bluuebunny/crossref_metadata_2025 huggingface dataset:
Histopathology of Calciphylaxis: Cohort Study With Clinical Correlations
Authors: Chen Tiffany Y. , Lehman Julia S. , Gibson Lawrence E. , Lohse Christine M. , el-Azhary Rokea A.
Published: October 2017

Calciphylaxis is a rare, painful, and life-threatening condition with a high mortality rate. Although the etiology of calciphylaxis is not well understood, it has been proposed that calcium deposition within and around subcutaneous vessels restricts blood flow chronically, thereby predisposing the patient to acute pannicular and dermal thrombosis. Given increasing recognition of the role of hypercoagulability in calciphylaxis, this retrospective cohort study sought to evaluate the presence of thromboses and dermal angioplasia in calciphylaxis. Moreover, we aimed to validate previous observations about the histopathology of calciphylaxis compared with skin biopsies from patients with end-stage renal disease but without calciphylaxis. After a meticulous clinical chart review, we assessed the corresponding skin biopsies for the presence of vessel calcification, thromboses, and dermal angioplasia in skin biopsies from patients with calciphylaxis (n = 57) and compared with those from patients with end-stage renal disease but without calciphylaxis (n = 26). Histopathologic findings were correlated with clinical features such as chronic kidney disease, diabetes, or associated malignancy. Our results validated a prior observation that calciphylaxis was significantly more likely to show calcification of dermal vessels and diffuse dermal thrombi. This study reports the frequent finding of dermal angioplasia, a potential marker of chronic low-grade ischemia, as another frequent microscopic finding in calciphylaxis. Among cases of calciphylaxis, histopathologic changes in patients with chronic kidney disease were indistinguishable from those in patients without chronic kidney disease, thereby implying a final common pathogenic pathway in both uremic and nonuremic calciphylaxis. In future, larger, prospective studies may be useful in validating these findings.
Primary Cutaneous Sarcomatoid Anaplastic Lymphoma Kinase-Positive Anaplastic Large-Cell Lymphoma With Linear Distributional Lesions
Authors: Chen Hao , Xiong Jing-shu , Sheng Nan , Zong Wen-kai , Wang Yi-hua , Li Min , Sun Jian-fang
Published: October 2017

We report a case of cutaneous anaplastic lymphoma kinase-positive anaplastic large-cell lymphoma (ALCL) with linear distributional lesions and sarcomatoid histologic features. A sarcomatoid variant is the rarest morphological pattern of ALCL. Interestingly, the morphology of tumor cells in the present case transitioned from a sarcomatoid variant of ALCL at first diagnosis to a classic variant at relapse. The case is a diagnostic challenge considering both the clinical and histologic aspects. Awareness of the sarcomatoid variant of ALCL and its morphological changes can lead to a correct diagnosis.
Randomized, Evaluator-Blinded Study Comparing Safety and Effect of Two Hyaluronic Acid Gels for Lips Enhancement
Authors: Hilton Said , Sattler Gerhard , Berg Anna-Karin , Samuelson Ulf , Wong Cindy
Published: October 2017

BACKGROUND

Hyaluronic acid (HA) fillers may differ in terms of gel characteristics and ease of use and it is of interest whether this might affect safety and duration of effect.

OBJECTIVE

To compare the long-term safety and effect of 2 HA fillers produced by 2 different technologies for lip enhancement.

MATERIALS AND METHODS

Subjects with very thin to moderately thick lips were randomized and treated with HA-RK (N = 31) or HA-JV (N = 29) to improve lip fullness by ≥ 1 grade on a 5-point scale, using a maximum of 3 mL of product.

RESULTS

A smaller volume of HA-RK compared with HA-JV was required to improve lip fullness by ≥ 1 grade (mean: 1.54 mL vs 1.94 mL, p < .001). Despite the smaller volume, lip fullness and global aesthetic improvement were comparably sustained in both groups. At 6 months, 60.0% versus 57.7% of subjects (HA-RK vs HA-JV) had improved lip fullness. At 12 months, 71.4% versus 76.0% had aesthetic improvement (blinded evaluations) and 85.7% versus 86.2% felt more attractive. Both products were well tolerated.

CONCLUSION

Both products achieved durable improvement in lip fullness and aesthetic appearance. A significantly smaller amount of HA-RK was required compared with HA-JV to achieve optimal treatment effect.
Atypical Melanocytic Proliferations: A Review of the Literature
Authors: Ensslin Courtney J. , Hibler Brian P. , Lee Erica H. , Nehal Kishwer S. , Busam Klaus J. , Rossi Anthony M.
Published: October 2017

BACKGROUND

Ambiguous histopathologic diagnoses represent a challenge for clinicians because of a lack of definitive diagnosis and related uncertainty about management.

OBJECTIVE

To review the literature on atypical melanocytic proliferations and detail synonymous terms, epidemiology, diagnostic work-up, histopathology, treatment, and prognosis.

METHODS

Databases from PubMed and Web of Science were searched for articles related to atypical melanocytic proliferations.

RESULTS

Intraepidermal melanocytic proliferations with features worrisome for possible melanoma in situ (MIS) are generally excised as for MIS. Reported rates of upstaging of such cases to invasive melanoma on review of the excision are very low. Because invasion, lymph node spread, and metastasis can occur in atypical melanocytic lesions with a thick intradermal component, these are often treated as for malignant melanoma.

