bluuebunny/crossref_metadata_2025 huggingface dataset:
Development and Validation of Nomograms Predicting Overall and Cancer-Specific Survival of Spinal Chondrosarcoma Patients
Authors: Song Kehan , Song Jian , Shi Xio , Wang Hongli , Ma Xiaosheng , Xia Xinlei , Liang Xin , Lin Kaiyuan , Jiang Jianyuan
Published: April 2018

Study Design.

Retrospective analysis.

Objective.

To develop and validate nomograms to predict overall survival (OS) and cancer-specific survival (CSS) of spinal chondrosarcoma patients.

Summary of Background Data.

In this era of personalized medicine, data those are available to predict the survival of spinal chondrosarcoma patients are still limited due to the rarity of the disease. Nomogram, which has been widely used in clinical oncology, could conveniently and precisely predict survival outcome for individual patient.

Methods.

We retrospectively collected 450 spinal chondrosarcoma patients from the Surveillance, Epidemiology, and End Results (SEER) database between 1984 and 2013. Univariate log-rank and multivariate Cox analyses were used to identify independent prognostic factors. These prognostic factors were included in the nomograms, which predict 3- and 5-year OS and CSS rate. The nomograms were bootstrap validated internally and externally.

Results.

A total of 450 patients were collected and randomly assigned into the training (n = 225) and validation (n = 225) cohorts. Age, histologic subtype, grade, tumor size, stage, and surgery were identified as independent prognostic factors for OS and CSS (all P < 0.05) and were further incorporated to construct the nomograms. The concordance indices (C-indices) for internal validation of OS and CSS prediction were 0.807 and 0.821, while for external validation of OS and CSS prediction were 0.756 and 0.767. Internal and external calibration plots both revealed an excellent agreement between nomogram prediction and actual survival.

Conclusion.

Nomograms were developed to predict OS and CSS for spinal chondrosarcoma patients. The nomograms could assist clinicians in making more accurate survival evaluation and identifying patients with high risk of mortality.

Level of Evidence: 4
Revision of Synthetic Cartilage Implant Hemiarthroplasty of the Great Toe to Metatarsophalangeal Joint Arthrodesis: Technique and Indications
Authors: Davies Mark B. , Roberts Veronica I. , Chadwick Carolyn , Glazebrook Mark A.
Published: April 2018

The use of a polyvinyl alcohol hydrogel synthetic cartilage implant hemiarthroplasty for osteoarthritis of the first metatarsophalangeal joint has increased since publication of the results of a pivotal, prospective, randomized, multicenter, noninferiority, clinical trial performed in the United Kingdom and Canada. The synthetic cartilage implant was awarded FDA approval in July 2016, permitting its commercial distribution in the United States, which has led to a notable escalation in its use. Concomitant failures in a small proportion of these patients will require conversion to arthrodesis. This study describes the surgical technique used to convert synthetic cartilage implant hemiarthroplasty of the first metatarsophalangeal joint to arthrodesis and the 3 cases that underwent revision at a single center in the United Kingdom.

Level of Evidence: Diagnostic Level IV, case series. See Instructions for Authors for a complete description of levels of evidence.
Free Thoracoacromial Artery Perforator Flap for Skin Defects of the Dorsal Hand
Authors: Kodaira Satoshi , Fukumoto Keizo , Kato Naoki
Published: April 2018

Various flaps are used for skin defects of the dorsal hand and fingers. A sensory flap is not essential, but a thin and good color-matched flap is suitable, and donor site mobility of the flap should be considered. A reverse or free posterior interosseous artery perforator flap is one of the standard flaps. This flap requires no major arterial sacrifice, but direct closure of the donor site is difficult when the width of the flap is >3 cm, and there is also the risk of posterior interosseous nerve injury, especially the motor branch of the extensor carpi ulnaris muscle. The deltoid or acromial branch of the thoracoacromial artery has a large skin perforator, and this perforator is the vascular pedicle of the free thoracoacromial artery perforator flap. This flap is not bulky, is pliable and well color-matched for the dorsal hand, and direct closure of the donor site is easier than the posterior interosseous artery perforator flap. A free thoracoacromial artery perforator flap based on the deltoid or acromial branch is a good option for dorsal hand and finger reconstruction.
Randomized Controlled Trial of Extended Perioperative Counseling in Enhanced Recovery After Colorectal Surgery
Authors: Forsmo Håvard Mjørud , Erichsen Christian , Rasdal Anne , Tvinnereim Jon Meyer , Körner Hartwig , Pfeffer Frank
Published: April 2018

BACKGROUND:

Enhanced recovery after surgery programs reduce the length of hospital stay in patients who undergo elective colorectal resection, but the reasons for this reduction are not well understood.

OBJECTIVE:

The aim of this randomized controlled trial was to assess the impact of extended perioperative counseling in treatment groups that were otherwise the same with respect to enhanced recovery after surgery criteria.

DESIGN:

Patients eligible for open or laparoscopic colorectal resection were randomly assigned to extended counseling (repeated information and guidance by a dedicated nurse) or standard counseling.

SETTINGS:

This study was conducted at a single institution.

PATIENTS:

Patients (n = 164) were randomly assigned to enhanced recovery after surgery plus extended counseling (n = 80) or enhanced recovery after surgery with standard counseling (n = 84).

MAIN OUTCOME MEASURES:

The primary end point was the total length of hospital stay. Discharge criteria were defined. Secondary end points were postoperative complications, postoperative length of hospital stay, readmission rate, and mortality.

