bluuebunny/crossref_metadata_2025 huggingface dataset:
Temporal subtraction of low-dose and relatively thick-slice CT images with large deformation diffeomorphic metric mapping and adaptive voxel matching for detection of bone metastases
Authors: Tsuchiya Mitsuteru , Masui Takayuki , Katayama Motoyuki , Hayashi Yuki , Yamada Takahiro , Terauchi Kazuma , Kawamura Kenshi , Ishikawa Ryo , Mizobe Hideaki , Yamamichi Junta , Sakahara Harumi , Goshima Satoshi
Published: March 2020

To evaluate the improvement of radiologist performance in detecting bone metastases at follow up low-dose computed tomography (CT) by using a temporal subtraction (TS) technique based on an advanced nonrigid image registration algorithm.

Twelve patients with bone metastases (males, 5; females, 7; mean age, 64.8 ± 7.6 years; range 51–81 years) and 12 control patients without bone metastases (males, 5; females, 7; mean age, 64.8 ± 7.6 years; 51–81 years) were included, who underwent initial and follow-up CT examinations between December 2005 and July 2016. Initial CT images were registered to follow-up CT images by the algorithm, and TS images were created. Three radiologists independently assessed the bone metastases with and without the TS images. The reader averaged jackknife alternative free-response receiver operating characteristics figure of merit was used to compare the diagnostic accuracy.

The reader-averaged values of the jackknife alternative free-response receiver operating characteristics figures of merit (θ) significantly improved from 0.687 for the readout without TS and 0.803 for the readout with TS (P value = .031. F statistic = 5.24). The changes in the absolute value of CT attenuations in true-positive lesions were significantly larger than those in false-negative lesions (P < .001). Using TS, segment-based sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the readout with TS were 66.7%, 98.9%, 94.4%, 90.9%, and 94.8%, respectively.

The TS images can significantly improve the radiologist's performance in the detection of bone metastases on low-dose and relatively thick-slice CT.
The association between Bell's palsy and rheumatoid arthritis
Authors: Lee Sang-Yeon , Lim Jae-Sung , Oh Dong Jun , Park Bumjung , Park Il-Seok , Choi Hyo Geun
Published: March 2020

This study aimed to evaluate the relationship between Bell's palsy and rheumatoid arthritis in a national sample cohort from Korea.

Data were collected for individuals ≥20 years old from 2002 to 2013 in the Korean National Health Insurance Service-National Sample Cohort. We extracted data for patients with rheumatoid arthritis (n = 7628) and 1:4-matched controls (n = 30,512) and analyzed the occurrence of Bell's palsy in both groups. Matching was performed based on age, sex, income, and region of residence. Rheumatoid arthritis was diagnosed according to International Classification of Disease-10 (ICD-10) codes (M05-M06) and the prescription of biological agents and/or disease-modifying antirheumatic drugs. Bell's palsy patients were diagnosed according to ICD-10 code H912 and treatment ≥2 times with steroids. Adjusted hazard ratios (HRs) were calculated using stratified Cox proportional hazard models for the Charlson comorbidity index and 95% confidence intervals (CIs). Subgroup analyses based on age and sex were also performed.

The rates of Bell's palsy were similar between the rheumatoid arthritis group (0.5% [38/7628]) and the control group, with no significant difference (0.4% [124/30,512], P = .270). The adjusted HR for Bell's palsy was 1.12 (95% CI, 0.78–1.62) in the rheumatoid arthritis group (P 
= .540). In the subgroup analyses according to age and sex, the relationship between Bell's palsy and rheumatoid arthritis did not reach statistical significance.

The risk of Bell's palsy was not increased in patients with rheumatoid arthritis.
Rapid Advancement in Enteral Nutrition Does Not Affect Systemic Inflammation and Insulin Homeostasis Following Pediatric Cardiopulmonary Bypass Surgery*
Authors: Floh Alejandro A. , Herridge Joann , Fan Chun-Po S. , Manlhiot Cedric , McCrindle Brian W. , Van Arsdell Glen , Balmer-Minnes Diana , Schwartz Steven M.
Published: March 2020

Objectives:

To determine impact of enteral nutrition delivery on the relationship among inflammation, insulin resistance, and outcomes following pediatric cardiopulmonary bypass surgery.

Design:

Pilot, randomized study analyzed according to intention-to-treat analysis.

Setting:

Pediatric cardiac ICU.

Patients:

Infants (≤ 6 mo) undergoing cardiopulmonary bypass.

Interventions:

Patients randomly assigned to receive rapid escalation to enteral nutrition reaching goal feeds by 27 hours or standard feeding practice reaching goal feeds by 63 hours. Feeds were initiated on the first postoperative day.

