bluuebunny/crossref_metadata_2025 huggingface dataset:
3D Tibia Reconstruction Using 2D Computed Tomography Images
Authors: Iyoho Anthony E , Young Jonathan M , Volman Vladislav , Shelley David A , Ng Laurel J , Wang Henry
Published: March 2019

OBJECTIVE

Skeletal stress fracture of the lower limbs remains a significant problem for the military. The objective of this study was to develop a subject-specific 3D reconstruction of the tibia using only a few CT images for the prediction of peak stresses and locations.

METHODS

Full bilateral tibial CT scans were recorded for 63 healthy college male participants. A 3D finite element (FE) model of the tibia for each subject was generated from standard CT cross-section data (i.e., 4%, 14%, 38%, and 66% of the tibial length) via a transformation matrix. The final reconstructed FE models were used to calculate peak stress and location on the tibia due to a simulated walking load (3,700 N), and compared to the raw models.

RESULTS

The density-weighted, spatially-normalized errors between the raw and reconstructed CT models were small. The mean percent difference between the raw and reconstructed models for peak stress (0.62%) and location (−0.88%) was negligible.

CONCLUSIONS

Subject-specific tibia models can provide even great insights into the mechanisms of stress fracture injury, which are common in military and athletic settings. Rapid development of 3D tibia models allows for the future work of determining peak stress-related injury correlates to stress fracture outcomes.
Reduced Complications of Supraclavicular Approach in Simulated Central Venous Access: Applicability to Military Medicine
Authors: Sappenfield Joshua , Grek Sasha , Cooper Lou Ann , Lizdas David E , Lampotang Samsun
Published: March 2019

In a study with 76 anesthesia providers on a mixed reality simulator, central venous access via the supraclavicular approach to the subclavian vein, without ultrasonography required less attempts compared to the infraclavicular approach. Participants had shorter times to venous access and larger improvements in confidence. Results from this simulation-based study indicate that the supraclavicular approach may deserve consideration as an alternative approach for central venous access in deployed military environments. The use of ultrasonography during the supraclavicular approach to the subclavian vein is also described which may improve its safety profile. This technique could be more appropriate in scenarios when central venous access is preferred over intraosseous access for patients being transported to another location for further care.
Mechanical and Finite Element Analysis of an Innovative Orthopedic Implant Designed to Increase the Weight Carrying Ability of the Femur and Reduce Frictional Forces on an Amputee’s Stump
Authors: Chillale Tejas P , Kim Nam Ho , Smith Larry N
Published: March 2019

This study was designed to test the hypothesis that: “A properly designed implant that harnesses the principle of the incompressibility of fluids can improve the weight carrying ability of an amputee’s residual femur and reduce the frictional forces at the stump external socket interface.” The hypothesis was tested both mechanically on an Amputee Simulation Device (ASD) and through Finite Element Analysis (FEA) modeling software. With the implant attached to the femur, the FEA and ASD demonstrated that the femur carried 90% and 93% respectively of the force of walking. Without the implant, the FEA model and ASD femur carried only 35% and 77%, respectively, of the force of walking. Statistical calculations reveal three (3) degrees of separation (99% probability of non-random significant difference) between with and without implant data points. FEA modeling demonstrates that the normal contact forces and shear forces are pushed the distal weight-bearing area of the amputee stump, relieving the lateral stump of frictional forces. The ASD mechanical and FEA modeling data validate each other with both systems supporting the hypotheses with confidence intervals of three degrees of separation between with implant and without implant models.
Is Vitamin D Level at Melanoma Diagnosis Associated With Stage Of Tumor? An Observational Study of Melanoma Patients Living in a High Ultraviolet Radiation Environment
Authors: Kimlin Michael G , Youl Pip , Baade Peter , Rye Sheree , Brodie Alison
Published: March 2019

Objectives

This study will assess the relationship between vitamin D concentration at melanoma diagnosis and melanoma tumor characteristics, in individuals in a high ultraviolet radiation (UVR) environment.

Methods

We aim to recruit 600 recently diagnosed melanoma patients from Queensland, Australia, a high UVR location with one of the world’s highest melanoma incidence rates. Patients are recruited through general practitioner, skin cancer specialist, dermatological and hospital-based practices. As close as possible to diagnosis, participants provide a blood sample for vitamin D analysis and have their sun exposure/sun protection behavior, melanoma risk factors and dietary vitamin D intake assessed by questionnaire and phone interview. Details of tumor pathology, including tumor level, thickness, and ulceration, are abstracted from cancer registry records. Here, we describe the study methods and present preliminary findings from early participants.

Results

As of December 2017, we have recruited 128 participants (48% male, mean age 60.2 years, mean Breslow thickness 0.63 mm).

Conclusions

When complete, this study will give insights into the association between vitamin D at diagnosis and melanoma tumor characteristics whilst adjusting for recent sun exposure and sun protection use. This study may impact military sun exposure and nutrition policies as vitamin D may play a role in melanomagenesis.
Formative Assessment of Performance in Diagnostic Ultrasound Using Simulation and Quantitative and Objective Metrics
Authors: Sheehan Florence H , McConnaughey Shannon , Freeman Rosario , Zierler R Eugene
Published: March 2019

Background

We developed simulator-based tools for assessing provider competence in transthoracic echocardiography (TTE) and vascular duplex scanning.