RESULTS:

Total hospital stay was significantly shorter among patients randomly assigned to enhanced recovery after surgery plus extended counseling (median 5 (range 2–29) days vs 7 (range 2–39) days, p < 0.001). The 2 treatment groups differed in adherence to the elements of postoperative enhanced recovery after surgery such as mobilization and total oral intake. The 2 treatment groups did not differ in overall, major, and minor morbidity; reoperation rate; readmission rate; and 30-day mortality.

LIMITATIONS:

The main limitation of this study was the absence of blinding.

CONCLUSIONS:

Perioperative information and guidance were important factors in enhanced recovery after surgery care and were associated with a significantly shorter length of hospital stay. Our findings suggest that perioperative counseling enables patients to comply with the elements of postoperative enhanced recovery after surgery and thereby reduces the length of hospital stay. This study was registered with ClinicalTrials.gov (NCT01610726). See Video Abstract at http://links.lww.com/DCR/A505.
Functional Outcomes After Rectal Resection for Deep Infiltrating Pelvic Endometriosis: Long-term Results
Authors: Erdem Suna , Imboden Sara , Papadia Andrea , Lanz Susanne , Mueller Michael D. , Gloor Beat , Worni Mathias
Published: April 2018

BACKGROUND:

Curative management of deep infiltrating endometriosis requires complete removal of all endometriotic implants. Surgical approach to rectal involvement has become a topic of debate given potential postoperative bowel dysfunction and complications.

OBJECTIVE:

This study aims to assess long-term postoperative evacuation and incontinence outcomes after laparoscopic segmental rectal resection for deep infiltrating endometriosis involving the rectal wall.

DESIGN:

This is a retrospective study of prospectively collected data.

SETTINGS:

This single-center study was conducted at the University Hospital of Bern, Switzerland.

PATIENTS:

Patients with deep infiltrating endometriosis involving the rectum undergoing rectal resection from June 2002 to May 2011 with at least 24 months follow-up were included.

MAIN OUTCOME MEASURES:

Aside from endometriosis-related symptoms, detailed symptoms on evacuation (points: 0 (best) to 21 (worst)) and incontinence (0–24) were evaluated by using a standardized questionnaire before and at least 24 months after surgery.

RESULTS:

Of 66 women who underwent rectal resection, 51 were available for analyses with a median follow-up period of 86 months (range: 26–168). Forty-eight patients (94%) underwent laparoscopic resection (4% converted, 2% primary open), with end-to-end anastomosis in 41 patients (82%). Two patients (4%) had an anastomotic insufficiency; 1 case was complicated by rectovaginal fistula. Dysmenorrhea, nonmenstrual pain, and dyspareunia substantially improved (p < 0.001 for all comparisons). Overall evacuation score increased from a median of 0 (range: 0–11) to 2 points (0–15), p = 0.002. Overall incontinence also increased from 0 (range: 0–9) to 2 points (0–9), p = 0.003.

LIMITATIONS:

This study was limited by its retrospective nature and moderate number of patients.

CONCLUSIONS:

Laparoscopic segmental rectal resection for the treatment of deep infiltrating endometriosis including the rectal wall is associated with good results in endometriotic-related symptoms, although patients should be informed about possible postoperative impairments in evacuation and incontinence. However, its clinical impact does not outweigh the benefit that can be achieved through this approach. See Video Abstract at http://links.lww.com/DCR/A547.
Cross-tolerance between nitric oxide synthase inhibition and atypical antipsychotics modify nicotinamide-adenine-dinucleotide phosphate-diaphorase activity in mouse lateral striatum
Authors: Prieto Sonia G. , Silva João C.S. , de Lima Mairon O. , Almeida Maria C. , Echeverry Marcela B.
Published: April 2018

Previous research indicates that the subchronic administration of NG-nitro-l-arginine (l-NOARG) produces tolerance to haloperidol-induced catalepsy in Swiss mice. The present study aimed to further investigate whether intermittent subchronic systemic administration of l-NOARG induces tolerance to the cataleptic effects of haloperidol as well as olanzapine or clozapine (Clz) in C57Bl mice after subchronic administration for 5 consecutive days. Striatal FosB protein expression was measured in an attempt to gain further insights into striatal mechanisms in antipsychotic-induced extrapyramidal symptoms side effects. An nicotinamide-adenine-dinucleotide phosphate-diaphorase histochemical reaction was also used to investigate whether tolerance could induce changes in the number of nitric oxide synthase-active neurons. Subchronic administration of all antipsychotics produced catalepsy, but cross-tolerance was observed only between l-NOARG (15 mg/kg, intraperitoneally) and Clz (20 mg/kg, intraperitoneally). This cross-tolerance effect was accompanied by decreased FosB protein expression in the dorsal striatum and the nucleus accumbens shell region, and reduced icotinamide-adenine-dinucleotide phosphate-diaphorase activity in the dorsal and ventral lateral striatum. Overall, these results suggest that interference with the formation of nitric oxide, mainly in the dorsal and ventral lateral-striatal regions, appears to improve the cataleptic effects induced by antipsychotics acting as antagonists of low-affinity dopamine D2 receptor, such as Clz.
Added value today of hormonal measurements in ovarian stimulation in gonadotropin-releasing hormone antagonist treatment cycle
Authors: Popovic-Todorovic Biljana , Racca Annalisa , Blockeel Christophe
Published: April 2018

Purpose of review

Traditional approach of ovarian stimulation monitoring for in-vitro fertilization involves transvaginal sonography and serum estradiol measurements. Accumulating evidence has shown that hormonal evaluations during ovarian stimulation allow individual cycle optimization, moving away from only predicting the risk of ovarian hyperstimulation syndrome, but in addition assessing the impact of ovarian stimulation on endometrial receptivity, quality of oocytes, and subsequently embryos. The purpose of this review is to discuss the relevance and added value of hormonal monitoring during ovarian stimulation in gonadotropin-releasing hormone antagonist cycles where most of the advances have occurred.