Measurements and Main Results:

Fifty patients were randomized equally to study arms. Patients were a median (interquartile range) of 16 days old (7–110 d old), undergoing biventricular surgery (88%) with a median cardiopulmonary bypass time of 125 minutes (105–159 min). Serial blood samples were drawn before and after cardiopulmonary bypass, cardiac ICU admission, and every 12 hours (up to 96 hr) for glucose, insulin, and cytokines (interleukin-1α, interleukin-6, interleukin-8, interleukin-10, and tumor necrosis factor-α) levels. Glucose-insulin ratio was calculated to quantify insulin resistance. Patient characteristics, time to enteral nutrition initiation, enteral nutrition interruptions, and insulin administration were similar across intervention arms. FF reached goal feeds at similar intervals as standard feeding (39 hr [30–60 hr] vs 60 hr [21–78 hr]; p = 0.75). No difference in cytokine, insulin, or glucose-insulin ratio was noted between groups. Higher inflammation was associated with increased glucose-insulin ratio and higher risk of adverse events. In multivariable models of interleukin-8, FF was associated with increased glucose-insulin ratio (estimate of effect [95% CI], 0.152 [0.033–0.272]; p = 0.013). Although higher interleukin-8 was associated with an elevated risk of adverse event, this relationship was possibly mitigated by FF (odds ratio [95% CI], 0.086 [0.002–1.638]; p = 0.13).

Conclusions:

A FF strategy was not associated with changes to early enteral nutrition delivery. Inflammation, insulin resistance, and morbidity were similar, but FF may modify the relationship between inflammation and adverse event. Multicenter nutrition studies are possible and necessary in this vulnerable population.
Validation of an Electronic Pediatric Index of Mortality 2 Score in a Mixed Quaternary PICU*
Authors: Joyce Emily L. , Crana Christine M. , Yabes Jonathan , Kellum John A.
Published: March 2020

Objective:

To assess the validity of an electronic version of the Pediatric Index of Mortality 2 score.

Design:

Retrospective observational study.

Setting:

Pediatric and cardiac ICUs at a quaternary medical center.

Patients:

Patients more than 60 days old admitted to the PICU or cardiac ICU between January 1, 2010, and December 31, 2014.

Interventions:

None.

Measurements and Main Results:

After adapting the Pediatric Index of Mortality 2 score into a version applicable to retrospective electronic health record data, it was validated in a mixed-ICU cohort. A manually ascertained Pediatric Index of Mortality 2 score was directly compared with the electronically derived electronic version of the Pediatric Index of Mortality 2 score in 100 randomly selected patients with good agreement between score components with nine out of 11 components having an intraclass correlation coefficient or Cohen κ greater than or equal to 0.6. In assessing the electronic version of the Pediatric Index of Mortality 2 score in the entire cohort of 12,582 patient encounters, it had good discrimination with area under the receiver operating curve of 0.89, appropriate calibration with no significant difference between observed and expected deaths, and excellent predictive ability with a Brier score of 0.0135.

Conclusions:

The Pediatric Index of Mortality 2 score can be adapted to utilize retrospective electronic health record data with acceptable discrimination, calibration and accuracy a large mixed-ICU cohort.
Sedation, Analgesia, and Neuromuscular Blockade: An Assessment of Practices From 2009 to 2016 in a National Sample of 66,443 Pediatric Patients Cared for in the ICU*
Authors: Patel Anita K. , Trujillo-Rivera Eduardo , Faruqe Farhana , Heneghan Julia A. , Workman T. Elizabeth , Zeng-Treitler Qing , Chamberlain James , Morizono Hiroki , Kim Dongkyu , Bost James E. , Pollack Murray M.
Published: March 2020

Objectives:

To describe the pharmaceutical management of sedation, analgesia, and neuromuscular blockade medications administered to children in ICUs.

Design:

A retrospective analysis using data extracted from the national database Health Facts.

Setting:

One hundred sixty-one ICUs in the United States with pediatric admissions.

Patients:

Children in ICUs receiving medications from 2009 to 2016.

Exposure/Intervention:

Frequency and duration of administration of sedation, analgesia, and neuromuscular blockade medications.

Measurements and Main Results:

Of 66,443 patients with a median age of 1.3 years (interquartile range, 0–14.5), 63.3% (n = 42,070) received nonopioid analgesic, opioid analgesic, sedative, and/or neuromuscular blockade medications consisting of 83 different agents. Opioid and nonopioid analgesics were dispensed to 58.4% (n = 38,776), of which nonopioid analgesics were prescribed to 67.4% (n = 26,149). Median duration of opioid analgesic administration was 32 hours (interquartile range, 7–92). Sedatives were dispensed to 39.8% (n = 26,441) for a median duration of 23 hours (interquartile range, 3–84), of which benzodiazepines were most common (73.4%; n = 19,426). Neuromuscular-blocking agents were dispensed to 17.3% (n = 11,517) for a median duration of 2 hours (interquartile range, 1–15). Younger age was associated with longer durations in all medication classes. A greater proportion of operative patients received these medication classes for a longer duration than nonoperative patients. A greater proportion of patients with musculoskeletal and hematologic/oncologic diseases received these medication classes.

Conclusions:

Analgesic, sedative, and neuromuscular-blocking medications were prescribed to 63.3% of children in ICUs. The durations of opioid analgesic and sedative medication administration found in this study can be associated with known complications, including tolerance and withdrawal. Several medications dispensed to pediatric patients in this analysis are in conflict with Food and Drug Administration warnings, suggesting that there is potential risk in current sedation and analgesia practice that could be reduced with practice changes to improve efficacy and minimize risks.
Efficacy of Cartoons as a Distraction Technique for Children Undergoing Suture of Facial Lacerations in the Emergency Department
Authors: Choi Hyo Jeong , Kim Ho Jung
Published: March 2020

Purpose

To show the efficacy of cartoon as a distraction technique in suturing a child patient in the emergency room.

