoma
Authors: Boundaoui Oussama N. , Woodruff Todd E.
Published: August 2016

Purpose:

To report a case of presumed furosemide-associated bilateral angle-closure glaucoma.

Methods:

Retrospective case report with spectral domain anterior segment optical coherence tomography imaging.

Results:

A 21-year-old African American woman in her 17th week of pregnancy presented with acute angle-closure glaucoma in both eyes after being started on furosemide in her first trimester for fluid overload. Intraocular pressures were elevated in the low 40s mm Hg bilateral (OU) and anterior chambers were shallow with narrow grade 1 angles on gonioscopy (Schaffer classification). Medical history included type 1 diabetes mellitus, chronic kidney disease, and 2 prior failed pregnancies complicated by fluid overload. She was started on 60 mg of prednisone daily along with topical brimonidine in both eyes twice daily. After 3 days, her intraocular pressures normalized. At 1 week, slit-lamp examination showed deepened anterior chambers and gonioscopy confirmed widened angles. Oral prednisone was titrated down slowly for the remainder of her uneventful pregnancy. On follow-up 1 month after delivery, intraocular pressures and best-corrected visual acuities reached preterm baseline values of 15 mm Hg OU and 20/30 OU.

Conclusions:

This is the first reported case of furosemide-associated bilateral angle-closure glaucoma. Similar idiosyncratic reactions following exposure to other sulphonamide-containing drugs have been described. We propose discontinuation of the offending agent and treatment with oral prednisone in similar clinical settings.
Bacterial Biofilms in Jones Tubes
Authors: Ahn Eric S. , Hauck Matthew J. , Kirk Harris Jonathan , Robertson Charles E. , Dailey Roger A.
Published: August 2016

Purpose:

To investigate the presence and microbiology of bacterial biofilms on Jones tubes (JTs) by direct visualization with scanning electron microscopy and polymerase chain reaction (PCR) of representative JTs, and to correlate these findings with inflammation and/or infection related to the JT.

Methods:

In this study, prospective case series were performed. JTs were recovered from consecutive patients presenting to clinic for routine cleaning or recurrent irritation/infection. Four tubes were processed for scanning electron microscopy alone to visualize evidence of biofilms. Two tubes underwent PCR alone for bacterial quantification. One tube was divided in half and sent for scanning electron microscopy and PCR. Symptoms related to the JTs were recorded at the time of recovery.

Results:

Seven tubes were obtained. Five underwent SEM, and 3 out of 5 showed evidence of biofilms (60%). Two of the 3 biofilms demonstrated cocci and the third revealed rods. Three tubes underwent PCR. The predominant bacteria identified were Pseudomonadales (39%), Pseudomonas (16%), and Staphylococcus (14%). Three of the 7 patients (43%) reported irritation and discharge at presentation. Two symptomatic patients, whose tubes were imaged only, revealed biofilms. The third symptomatic patient’s tube underwent PCR only, showing predominantly Staphylococcus (56%) and Haemophilus (36%) species. Two of the 4 asymptomatic patients also showed biofilms. All symptomatic patients improved rapidly after tube exchange and steroid antibiotic drops.

Conclusions:

Bacterial biofilms were variably present on JTs, and did not always correlate with patients’ symptoms. Nevertheless, routine JT cleaning is recommended to treat and possibly prevent inflammation caused by biofilms.
The Effectiveness and Long-Term Outcome of Conjunctivodacryocystorhinostomy With Frosted Jones Tubes
Authors: Ahn Eric S. , Dailey Roger A. , Radmall Bryce
Published: August 2016

Purpose:

To describe success rates and long-term outcomes of conjunctivodacryocystorhinostomy (CDCR) with frosted Jones tubes (FJT) for epiphora with proximal outflow obstruction.

Methods:

A retrospective chart review of all patients undergoing external and endoscopic CDCR with FJTs by one author (RAD) was performed between January 1, 2006 and November 1, 2014 at the Casey Eye Institute. Patient demographics, etiology of tearing, concurrent endonasal and eyelid procedures, and FJT size were recorded. After CDCR, follow-up time, tube size changes, tube position, and tearing status were noted. Exclusion criteria included follow up less than 6 months and/or prior CDCR. The study was IRB approved, HIPAA compliant, and adherent to the declaration of Helsinki.

Results:

Forty-two eyes of 31 patients met the inclusion criteria, with the majority having epiphora from canalicular obstruction (31%) or flaccid canaliculi (31%). Average follow up was 1,088 days. Forty of 42 eyes, or 30 of 31 patients, had complete resolution of tearing after surgery. Twenty of 42 eyes required tube size changes, usually an increase in collar size (45%) and/or decrease in tube length (55%). Six of 42 FJTs were lost, one migrating outward, with an average time to loss between 61 and 1,122 days (mean 817 days). After collars larger than 4 mm became available, only one tube was lost. All epiphora resolved after repeat CDCR. The most common complication was intermittent irritation (17%) near the FJT that resolved after antibiotic–steroid drops and/or tube replacement/cleaning.