Recent findings

Basal hormonal status, particularly estradiol, progesterone, and luteinizing hormone are instrumental in prediction of the patients with poor prognosis. Estradiol levels on the day of trigger are less sensitive in predicting ovarian hyperstimulation syndrome then the number of follicles more than 11 mm in diameter. Progesterone elevation on the day of trigger is associated with lower pregnancy rates. The gold standard treatment for progesterone elevation is to adopt a freeze-all strategy when the threshold of 1.50 ng/ml is exceeded. The effect of progesterone elevation on embryo quality remains to be confirmed by more trials.

Endocrine monitoring during ovarian stimulation allows fine-tuning of the physiology of the stimulated cycle and thereby increases the chances of successful treatment outcome.
Crowdsourcing Public Perceptions of Plastic Surgeons: Is There a Gender Bias?
Authors: Bucknor Alexandra , Christensen Joani , Kamali Parisa , Egeler Sabine , van Veldhuisen Charlotte , Rakhorst Hinne , Mathijssen Irene , Lin Samuel J. , Furnas Heather
Published: April 2018

Background:

Implicit gender bias may result in lower wages for women, fewer leadership positions, and lower perceived competence. Understanding public and patient gender preferences for plastic surgeons may enable opportunities to address public perceptions. This investigation evaluates public preferences for a plastic surgeon’s gender or demeanor.

Methods:

Members of the Amazon Mechanical Turk crowdsourcing platform read 1 of the 8 randomly assigned scenarios describing a hypothetical situation requiring a plastic surgeon to operate on their mother. The scenarios differed only by surgeon gender, surgeon demeanor (“agentic,” traditionally more masculine versus “communal,” traditionally more feminine), or type of surgery. Using a Likert scale, respondents indicated their agreement with 7 statements on surgeon competence, skills, leadership qualities, likeability, respect, trustworthiness, and, ultimately, preference as a surgeon. Independent t tests were used to compare scores. Lower scores indicated a more negative response.

Results:

Overall, 341 responses were received: 55.7% were male and 45.5% white. There were no significant differences in any of the 7 characteristics assessed when examining by surgeon gender, only. However, female surgeons with a communal demeanor were perceived as less competent (4.32 versus 4.51, P = 0.018) and less skilled (4.36 versus 4.56, P = 0.019) than agentic female surgeons. Male respondents rated female surgeons lower than male surgeons in terms of competence (P = 0.018), skills (P = 0.034), likeability (P = 0.042), and preferred choice as a surgeon (P = 0.033).

Conclusions:

Women plastic surgeons’ demeanor and respondent gender affected perception of certain characteristics. Women plastic surgeons may consider ways to engage with the public to address possible gender role stereotypes.
Buried Versus Exposed Kirschner Wires Following Fixation of Hand Fractures: l Clinician and Patient Surveys
Authors:   WIRE Research Collaborative
Published: April 2018

Background:

Fractures of the metacarpals and phalanges are common. Placement of Kirschner wires (K-wires) is the most common form of surgical fixation. After placement, a key decision is whether to bury the end of a K-wire or leave it protruding from the skin (exposed). A recent systematic review found no evidence to support either approach. The aim of study was to investigate current clinical practice, understand the key factors influencing clinician decision-making, and explore patient preferences to inform the design of a randomized clinical trial.

Methods:

The steering group developed surveys for hand surgeons, hand therapists, and patients. Following piloting, they were distributed across the United Kingdom hand surgery units using the Reconstructive Surgery Trials Network.

Results:

A total of 423 hand surgeons, 187 hand therapists, and 187 patients completed the surveys. Plastic surgeons and junior surgical trainees preferred to leave K-wires not buried. Ease of removal correlated with a decision to leave wires exposed, whereas perceived risk of infection correlated with burying wires. Cost did not affect the decision. Hand therapists were primarily concerned about infection and patient-related outcomes. Patients were most concerned about wire-related problems and pain.

Conclusion:

This national survey provides a new understanding of the use of K-wires to manage hand fractures in the United Kingdom. A number of nonevidence-based factors seem to influence the decision to bury or leave K-wires exposed. The choice has important clinical and health economic implications that justify a randomized controlled trial.
Mucinous Adenocarcinoma of the Scalp: Primary Cutaneous Neoplasm Versus Underlying Metastatic Disease
Authors: Brown Ciara A. , Lynch Michael C. , Ueno Cristiane M.
Published: April 2018

Primary cutaneous mucinous carcinoma (PCMC) is a rare mucin-producing malignancy derived from epithelial glandular structures. The literature regarding this topic is mostly in the form of case reports and case series. PCMC tends to present in the elderly with predilection for the head and neck and on initial assessment it can be easily mistaken for a simple inclusion cyst. Although PCMC is often indolent in nature, in rare instances it can metastasize and should remain a differential diagnosis in a selected population. The significance in identifying PCMC is reliably differentiating it from metastatic mucinous adenocarcinoma. We present a review of literature and case of PCMC on the scalp of a 67-year-old female.
Adenovirus Ocular Infections: Prevalence, Pathology, Pitfalls, and Practical Pointers
Authors: Garcia-Zalisnak Debora , Rapuano Christopher , Sheppard John D. , Davis Andrew R.
Published: April 2018