CONCLUSION

Because the diagnosis dictates treatment, it is incumbent to establish a diagnosis as definitive as possible, obtaining second or third opinions and using ancillary studies when appropriate. When the diagnosis remains uncertain, it is difficult to provide guidelines for treatment. Clinical care decisions for patients with an uncertain diagnosis are best done on a case-by-case basis weighing probabilities of adverse outcomes against potential benefits and risks from various treatment options.
Hyaluronic Acid Gel With (HARRL) and Without Lidocaine (HAJU) for the Treatment of Moderate-to-Severe Nasolabial Folds: A Randomized, Evaluator-Blinded, Phase III Study
Authors: Fagien Steven , Monheit Gary , Jones Derek , Bank David , Sadick Neil , Nogueira Alessandra , Mashburn Jay H.
Published: October 2017

BACKGROUND

Hyaluronic acid (HA) dermal fillers are frequently used to correct or smooth facial wrinkles and folds such as nasolabial folds.

OBJECTIVE

To compare the efficacy and safety of 2 HA gels, formulated by 2 different manufacturing processes: XpresHAn Technology (HARRL [with lidocaine]) and Hylacross technology (HAJU—a comparator product without lidocaine).

PATIENTS AND METHODS

One hundred seventy subjects with bilateral nasolabial folds rated as moderate or severe, according to the Wrinkle Severity Rating Scale (WSRS), received injections of HARRL in the nasolabial folds on one side of the face and HAJU on the other side. Investigator- and subject-assessed wrinkle severity was measured up to 48 weeks after final injection.

RESULTS

HARRL exhibited a similar safety and efficacy profile compared with HAJU. Noninferiority of HARRL was demonstrated at 24 weeks (WSRS mean change from baseline mean difference −0.1 [95% confidence interval: −0.15, 0.01], p = .090). Incidence of adverse events was 40% for both treatments.

CONCLUSION

HARRL exhibited a similar safety and efficacy profile compared with HAJU.
Impact of National Comprehensive Cancer Network Guidelines on Case Selection and Outcomes for Sentinel Lymph Node Biopsy in Thin Melanoma
Authors: Nguyen Bichchau , Karia Pritesh S. , Hills Victoria M. , Besaw Robert J. , Schmults Chrysalyne D.
Published: October 2017

BACKGROUND

In 2010, the National Comprehensive Cancer Network (NCCN) recommended sentinel lymph node biopsy (SLNB) for thin melanomas ≤1 mm with mitotic rate (MR) ≥1. In 2016, the criteria were changed to Breslow depth >0.75 mm and MR ≥1.

OBJECTIVE

To compare the impact of 2010 and 2016 NCCN guidelines on SLNB case selection and thin melanoma outcomes.

MATERIALS AND METHODS

Ten-year retrospective cohort of primary thin melanomas at an academic hospital was retroactively stratified for SLNB eligibility using the 2010 and 2016 NCCN guidelines. Nodal recurrence-free survival (NRFS) and disease-free survival (DFS) were compared.

RESULTS

Eight hundred two patients with 859 tumors and median follow-up of 79 months were included. Eleven percent fewer tumors qualified for SLNB under 2016 versus 2010 NCCN guidelines (19% vs 8%, p < .001). The 2016-qualifying cases also had lower 10-year NRFS (70.7% vs 95.2%, p < .001) and DFS (64.7% vs 91.4%, p < .001). Among 2016-qualifying cases, those that received SLNB had improved NRFS (85.6% vs 35.3%, p = .001) and DFS (80.2% vs 30.5%, p < .001) as compared to those that did not receive SLNB.

CONCLUSION

The 2016 NCCN guidelines reduced the number of thin melanomas qualifying for SLNB and more accurately selected cases with higher risks of nodal recurrence and death.
Cohesion of Hyaluronic Acid Fillers: Correlation Between Cohesion and Other Physicochemical Properties
Authors: Edsman Katarina L.M. , Öhrlund Åke
Published: October 2017

BACKGROUND

There are several published articles on characterization of fillers, describing methods for both chemical and physicochemical characterization. Recently a lot of focus has been on the development of methods for measuring cohesion of hyaluronic acid (HA) fillers.

OBJECTIVE

The aim of this study is to investigate and compare the drop-weight method and the correlation between cohesion and other physicochemical properties using a variety of HA fillers.

MATERIALS AND METHODS

HA fillers covering several product families and manufacturing techniques were used. The HA fillers also covered a range of HA concentrations from 12 to 24 mg/mL. Cohesion was determined using sensory evaluation and the drop-weight method. Other physicochemical properties evaluated were rheology and the swelling factor.

RESULTS

In this study, it was verified that values obtained by the drop-weight method reflect the perceived cohesion very well. The correlation with rheology is affected by the HA concentration in the products. A remarkably good correlation between swelling factor and cohesion was found.