Conclusion:

CDCR with FJTs is highly effective in correcting epiphora, and well tolerated by the majority.
The Vulvar Pain Assessment Questionnaire inventory
Authors: Dargie Emma , Holden Ronald R. , Pukall Caroline F.
Published: August 2016

Millions suffer from chronic vulvar pain (ie, vulvodynia). Vulvodynia represents the intersection of 2 difficult subjects for health care professionals to tackle: sexuality and chronic pain. Those with chronic vulvar pain are often uncomfortable seeking help, and many who do so fail to receive proper diagnoses. The current research developed a multidimensional assessment questionnaire, the Vulvar Pain Assessment Questionnaire (VPAQ) inventory, to assist in the assessment and diagnosis of those with vulvar pain. A large pool of items was created to capture pain characteristics, emotional/cognitive functioning, physical functioning, coping skills, and partner factors. The item pool was subsequently administered online to 288 participants with chronic vulvar pain. Of those, 248 participants also completed previously established questionnaires that were used to evaluate the convergent and discriminant validity of the VPAQ. Exploratory factor analyses of the item pool established 6 primary scales: Pain Severity, Emotional Response, Cognitive Response, and Interference with Life, Sexual Function, and Self-Stimulation/Penetration. A brief screening version accompanies a more detailed version. In addition, 3 supplementary scales address pain quality characteristics, coping skills, and the impact on one's romantic relationship. When relationships among VPAQ scales and previously researched scales were examined, evidence of convergent and discriminant validity was observed. These patterns of findings are consistent with the literature on the multidimensional nature of vulvodynia. The VPAQ can be used for assessment, diagnosis, treatment formulation, and treatment monitoring. In addition, the VPAQ could potentially be used to promote communication between patients and providers, and point toward helpful treatment options and/or referrals.
A Phase 2 Randomized Dose-Finding Study With Esmirtazapine in Patients With Primary Insomnia
Authors: Ruwe Frank , IJzerman-Boon Pieta , Roth Thomas , Zammit Gary , Ivgy-May Neely
Published: August 2016

The antidepressant mirtazapine is an alternative to classical hypnotics, and this study investigated the efficacy and safety of esmirtazapine (Org 50081, the maleic acid salt of S-mirtazapine) in patients given a diagnosis of primary insomnia after acute (2-day) treatment. Patients aged 18 to 65 years with primary insomnia were randomized to receive placebo or 1.5-, 3.0-, or 4.5-mg esmirtazapine in a balanced 4-way crossover study; 2 sleep laboratory nights with polysomnography were separated by 5-day, single-blind placebo washout periods. Polysomnography-determined total sleep time (primary end point) and patient-reported total sleep time improved by at least 25 minutes with all 3 doses of esmirtazapine (P ≤ 0.001 vs placebo). Polysomnography-measured wake time after sleep onset (P ≤ 0.0001) and latency to persistent sleep also improved vs placebo (P ≤ 0.01, 3.0 and 4.5 mg). Patient-reported sleep quality improved with 3.0- and 4.5-mg esmirtazapine (P ≤ 0.01 and P ≤ 0.05, respectively, vs placebo). Morning alertness and contentment were not altered after esmirtazapine, and calmness increased with 4.5-mg esmirtazapine vs placebo. Evening questionnaires showed no difference in duration of daytime naps but reduced energy and ability to work/function after esmirtazapine treatment periods vs placebo (P < 0.05), although this effect was limited to the first night of each 2-night period. There were few adverse events, no serious adverse events, or clinically relevant treatment differences in vital signs, laboratory values, or electrocardiogram. Esmirtazapine doses of 1.5 to 4.5 mg/day significantly improved quantity and quality of sleep and were generally well tolerated, with no evidence of safety concerns or consistent pattern of residual effects.
Neurological, Metabolic, and Psychiatric Adverse Events in Children and Adolescents Treated With Aripiprazole
Authors: Jakobsen Klaus Damgaard , Bruhn Christina Hedegaard , Pagsberg Anne-Katrine , Fink-Jensen Anders , Nielsen Jimmi
Published: August 2016