Methods

Psychomotor (technical) skill in TTE image acquisition was calculated from the deviation angle of an acquired image from the anatomically correct view. We applied this metric for formative assessment to give feedback to learners and evaluate curricula.

Psychomotor skill in vascular ultrasound was measured in terms of dexterity and image plane location; cognitive skill was assessed from measurements of blood flow velocity, parameter settings, and diagnosis. The validity of the vascular simulator was assessed from the accuracy with which experts can measure peak systolic blood flow velocity (PSV).

Results

In the TTE simulator, the skill metric enabled immediate feedback, formative assessment of curriculum efficacy, and comparison of curriculum outcomes. The vascular duplex ultrasound simulator also provided feedback, and experts’ measurements of PSV deviated from actual PSV in the model by <10%.

Conclusions

Skill in acquiring diagnostic ultrasound images of organs and vessels can be measured using simulation in an objective, quantitative, and standardized manner. Current applications are provision of feedback to learners to enable training without direct faculty oversight and formative assessment of curricula. Simulator-based metrics could also be applied for summative assessment.
Characteristics of Iraqi Patients Treated During Operation Inherent Resolve by a Forward Surgical Team
Authors: Hahn Christina , Staudt Amanda M , Brockmeyer Joel , Mann-Salinas Elizabeth A , Gurney Jennifer M
Published: March 2019

Introduction

The combat experience during the re-entry stages of Operation Inherent Resolve was distinct from other recent operations, but there is no published literature regarding these “initial entry operations” experiences among forward surgical teams (FSTs) deployed to Role 2 facilities A descriptive analysis of patients treated by FSTs may provide valuable information for Role 2 surgical teams preparing to deploy in support of initial entry operations. The purpose of this analysis was to describe injury mechanism, wounding patterns and interventions performed by a small FST in the re-entry phase in Iraq.

Materials and Methods

From July 17, 2015 to January 31, 2016, a split surgical team with two surgeons and an ER physician documented care for all patients treated by their FST located in Iraq. Given their austere environment, FSTs have limited holding capacity, blood supply, and ability to triage and perform advanced procedures. Patients, who arrived to the Role 2 in asystole, were ineligible for the study. The patient population was Iraqi Security Forces as well as Iraqi civilians. No follow-up data were obtained. Using descriptive statistics, we described the basic demographics, health status, blood utilization, injury severity, and injury pattern of the patient population.

Results

The final study population included 300 Iraqi casualties. The majority of patients (96%) were discharged alive. Many patients were 16 years or older (96%), male (96%), Iraqi soldiers (86%), and injured during battle (96%). Over one-third of patients (35%) had a form of metabolic acidosis, 7% were hypothermic, and 18% were in shock at admission. The median amount of blood products used was 6 (interquartile ranges (IQR) = 2–12) units, while the median red blood cells:fresh frozen plasma ratio was 1.2:1. Six or more units of blood were given to 67 (22%) patients. The top three diagnoses were laceration (n = 197, 21%), penetrating injury (n = 185, 19%), and fracture (n = 174, 18%). A high number of injuries occurred in the extremities/pelvis and buttocks (n = 360, 38%) and in the abdomen and pelvic contents (n = 145, 15%). Over a quarter of patients (26%) had critical injuries (i.e., military injury severity score ≥25).

Conclusions

Given the Role 2 configuration, these results demonstrate FSTs must be capable of managing critically ill patients with markedly limited resources. This management will include general operations in both adult and pediatric patients, resuscitation with a limited blood supply, and patient assessment with minimal to no diagnostic tools. This analysis can inform resident training, pre-deployment training, as well as sustainment training for surgeons after residency.
A Comparative in vivo Study of Semi-constrained and Unconstrained Cervical Artificial Disc Prostheses
Authors: Choi Hoon , Baisden Jamie L , Yoganandan Narayan
Published: March 2019

Purpose

The objective of this study is to directly compare different types of cervical artificial disc implants using an in vivo model capable of simulating the axial load on a neck that is similar to the human neck.

Methods

Cervical arthroplasty was performed at C3-4 in 14 healthy female adult Alpine goats. The goats were divided into three groups. Group A received Bryan (unconstrained one-piece design); Group B received ProDisc-C (semi-constrained two-piece design); and Group C received Mobi-C (unconstrained three-piece design) artificial discs. The goats were monitored in a veterinary unit for 6 months with radiography at regular intervals.

Results

Each goat tolerated cervical arthroplasty well and had satisfactory placement of their implant per intra-operative radiography. Implants monitored in Group A demonstrated no migration. One out of five implants in Group B experienced anterior migration at 3 months. In Group C, anterior migration and disintegration occurred in all four implants, with migration occurring during the first postoperative week in three implants and after 5 weeks in the fourth.