Methods

We studied children aged 2 to 8 years who had sustained a facial laceration 3 cm or less that required suturing from September 2015 to November 2016. We used local anesthesia and attempted to place the sutures without sedation while showing the children cartoons instead. If the first attempt failed, 1 more attempt was made. The patients were divided into 3 groups: success, success on second attempt, and failure. Age, location and size of the wound, and scores on the FACES Pain Rating Scale (FPS) before and after local anesthesia were recorded.

Results

The study included 106 children. Cartoon distraction was most effective for those aged 3 to 6 years (4.6 ± 1.9 years). The second-attempt group tended to be older, whereas the failure group was much younger (mean age, 7.4 ± 1.0 vs 2.7 ± 1.8 years). The FPS-R score differed widely among the groups. The success group tended to have a low score before and after local anesthetic injection (4.1 ± 2.0 and 3.1 ± 1.3), whereas the second-attempt and failure groups had much higher scores after injection (8.0 ± 1.7 and 8.8 ± 0.8; 5.2 ± 2.6 and 9.3 ± 0.8).

Conclusions

Cartoon distraction techniques can reduce the treatment duration and number of assistants, which also makes it appropriate for the emergency room. In addition, our results indicate that the pre–/post–local injection FPS score is a good predictor of success.
Prevalence of Abuse and Additional Injury in Young Children With Rib Fractures as Their Presenting Injury
Authors: Brennan Brian , Henry M. Katherine , Altaffer Ana , Wood Joanne N.
Published: March 2020

Objective

The primary objective of this study was to determine the prevalence of (a) additional injuries, (b) abuse as determined by a standardized scale, and (c) reports to child protective services (CPS) among children younger than 5 years in whom a rib fracture was the first presenting injury concerning for abuse.

Methods

A retrospective study of children younger than 5 years diagnosed with rib fractures at a tertiary pediatric hospital between 2007 and 2018 was performed. Children in motor vehicle crashes, hospitalized after birth, or with previously diagnosed metabolic bone disease were excluded. We included only those children whose rib fractures were the first presenting injury. Demographic and clinical information was abstracted from the records. Prevalence of additional injuries, a diagnosis of abuse, and a report to CPS were calculated. Associations between patient demographic and clinical characteristics and the outcomes of interest were examined.

Results

Of the 67 cases included, additional injuries concerning for abuse were identified in 40 (60%), and 58% were deemed likely or definite abuse. Reports to CPS were filed in 72% of cases. Posterior rib fractures, multiple rib fractures, and presence of rib fractures of multiple ages were all associated with presence of additional injuries and classification as definite or likely abuse (all P ≤ 0.05).

Conclusions

The presence of a rib fracture in young children is associated with a high likelihood of additional concerning injuries and should prompt a thorough evaluation for child abuse.
Factors Associated With Increased Risk of Pediatric Orbital Cellulitis—Who Should Be Scanned?
Authors: Ohana-Sarna-Cahan Lea , Hurvitz Noa , Gross Itai , Cohen Adi , Hashavya Saar
Published: March 2020

Background

Evaluation of a child with POC/OC is complicated due difficulties in physical examination and risks of imaging by computed tomography.

Method

Retrospective review of children 0–16 years admitted to the pediatric emergency department for POC/OC from 2009 to 2019.

Results

Ten years study period, 243 children younger than 16 years presented to the pediatric emergency department with a diagnosis of POC/OC. OC was documented in 51 (20.6%) patients. The mean age was 7.8 years (±4.3 years). Fever (80.4%), upper respiratory tract infection (43%), swelling of both eyelids (96%), proptosis (33.3%), and tenderness on percussion (24.5%) were more common in comparison to POC (P = 0.0001, 0.03, 0.0001, 0.0001, 0.0001 respectively). All children with suspected diagnosis of OC underwent computed tomography scan. POC accounted for 196 patients. Mean age was 4.6 (±4.3) years. Twenty percent of the cases were recorded as local trauma or insect bite in the infected eye.

Mean leukocyte count in the OC group had higher mean of 15.2 (109/L) versus 13.4(109/L) (P = 0.05), absolute neutrophil count was significantly higher in the OC 11.3(109/L) versus 7.2(109/L) (P = 0.0001) whereas the lymphocyte count was higher in the POC 4.5(109/L) versus 2.4(109/L) (P = 0.0001), NLR of 0.318 correlates with orbital cellulitis with sensitivity of 75.5% and specificity of 77.4%.

Patients with OC had mean C-reactive protein levels of 11.7 (mg/dL) versus 4.9(mg/dL) (P = 0.0001), erythrocyte sedimentation rate was elevated in the OC 53.6 (cm/h) versus 36.4 (cm/h) (P = 0.02).

Based on the aforementioned study a risk calculator for OC was formulated with 6 major variables.

Conclusions

Differentiation between POC/OC is cardinal. This study highlights the importance of ancillary laboratory tests especially C-reactive protein in the assessment of infections of the eye.
Postoperative Antibiotic Prophylaxis in Reduction Mammaplasty: A Randomized Controlled Trial
Authors: Garcia Edgard S. , Veiga Daniela F. , Veiga-Filho Joel , Cabral Isaías V. , Pinto Natália L. L. , Novo Neil F. , Sabino-Neto Miguel , Ferreira Lydia M.
Published: March 2020

Background:

Reduction mammaplasty is a well-established procedure. Studies have shown benefits of using antibiotics in this procedure. Nevertheless, there is no solid evidence to support postoperative antibiotic prophylaxis. The authors evaluated the influence of postoperative antibiotic delivery on infection rates after reduction mammaplasty.