CONCLUSION

Cohesion correlates with other physicochemical methods. It could be discussed whether there is a need for a separate cohesion method because other already established physicochemical methods such as rheology and swelling factor can describe the underlying properties that affect cohesion.
Use of fast-scan cyclic voltammetry to assess phasic dopamine release in rat models of early postpartum maternal behavior and neglect
Authors: Shnitko Tatiana A. , Mace Kyla D. , Sullivan Kaitlin M. , Martin W. Kyle , Andersen Elizabeth H. , Williams Avram Sarah K. , Johns Josephine M. , Robinson Donita L.
Published: October 2017

Maternal behavior (MB) is a complex response to infant cues, orchestrated by postpartum neurophysiology. Although mesolimbic dopamine contributes toward MB, little is known about real-time dopamine fluctuations during the postpartum period. Thus, we used fast-scan cyclic voltammetry to measure individual dopamine transients in the nucleus accumbens of early postpartum rats and compared them with dopamine transients in virgins and in postpartum females exposed to cocaine during pregnancy, which is known to disrupt MB. We hypothesized that dopamine transients are normally enhanced postpartum and support MB. In anesthetized rats, electrically evoked dopamine release was larger and clearance was faster in postpartum females than in virgins and gestational cocaine exposure blocked the change in clearance. In awake rats, control mothers showed more dopamine transients than cocaine-exposed mothers during MB. Salient pup-produced stimuli may contribute toward differences in maternal phasic dopamine by evoking dopamine transients; supporting the feasibility of this hypothesis, urine composition (glucose, ketones, and leukocytes) differed between unexposed and cocaine-exposed infants. These data, resulting from the novel application of fast-scan cyclic voltammetry to models of MB, support the hypothesis that phasic dopamine signaling is enhanced postpartum. Future studies with additional controls can delineate which aspects of gestational cocaine reduce dopamine clearance and transient frequency.
Review of 494 Consecutive Breast Augmentation Patients: System to Improve Patient Outcomes and Satisfaction
Authors: Diaz John F.
Published: October 2017

Background:

Breast augmentation continues to be one of the most common surgical procedures performed by plastic surgeons. As implant options expand, controlling the numerous variables required for a successful result will prove increasingly challenging. The purpose of this study was to outline specific steps that can be taken during the patient consultation and during surgery to decrease complications and improve overall patient satisfaction and patient outcomes.

Methods:

A retrospective review of 494 consecutive patients who underwent primary augmentation mammaplasty performed by a single surgeon was undertaken. Surgical outcomes were recorded and compared with previously published results. Patient satisfaction was measured using the BREAST-Q Augmentation Module.

Results:

Patients were followed for an average of 6 months (range, 0–45 months). Of the 494 patients, 1.3% developed capsular contracture. Other complications included 0.6% asymmetry, 0.4% malposition, 0.2% hematoma, and 0.2% rippling. The median BREAST Q score for the patient's overall satisfaction with outcome was 86%. The median BREAST Q score for patient's satisfaction with the plastic surgeon, medical team, and office staff was 100% in each case. The median score for psychological well-being, physical well-being, and sexual well-being was 100%, 90%, and 88%, respectively.

Conclusions:

The system outlined in this study showed very low rates of complications and high scores for patient satisfaction. Following a system like this will become increasingly important as breast augmentation continues to become more popular, implant options continue to expand, and social media continues to be used by patients to share surgical experiences.
Can Friedberg’s Triad Solve Persistent Anesthesia Problems? Over-Medication, Pain Management, Postoperative Nausea and Vomiting
Authors: Friedberg Barry L.
Published: October 2017

Friedberg’s Triad is (1) measure the brain; (2) preempt the pain; (3) emetic drugs abstain. Persistent anesthesia problems include over- and under-medication, postoperative pain management, and postoperative nausea and vomiting. Inspired by Vinnik’s diazepam-ketamine paradigm, Friedberg’s propofol ketamine paradigm was first published in 1993. The 1997 addition of the bispectral (BIS) index brain monitor made the propofol ketamine paradigm numerically reproducible. The 1998 addition of the frontalis electromyogram (EMG) as a secondary trend to the BIS transformed the time-delayed BIS monitor into a real-time, extremely useful device. Before BIS monitoring, anesthesiologists only had heart rate (HR) and blood pressure (BP) changes to guide depth of anesthesia. Not surprisingly, the American Society of Anesthesiologists’ Awareness study showed no HR or BP changes in half of the patients experiencing awareness with recall. HR and BP changes may only reflect brain stem signs while consciousness and pain are processed at higher, cortical brain levels. BIS/electromyogram measurement can accurately reflect propofol effect on the cerebral cortex in real time. Although propofol requirements can vary as much as a hundred-fold, titrating propofol to 60 < BIS < 75 with baseline electromyogram assures every patient will be anesthetized to the same degree and allows more scientific analysis of outcomes. Numerous publications are cited to support the author’s 25-year clinical experience. Over that period, no office-based, cosmetic surgery patients were admitted to the hospital for unmanageable pain or postoperative nausea and vomiting. Friedberg’s Triad appears to solve persistent anesthesia problems.
Psychometric Validation of the BODY-Q in Danish Patients Undergoing Weight Loss and Body Contouring Surgery
Authors: Poulsen Lotte , Klassen Anne , Rose Michael , Roessler Kirsten K. , Juhl Claus Bogh , Støving René Klinkby , Cano Stefan , Sørensen Jens Ahm
Published: October 2017

Background:

A well-developed patient-reported outcome instrument is needed for use in Danish bariatric and body contouring patients. The BODY-Q is designed to measure changes in important patient outcomes over the entire patient journey, from obesity to post-body contouring surgery. The current study aims to psychometrically validate the BODY-Q for use in Danish patients.

Methods:

The process consisted of 3 stages: translation and linguistic validation, field-test, and data analysis. The translation was performed in accordance with the International Society for Pharmacoeconomics and Outcomes Research and World Health Organization guidelines, and field-test data were collected in 4 departments in 2 different hospitals. Field-test data were analyzed using Rasch Measurement Theory.