Conclusions

Unconstrained multi-piece artificial cervical discs may be prone to anterior migration and extrusion out of the disc space. This outcome deserves attention in individuals with a hypermobile neck and/or an occupation involving the use of a head-supported mass, such as helmets.
Maximizing the Resilience of Healthcare Workers in Multi-hazard Events: Lessons from the 2014–2015 Ebola Response in Africa
Authors: Schreiber Merritt , Cates David S , Formanski Stephen , King Michael
Published: March 2019

There is increasing knowledge that health care workers (HCWs) can experience a variety of emotional impacts when responding to disasters and terrorism events. The Anticipate, Plan and Deter (APD) Responder Risk and Resilience Model was developed to provide a new, evidence-informed method for understanding and managing psychological impacts among HCWs. APD includes pre-deployment development of an individualized resilience plan and an in-theater, real-time self-triage system, which together allow HCWs to assess and manage the full range of psychological risk and resilience for themselves and their families. The inclusion of objective mental health risk factors to prompt activation of a coping plan, in connection with unit leadership real-time situational awareness, enables the first known evidence-driven “targeted action” plan to address responder risk early before Post Traumatic Stress Disorder and impairment become established. This paper describes pilot work using the self-triage system component in Alameda County’s Urban Shield and the Philippines’ Typhoon Haiyan, and then reports a case example of the full APD model implementation in West Africa’s Ebola epidemic.
Quantification of Mild Traumatic Brain Injury via Cortical Metrics: Analytical Methods
Authors: Favorov Oleg V , Francisco Eric , Holden Jameson , Kursun Olcay , Zai Laila , Tommerdahl Mark
Published: March 2019

Mild traumatic brain injuries are difficult to diagnose or assess with commonly used diagnostic methods. However, the functional state of cerebral cortical networks can be rapidly and effectively probed by measuring tactile-based sensory percepts (called cortical metrics), which are designed to exercise various components of cortical machinery. In this study, such cortical metrics were obtained from 52 college students before and after they experienced sports-related concussions by delivering vibrotactile stimuli to the index and middle fingertips. Performance on four of the sensory test protocols is described: reaction time, amplitude discrimination, temporal order judgment, and duration discrimination. The collected test performance data were analyzed using methods of uni- and multivariate statistics, receiver operated characteristic (ROC) curves, and discriminant analysis. While individual cortical metrics vary extensively in their ability to discriminate between control and concussed subjects, their combined discriminative performance greatly exceeds that of any individual metric, achieving cross-validated 93.0% sensitivity, 92.3% specificity, 93.0% positive predictive value, and 92.3% negative predictive value. The cortical metrics vector can be used to track an individual’s recovery from concussion. The study thus establishes that cortical metrics can be used effectively as a quantitative indicator of central nervous system health status.
Early Complement and Fibrinolytic Activation in a Rat Model of Blast-Induced Multi-Organ Damage
Authors: Yang Zhangsheng , Aderemi Olawale A , Zhao Qingwei , Edsall Peter R , Simovic Milomir O , Lund Brian J , Espinoza Mark D , Woodson Amber M , Li Yansong , Cancio Leopoldo C
Published: March 2019

Objective

Blast injury is associated with multi-organ failure (MOF), causing significant morbidity and mortality in trauma patients. However, the pathogenesis of blast-induced MOF still remains obscure. In this study, we evaluate the pathophysiological changes related to blast-induced MOF in a clinically relevant rat model of blast injury.

Methods

A moderate blast overpressure was applied to induce injury in anesthetized rats. Pathological changes were evaluated by H&E staining. Complement activation, plasminogen, and myeloperoxidase levels were analyzed by complement hemolytic assay (CH50) and/or ELISA in blood samples.

Results

Analysis of lung, brain, and liver tissue at 24 hour after blast overpressure revealed severe injuries. The level of complement components C3 and C1q decreased in parallel with the reduction of CH50 level in injured animals at 1, 3, and 6 hours after blast. Consumption of plasminogen was also detected as early as 1 hour post-injury. Myeloperoxidase levels were elevated within 1 hour of blast injury.

Conclusion

Our data reveal that blast injury triggers the complement and fibrinolytic systems, which likely contribute to blast-induced MOF. Conceivably, therapies that target these systems early may improve clinical outcomes in blast patients.
Prehospital Use of Ketamine: Effectiveness in Critically Ill and Injured Patients
Authors: Zietlow John , Berns Kathy , Jenkins Donald , Zietlow Scott
Published: March 2019

Background

The military use of ketamine is well established. The benefits of prehospital civilian use have not been extensively reported.

Methods

A retrospective review was performed of patients with prehospital ketamine use in Mayo One’s air and critical care ground transport.

Results

The medical records were reviewed from 2014 to 2016 to assess the efficacy of Ketamine. During this time frame, 158 (167 instances) patients were treated with ketamine for analgesia (38%), sedation (44%), or procedural (18%) use. The patient population had a mean age of 49 (range: 1–100), with 105 (67%) male patients. Indications included trauma (69%), which was further broken down into blunt (57%), penetrating (4%), and miscellaneous (8%), and medical illness (31%). The mean ketamine dose was 52.6 mg (range: 5–200 mg) via intravenous route. Ketamine was utilized in 61% of patients after other medications were ineffective. Overall success rate was 98%. Mean pain scale before and after ketamine use was 9/10 and 3/10, respectively. Ketamine use increased yearly from 21 (13%) in 2014, 56 (36%) in 2015, and 81 (51%) in 2016.