Adenoviral conjunctivitis comprises a large number of physician office visits in the United States and places a great financial burden on health care. It is estimated that the incidence of adenovirus infection to be as high as 20 million cases per year in the United States. There are multiple adenovirus serotypes, each associated with different types and severity of infection. Ocular manifestations of adenovirus include epidemic keratoconjunctivitis, pharyngoconjunctival fever, and nonspecific conjunctivitis. Adenoviral conjunctivitis is primarily a clinical diagnosis. Laboratory diagnosis is available although until recently rarely used. At present, there is no established or approved specific effective drug against adenovirus. Treatment is primarily supportive and includes artificial tears and cool compresses. Topical antibiotics are only indicated if a bacterial coinfection is suspected or in high-risk patients such as children. Prevention against this extremely contagious disease is of utmost importance. Although most cases are self-limited and have a relatively benign course, permanent visual disability can occur. For this reason, it is imperative that all eye care providers are capable of diagnosing and effectively treating these patients, and also preventing the spread of this contagious disease to others.
Scleral Patch Graft With a Suture Reinforcement Technique in Surgical Management of Necrotizing Scleritis With Ectasia
Authors: Wen Joanne C. , Lam Jocelyn , Banitt Michael R.
Published: April 2018

Purpose:

To describe a technique for reducing and reinforcing scleral thinning in cases of necrotizing scleritis with ectasia.

Methods:

Descriptive report of a surgical technique in 2 surgical cases with a video.

Results:

Successful repair and reduction in uveal prolapse from scleral thinning in 2 cases of necrotizing scleritis with ectasia with a suturing technique using overlapping (weave) compressive suturing over a scleral patch.

Conclusions:

In cases of necrotizing scleritis with ectasia in which there is perforation or prolapsing uvea, this technique should be considered.
Transcaval Valve-in-Valve-in-Valve Aortic Valve Replacement for Bioprosthetic Valve Degeneration
Authors: Watkins A. Claire , Devireddy Chandan M. , Al-Atassi Talal , Simone Amy E. , Forcillo Jessica , Thourani Vinod H.
Published: April 2018

A 74-year-old man presented with progressive dyspnea on exertion. History included peripheral arterial disease and coronary artery bypass grafting with aortic valve replacement 12 years ago. Subsequently, the surgical valve developed severe stenosis and moderate insufficiency. He underwent a transapical valve-in-valve transcatheter aortic valve replacement 5 years before presentation. This second valve developed a mean gradient of 66 mm Hg with mild insufficiency. The patient was treated with a third aortic valve using an alternative transcaval approach, significantly alleviating his symptoms.
Transcatheter Aortic Valve Replacement
Authors: Aalaei-Andabili Seyed Hossein , Anderson R. David , Bavry Anthony A. , Lee Teng C. , Wayangankar Siddharth , Arnaoutakis George J. , Beaver Thomas M.
Published: April 2018

Objective

Transcatheter aortic valve replacement is now commercially available for intermediate-risk, high-risk, or inoperable patients with severe aortic stenosis. In this study, we investigated change in the safety and efficiency of the transcatheter aortic valve replacement procedure at our institution and patient outcomes comparing our first 100, second 100, and last 100 patients.

Methods

From March 2012 to June 2016, 544 patients underwent transcatheter aortic valve replacement at our center. Three hundred patients were selected for this study and were categorized in the following three groups: group A, first to 100th patient; group B, 101st to 200th patient; and group C, 444th to 544th patient. Preoperative, intraoperative, and postoperative data were collected.

Results

Three hundred patients, 162 male (54%) male and 138 female (46%) with a mean ± SD age of 79.10 ± 8.93 years and mean ± SD society of thoracic surgeons’ risk score of 7.47 ± 0.76 were included. Fluoroscopy time, operation time, and incision time significantly decreased form group A to group C (all P < 0.05). Mean of contrast volume was also the highest in group A and the lowest in group C ( P < 0.001). Acute kidney injury rate was 26% (n = 26) in group A versus 23% (n = 23) in group B ( P = 0.743), and only one patient in group C (group C vs. group B, P < 0.001). Strokes declined over time: five (5%) stroke in group A; two (2%) stroke in group B, and no patient in group C (group C vs. group B, P = 0.1, and group C vs. group A, P = 0.059). In-hospital mortality was 5% (n = 5) in group A, 4% (n = 4) in group B, and 1% in group C ( P = 0.21).

Conclusions

Progressive experience and technology advances with transcatheter aortic valve replacement procedures improved operators’ expertise, making the transcatheter aortic valve replacement more efficient and safer over time.
Initial Clinical Experience With a Flexible Peripheral 21-G Needle Device
Authors: Tremblay Alain , Myers Renelle , Beaudoin Eve-Lea , Bonifazi Martina , Delage Antoine , Fortin Marc , Hergott Christopher A. , MacEachern Paul R. , Shaipanich Tawimas , Shieh Benjamin , Gasparini Stefano , Lam Stephen
Published: April 2018

Background:

Bronchoscopic techniques can be used to safely sample peripheral lung nodules (PLN), and transbronchial needle aspiration (TBNA) can further increase the diagnostic yield. Current needle devices not necessarily designed for this indication have limitations. We report our initial experience with a new flexible nitinol peripheral TBNA needle specifically designed for such sampling.