Results:

A total of 495 patients completed the Danish BODY-Q field-test 1–4 times, leading to a total of 681 assessments with an overall response rate at 76%. Cronbach α values were ≥ 0.90, and person separation index values were in general high. The Rasch Measurement Theory analysis provided broad support for the reliability and validity of the Danish version of the BODY-Q scales. Item fit was outside the criteria for 34 of 138 items, and of these, 21 had a significant chi-square P value after Bonferroni adjustment. Most items (128 of 138) had ordered thresholds, indicating that response options worked as intended.

Conclusion:

The Danish version of the BODY-Q is a reliable and valid patient-reported outcome instrument for use in Danish bariatric and body contouring patients.
A Breast Reconstruction Using a Breast Prosthesis and Capsular Flap for a Lymphocele Patient
Authors: Yano Tomoyuki , Shimizu Daisuke , Ishii Yoshitaka , Ito Osamu , Sawaizumi Masayuki
Published: October 2017

We encountered a very rare condition where the patient had a lymphocele under the skin envelope of the breast following mastectomy during the course of breast reconstruction with a tissue expander. The incidence rate of axillary lymphoceles is reported as 2.2–50% in breast cancer patients, but there have been no reports mentioning lymphoceles under the breast skin during the course of breast reconstruction with a prosthesis. The patient had a lymphocele in the lower lateral part of the breast following mastectomy and had multiple cellulitis-like inflammations. These inflammations were treated with conservative therapy such as administration of antibiotics, resting, and cooling. After 6 months of the initial surgery, the patient underwent complete resection of the lymphocele, preventative elimination of a possible lymphatic leakage, and breast reconstruction using a prosthesis combined with a capsular flap. The capsular flap is a transposition flap that uses capsular tissue around the expander to cover adjacent thinned skin. There were no postoperative complications such as breast skin necrosis, exposure of the prosthesis, or recurrence of the lymphocele and cellulitis. The patient had a successful breast reconstruction even though a lymphocele of the breast was observed. Even though a patient may have a lymphocele in the breast following mastectomy, with careful resection of the lymphocele, complete elimination of possible lymphatic leakage, and by performing the capsular flap technique, complete breast reconstruction with a breast prosthesis may be successful.
Infectious Complications following Breast Reconstruction Using Tissue Expanders in Patients with Atopic Dermatitis
Authors: Taminato Mifue , Tomita Koichi , Yano Kenji , Hosokawa Ko
Published: October 2017

Infectious complications represent one of the most prominent factors contributing to tissue expander (TE) loss in breast reconstruction procedures. Several patient characteristics that increase the risk for surgical-site infection or TE infection have been reported, but no study has focused on the relationship between atopic dermatitis (AD) and TE infection or surgical-site infection. Recently, we investigated 203 cases of breast reconstruction surgeries performed using TEs and noted that all 3 patients who had AD developed infectious complications that ultimately led to TE removal. Considering its pathophysiology, it is likely that patients with AD relatively easily develop infectious complications due to barrier dysfunction, abnormalities in innate immune responses, or colony formation by Staphylococcus aureus. Particular caution should be exercised for breast reconstruction using man-made materials in cases complicated by AD.
RESIDUAL CHOROIDAL VESSELS IN ATROPHY CAN MASQUERADE AS CHOROIDAL NEOVASCULARIZATION ON OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY
Authors: Nesper Peter L. , Lutty Gerard A. , Fawzi Amani A.
Published: October 2017

Purpose:

To present a postprocessing approach in optical coherence tomography angiography (OCTA) to facilitate the visualization and interpretation of lesions in age-related macular degeneration with coexisting atrophy and choroidal neovascularization (CNV).

Methods:

This retrospective study included 32 eyes of 26 patients with atrophy and treated CNV and 8 eyes with treatment-naive geographic atrophy. En face optical coherence tomography slabs highlighting atrophy were pseudocolored and merged with the corresponding OCTA. Cross-sectional optical coherence tomography and postprocessed OCTA were analyzed to identify CNV and normal choroidal vessels in relationship to the atrophy. We correlate the OCTA findings with those in a donor eye with treatment-naive geographic atrophy studied with transmission electronic microscopy.

Results:

Medium-sized choroidal vessels were displaced anteriorly in areas of atrophy in all 40 eyes (100%), visualized in the choriocapillaris slab in all eyes, and in the outer retinal slab in 30 of 40 eyes (75.0%). Cross-sectional OCTA was used to confirm the presence of CNV. Postprocessing successfully highlighted the CNV and distinguished it from choroidal vessels in atrophy. Donor eye transmission electronic microscopy confirmed the anterior displacement of medium-sized choroidal vessels in geographic atrophy.

Conclusion:

The anterior displacement of larger choroidal vessels in atrophy requires clinician vigilance to avoid misinterpreting these vessels as CNV on en face OCTA. Our proposed postprocessing approach offers a potential solution to facilitate the interpretation of en face OCTA in these cases. In the absence of other tools, clinicians are encouraged to rely on the location of flow relative to Bruch membrane on cross-sectional OCTA flow images.
PREFERRED RETINAL LOCUS LOCATIONS IN AGE-RELATED MACULAR DEGENERATION
Authors: Erbezci Murat , Ozturk Taylan
Published: October 2017

Purpose:

An evaluation of the preferred retinal locus (PRL) in patients with age-related macular degeneration and a central scotoma is becoming a standard of care in the practice of low-vision rehabilitation. This is a retrospective study of PRL specifications and whether they have a correlation with the best-corrected visual acuities of patients with age-related macular degeneration.