Methods:

The authors conducted a randomized trial of noninferiority, with two parallel groups, with triple blinding. The participants were 124 women with breast hypertrophy, with reduction mammaplasty already scheduled, selected consecutively. All patients underwent reduction mammaplasty, performed by the same surgical team, using the superomedial pedicle technique for ascending the nipple-areola complex. All patients received cephalothin (1 g) intravenously at the anesthetic induction and every 6 hours for 24 hours. At hospital discharge, they were assigned randomly to either the placebo (n = 62) or antibiotic group (n = 62) and were instructed to take identical capsules containing 500 mg of cephalexin or placebo, respectively, every 6 hours, for 7 days. Patients were assessed weekly, for 4 weeks, regarding the occurrence of surgical-site infection, by a surgeon who was unaware of the allocation. The criteria and definitions of the Centers for Disease Control and Prevention were adopted.

Results:

There was no statistical difference between groups regarding age, body mass index, or resected breast tissue weight. The overall surgical-site infection rate was 0.81 percent. Only one patient, allocated to the antibiotic, presented infection, classified as superficial incisional (p = 1.00). In the placebo group, surgery time was higher (p = 0.003).

Conclusion:

The maintenance of antibiotics in the postoperative period of reduction mammaplasty did not influence the rates of surgical-site infection.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, I.
Syndrome of the Trephined: Quantitative Functional Improvement after Large Cranial Vault Reconstruction
Authors: Tarr Joseph T. , Hagan Matthew , Zhang Ben , Tanna Neil , Andrews Brian T. , Lee Justine C. , Bradley James P.
Published: March 2020

Background:

Large decompressive craniectomies may be life-saving; however, they may also result in syndrome of the trephined. This postrecovery sequela is characterized by dizziness, fatigue, depression, weakness, speech slowing, gait disturbance, and impaired mentation. Because this entity is poorly understood, the authors attempted to quantify the functional improvement in patients with syndrome of the trephined after cranial vault reconstruction.

Methods:

Patients with cranial vault defects (>50 cm2) from trauma, meningioma, and hemorrhage were studied preoperatively and postoperatively (6 months) after cranial vault reconstruction using (1) the Cognistat Active Form and (2) the Functional Independence Measure instrument (n = 40). Cranial vault reconstructive techniques varied from split cranial bone to alloplastic implants (polyetheretherketone or titanium mesh).

Results:

Of the 143 patients treated with decompressive craniectomies, 28 percent (n = 40) developed symptoms of syndrome of the trephined. A larger craniectomy defect size correlated with development of syndrome of the trephined. Time from craniectomy to presentation of symptoms was 4.5 months. Time from craniectomy to cranial vault reconstruction was 6.1 months. Time from cranial vault reconstruction to symptom improvement was 4.3 days. Complete functional recovery of syndrome of the trephined was seen in 70 percent. Type of cranial vault reconstruction included polyetheretherketone implant (57.5 percent), split calvarial graft (22.5 percent), and titanium mesh (20 percent), and was not a determinant of functional improvement. Cognistat assessment score noted improvement (from 38 to 69); likewise, the Functional Independence Measure measurement tool showed improvement (from 38 to 98).

Conclusions:

Syndrome of the trephined occurs more frequently than previously described in posttraumatic patients with large cranial vault defects. Cranial vault reconstruction leads to significant, quantifiable functional improvement in a large number of patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Transforming the Culture of Peer Review: Implementation Across Three Departments in an Academic Health Center
Authors: Lossius Michele N. , Rosenberg Eric I. , Thompson Lindsay A. , Gerner Janet , Holland Carolyn K.
Published: March 2020

Objectives

Although many health care institutions believe that clinical peer review is vital for identifying and improving quality of care, peer review is perceived by many clinicians as variable and inherently punitive. Successful peer review requires institutional leadership and adoption of a just culture approach to investigating and determining accountability for medical errors that result in harm.

Methods

We describe how an academic medical center implemented and adapted its clinical peer review processes to be consistent with just culture theory and provide a roadmap that other institutions may follow. Specific examples of peer review are highlighted to show how the process improved patient safety in the departments of emergency medicine, internal medicine, and pediatrics.

Results

The most significant process improvement was shifting from a tradition of assigning letter grades of “A,” “B,” or “C” to determine whether preventable adverse events were caused by “human error,” “at-risk behavior,” or “reckless behavior.” This categorization of human behaviors enabled patient safety officers within 3 departments to develop specific interventions to protect patients and enlist physician support for improving clinical systems.

Conclusions

Each department’s success was due to recognition of different patient and provider cultures that offer unique challenges. The transformation of peer review was a crucial first step to shift perceptions of peer review from a punitive to a constructive process intended to improve patient safety. Our experience with reengineering clinical peer review shows the importance of focusing on just culture as a key method to prevent patient harm.
Mother-to-Child HIV Transmission With In Utero Dolutegravir vs. Efavirenz in Botswana
Authors: Davey Sonya , Ajibola Gbolahan , Maswabi Kenneth , Sakoi Maureen , Bennett Kara , Hughes Michael D. , Isaacson Arielle , Diseko Modiegi , Zash Rebecca , Batlang Oganne , Moyo Sikhulile , Lockman Shahin , Lichterfeld Mathias , Kuritzkes Daniel R. , Makhema Joseph , Shapiro Roger
Published: March 2020

Background:

A large-scale evaluation of mother-to-child transmission (MTCT) with dolutegravir (DTG)-based antiretroviral treatment (ART) has not been conducted previously.