Aripiprazole is a partial dopamine agonist with only minor neurological and psychiatric adverse effects, making it a potential first-line drug for the treatment of psychiatric disorders. However, the evidence of its use in children and adolescents is rather sparse. The aim of this case study is to discuss adverse drug reaction (ADR) reports concerning aripiprazole-associated neurological and psychiatric events in children and adolescents. The ADR report database at Danish Medicines Agency was searched for all ADRs involving children and adolescents (<18 years) reported by the search term [aripiprazole] AND all spontaneous reports since the introduction of aripiprazole in 2003 until December 31, 2015. Nineteen case reports were included in the study and included both patients with psychotic disorders (PS group) and nonpsychotic disorders (non-PS group). The PS group consisted of 5 patients with schizophrenia and psychoses, not otherwise specified; and the non-PS group consisted of fourteen cases including autism spectrum disorders, attention deficit and hyperactivity disorder, obsessive-compulsive disorder, and Tourette syndrome. The main reported adverse effects in the non-PS group were chronic insomnia, Parkinsonism, behavioral changes psychoses, and weight gain, whereas the adverse effects in the PS group was predominantly anxiety, convulsions, and neuroleptic malignant syndrome. Although aripiprazole is considered safe and well tolerated in children and adolescents, severe adverse events as neuroleptic malignant syndrome, extreme insomnia, and suicidal behavior has been reported to health authorities. Clinicians should pay attention to these possible hazards when prescribing aripiprazole to this vulnerable group of patients.
Lessons Learned From Nocebo Effects in Clinical Trials for Pain Conditions and Neurodegenerative Disorders
Authors: Amanzio Martina , Palermo Sara , Skyt Ina , Vase Lene
Published: August 2016

It has been demonstrated that patients in the placebo arm of a clinical trial may experience adverse events (AEs), which may lead to nonadherence and dropout. However, so far, it is unknown to which extent this phenomenon is observed consistently across different diseases such as pain and neurodegenerative disorders.

The current review shows for the first time that different diseases share a common risk for patients in terms of a negative outcome: a large percentage of placebo-treated patients experience AEs in pain conditions (up to 59%) and neurodegenerative disorders (up to 66%). In addition, the rate of patients who discontinue because of AEs is up to 10% and 11% in pain conditions and neurodegenerative disorders, respectively.

We highlight methodological shortcomings with the aim of suggesting how the detection and reporting of AEs can be improved in future trials. The insights from the current review should be taken into consideration when designing clinical trials to tailor individualized treatments.
Oral Lesions
Authors: Beyer Donna , Torgerson Rochelle
Published: August 2016

Oral lesions can be a challenge to diagnose and treat. Talking, chewing, and swallowing cause friction within the mouth, making it difficult to determine the clinical appearance of the original lesion. Underlying health issues can also impact oral health so the patient health history, as well as the history and appearance of the oral lesions, is important to consider when diagnosing oral lesions. The patient presented here is a middle-aged man with oral lesions for 3 months, which severely impacted his life. This article allows the reader to identify a diagnosis based on information given, then discusses the differential diagnoses, and reveals the diagnosis and treatment plan.
The Impact of Early Ambulation in the Pediatric Postoperative Appendectomy Patient
Authors: Rothman Kelly , Garvan Cynthia , Neu Madalynn
Published: August 2016

The purposes of this study were to quantify the mean time to ambulate in a population of pediatric postoperative appendectomy patients at a stand-alone children’s hospital and to identify the associations between mean time to ambulate with admitting floor, patient age, pain medication, occurrence of nausea and vomiting, and length of stay. For decades, it has been suggested that extended immobilization in the postoperative patient should be avoided. Scant literature is available addressing early ambulation for pediatric patients after appendectomy. In practice, we noted that patients are not routinely ambulated early. Data were gathered from a retrospective review of 300 pediatric appendectomy patient charts at a children’s hospital. The mean time to ambulate was 16.05 hours (95% CI [14.14, 17.96]). The mean time to ambulate for patients placed on the surgical specialty unit was 13.48 (95% CI [11.90, 15.07]), compared with 20.36 hours for patients admitted to overflow units (95% CI [16.97, 25.36], p < .0007). Patients who experienced nausea and/or vomiting had a longer mean time to ambulate than those patients who did not (21.17 and 13.49 hours, respectively; p < .0001). Patients who received intravenous narcotics, oral narcotics, and nonnarcotic analgesics had a mean time to ambulate of 17.30, 13.03, and 11.61 hours, respectively (p = .0661). The Spearman’s rank correlation coefficient between length of stay and time to ambulate was .47. The results of this research study suggest that early ambulation has a significant impact on length of stay. Despite ambulation being taught in basic nursing education as a crucial component of postoperative care, this nursing-driven intervention is not routinely practiced. Placing these patients on a surgical specialty unit may lead to improved patient outcomes and will provide a targeted audience for future educational interventions.