Conclusion

Prehospital ketamine use is effective alone or in conjunction with other medications for analgesia, sedation, and procedural use in trauma and critically ill patients with minimal hemodynamic and respiratory consequences.
Precise optical timing of PSR J1023+0038, the first millisecond pulsar detected with Aqueye+ in Asiago
Authors: Zampieri Luca , Burtovoi Aleksandr , Fiori Michele , Naletto Giampiero , Spolon Alessia , Barbieri Cesare , Papitto Alessandro , Ambrosino Filippo
Published: March 2019

We report the first detection of an optical millisecond pulsar with the fast photon counter Aqueye+ in Asiago. This is an independent confirmation of the detection of millisecond pulsations from PSR J1023+0038 obtained with SiFAP at the Telescopio Nazionale Galileo. We observed the transitional millisecond pulsar PSR J1023+0038 with Aqueye+ mounted at the Copernicus telescope in 2018 January. Highly significant pulsations were detected. The rotational period is in agreement with the value extrapolated from the X-ray ephemeris, while the time of passage at the ascending node is shifted by 11.55 ± 0.08 s from the value predicted using the orbital period from the X-rays. An independent optical timing solution is derived over a baseline of a few days that has an accuracy of ∼0.007 in pulse phase (∼12 μs in time). This level of precision is needed to derive an accurate coherent timing solution for the pulsar and to search for possible phase shifts between the optical and X-ray pulses using future simultaneous X-ray and optical observations.
PIXUL-ChIP: integrated high-throughput sample preparation and analytical platform for epigenetic studies
Authors: Bomsztyk Karol , Mar Daniel , Wang Yuliang , Denisenko Oleg , Ware Carol , Frazar Christian D , Blattler Adam , Maxwell Adam D , MacConaghy Brian E , Matula Thomas J
Published: March 2019

Chromatin immunoprecipitation (ChIP) is the most widely used approach for identification of genome-associated proteins and their modifications. We have previously introduced a microplate-based ChIP platform, Matrix ChIP, where the entire ChIP procedure is done on the same plate without sample transfers. Compared to conventional ChIP protocols, the Matrix ChIP assay is faster and has increased throughput. However, even with microplate ChIP assays, sample preparation and chromatin fragmentation (which is required to map genomic locations) remains a major bottleneck. We have developed a novel technology (termed ‘PIXUL’) utilizing an array of ultrasound transducers for simultaneous shearing of samples in standard 96-well microplates. We integrated PIXUL with Matrix ChIP (‘PIXUL-ChIP’), that allows for fast, reproducible, low-cost and high-throughput sample preparation and ChIP analysis of 96 samples (cell culture or tissues) in one day. Further, we demonstrated that chromatin prepared using PIXUL can be used in an existing ChIP-seq workflow. Thus, the high-throughput capacity of PIXUL-ChIP provides the means to carry out ChIP-qPCR or ChIP-seq experiments involving dozens of samples. Given the complexity of epigenetic processes, the use of PIXUL-ChIP will advance our understanding of these processes in health and disease, as well as facilitate screening of epigenetic drugs.
Risk and Cost Associated With Drug–Drug Interactions Among Aging HIV Patients Receiving Combined Antiretroviral Therapy in France
Authors: Demessine Ludivine , Peyro-Saint-Paul Laure , Gardner Edward M , Ghosn Jade , Parienti Jean-Jacques
Published: March 2019

Background

We aimed to describe the frequency, risk factors, and costs attributable to drug–drug interactions (DDIs) among an aging French HIV population.

Methods

We conducted a retrospective cohort study using French nationwide health care e-records: the SNIIRAM database. People living with HIV (PLWH) aged >65 years and receiving combined antiretroviral treatment (cART) during 2016 were included. A DDI was defined as “These drugs should not be co-administered,” represented by a red symbol on the University of Liverpool website. Attributable DDIs’ cost was defined as the difference between individuals with and without DDIs regarding all reimbursed health care acts.

Results

Overall, 9076 PLWH met the study criteria. Their baseline characteristics were: mean age, 71.3 ± 4.9 years; 25% female; median HIV duration (interquartile range [IQR]), 16.2 (9.5–20.3) years; median comorbidities (IQR), 2 (1–3). During 2016, they received a median (IQR) of 14 (9–21) comedications (non-cART), and 1529 individuals had at least 1 DDI (16.8%; 95% confidence interval [CI], 16.1–17.6). In multivariate analysis, raltegravir or dolutegravir plus 2 nucleoside reverse-transcriptase inhibitors (NRTIs) significantly and independently reduced the risk of DDIs (adjusted odds ratio [aOR], 0.02; 95% CI, 0.005–0.050; P < .0001) compared with non-nucleoside reverse-transcriptase inhibitor plus 2 NRTIs, whereas cART with boosted agents (protease inhibitors or elvitegravir) significantly increased the risk (aOR, 4.12; 95% CI, 3.34–5.10; P < .0001). Compared with propensity score–matched PLWH without DDIs, the presence of DDIs was associated with a $2693 additional cost per year (P < .0001).