Methods:

Seventy-two patients with macular degeneration (144 eyes) were included in the study. The PRLs were evaluated monocularly with a scanning laser ophthalmoscope. Each PRL's location, the fovea-PRL distance, the PRL edge of the lesion distance, and PRL stability were measured with the built-in caliper of the ophthalmoscope.

Results:

The most frequent location of a PRL was nasal (29.2%). The PRL was located in the left visual field of 34.0% of the patients. The best-corrected visual acuity values were positively correlated with the lesion's vertical and horizontal dimensions, as well as its surface area, the PRL-fovea distance, the PRL border of the lesion distance, and PRL stability.

Conclusion:

The clinical PRL evaluation methodology that we describe can be used to facilitate making decisions on how to provide best visual rehabilitation to patients with a central scotoma.
Drugs in Dermatology
Authors: Eng David J. , Grigsby Phillip M. , Jacob Sharon E.
Published: October 2017

A drug is a substance used to cause a physiological change in the human body. In dermatology, drugs that treat different disorders usually fall into three categories: oral, topical, and biologic medications. Topical drugs include antibacterial and antifungal creams, corticosteroids, and gels. This column will explore the mechanism of action of Ameluz as well as its efficacy, dosage, administration, adverse effects, and alternatives.
Increasing the Accessibility of Sexual Assault Forensic Examinations: Evaluation of Texas Law SB 1191
Authors: Davis Robert C. , Auchter Bernard , Howley Susan , Camp Torie , Knecht Ilse , Wells William
Published: October 2017

Introduction:

Texas SB 1191 was enacted in 2013 with the intent of increasing access to medical forensic examinations for sexual assault victims by requiring every hospital with an emergency department to be prepared to provide a medical forensic examination if requested by a sexual assault victim. To realize that goal, the law also required basic forensic training for medical professionals before conducting a medical forensic examination as well as a requirement that hospitals develop a “plan to train personnel on sexual assault forensic evidence collection.”

Methods:

Interviews were conducted in 18 healthcare facilities (five with sexual assault nurse examiner [SANE] programs and 13 without SANE programs) in Dallas, Lubbock, and Austin to determine their awareness and compliance with SB 1191.

Results:

The data suggest that the law had a little effect on actual practice, and sexual assault survivors still sought a SANE program for a medical forensic examination.

Discussion:

Although SB 1191 is an important state level effort to make forensic examinations more readily available, it did not fully account for the challenges faced by smaller hospitals that do not see enough sexual assault victims to justify training staff to SANE standards and did not adequately address the training required by medical professionals to feel prepared to conduct a medical forensic examination.
Red blood cell distribution width independently predicts 1-month mortality in acute decompensation of cirrhotic patients admitted to emergency department
Authors: Turcato Gianni , Campagnaro Tommaso , Bonora Antonio , Vignola Nicola , Salvagno Gian Luca , Cervellin Gianfranco , Ricci Giorgio , Maccagnani Antonio , Lippi Giuseppe
Published: October 2017

Aim

The aim of this study was to explore whether red blood cell distribution width (RDW) can help predict the risk of short-term mortality in patients with acute decompensation of cirrhosis.

Patients and methods

We carried out a retrospective analysis of all patients consecutively admitted to the emergency department (ED) of the University Hospital of Verona (Italy) for acute decompensation of liver cirrhosis, between 1 June 2013 and 31 December 2016. The RDW value was measured at ED admission, along with collection of clinical features and other laboratory data, and was then correlated with severity of disease (Chronic Liver Failure Consortium Acute Decompensation score; CLIF-C AD score) and 1-month mortality.

Results

The final study population consisted of 542 patients, 80 (14.8%) of whom died within 30 days after ED admission. The median RDW of patients who died was significantly higher than the median RDW of those who survived (17.4 vs. 15.5%; P<0.001). The percentage of patients who died significantly increased across different RDW quartiles (6.8, 9.7, 11.5 and 32.1%, P<0.001). In univariate analysis, significant correlation was observed between RDW and clinical severity of acute decompensate cirrhosis (Child–Pugh score: r=0.198, P<0.001; Model for End-Stage Liver Disease score: r=0.311, P=0.001; CLIF-C AD: 0.127, P=0.005). The combination of RDW and CLIF-C AD score exhibited better performance for predicting 1-month mortality than the CLIF-C AD score alone (area under the curve=0.769 vs. 0.720; P=0.006). In multivariate analysis, RDW was independently associated with a 1.2–2.3 higher risk of 1-month mortality.

Conclusion

The assessment of RDW at ED admission may improve risk stratification of patients with acute decompensation of cirrhosis.
Association between insulin therapy and risk of liver cancer among diabetics: a meta-analysis of epidemiological studies
Authors: Liu Xiao-Li , Wu Hua , Zhao Long-Gang , Xu Hong-Li , Zhang Wei , Xiang Yong-Bing
Published: October 2017