Setting:

Botswana was the first African country to change from efavirenz (EFV)/tenofovir (TDF)/emtricitabine (FTC) to DTG/TDF/FTC first-line ART.

Methods:

From April 2015 to July 2018, the Early Infant Treatment Study offered HIV DNA testing at <96 hours of life. Maternal ART regimen was available for screened infants who could be linked to the separate Tsepamo surveillance study database. We evaluated characteristics of HIV-positive infants, and compared MTCT rates by ART regimen for linked infants.

Results:

Of 10,622 HIV-exposed infants screened, 42 (0.40%) were HIV-positive. In total, 5064 screened infants could be linked to the surveillance database, including 1235 (24.4%) exposed to DTG/TDF/FTC and 2411 (47.6%) exposed to EFV/TDF/FTC. MTCT was rare when either regimen was started before conception: 0/213 [0.00%, 95% confidence interval (CI): 0.00% to 1.72%] on DTG, 1/1497 (0.07%, 95% CI: 0.00% to 0.37%) on EFV. MTCT was similar for women starting each ART regimen in pregnancy: 8/999 (0.80%, 95% CI: 0.35% to 1.57%) for DTG and 8/883 (0.91%, 95% CI: 0.39% to 1.78%) for EFV (risk difference 0.11%, 95% CI: −0.79% to 1.06%). Most MTCT events (4/8 with DTG, 6/9 with EFV) occurred when ART was started <90 days before delivery. Infants exposed to DTG in utero had lower baseline HIV RNA compared with other HIV-infected infants.

Conclusion:

In utero MTCT in Botswana remains rare in the DTG era. No significant MTCT differences were observed between DTG/TDF/FTC and EFV/TDF/FTC. Risk was highest for both groups when ART was started in the third trimester.
Imaging of Fulminant Demyelinating Disorders of the Central Nervous System
Authors: Razek Ahmed Abdel Khalek Abdel , Elsebaie Nermeen A.
Published: March 2020

We aim to review the imaging appearance of fulminant demyelinating disorders of central nervous system that have different pathological features, clinical course, clinical features, and imaging findings different from classic multiple sclerosis. Routine magnetic resonance imaging (MRI) can help in accurate localization of the lesions, detection of associated lesions, and monitoring of these patients. Advanced MRI combined with routine MRI can aid in differentiation fulminant demyelinating lesions from simulating malignancy. Tumefactive demyelination lesions are located in supratentorial white matter mainly frontal and parietal regions with incomplete rim enhancement. Baló concentric sclerosis shows characteristic concentric onion skin appearance. Schilder disease is subacute or acute demyelinating disorders with one or more lesions commonly involving the centrum semiovale. Marburg disease is the most severe demyelinating disorder with diffuse infiltrative lesions and massive edema involving both the cerebral hemisphere and brain stem.
Diagnostic Yield of Computed Tomography–Guided Percutaneous Lung Biopsy in Patients With Prior Nondiagnostic Transbronchial Biopsy
Authors: Li Quan-Kui , Ding Yuan-Kun , Liu Yi , Xia Feng-Fei , Li Lin , Fu Yu-Fei
Published: March 2020

Purpose

The purpose of this study was to assess the diagnostic yield of computed tomography (CT)–guided core needle biopsy (CNB) for initial transbronchial biopsy (TBB)–based nondiagnostic lung lesions.

Methods

From January 2014 to December 2017, 101 consecutive patients with initial TBB-based nondiagnostic lung lesions underwent CT-guided CNB. All procedures were performed with an 18G core needle by a chest radiologist with more than 5 years of experience. The CT-guided CNB was performed within 30 days after the initial TBB. In total, 90 and 11 central and peripheral lung lesions were observed, respectively. The mean ± SD diameter of these lesions was 58.8 ± 21.8 mm. The diagnostic yield of CT-guided CNB was assessed.

Results

Computed tomography–guided CNB provided a definite diagnosis for 63 (62.4%) of the 101 lesions. The 63 CNB-based lesion diagnoses included malignant (n = 57) and specific benign (n = 6) lesions. The remaining 38 CNB-based nondiagnostic lesions included nonspecific benign (n = 35) and suspected malignant (n = 3) lesions. The 38 CNB-based nondiagnostic lesions were confirmed by surgery (n = 5), repeat CNB (n = 5), or CT follow-up (n = 28). The mean ± SD follow-up was 9.9 ± 7.3 months. Based on the final diagnosis, 67 lesions were malignant and 34 lesions were benign. The sensitivity, specificity, and accuracy of CT-guided CNB were 89.6% (60/67), 100% (34/34), and 93.1% (94/101), respectively.