Conclusions

The presence of DDIs is frequent and significantly increases health care costs in the aging population of PLWH.
Adopting Population Health Frameworks in Physical Therapist Practice, Research, and Education: The Urgency of Now
Authors: Magnusson Dawn M , Eisenhart Mike , Gorman Ira , Kennedy V Kai , E. Davenport Todd
Published: March 2019

Chronic, noncommunicable diseases have replaced acute, infectious diseases as the leading causes of global mortality and morbidity. Efforts among physical therapists to address noncommunicable diseases have primarily focused on the promotion of healthy behaviors among individual clients. However, the strongest predictors of chronic disease are tied to where we live, work, learn, and play, our families, and our communities. Population health frameworks can help us better understand the complex interrelations between individuals’ health condition and their social and physical environment over time and also inform the development of effective programs and policies that improve the health of individuals and communities. The objectives of this article are to: (1) define population health, prevention, and health promotion; (2) provide a current perspective on the utility of population health frameworks in physical therapy; and (3) identify opportunities for the expanded use of population health frameworks in physical therapist practice, research, and education.
Religion and Sanitation Practices
Authors: Adukia Anjali , Alsan Marcella , Babiarz Kim , Goldhaber-Fiebert Jeremy D , Prince Lea
Published: March 2019

In India, infant mortality among Hindus is higher than among Muslims, and religious differences in sanitation practices have been cited as a contributing factor. To explore whether religion itself is associated with differences in sanitation practices, this study compares sanitation practices of Hindus and Muslims living in the same locations using three nationally representative data sets from India. Across all three data sets, the unconditional religion-specific gap in latrine ownership and latrine use declines by approximately two-thirds when conditioning on location characteristics or including location fixed effects. Further, the estimates do not show evidence of religion-specific differences in other sanitation practices, such as handwashing or observed fecal material near homes. Household sanitation practices vary substantially across areas of India, but religion itself has less direct influence when considering differences between Hindus and Muslims within the same location.
“Piler Dirt” Survey for the Sampling and Detection of Potato Cyst Nematodes
Authors: Mimee Benjamin , Dauphinais Nathalie , Bélair Guy
Published: March 2019

Potato cyst nematodes are a significant threat to potato production worldwide and have important economic impacts due to yield losses but also because of the expenses associated with regulation procedures. In order to reduce the sampling labor, an alternative strategy named the “Piler Dirt” that collects the soil carried with potato tubers during their transfer to storage was proposed. The method showed a better sensitivity than the reference method to detect fields infested with G. rostochiensis. The quantification of the number of cysts per kilogram of soil was proportional between the two methods at low and moderate population densities (R2 = 0.885) but no correlations were found at high density. However, the quantity of soil generated by the method was exceedingly large to be treated by diagnostic labs. It was shown that subsampling six aliquots, each equivalent to 5,000 cm3/ha, from the total quantity of soil generated by the Piler Dirt method, resulted in a probability of 97% to detect infested fields, 95% of the time in our dataset. Overall, Piler Dirt appears as a good compromise to reduce labor time and cost without significantly affecting sensitivity. However, it will be challenging to implement because it needs to be done simultaneously with harvest and will require the participation of farmers during a busy period.
The Substance Use Intervention Team: A Preliminary Analysis of a Population-level Strategy to Address the Opioid Crisis at an Academic Health Center
Authors: Thompson Hale M. , Hill Kristin , Jadhav Riddhi , Webb Thomas A. , Pollack Mark , Karnik Niranjan
Published: March 2019

Objective:

In 2017, an academic health center in Chicago launched the multidisciplinary Substance Use Intervention Team (SUIT) to address opioid misuse across 18 inpatient units and in a new outpatient addiction medicine clinic. This report assesses the first 5 months of implementation and associations with patient health and healthcare utilization.

Methods:

Patient demographic and screening data were extracted from the administrative data warehouse of the electronic health record (EHR) infrastructure. Distribution of sample characteristics for positive initial screens for opioid misuse was tested against those of all patients screened using a 2-tailed test of proportions (P < 0.05). A second analysis compared length of stay and 30-day readmissions within a cohort of patients with a secondary diagnosis of substance use disorder.

Results:

Between November, 2017 and March, 2018, 76% of 15,054 unique patients were screened, 578 had positive scores on the Alcohol Use Disorders Identification Test and Drug Abuse Screening Test, 131 had positive scores for opioid misuse, and 52 patients initiated medication treatment. Patients with a secondary diagnosis of substance use disorder who received a SUIT consult (n = 161), compared with those who did not (n = 612), had a shorter average length of stay (5.91 vs 6.73 days) and lower 30-day readmission rate (13.6% vs 15.7%).

Conclusion:

Leveraging the EHR to conduct standardized screenings and treatment has helped identify an at-risk population—disproportionately younger, black, and male—and treat new cases of opioid and substance misuse. The intervention indicates trends toward a shortened length of stay, reduced 30-day readmissions, and has linked patients to outpatient care.
Airway Closure during Surgical Pneumoperitoneum in Obese Patients
Authors: Grieco Domenico Luca , Anzellotti Gian Marco , Russo Andrea , Bongiovanni Filippo , Costantini Barbara , D’Indinosante Marco , Varone Francesco , Cavallaro Fabio , Tortorella Lucia , Polidori Lorenzo , Romanò Bruno , Gallotta Valerio , Dell’Anna Antonio Maria , Sollazzi Liliana , Scambia Giovanni , Conti Giorgio , Antonelli Massimo
Published: March 2019

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Airway closure causes lack of communication between proximal airways and alveoli, making tidal inflation start only after a critical airway opening pressure is overcome. The authors conducted a matched cohort study to report the existence of this phenomenon among obese patients undergoing general anesthesia.