Methods:

Retrospective case review describing the first clinical cases performed with a commercially available 21-G peripheral TBNA device in 4 centers.

Results:

Eleven different operators performed 40 procedures for PLNs of a mean size of 35.1 mm (±18), and located 18.8 mm (±18.8) from the pleural surface, with 50% of them being present in the upper lobes. Bronchoscopists rated the use of the needle as good or excellent for reaching the PLN in 27/30 (90%) of cases. The TBNA sample was diagnostic in 18/40 cases (45%) overall and in 18/28 (64.3%) of cases where a diagnosis on bronchoscopy was possible. No episode of pneumothorax, significant bleeding, hypoxemia, escalation of care, or other complications were noted.

Conclusion:

Our initial experience with a novel peripheral TBNA device appears safe and effective, and may offer technical advantages over other available devices. Additional studies will be required to confirm the role of this device in the approach to bronchoscopic sampling of parenchymal lung nodules.
Vestibular Manifestations in Subjects With Enlarged Vestibular Aqueduct
Authors: Song Jae-Jin , Hong Sung Kwang , Lee Sang Yeon , Park Sung Joon , Kang Seong Il , An Yong-Hwi , Jang Jeong Hun , Kim Ji Soo , Koo Ja-Won
Published: April 2018

Objective:

To describe the results of a thorough evaluation in a large series of patients with an enlarged vestibular aqueduct (EVA), focusing on vestibular manifestations with etiological considerations.

Study Design:

Retrospective chart review of patients with EVA.

Setting:

Tertiary referral center.

Patients:

A total of 22 EVA patients with a median age of 8 years (6 mo–35 yr) who underwent both audiovestibular and radiologic examinations.

Main Outcome Measures:

Patient demographics, radiologic findings, audiologic results, vestibular symptoms, findings of neurotologic examinations, and laboratory evaluations were collected and analyzed. Standard descriptive statistics were used to summarize patient characteristics. Subjects who had a history of vertigo attack were categorized as “vestibulopathy group,” while subjects without any history of vertigo as “non-vestibulopathy group.”

Results:

Of the 41 ears included, 37 (90.2%) had hearing loss on initial audiometric evaluations. Among the 22 patients, 14 (63.6%) complained of dizziness. Of the 14 vertiginous patients, seven had recurrent episodes, five had a history of single attack, and two presented with postural imbalances. There were no significant differences between vestibulopathy and non-vestibulopathy groups with regard to the relationship between the development of vestibular symptoms and aqueductal size, hearing threshold, or age at first visit. Four of the 22 (18.2%) patients developed secondary benign paroxysmal positional vertigo (BPPV) and all patients complained of simultaneous decreases in hearing.

Conclusions:

Our results demonstrate that patients may develop vestibular symptoms during their clinical course, and all patients with an enlarged vestibular aqueduct should be cautioned regarding the potential development of vestibular pathology. Moreover, the non-negligible incidence of secondary BPPV mandates positional tests when evaluating EVA patients with vertigo.
EUS-directed Transgastric ERCP (EDGE) Versus Laparoscopy-assisted ERCP (LA-ERCP) for Roux-en-Y Gastric Bypass (RYGB) Anatomy
Authors: Kedia Prashant , Tarnasky Paul R. , Nieto Jose , Steele Stephen L. , Siddiqui Ali , Xu Ming-ming , Tyberg Amy , Gaidhane Monica , Kahaleh Michel
Published: April 2018

Background and Aims:

The standard of care for managing pancreaticobiliary disease in altered Roux-en-Y gastric bypass patients is laparoscopy-assisted endoscopic retrograde cholangiopancreatography (LA-ERCP), but is limited by cost and adverse events. Recently a minimally invasive, completely endoscopic approach using endoscopic ultrasound (EUS) directed transgastric ERCP (EDGE) has been described. We aim to compare EDGE to LA-ERCP in this study.

Methods:

Patients from May 2005 to June 2017 with Roux-en-Y gastric bypass anatomy having undergone LA-ERCP or EDGE at 4 tertiary centers were captured in a registry. Patient demographics, procedural details, and clinical outcomes were measured for each group.

Results:

Seventy-two patients (n=29 EDGE, n=43 LA-ERCP) were included in this study. There was no significant difference in the technical success of EDGE gastrogastric fistula (96.5%) versus LA-gastrostomy creation (100%). The success rate of achieving therapeutic ERCP (EDGE 96.5% vs. LA-ERCP 97.7%) and number of ERCP (EDGE 1.2 vs. LA-ERCP 1.02) needed to achieve clinical resolution was similar between both groups. Adverse event rate for EDGE, 24% (7/29) and LA-ERCP, 19% (8/43) was similar. The total procedure time (73 vs. 184 min) and length of hospital stay (0.8 vs. 2.65 d) was significantly shorter for EDGE compared to LA-ERCP. The overall weight change after EDGE was −6.6 lbs at an average 28-week follow-up.

Conclusions:

This study suggests that the EDGE procedure has similar technical success and adverse events compared with LA-ERCP with the benefit of significantly shorter procedure times and hospital stay. EDGE may offer a minimally invasive, effective option, with less resource utilization, and without significant weight gain.
In Data We Trust? Comparison of Electronic Versus Manual Abstraction of Antimicrobial Prescribing Quality Metrics for Hospitalized Veterans With Pneumonia
Authors: Jones Barbara E. , Haroldsen Candace , Madaras-Kelly Karl , Goetz Matthew B. , Ying Jian , Sauer Brian , Jones Makoto M. , Leecaster Molly , Greene Tom , Fridkin Scott K. , Neuhauser Melinda M. , Samore Matthew H.
Published: April 2018

Background:

Electronic health records provide the opportunity to assess system-wide quality measures. Veterans Affairs Pharmacy Benefits Management Center for Medication Safety uses medication use evaluation (MUE) through manual review of the electronic health records.