Conclusions

Computed tomography–guided CNB is a useful diagnostic modality for accurate diagnosis of lung lesions with inconclusive pathologic results after initial TBB.
Machine Learning and Deep Neural Networks Applications in Computed Tomography for Coronary Artery Disease and Myocardial Perfusion
Authors: Monti Caterina B. , Codari Marina , van Assen Marly , De Cecco Carlo N. , Vliegenthart Rozemarijn
Published: March 2020

During the latest years, artificial intelligence, and especially machine learning (ML), have experienced a growth in popularity due to their versatility and potential in solving complex problems. In fact, ML allows the efficient handling of big volumes of data, allowing to tackle issues that were unfeasible before, especially with deep learning, which utilizes multilayered neural networks. Cardiac computed tomography (CT) is also experiencing a rise in examination numbers, and ML might help handle the increasing derived information. Moreover, cardiac CT presents some fields wherein ML may be pivotal, such as coronary calcium scoring, CT angiography, and perfusion. In particular, the main applications of ML involve image preprocessing and postprocessing, and the development of risk assessment models based on imaging findings. Concerning image preprocessing, ML can help improve image quality by optimizing acquisition protocols or removing artifacts that may hinder image analysis and interpretation. ML in image postprocessing might help perform automatic segmentations and shorten examination processing times, also providing tools for tissue characterization, especially concerning plaques. The development of risk assessment models from ML using data from cardiac CT could aid in the stratification of patients who undergo cardiac CT in different risk classes and better tailor their treatment to individual conditions. While ML is a powerful tool with great potential, applications in the field of cardiac CT are still expanding, and not yet routinely available in clinical practice due to the need for extensive validation. Nevertheless, ML is expected to have a big impact on cardiac CT in the near future.
Diagnostic Performance of Abnormal Nulling on Cardiac Magnetic Resonance Imaging Look Locker Inversion Time Sequence in Differentiating Cardiac Amyloidosis Types
Authors: Tavoosi Anahita , Yu Boxin , Aghel Nazanin , Karur Gauri R. , Pakkal Mini , Wald Rachel , Wintersperger Bernd J. , Delgado Diego H. , Hanneman Kate
Published: March 2020

Purpose:

To evaluate the diagnostic utility of the Look Locker inversion time (TI) sequence on cardiac magnetic resonance imaging in patients with suspected cardiac amyloidosis and to evaluate whether there are differences in the nulling pattern between amyloid types.

Materials and Methods:

A total of 144 patients with suspected cardiac amyloidosis who had undergone cardiac magnetic resonance imaging were included in this retrospective study. Sixty-four had cardiac amyloidosis (62.1±9.2 y, 70.3% male, 68.8% had light chain amyloid [AL], 18.8% had familial transthyretin amyloid caused by mutant genes [ATTRm], and 12.5% had wild-type transthyretin amyloid [ATTRwt]) and 80 did not have cardiac amyloidosis (61.3±13.3 y, 58.8% male). Time to myocardial and blood pool nulling on the Look Locker TI sequence was classified as normal if blood pool nulled before myocardium or abnormal if blood pool nulling was coincident with or after myocardial nulling.

Results:

The nulling pattern was abnormal in 26 patients with cardiac amyloidosis compared with none of the patients without cardiac amyloidosis (40.6% vs. 0.0%, P<0.0001). Abnormal nulling had 40.6% sensitivity and 100% specificity for cardiac amyloidosis (area under the receiver operating characteristic curve: 0.703, 95% confidence interval: 0.642-0.764). All patients with cardiac amyloidosis with an abnormal nulling pattern demonstrated late gadolinium enhancement. Among patients with cardiac amyloidosis, there was no significant difference in abnormal nulling between AL, ATTRm, and ATTRwt amyloid types (31.8%, 58.3%, 62.5%, respectively, P=0.10).

Conclusions:

An abnormal nulling pattern on the Look Locker TI sequence is highly specific for cardiac amyloidosis when present. However, abnormal nulling is a late finding with low sensitivity and does not differentiate between amyloid types.
Neonatal Mandibular Distraction Osteogenesis in Infants With Pierre Robin Sequence
Authors: Diep Gustave K. , Eisemann Bradley S. , Flores Roberto L.
Published: March 2020

Pierre Robin sequence is the constellation of micrognathia, glossoptosis, and tongue-based airway obstruction. When airway obstruction is severe, feeding, growth, and respiratory demise are at risk. Neonatal mandibular distraction osteogenesis is a technique which improves tongue-based airway obstruction and avoids tracheostomy in patients with severe expressions of Pierre Robin sequence. Its efficacy in relieving airway obstruction is well documented, and it has become the surgical intervention of choice at many craniofacial centers. However, this is an uncommon procedure which can be performed within the first weeks of life, offering little space for a learning curve. The success of neonatal distraction and avoidance of complications is highly dependent on proper surgical technique. This report provides a brief overview of the disease, details the technique of the senior surgeon with captioned videos, describes the protocol used at our institution and reports long-term outcomes with a case description.
Terminology and Etymology in Oculoplastic Surgery
Authors: Mohammad Syed , Hussain Ahsen
Published: March 2020

Purpose:

To provide a collection of important terms in oculoplastic surgery, their etymology, current usage, and clarification of terms with overlapping or often misconstrued definitions.

Methods:

Commonly employed terms in oculoplastic surgery were collected, and their etymologies were determined. The authors then examined how these terms are being currently used in the published literature to determine how closely their usage matched the origin of the terms, if any terms had developed multiple meanings, or if multiple terms were being used to describe the same concept.