Methods

Within the procedures of a clinical trial during gynecological surgery, obese patients underwent respiratory/lung mechanics and lung volume assessment both before and after pneumoperitoneum, in the supine and Trendelenburg positions, respectively. Among patients included in this study, those exhibiting airway closure were compared to a control group of subjects enrolled in the same trial and matched in 1:1 ratio according to body mass index.

Results

Eleven of 50 patients (22%) showed airway closure after intubation, with a median (interquartile range) airway opening pressure of 9 cm H2O (6 to 12). With pneumoperitoneum, airway opening pressure increased up to 21 cm H2O (19 to 28) and end-expiratory lung volume remained unchanged (1,294 ml [1,154 to 1,363] vs. 1,160 ml [1,118 to 1,256], P = 0.155), because end-expiratory alveolar pressure increased consistently with airway opening pressure and counterbalanced pneumoperitoneum-induced increases in end-expiratory esophageal pressure (16 cm H2O [15 to 19] vs. 27 cm H2O [23 to 30], P = 0.005). Conversely, matched control subjects experienced a statistically significant greater reduction in end-expiratory lung volume due to pneumoperitoneum (1,113 ml [1,040 to 1,577] vs. 1,000 ml [821 to 1,061], P = 0.006). With airway closure, static/dynamic mechanics failed to measure actual lung/respiratory mechanics. When patients with airway closure underwent pressure-controlled ventilation, no tidal volume was inflated until inspiratory pressure overcame airway opening pressure.

Conclusions

In obese patients, complete airway closure is frequent during anesthesia and is worsened by Trendelenburg pneumoperitoneum, which increases airway opening pressure and alveolar pressure: besides preventing alveolar derecruitment, this yields misinterpretation of respiratory mechanics and generates a pressure threshold to inflate the lung that can reach high values, spreading concerns on the safety of pressure-controlled modes in this setting.
Relationship of Necrotizing Enterocolitis Rates to Adoption of Prevention Practices in US Neonatal Intensive Care Units
Authors: Gephart Sheila M. , Quinn Megan C.
Published: March 2019

Background:

Applying quality improvement methods has reduced necrotizing enterocolitis (NEC) in some neonatal intensive care units (NICUs) by 40% to 90%.

Purpose:

This study was conducted to (1) examine relationships between adoption of prevention practices using the NEC-Zero adherence score and NEC rates, and (2) describe implementation strategies NICUs use to prevent NEC.

Methods:

A descriptive cross-sectional correlational study was completed among US quality improvement–focused NICUs. Relationships of the NEC-Zero adherence score to NEC rates were examined. Subgroup analyses explored relationships of a human milk adherence subscore and differences between high NEC rate (≥8%) and low NEC rate (≤2%) NICUs.

Results:

NICUs (N = 76) ranged in size from 18 to 114 beds. The mean adherence score was 7.3 (standard deviation = 1.7; range, 3-10). The 10-point adherence score was not related to the NEC rate. The human milk subscore related to lower NEC rates (Rho = −0.26, P = .049), as was colostrum for oral care (Rho = −0.27, P = .032). The units that used a feeding protocol showed higher NEC rates (Rho = 0.27, P = .03), although very few addressed the use of effective implementation strategies to track adherence or to ensure consistency among clinicians. The units that used colostrum for oral care were more likely to adopt strategies to limit inappropriate antibiotic exposure (Rho = 0.34, P = .003).

Implications for Practice:

Broader use of evidence-based implementation strategies could bolster delivery of NEC prevention practices. Maternal lactation support is paramount.

Implications for Research:

Future studies are needed to identify how individual clinicians deliver prevention practices, to find the extent to which this relates to overall delivery of prevention, and to study effects of bundles on NEC outcomes.
Systematic Review of the Effects of Skin-to-Skin Care on Short-Term Physiologic Stress Outcomes in Preterm Infants in the Neonatal Intensive Care Unit
Authors: Pados Britt Frisk , Hess Francis
Published: March 2019

Background:

Infants in the neonatal intensive care unit (NICU) are exposed to many stressors. There is growing evidence that chronic stress early in life has long-term neurodevelopmental implications. Skin-to-skin care (SSC) is an intervention used to reduce stress in the NICU.

Clinical Question:

In premature infants in the NICU, what is the available evidence that SSC improves short-term physiologic stress outcomes compared with incubator care?

Search Strategy:

PubMed and CINAHL were searched for terms related to SSC, stress, physiology, and premature infants. Of 1280 unique articles, 19 were identified that reported on research studies comparing SSC with incubator care in the NICU and reported stress-related physiologic outcome measures.

Results:

Although there have been some mixed findings, the research supports that SSC improves short-term cardiorespiratory stress outcomes compared with incubator care. The evidence is clearer for studies reporting stress hormone outcomes, with strong evidence that SSC reduces cortisol and increases oxytocin levels in preterm infants.