Objective:

To compare an electronic MUE approach versus human/manual review for extraction of antibiotic use (choice and duration) and severity metrics.

Research Design:

Retrospective.

Subjects:

Hospitalizations for uncomplicated pneumonia occurring during 2013 at 30 Veterans Affairs facilities.

Measures:

We compared summary statistics, individual hospitalization-level agreement, facility-level consistency, and patterns of variation between electronic and manual MUE for initial severity, antibiotic choice, daily clinical stability, and antibiotic duration.

Results:

Among 2004 hospitalizations, electronic and manual abstraction methods showed high individual hospitalization-level agreement for initial severity measures (agreement=86%–98%, κ=0.5–0.82), antibiotic choice (agreement=89%–100%, κ=0.70–0.94), and facility-level consistency for empiric antibiotic choice (anti-MRSA r=0.97, P<0.001; antipseudomonal r=0.95, P<0.001) and therapy duration (r=0.77, P<0.001) but lower facility-level consistency for days to clinical stability (r=0.52, P=0.006) or excessive duration of therapy (r=0.55, P=0.005). Both methods identified widespread facility-level variation in antibiotic choice, but we found additional variation in manual estimation of excessive antibiotic duration and initial illness severity.

Conclusions:

Electronic and manual MUE agreed well for illness severity, antibiotic choice, and duration of therapy in pneumonia at both the individual and facility levels. Manual MUE showed additional reviewer-level variation in estimation of initial illness severity and excessive antibiotic use. Electronic MUE allows for reliable, scalable tracking of national patterns of antimicrobial use, enabling the examination of system-wide interventions to improve quality.
Cerebral Sinus Venous Thrombosis and Prothrombotic Risk Factors in Children: A Single-Center Experience From Turkey
Authors: Ozcan Alper , Canpolat Mehmet , Doganay Selim , Unal Ekrem , Karakukcu Musa , Ozdemir Mehmet A. , Patiroglu Turkan
Published: April 2018

Background:

Cerebral sinus venous thrombosis (CSVT) is a rare cerebrovascular disease that may be life-threatening, especially in children.

Objective:

The purpose of this study was to assess the clinical presentation, radiologic imaging, underlying conditions, treatment, and outcomes of children with CSVT.

Patients and Methods:

In total, 23 consecutive children aged between 1 month to 18 years with CSVT, who were followed-up in Erciyes University Children’s Hospital, were retrospectively enrolled in the study from January 2000 to December 2016.

Results:

The median age of the 23 children (13 female patients, 10 male patients) at initial diagnosis was 60 months (1 to 204 mo). The most common clinical manifestation was headache/irritability (n=9). The most common site of the CSVT was the transverse sinus (n=16). The most common prothrombotic risk factor was protein C deficiency (n=4). Underlying risk factors were detected in 15 patients. Genetic risk factors such as protein C deficiency, infections, trauma, malignancies, autoimmune hemolytic anemia, neurometabolic disorders, asphyxia, and cardiac malformations were common risk factors. Six children died. Multiple sinus involvement and parenchymal hemorrhages were seen in 4 and in 3 of the 6 children who died, respectively.

Conclusions:

Protein C deficiency seemed to be relatively high in the presented children. Multiple sinus involvement and additional parenchymal hemorrhages represent poor prognostic features.
Clinical Course of Homozygous Hemoglobin Constant Spring in Pediatric Patients
Authors: Komvilaisak Patcharee , Jetsrisuparb Arunee , Fucharoen Goonnapa , Komwilaisak Ratana , Jirapradittha Junya , Kiatchoosakun Pakaphan
Published: April 2018

Background:

Hemoglobin (Hb) Constant Spring is an alpha-globin gene variant due to a mutation of the stop codon resulting in the elongation of the encoded polypeptide from 141 to 172 amino acid residues. Patients with homozygous Hb Constant Spring are usually mildly anemic.

Methods:

We retrospectively describe clinical manifestations, diagnosis, laboratory investigations, treatment, and associated findings in pediatric patients with homozygous Hb Constant Spring followed-up at Srinagarind Hospital.

Results:

Sixteen pediatric cases (5 males and 11 females) were diagnosed in utero (N=6) or postnatal (n=10). Eleven cases were diagnosed with homozygous Hb Constant Spring, 4 with homozygous Hb Constant Spring with heterozygous Hb E, and 1 with homozygous Hb Constant Spring with homozygous Hb E. Three cases were delivered preterm. Six patients had low birth weights. Clinical manifestations included fetal anemia in 6 cases, hepatomegaly in 1 case, hepatosplenomegaly in 2 cases, splenomegaly in 1 case. Twelve cases exhibited early neonatal jaundice, 9 of which required phototherapy. Six cases received red cell transfusions; 1 (3), >1 (3). After the first few months of life, almost all patients had mild microcytic hypochromic anemia and an increased reticulocyte count with a wide red cell distribution (RDW), but no longer required red cell transfusion. At 1 to 2 years of age, some patients still had mild microcytic hypochromic anemia and some had normocytic hypochromic anemia with Hb around 10 g/dL, increased reticulocyte count and wide RDW. Associated findings included hypothyroidism (2), congenital heart diseases (4), genitourinary abnormalities (3), gastrointestinal abnormalities (2), and developmental delay (1).