Results:

This article assembles in one area much of the important terms in oculoplastic surgery, highlighting how the etymology of the terms both links to their meanings as well as clarifies the appropriate usage of terms that have evolved to develop several different definitions. Special attention is placed on clarifying the correct definitions of closely related but distinct terms.

Conclusions:

Most terms in ophthalmology are used in a uniform manner across the literature with definitions closely matching their etymology, but some terms in oculoplastic surgery are being used in a potentially confusing overlapping manner and warrant clarification.
Dental Topics for Plastic Surgeons, Part One: Normal Anatomy, Growth and Development
Authors: Zajac Jocelyn C. , Abbate Olivia , Oh Albert K. , Mantilla-Rivas Esperanza , Aivaz Marudeen , Wang Raymond , Talbet Joseph , Manrique Monica , Tate Anupama R. , Rogers Gary F.
Published: March 2020

Normal and abnormal conditions affecting the dentition and the periodontal structures receive sparse coverage in the plastic surgery literature, textbooks, and training programs. Nevertheless, a working knowledge of this subject matter is important in certain areas of clinical practice, and a fundamental understanding is often part of plastic surgery competency tested for in the In-service and written board examinations. This four-part series is written to provide plastic surgeons with a working knowledge of relevant dental topics. Part 1 covers fundamental aspects of normal dental embryology, growth and anatomy.
Transoral Robotic Surgery in the Management of a Tongue Base Schwannoma
Authors: Petruzzi Gerardo , Costantino Andrea , Arosio Alberto Daniele , De Virgilio Armando , Pichi Barbara , Zocchi Jacopo , Mercante Giuseppe , Spriano Giuseppe , Pellini Raul
Published: March 2020

Schwannomas are the most common benign tumors arising from the peripheral nerve sheath, and the intraoral location is very atypical, representing less than 1% of all cases. Surgical excision is the treatment of choice, and a variety of surgical approaches have been described. The authors report the first described case of tongue base schwannoma treated with transoral robotic surgery (TORS). A 47-years-old female patient complaining mild dysphagia and snoring, presented a submucosal swelling at the right side of the tongue base. MRI showed a large well-circumscribed solid mass, homogeneously isointense in T1WI and hyperintense on T2WI, with no lymph node metastasis. According to size, location and radiological characteristic of the mass a TORS approach was chosen. An extracapsular dissection was performed, and the lesion was completely removed with no intraoperative complications. The final diagnosis based on histopathological examination and IHC analysis (S-100 positive) was a schwannoma of the tongue base. The post-operative course was uneventful, and no recurrence was observed after 6 months of follow-up. This study demonstrates the feasibility of TORS in the treatment of a tongue base schwannoma. This is a valid alternative to the common transoral approach in order to avoid more invasive external approaches, and further studies are recommended in order to clarify if this approach could be proposed as the first line treatment in selected cases.
Measurement of Mandibular Condylar Height Based on Magnetic Resonance Imaging
Authors: Liu Zhiyang , Xie Qianyang , Chen Minjie , Yang Chi , Bai Guo
Published: March 2020

The aim of this study was to find out the most appropriate method of measuring condylar height on temporomandibular joint (TMJ) magnetic resonance imaging (MRI). Traditional three-circle method, modified three-circle method and ramal plane (RP) method were used by 2 separate observers for the measurement of condylar height and long axis of condyle on TMJ MRI. Pearson correlation coefficient (PCCs), intra-class correlation coefficient (ICC), paired t test and Bland–Altman analysis were applied for the comparison of CH and long axis of condyle between 2 observers. Thirty-two patients’ images were finally included in our study. Comparing the 3 methods, it was revealed that the RP method has the highest consistency among the observers, followed by the modified three-circle method, and the traditional three-circle method has the worst consistency. The RP method is preferred for measuring the condylar height on MRI. If mandible edge cannot be observed on MRI, the modified three-circle method is recommended.
Future Direction in Rhinoplasty: Functional Improvements for a Better Outcome
Authors: Wo Luccie M. , Al Bayati Mahmood , Weber Lee E. , Habal Mutaz B. , Thaller Seth R.
Published: March 2020

The nose plays both an aesthetic and functional role in the human body. Physiologically, the nose is an important part of the upper airway. Aesthetically, it is the central focal point of the face. Thus, rhinoplasty has evolved to be both an aesthetic and functional surgery, as the manipulation of the aesthetic subunits of the nose inadvertently leads to the functional alterations of the nose. While the aesthetic goals of rhinoplasty are well described in the literature, functional outcomes from rhinoplasty have been more challenging to delineate. Rhinoplasty can have an impact on the sense of smell, sleep apnea, oxygenation, cognitive function, cardiovascular function, and voice. We have systematically reviewed the current literature in regard to functional rhinoplasty and septoplasty to summarize current surgical maneuvers and their impact on nasal function, along with physiological and perceived functional changes from rhinoplasty.
Dusk to Dawn: Evaluating the effect of a hospital-based youth violence prevention program on youths' perception of risk
Authors: Snyder Katherine Brooke , Farrens Ashley , Raposo-Hadley Ashley , Tibbits Melissa , Burt Jennifer , Bauman Zachary M. , Evans Charity H.
Published: March 2020

BACKGROUND

Historically, youth violence prevention strategies used deterrence-based programming with limited success. We developed a youth violence prevention program, Dusk to Dawn (D2D), intended to improve youths' recognition of high-risk situations and teach new skills in conflict resolution. The aim of this study was to evaluate the effect of D2D on youths' perceptions of personal risk factors and high-risk situations.