Implications for Practice and Research:

SSC is safe and has stress-reducing benefits. SSC should be considered an essential component to providing optimal care in the NICU. More research is needed to determine the timing of initiation, duration, and frequency of SSC to optimize the stress-reducing benefits. Future research should include the most fragile infants, who are most likely to benefit from SSC, utilize power analyses to ensure adequate sample sizes, and use sophisticated data collection and analysis techniques to more accurately evaluate the effect of SSC on infants in the NICU.
NICU Graduate Reunion
Authors: Dweck Natalie , Golombek Sergio G.
Published: March 2019

Background:

Few understand the experience of having an infant in the neonatal intensive care unit (NICU). This article provides a discussion about the importance of an annual reunion for former NICU infants, their families, and neonatal staff.

Purpose:

The purpose of this article is to explain the impact of the NICU reunion on families and neonatal healthcare providers and describe the experience of organizing this reunion over the past 20 years.

Methods:

This is a description of how a NICU reunion was organized at a regional neonatal center. Graphic-designed invitations were e-mailed to NICU graduates, who previously agreed to being contacted, 2 months prior to the reunion date. Social media were utilized to publicize the event on the hospital's Web site.

Results:

At the reunion, parents and families introduced their NICU graduate to the neonatal staff who cared for them while hospitalized. Sometimes staff found it difficult to recognize the NICU graduates, who were toddlers or older. Parents were relaxed, expressing their appreciation for care received.

Implications for Practice:

The impact of seeing an infant, born at 24 weeks, now walking, talking, and running cultivates pride in the NICU healthcare team. The reunion adds a positive dimension to the work of NICU caregivers. Parents look forward to attending the reunion to reconnect with NICU staff and other NICU parents.

Implications for Research:

Directions for future study include a comparison of staff and families who attend the NICU reunion and those who do not, by using a survey or online evaluation tool, to improve future reunions.
Improving Access to Diagnostic Assessments for Autism Spectrum Disorder Using an Arena Model
Authors: Williams-Arya Pamela , Anixt Julia , Kuan Lisa , Johnson Heather , Kent Bridget , Bing Nicole , Ehrhardt Jennifer , Manning-Courtney Patricia
Published: March 2019

Objective:

To improve access to diagnostic evaluations for children younger than 3 years with concerns for possible autism spectrum disorder.

Methods:

A multidisciplinary “arena model” for children younger than 3 years was developed, tested, and implemented over an approximately 2-year period. Arena assessment teams comprised a developmental behavioral pediatrician (DBP), psychologist, and speech language pathologist (SLP). Quality improvement methods were used during the design phase, conducting Plan-Do-Study-Act (PDSA) cycles and collecting feedback from key stakeholders, and during implementation, plotting data on run charts to measure outcomes of the time to initial visit and time to diagnosis.

Results:

Over the 9-month implementation period, 6 arena assessment teams were formed to provide 60 evaluation slots per month for children younger than 3 years. The time to first visit was reduced from a median of 122 days to 19 days, and the time to final diagnosis was reduced from 139 days to 14 days, maintaining these outcomes at <35 and <18 days, respectively, over a 2-year period. Total visits required decreased from 4 to 5 visits to just 2 visits, and the average assessment cost was reduced by $992 per patient. Feedback from both providers and families participating in this model was overwhelmingly positive.

Conclusion:

Access for young children referred for developmental assessments can be improved through an understanding of supply and demand and the development of creative and flexible care delivery models.
Features of Catatonia in a 12-Year-Old Boy with Autism Spectrum Disorder
Authors: Irwin Margaret , Harstad Elizabeth , Deister Diana , Augustyn Marilyn
Published: March 2019

CASE:

Thomas is a 12-year-old boy with autism spectrum disorder who presents to his primary care clinician with symptoms of worsening mood in the last 3 months. On review of his last school testing, his cognitive abilities are found to be within the average range, with a relative vulnerability with his processing speed. He can speak in sentences to communicate and answer questions, but he rarely picks up on conversational bids. He has had difficulties developing friendships and often prefers to play by himself.

Thomas has a long history of some features of anxiety and depression for which it was recommended that he establish care with a therapist, but his family has had a hard time finding a provider for him. At this visit, the mother reports that for the past several months he has been more anxious, sad, and easily overwhelmed. He seems irritable at home and school and cries often. His family has been advocating for him to receive increased school supports, as school is a source of anxiety for him, but there are no recent changes in school services. There is a family history of both anxiety and depression. Given his worsening mood functioning, Thomas was started on selective serotonin reuptake inhibitor (SSRI) medication in addition to again recommending a therapist. Weekly phone call check-ins and an in-person clinic visit in 1 month are planned.

About 1 month after starting the SSRI medication, he is still not showing any improvement in mood functioning, and his family reports he seems more “sluggish” than usual. There are no side effects reported with the medication, and the dose is increased to see whether it will help. However, about 2 weeks later, he is seen again in the clinic because there are increasing concerns. He continues to be “sluggish.” During the clinic visit, he lies down on the examination table, sometimes holding his head off the edge of the table, which he has never done before. He responds very slowly to the questions and often says “I don't know, I don't know,” almost in an automatic way. His mother reports that he is now engaging in some repetitive hand movements which he had not done previously. He is no longer able to shower independently. He is still eating and drinking adequately. What would you do next?
Consensus Recommendations for the Use of Hyperdiluted Calcium Hydroxyapatite (Radiesse) as a Face and Body Biostimulatory Agent
Authors: de Almeida Ada Trindade , Figueredo Vinicius , da Cunha Ana Lúcia Gonzaga , Casabona Gabriela , Costa de Faria Joana Ribeiro , Alves Emerson Vicente , Sato Mauricio , Branco Adeíza , Guarnieri Christine , Palermo Eliandre
Published: March 2019

Background:

Calcium hydroxyapatite (CaHA) is a well-established collagen stimulator. In recent years, it has been increasingly used in hyperdiluted form as a biostimulatory agent rather than a volumizing filler to improve skin quality and firmness in both facial and corporal areas. However, guidelines on the techniques required to achieve optimal results are still lacking. The objective of this study was to develop a consensus recommendation for the safe and effective use of hyperdiluted CaHA for face and body biostimulation.