As the results of the association between insulin therapy and risk of liver cancer among diabetics have been inconsistent in epidemiological studies, we conducted a meta-analysis to quantify this issue. Data of relevant epidemiological studies were collected by searching articles in PubMed, Web of Science, and Embase till 29 June 2017. Random-effects models were employed to combine study-specific risks. Five cohort studies and nine case–control studies were included in our meta-analysis with 285 008 patients with diabetes mellitus and 4329 liver cancer cases. When we compared insulin-use group with noninsulin use group in patients with diabetes mellitus, we observed a statistically significant association between insulin therapy and liver cancer, with an overall relative risk of 1.90 (95% confidence interval: 1.44–2.50, I
2=76.1%). We did not find heterogeneity between subgroups stratified by study characteristics and adjusted confounders, except for subgroups related to ‘follow-up years’ of cohort studies. The combined estimate was robust across sensitivity analysis, and no publication bias was detected. Our results indicated that insulin therapy was associated with elevated incidence of liver cancer among diabetics. Given the high prevalence of diabetes, avoiding excess or unnecessary insulin use to control the blood glucose may offer a potential public health benefit in reducing liver cancer risk. Further studies are warranted to investigate the types, doses, and treatment duration of insulin use in large sample size or cohort of diabetic patients.
Efficacy and Acceptability of Psychotherapy for Anxious Young Children
Authors: Zhang Hanping , Zhang Yuqing , Yang Lining , Yuan Shuai , Zhou Xinyu , Pu Juncai , Liu Lanxiang , Jiang Xiaofeng , Xie Peng
Published: October 2017

We aimed to provide an overview of psychotherapy in young anxious children (mean age, <7 years). Seven electronic databases, including PubMed, EMBASE, Cochrane, Web of Science, PsycINFO, CINAHL, and ProQuest Dissertations, were searched. Randomized controlled trials that compared psychotherapies with control conditions were included. Efficacy (score change on an anxiety rating scale and rate of being freed from anxiety) and acceptability (discontinuations due to any event) were evaluated. Six of the total seven studies included in our study adopted cognitive behavioral therapy (CBT), with only one adopting behavior therapy (BT). Psychotherapy effectively reduced anxiety symptoms (standardized mean difference = −0.83; 95% confidence interval [CI], −1.08 to −0.57), and its rate of freeing patients from anxiety was high (risk ratio [RR] = 0.30; 95% CI, 0.19 to 0.47). No remarkable difference for acceptability was found between the two therapy types (RR = 0.54; 95% CI, 0.25 to 1.18). Psychotherapy, both CBT and BT, benefits young anxious children.
Efficacy of Armeo® Robotic Therapy Versus Conventional Therapy on Upper Limb Function in Children With Hemiplegic Cerebral Palsy
Authors: El-Shamy Shamekh Mohamed
Published: October 2017

Objective

The aim of this study was to examine the efficacy of Armeo robotic therapy, compared with conventional therapy, on upper limb function in children with hemiplegic cerebral palsy.

Design

Thirty children with hemiplegic cerebral palsy, with ages ranging from 6 to 8 yrs, were selected for this randomized controlled study and randomly assigned to two groups. The study group (n = 15) received 12 wks of Armeo robotic therapy (45 min/session, 3 days/wk) and the control group (n = 15) received conventional therapy for the same period. The measured outcomes were the Modified Ashworth Scale and the Quality of Upper Extremity Skills Test, measured at baseline and after 12 wks of intervention.

Results

Children in the study group showed significant improvement in the mean values of all the measured variables, compared with those in the control group (P < 0.05). Postintervention Modified Ashworth Scale scores for the study and control groups were 1.6 (0.3) and 2 (0.5), respectively. Postinterventional Quality of Upper Extremity Skills Test total scores for the study and control groups were 84.6 (2.7) and 79.1 (2), respectively.

Conclusions

Armeo robotic therapy is significantly more effective than conventional therapy in improving the upper limb quality of movement in children with hemiplegic cerebral palsy.
Osteogenesis of Crouzon-Mutated Cells in an Experimental Model
Authors: Alcon Andre , Metzler Philipp , Eswarakumar Jacob , Wilson Alexander T. , Steinbacher Derek M.
Published: October 2017

Crouzon syndrome is an autosomal-dominant congenital disease due to a mutation in the fibroblast growth factor receptor 2 protein. The purpose of this study is to evaluate wound-healing potential of Crouzon osteoblasts and adipose-derived stem cells (ADSCs) in a murine model. Parietal skull defects were created in Crouzon and mature wild-type (WT) CD-1 mice. One group of WT and Crouzon mice were left untreated. Another group was transplanted with both WT and Crouzon adipose-derived stem cells. Additional groups compared the use of a fibrin glue scaffold and periosteum removal. Skulls were harvested from each group and evaluated histologically at 8-week and/or 16-week periods. Mean areas of defect were quantified and compared via ANOVA F-test. The average area of defect after 8 and 16 weeks in untreated Crouzon mice was 15.37 ± 1.08 cm2 and 16.69 ± 1.51 cm2, respectively. The average area of the defect in untreated WT mice after 8 and 16 weeks averaged 14.17 ± 1.88 cm2 and 14.96 ± 2.26 cm2, respectively. WT mice with autologous ADSCs yielded an average area of 15.35 ± 1.34 cm2 after 16 weeks while Crouzon mice with WT ADSCs healed to an average size of 12.98 ± 1.89 cm2. Crouzon ADSCs transplanted into WT mice yielded an average area of 15.47 ± 1.29 cm2 while autologous Crouzon ADSCs yielded an area of 14.22 ± 3.32 cm2. ANOVA F-test yielded P = .415. The fibroblast growth factor receptor 2 mutation in Crouzon syndrome does not promote reossification of critical-sized defects in mature WT and Crouzon mice. Furthermore, Crouzon ADSCs do not possess osteogenic advantage over WT ADSCs.
Primary Central Nervous System Lymphoma of Optic Chiasma: Endoscopic Endonasal Treatment
Authors: Ozdemir Evin Singar , Yildirim Ali Erdem , Can Aslihan Yavas
Published: October 2017

Background:

Isolated primary central nervous system lymphoma arising from anterior visual pathway is very rare.