METHODS

Youth ages 12 years to 18 years were referred to D2D by community-based organizations, probation, or youth detention center. The youth completed a self-report survey before and after participating in D2D.

RESULTS

One hundred eight youth participated in D2D. Pretest and posttest results for self-reported personal risk factors and high-risk situations for violence are presented. For personal risk factors, a statistically significant increase in the perception that family (p < 0.01) and other issues (p < 0.05), and a decrease in the perception that school problems (<0.05) were seen as important personal risk factors. For high-risk situations, increases in the perception that peer violence and substance use as high-risk situations were seen as significant at the trend level (p < 0.10). Of the 60% of participants who answered questions regarding satisfaction with D2D, 83.3% agreed or strongly agreed that D2D helped them to better understand violence and 83.3% would recommend D2D to others.

CONCLUSION

Youth violence prevention programming including an explicit discussion of how violence is learned and the role of family, friends, school, and a community in shaping youths' attitudes toward violence can effectively raise awareness of one's own risk factors. Risk factors for youth violence are often preventable or modifiable, making awareness of one's own risk factors a realistic target for youth violence prevention programs.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level III.
Large volume transfusion with whole blood is safe compared with component therapy
Authors: Gallaher Jared Robert , Dixon Alexandra , Cockcroft April , Grey Maverick , Dewey Elizabeth , Goodman Andrew , Schreiber Martin
Published: March 2020

BACKGROUND

Transfusion with uncrossmatched cold-stored low-titer group O-positive or -negative whole blood (WB) in civilian trauma has been investigated as an alternative to component therapy but only in limited volumes. To our knowledge, this is the first analysis of the safety and efficacy of large volume transfusion of patients with trauma with WB.

METHODS

This is a retrospective cohort analysis comparing trauma patients resuscitated with component therapy (COMP) versus component therapy plus WB. The COMP group was comprised of patients who presented from January 2017 through June 2018 and the WB group from patients who presented from July 2018 through January 2019 after WB became available. We included patients if they received 1 unit of WB or red blood cells (RBCs) within 24 hours of admission and had massive transfusion protocol activated. We used bivariate analysis to compare groups. For analysis, one unit of WB equaled 1 unit of RBCs, 1 unit of plasma, and 1/6 of a unit of platelets.

RESULTS

Forty-two patients received WB and 83 patients received COMP with similar baseline characteristics. Patients had a median age of 41 years (interquartile range [IQR], 28–61 years) and 73% were male. Thirty percent had penetrating injuries with a median Injury Severity Score of 29 (IQR, 17–38). The WB group received a median of 6.5 units (IQR, 3–11). The WB group received significantly more component-equivalent units but with a plasma/RBC ratio of 0.94:1 compared with 0.8:1 (p < 0.001). There were no differences in 24-hour mortality (COMP, 27% vs. WB, 29%, p = 0.8) or 30-day mortality (COMP, 46% vs. WB, 58% p = 0.2). There were no transfusion reactions.

CONCLUSION

Transfusion utilizing primarily WB in civilian trauma is feasible, even in large volumes. It appears to be a safe and effective addition to component therapy and may lead to a more balanced resuscitation but with more overall product used.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.
Vasopressor selection during critical care management of brain dead organ donors and the effects on kidney graft function
Authors: Swanson Elizabeth A. , Patel Madhukar S. , Groat Tahnee , Jameson Nora E. , Ellis Margaret K. M. , Hutchens Michael P. , Niemann Claus U. , Malinoski Darren J. , Sally Mitchell B.
Published: March 2020

BACKGROUND

Delayed graft function (DGF), the need for dialysis in the first week following kidney transplant, affects approximately one quarter of deceased-donor kidney transplant recipients. Donor demographics, donor serum creatinine, and graft cold ischemia time are associated with DGF. However, there is no consensus on the optimal management of hemodynamic instability in organ donors after brain death (DBDs). Our objective was to determine the relationship between vasopressor selection during donor management and the development of DGF.

METHODS

Prospective observational data, including demographic and critical care parameters, were collected for all DBDs managed by 17 organ procurement organizations from nine Organ Procurement and Transplantation Network Regions between 2012 and 2018. Recipient outcome data were linked with donor data through donor identification numbers. Donor critical care parameters, including type of vasopressor and doses, were recorded at three standardized time points during donor management. The analysis included only donors who received at least one vasopressor at all three time points. Vasopressor doses were converted to norepinephrine equivalent doses and analyzed as continuous variables. Univariate analyses were conducted to determine the association between donor variables and DGF. Results were adjusted for known predictors of DGF using binary logistic regression.

RESULTS

Complete data were available for 5,554 kidney transplant recipients and 2,985 DBDs. On univariate analysis, donor serum creatinine, donor age, donor subtype, kidney donor profile index, graft cold ischemia time, phenylephrine dose, and dopamine dose were associated with DGF. After multivariable analysis, increased donor serum creatinine, donor age, kidney donor profile index, graft cold ischemia time, and phenylephrine dose remained independent predictors of DGF.

CONCLUSION

Higher doses of phenylephrine were an independent predictor of DGF. With the exception of phenylephrine, the selection and dose of vasopressor during donor management did not predict the development of DGF.

LEVEL OF EVIDENCE

Prognostic study, Level III.