Pediatric patients with homozygous Hb Constant Spring developed severe anemia in utero and up to the age of 2 to 3 months postnatal, requiring blood transfusions. Subsequently, their anemia was mild with no evidence of hepatosplenomegaly. Their Hb level was above 9 g/dL with hypochromic microcytic blood pictures as well as wide RDW. Blood transfusions have not been necessary since then.
Glucose Homeostasis Markers in Beta-Thalassemia
Authors: Gomber Sunil , Bagaria Anjali , Madhu Sri V. , Dewan Pooja
Published: April 2018

Background:

Glycosylated hemoglobin (HbA1c) has been a well-recognized marker of glucose homeostasis among thalassemics. Recently some studies have proposed the role of fructosamine as a better marker as compared with HbA1c. Hence, the study was carried out to find out which marker holds promise among Indian beta-thalassemic children.

Methods:

In this case-control study, 60 diagnosed cases of beta-thalassemia major and equal number of normal controls who were ≥8 years of age were enrolled. HbA1c, fructosamine, and fasting insulin levels were measured in all. Oral glucose tolerance test was done as a gold standard and the measured parameters were compared.

Results:

HbA1c was significantly higher in cases (7.10% [±0.47%]) than in controls (5.15% [±0.19%]) (P<0.001). Thalassemics with abnormal glucose tolerance had higher HbA1c level (7.34% [±0.57%]) than those with normal glucose tolerance (7.05% [±0.43%]) (P=0.05). Insulin resistance was noticed among thalassemics with abnormal glucose tolerance as compared with their normal counterparts (P=0.04). No significant difference was found in fructosamine levels between cases (239.80 [±31.80] μmol/L) and controls (234.10 [±21.34] μmol/L) (P=0.25) or between thalassemics with abnormal glucose tolerance (243.92 [±21.94] μmol/L) and their normal counterparts (238.77 [±33.93] μmol/L) (P=0.62).

Conclusions:

The use of HbA1c as a diagnostic marker for diabetes in hemolytic anemias has to be done with caution as its baseline values are higher in them. Despite this finding, HbA1c continues to be a good marker for worsening glucose homeostasis in thalassemics as higher values were found in thalassemics with abnormal glucose tolerance compared with their normal counterparts. The present study did not find any relationship of fructosamine levels with impaired glucose tolerance in beta-thalassemia.
Red Cell Distribution Width (RDW): Normative Data in Indian Neonates
Authors: Desai Saumil A. , Martin Snehal L. , Nanavati Ruchi N. , Colah Roshan B. , Ghosh Kanjaksha , Kabra Nandkishor , Mukherjee Malay B.
Published: April 2018

Red cell distribution width (RDW) is altered because of prematurity and fetal growth restriction (FGR). We conducted a prospective observational study to determine normal RDW values in Indian neonates (N=964) with significant FGR. Mean RDW values in preterm neonates were higher than term neonates (P<0.0004). The RDW values in Indian neonates (with significant FGR) were higher than their western counterparts (P<0.0001). The mean RDW values for different gestational ages in Indian neonates are higher than those observed in other studies. This could be attributable to the FGR component among Indian neonates.
Cutaneous Hemorrhage Types as Supportive Factors for Predicting Chronic Immune Thrombocytopenia in Children
Authors: Kalfon Sarit , Hamadeh Haitham , Schachter Yaakov , Sharon Nechama
Published: April 2018

Our objective was to assess risk factors for developing chronic immune thrombocytopenia (ITP) in children. The charts of all consecutive children diagnosed with ITP between 2000 and 2015 at a single center were retrospectively reviewed, and clinical characteristics at initial presentation were analyzed. Sixty-two children were included in the study (mean age, 6.15 y); 44 (71%) were found to have acute ITP, and 18 (29%) developed chronic ITP (permanent or relapsing thrombocytopenia >12 mo). In a univariate analysis, cutaneous hemorrhages were observed significantly more in acute patients (90.9%) than in chronic patients (61.1%). Patients who had acute ITP were more likely to present with a combination of petechiae, purpura, and/or ecchymosis (75%) than patients with chronic disease (44.4%,P=0.010). In multivariate analysis, older age increased the risk (odds ratio=1.1;P<0.05) for chronic disease, and manifestations of combination skin hemorrhages (petechiae/purpura/ecchymosis) reduced the risk (odds ratio=0.167;P<0.05). In conclusion, the most important risk factor for chronic disease is older age. Skin hemorrhage types were found to be a supportive factor for the prediction process: the combination of petechia/purpura/ecchymosis was associated with a lower risk for developing chronic disease compared with petechiae alone. Future studies should assess the prognostic value of skin hemorrhage types that are a simple way to predict the course of ITP in children.
Splenectomy to Optimize Hemoglobin S Control in Children With Sickle Cell Anemia on Chronic Transfusion Therapy for Stroke Prevention
Authors: Black L. Vandy , Ramesar Jolie S. , Boston Catherine H.
Published: April 2018

Chronic transfusion therapy with the goal of maintaining a hemoglobin (Hb) S <30% is the primary recommended treatment for children with sickle cell anemia and a history of overt stroke or abnormal transcranial Doppler examination. We report chronic hypersplenism as a cause of poor HbS% control in 3 children on chronic transfusion therapy for stroke prevention. Splenectomy resulted in a 39.77% (95% confidence interval, 34.3-45.3, P<0.0001) mean reduction in HbS% with no perioperative or infectious complications suggesting the need for additional research into splenectomy as a therapeutic option for select high-risk children to optimize transfusion therapy for stroke prevention.
Characteristics of Medical Professional Liability Claims in Pediatric Orthopedics
Authors: Burns Jessica , Shrader M. Wade , Boan Carla , Belthur Mohan
Published: April 2018

Objectives

Medical malpractice is burdensome to the U.S. healthcare system. The following is an epidemiological analysis of the closed medical professional liability (MPL) claims in pediatric orthopedics using data maintained by the Physician Insurers Association of America.