Patient Presentation:

A 76-year-old immunocompetent previously healthy man presented bilateral decreased visual acuity in 1 month. Pituitary magnetic resonans imaging (MRI) showed a lobulated mass with homogeneous enhancement after gadolinium administration that arising from optic chiasm suggested that inflammatory disease or an optic glioma. The patient underwent an extended endoscopic endonasal transsphenoidal surgery. Postoperative course and outcomes were wonderful. Histopathological diagnosis was diffuse large B-cell lymphoma. The patient underwent investigations for systemic lymphomatous involvement, did not detect any evidence of systemic disease.

Conclusion:

In this case, we claimed that differential diagnoses of anterior visual pathway lesions are difficult because of similarity of lesions on clinical and radiological examinations. Biopsy is essential for these lesions. As a biopsy technique, endoscopic endonasal transsphenoidal approach is safer and more effective than open procedures.
Dermal Regenerative Template as a Cost-Effective Alternative for Complex Scalp Reconstruction
Authors: Agochukwu Nneamaka B. , Wong Lesley , Liau James Y.
Published: October 2017

Background:

Use of dermal regeneration template (DRT) is well documented in the literature for complex wounds ranging from the scalp, trunk, and lower extremity.

Methods:

A retrospective cohort study was performed of the use of dermal regeneration template and skin grafting. A literature review was performed of all studies where DRT was used for scalp reconstruction.

Results:

Patients in the DRT cohort had an average age of 70, with wounds averaging 108 cm2 in size. These patients also had a relatively low rate of complications (0.4), a short hospital stay (average 2 days), and a relatively short operating room time (114 minutes).

Conclusion:

This study demonstrates dermal regeneration template to be an effective and reliable option for soft tissue reconstruction with minimal morbidity and complications in patients with extensive medical comorbidities. Emerging applications include radiation exposure and hypercoaguable states.
Positive Effect of Incubated Adipose-Derived Mesenchymal Stem Cells on Microfat Graft Survival
Authors: Choi Jong Woo , Kim Sung-Chan , Park Eun-Jung , Lee Ju-A , Jeong Woo Shik
Published: October 2017

Autologous fat grafting is commonly used for soft tissue augmentation, but its unpredictably high resorption rate remains a major limitation. Although adipose-derived mesenchymal stem cells (ASCs) are an attractive candidate for enhancing graft retention, their poor posttransplantation viability limits their application. The authors aimed to evaluate the effect of incubated ASCs on microfat graft survival in an immunocompromised mouse model. Lipoaspirates for microfat injection were collected from the wasted lower abdominal adipose tissues of 5 patients who had undergone breast reconstructive surgery with an abdominal flap. Adipose-derived mesenchymal stem cells were also isolated and proliferated from these fat tissues. Sixty athymic mice were randomly allocated to a control group (microfat grafting alone; n = 30) or ASCs group (microfat grafting plus simultaneous human ASCs injection; n = 30). The volume and weight of survived fat were measured at 8 and 16 weeks, and histopathological and immunologic staining was performed at 16 weeks. The survived fat volume of the ASCs group was significantly greater than that of the control group at 8 and 16 weeks, whereas the weight of survived fat tissues did not significantly differ. Histologic evaluation of the harvested fat indicated significantly higher levels of adipocytes, and fewer cysts and fibrosis in the tissues in the ASCs group than in the control group. The ASCs group also exhibited a significantly higher number of capillary vessels than the control group on CD31 and alpha-smooth muscle actin staining. In conclusion, transplanted fat survival is markedly higher when simultaneous microfat graft and ASCs injection were performed, as compared with that in the classical microfat graft alone method in mice; this improvement was primarily attributed to the increased ability to produce blood vessels.
Isolated Intraorbital Frontosphenoidal Synostosis
Authors: Mittermiller Paul A. , Yeom Kristen W. , Menard Robert M.
Published: October 2017

Unilateral anterior plagiocephaly is most commonly the result of deformational plagiocephaly or unilateral coronal synostosis, a premature fusion of the frontoparietal suture. However, other sutures within the coronal ring have been implicated in producing anterior cranial asymmetries. These fusions can occur in isolation or in concert with adjacent sutures. The frontosphenoidal suture is one such suture within the coronal ring that has been involved both concomitantly with and independently of frontoparietal suture fusion. Although isolated frontosphenoidal synostosis has been presented previously in the literature, these reports include patients with fusion of the extraorbital portion of the frontosphenoidal suture. This clinical report presents the first clearly documented patient of isolated frontosphenoidal synostosis that occurs entirely within the intraorbital region.

The patient presented to Plastic Surgery Clinic at 3 months of age with left frontal flattening, supraorbital rim retrusion, and temporal bulging that was noted soon after birth. Computed tomography analysis revealed an isolated fusion of the greater and lesser wings of the sphenoid bone to the frontal bone on the left side. The patient had no family history of cranial anomalies and genetic testing was negative for mutations. The infant was treated with a cranial orthotic for 3 months, underwent open fronto-orbital advancement and cranial vault remodeling at 6 months, and continued wearing a cranial orthotic for another 4.5 months. Following surgical and orthotic treatment, the patient achieved a satisfactory result.
Transfusion Strategies are Associated with Epigenetic Changes Following Blunt Trauma
Authors: Sillesen Martin , Li Yongqing , Alam Hasan B.
Published: October 2017

Introduction:

Epigenetics has been identified in multiple diseases. The effect of transfusion strategy on epigenetics is unknown. We hypothesized that expression of epigenetic regulating genes would be associated with resuscitation strategy following blunt trauma.