Methods:

A team of 10 experts with extensive experience in dermal fillers and biostimulatory treatments for facial and body rejuvenation convened for a live meeting. Consensus was defined as approval by 70%–89% of all participants, whereas agreement of ≥90% denoted strong consensus.

Results:

For most items, the group achieved a majority consensus. Recommendations have been provided for the face, neck, décolletage, buttocks, thighs, arms, abdomen, knees, and elbows with detailed injection techniques, providing information on insertion points, dosages, and volumes for both needle and cannula injections as well as the number of treatment sessions and intervals.

Conclusions:

The expert consensus supports and provides guidance for the use of CaHA as a biostimulatory agent for face and body rejuvenation. However, further clinical studies are necessary to provide physicians with the best evidence for the best treatment practices.
Recovery of Motor Function after Mixed and Motor Nerve Repair with Processed Nerve Allograft
Authors: Safa Bauback , Shores Jaimie T. , Ingari John V. , Weber Renata V. , Cho Mickey , Zoldos Jozef , Niacaras Timothy R. , Nesti Leon J. , Thayer Wesley P. , Buncke Gregory M.
Published: March 2019

Background:

Severe trauma often results in the transection of major peripheral nerves. The RANGER Registry is an ongoing observational study on the use and outcomes of processed nerve allografts (PNAs; Avance Nerve Graft, AxoGen, Inc., Alachua, Fla.). Here, we report on motor recovery outcomes for nerve injuries repaired acutely or in a delayed fashion with PNA and comparisons to historical controls in the literature.

Methods:

The RANGER database was queried for mixed and motor nerve injuries in the upper extremities, head, and neck area having completed greater than 1 year of follow-up. All subjects with sufficient assessments to evaluate functional outcomes were included. Meaningful recovery was defined as ≥M3 on the Medical Research Council scale. Demographics, outcomes, and covariate analysis were performed to further characterize this subgroup.

Results:

The subgroup included 20 subjects with 22 nerve repairs. The mean ± SD (minimum–maximum) age was 38 ± 19 (16–77) years. The median repair time was 9 (0–133) days. The mean graft length was 33 ± 17 (10–70) mm with a mean follow-up of 779 ± 480 (371–2,423) days. Meaningful motor recovery was observed in 73%. Subgroup analysis showed no differences between gap lengths or mechanism of injury. There were no related adverse events.

Conclusions:

PNAs were safe and provided functional motor recovery in mixed and motor nerve repairs. Outcomes compare favorably to historical controls for nerve autograft and exceed those for hollow tube conduit. PNA may be considered as an option when reconstructing major peripheral nerve injuries.
Differences in Chest Measurements between the Cis-female and Trans-female Chest Exposed to Estrogen and Its Implications for Breast Augmentation
Authors: Nauta Allison C. , Baltrusch Kyle M. , Heston Aaron L. , Narayan Sasha K. , Gunther Sven , Esmonde Nick O. , Blume Kylie S. , Mueller Reid V. , Hansen Juliana E. , Berli Jens Urs
Published: March 2019

Background:

Gender confirming primary breast augmentation is becoming more common. The purpose of this study was to compare the demographic and anatomical differences in cis-female and trans-female populations.

Methods:

This was a retrospective analysis of trans-female patients and cis-female patients undergoing primary breast augmentation at a single institution. Analysis included patient demographics and preoperative chest measurements including sternal notch to nipple distance (SSN), breast width (BW), nipple to inframammary fold distance (N-IMF), and nipple to midline distance (N-M). Continuous variables were compared using independent t tests, and discrete variables were compared using Pearson’s χ2 tests.

Results:

Eighty-two trans-female and 188 cis-female patients undergoing primary breast augmentation were included. Trans-female patients were older (40.37 versus 34.07), more likely to have psychological comorbidities (50% versus 12.23%), and had a higher body mass index, 27.46 kg/m2 versus 22.88 kg/m2 (P = 1.91E-07), than cis-female patients. Cis-female patients most commonly had an ectomorph body habitus (52% versus 26%), whereas trans-female patients most commonly had an endomorph body habitus (40% versus 7%). Pseudoptosis or ptosis was more commonly seen in cis-female patients (P = 0.0056). There were significant differences in preoperative breast measurements including sternal notch to nipple distance, BW, and N-M between groups, but not in N-IMF. The ratio of BW/N-IMF was statistically significant (P = 2.65E-07 on right), indicating that the similarity in N-IMF distance did not adjust for the difference in BW.

Conclusions:

The trans-female and cis-female populations seeking primary breast augmentation have significant demographic and anatomical differences. This has implications for surgical decision-making and planning to optimize outcomes for trans-female patients.