Methods

The Physician Insurers Association of America registry of MPL claims from 1985 to 2013 for all specialties included 286,021 closed claims in the United States. All closed MPL claims for orthopedic surgery in patients younger than 18 years were retrospectively reviewed (N = 2,671). The error categories, result of the claim, the most common procedures, severity of injury, and the most common presenting and resultant medical conditions were reported with the paid-to-close ratios, average indemnity payment, and average cost of litigation. The pediatric orthopedic population was compared with all orthopedics. The data were adjusted for inflation and trended for the 29-year period.

Results

Of the 2671 pediatric orthopedic claims, 881 resulted in a payment and the average indemnity was U.S. $317,574 with adjustment for inflation - significantly higher than for all of orthopedics at U.S. $268,817 (P = 0.0013). The paid-to-close ratio was 33.0%, compared with 28.7% for all of orthopedics (P = 0.023).

Conclusions

Costs to defend individual medical malpractice claims and the average indemnity payment per claim have both increased over time, and pediatric (versus adult) orthopedic claims are more likely to result in payment and result in a higher payment. Knowledge of the details of liability claims should assist practicing general and pediatric orthopedic surgeons in improving patient safety and quality of care, reducing patient injury, and reducing the incidence of MPL claims.
Improvement of the Patient Safety Culture in the Primary Health Care Corporation – Qatar
Authors: El Zoghbi Mohamad , Farooq Saad , Abulaban Ali , Taha Heba , Ajanaz Sajna , Aljasmi Jawaher , Ahmad Shakil , Said Hana
Published: April 2018

Objectives

Primary Health Care Corporation (PHCC) is the public primary health care provider in Qatar. Having a patient safety culture (PSC) is the keystone to enabling a continuous process to improve the quality of services and to reduce errors. The objective of this study was to assess the impact of accreditation, quality improvement trainings, and patient safety (PS) trainings on the improvement of the PSC at the PHCC in Qatar.

Methods

The Medical Office Survey on Patient Safety Culture from the Agency for Healthcare Research and Quality was used in 2012 and 2015 to assess the culture of PS and health care quality in the 21 health centers. The results of the two surveys were compared using the χ2 test. A P value of less than 0.05 was considered significant.

Results

Out of 2689 staff working in the 21 health centers, 1810 (67.3%) completed the survey in 2012, and 2616 (70.0%) of 3735 completed the survey in 2015. The comparison between 2012 and 2015 survey’s results showed a statistically significant improvement for all the 10 dimensions (P < 0.05). Although a statistically significant difference was observed between 2012 and 2015 results for work pressure and pace, three of the four questions of the work pressure and pace dimension presented nonsignificant differences.

Conclusions

The survey was a good tool to raise awareness on PS and quality issues at PHCC. There is evidence that the implementation of accreditation program, the quality improvement trainings, and PS trainings helped the organization improve its PS culture.
Kinematic Magnetic Resonance Imaging of the Thorax Using 2-Dimensional Balanced Subsecond Steady-state Free Precession Sequence During Forced Breathing in Comparison With Spirometry
Authors: Tanimoto Daigo , Ito Katsuyoshi , Higashi Hiroki , Yamamoto Akira , Kanki Akihiko , Yasokawa Kazuya , Tamada Tsutomu
Published: April 2018

Purpose:

The purpose of this article was to investigate the feasibility of kinematic magnetic resonance imaging (MRI) during forced breathing for the assessment of thoracic and diaphragmatic movement and to compare the results of MRI and spirometry to determine the MRI parameters that are predominantly associated with pulmonary function.

Materials and Methods:

Forty-nine healthy volunteers who underwent kinematic MRI using 2-dimensional balanced subsecond steady-state free precession sequence during forced breathing were included. Several items on the MRI were measured and calculated: these were anteroposterior diameter (APD) of the thorax, APD1, ΔAPD, and cross-sectional area (CSA) of the lung field. The results were compared with the results of spirometry.

Results:

In the comparison between the spirometry results and the MRI kinematic changes, CSA1, ΔCSA, and CSA1% were most significantly correlated with forced expiratory volume in 1 second (right: P<0.001, r=0.814; left: P<0.001, r=0.759); vital capacity (right: P<0.001, r
=0.797; left: P<0.001, r=0.780); and forced expiratory volume% in 1 second (right: P<0.001, r=0.530; left: P<0.001, r=0.518), respectively. The APD1 values in the upper position were significantly larger than those in the middle (right: P<0.001; left: P<0.001) and lower (right: P<0.001; left: P<0.001) positions. The ΔAPD values in the upper position were also significantly larger than those in the middle (right: P<0.001; left: P<0.001) and lower (right: P<0.001; left: P<0.001) positions.

Conclusion:

Kinematic MRI with 2-dimensional balanced subsecond steady-state free precession can be used to assess thoracic and diaphragmatic movement during forced breathing. The dynamic changes in CSA correlated well with the results of spirometry.