Methods:

Retrospective study using the inflammation in host response to injury (glue grant) dataset. Volume transfused over 24 h of packed red blood cells (PRBC), fresh frozen plasma (FFP), platelets (PLT) as well as crystalloids was extracted along with leucocyte microarray data of genes with known epigenetic modulating activity from day 1 after injury.

Principal component analysis (PCA) was used to identify principal components (PC) within the transcriptomic dataset. Multiple regression associated these with volume of blood products and crystalloids while controlling for confounders. Genes co-expressed with genes central genes in the identified PCs were furthermore subjected to pathway analysis using the reactome database.

Results:

PCA identified seven components. PRBC and crystalloid volumes were positively associated with PC1, implicating histone acetylation (HAT1), DNA and histone methylation (KDM6B, SET1DB) and histone phosphorylation (RPS6KA5). Conversely, PLT volume was negatively associated with PC1,5 and 6, implicating DNA methylation (DNMT1) as well as histone acetylation (HAT1) and phosphorylation (RPSKA3).

FFP was negatively associated with PC3, implicating histone methylation (SETD1B) and phosphorylation (RPS6KA5).

Co-expression network analysis identified downstream pathways relevant to inflammation and the innate immune response, including Toll-like receptor, interleukin and mitogen activated protein kinase activation.

Conclusions:

Resuscitation strategy was associated with epigenetic transcriptomic alterations, especially for PRBC and PLT transfusions. Downstream effects may include pertubations of pathways involved in immune signaling and cellular survival.
A Novel Method of Setting Performance Standards in Surgery Using Patient Outcomes
Authors: Goldenberg Mitchell G. , Grantcharov Teodor P.
Published: October 2017

Objective:

To describe a novel, outcome-based method of standard setting that differentiates between clinical outcomes rather than arbitrary educational goals.

Background:

Standard setting methods used in assessments of procedural skill are currently not evidence-driven or outcome-based. This represents a potential obstacle for the broad implementation of these evaluations in summative assessments such as certification and credentialing.

Methods:

The concept is based on deriving a receiver operating characteristic curve from a regression model that incorporates measures of intraoperative surgeon performance and confounding patient characteristics. This allows the creation of a performance standard that best predicts a clinically significant outcome of interest. The discovery cohort used to create the predictive model was derived from pilot data that used the Global Evaluative Assessment of Robotic Skill assessment tool to predict patient urinary continence 3 months following robotic-assisted radical prostatectomy.

Results:

A receiver operating characteristic curve with an area under the curve of 0.75 was created from predicted probability statistic generated by the predictive model. We chose a predicted probability of 0.35, based on an optimal tradeoff in sensitivity and specificity (Youden Index). Rearranging the regression equation, we determined the performance score required to predict a 35%, patient-adjusted probability of postoperative urinary incontinence.

Conclusions:

This novel methodology is context, patient, and assessment-specific. Current standard setting methods do not account for the heterogeneity of the clinical environment. Workplace-based assessments in competency-based medical education require standards that are credible to the educator and the trainee. High-stakes assessments must ensure that surgeons have been evaluated to a standard that prioritizes satisfactory patient outcomes and safety.
Adherence to Enhanced Recovery Protocols in NSQIP and Association With Colectomy Outcomes
Authors: Berian Julia R. , Ban Kristen A. , Liu Jason B. , Ko Clifford Y. , Feldman Liane S. , Thacker Julie K.
Published: October 2017

Objective:

To evaluate the effect of protocol adherence on length of stay (LOS) and recovery-specific outcomes after colectomy.

Background:

Enhanced recovery protocols (ERPs) may decrease postoperative morbidity and LOS; however, the effect of overall protocol adherence remains unclear.

Methods:

Using American College of Surgeons’ National Surgical Quality Improvement Program colectomy data (July 2014–December 2015) and 13 novel ERP variables, propensity scores were constructed for low (0–5), moderate (6–9), and high adherence (10–13 components). Prolonged LOS (>75th percentile, uncomplicated cases) was modeled with multivariable logistic regression with robust standard errors, adjusted for hospital-level clustering and propensity score. Secondary recovery-specific outcomes were modeled with negative binomial regression. Subgroup analysis was conducted on uncomplicated cases.

Results:

Among 8139 elective colectomies at 113 hospitals, LOS increased with decreasing adherence (4.3 days [SD 3.3] high adherence vs 7.8 [SD 6.8] low adherence; P < 0.0001). High adherence was associated with fewer complications, including postoperative ileus, compared with moderate (P < 0.0001) and low adherence (P < 0.0001). High-adherence patients achieved recovery milestones earlier (vs low adherence), with return of bowel function at 1.9 (vs 3.7) days, tolerance of diet at 2.4 (vs 5.4) days, and oral pain control at 2.7 (vs 5.0) days (P < 0.0001). Risk-adjusted odds of prolonged LOS were significantly increased for low (odds ratio 2.7, 95% confidence interval 2.0–3.6) and moderate-adherence (odds ratio 1.7, 95% confidence interval 1.4–2.1) groups. In a negative binomial regression, time to recovery was 60% to 95% longer for low versus high adherence (P < 0.0001).

Conclusions:

In this large, multi-institutional North American data registry, high adherence to ERPs was associated with earlier recovery, decreased complications, and shorter LOS. ERPs can improve outcomes; however, benefits correlate with adherence.