bluuebunny/crossref_metadata_2025 huggingface dataset:
Novel Indications for Surgical Resection of Metachronous Lung Metastases From Pancreatic Cancer After Curative Resection
Authors: Nakajima Masao , Ueno Tomio , Suzuki Nobuaki , Matsui Hiroto , Shindo Yoshitaro , Sakamoto Kazuhiko , Tokuhisa Yoshihiro , Tokumitsu Yukio , Takeda Shigeru , Yoshino Shigefumi , Hazama Shoichi , Nagano Hiroaki
Published: June 2016

Few reports exist regarding surgical resection of metachronous lung metastases (MLM) from pancreatic ductal adenocarcinoma (PDA) after curative resection. To elucidate the indications for surgical resection of MLM and long-term survival, we analyzed Japanese case reports of MLM from PDA. Between 1983 and 2014, 17 Japanese case reports concerning surgical resection of MLM from PDA were published. We determined long-term survival in 16 patients (considering the published data of 15 patients and 1 of our own) by using a questionnaire survey and analyzing the relationships between background factors and long-term survival. In 16 patients with long-term survival, 4 patients were still alive without recurrence. The remaining 12 patients died of disease after recurrence. The median survival after the initial lobectomy was 37 months and the 3- and 5-year survival for all patients after lobectomy was 50% and 41%, respectively. Fourteen patients had a disease-free interval after initial resection of the primary pancreatic tumor of >20 months. These patients had a longer median survival period after lobectomy (46 vs. 25.5 mo, P=0.19). Seven patients had MLM of <16 mm. These patients had a statistically longer overall survival after lobectomy (83 vs. 16 mo, P=0.04). Three of 4 patients with primary stage I tumors were still alive without recurrence. We found that the conventional criteria for surgical resection of MLM from PDA (first disease-free interval of >20 mo with no other metastatic lesions) were appropriate. In addition, it is possible that MLM of <16 mm or primary stage I tumors are novel criteria.
Update on childhood craniopharyngiomas
Authors: Cohen Laurie E.
Published: June 2016

Purpose of review

Craniopharyngioma location impacts treatment approach. Imaging advances allow for better anatomical localization, which can help determine the best surgical plan. Recent discoveries have also led to a better understanding of craniopharyngioma development and potential treatments. This review includes publications January 2015 through March 2016 and prior key reports.

Recent findings

Recent findings confirm that third ventricular and hypothalamic involvement are associated with highest risk of hypothalamic dysfunction after surgery. Both presentation and MRI can aid in presurgical grading to try to limit development of hypothalamic obesity, somnolence, neurocognitive dysfunction, decreased quality of life, and other morbidities. Targeted therapies may also prove useful in avoiding treatment complications. In total, 14–50% of adult-onset craniopharyngioma are papillary; the majority with a mutation in exon 3 of BRAF and may respond to BRAF inhibitors and mitogen-activated protein kinase inhibitors. The remaining adult-onset and majority of childhood-onset are adamantinomatous; often with mutations in CTNNB1, which encodes β-catenin, leading to overactivation of the WNT signaling pathway.

Significant morbidities are associated with craniopharyngioma. Targeted medical therapies are on the horizon. Until that time, the surgical approach and decision for radiation therapy should be chosen to limit long-term sequelae.
Molecular markers in pituitary tumors
Authors: Robertson Asha M. , Heaney Anthony P.
Published: June 2016

Purpose of review

This review summarizes our current understanding of the mechanisms and factors involved in pituitary tumorigenesis. It provides a comprehensive review on the role of genetic mutations, epigenetics, oncogenes, tumor suppressor genes, cell cycle deregulation, and highlights recent findings of altered micro-RNA and long noncoding RNA expression in pituitary tumors.

Recent findings

This article provides a concise summary of our knowledge regarding oncogenes, tumor suppressor genes, and cell cycle deregulation in pituitary tumors. Additionally, it highlights new findings in epigenetics and altered micro-RNA and long noncoding RNA expression in pituitary tumors.

Improved understanding of the mechanism(s) and candidates implicated in pituitary tumorigenesis may result in the identification of new therapeutic targets in pituitary tumors.
Pediatric Gastrojejunostomy Tube Replacement
Authors: Sharafinski Mark E. , Sehnert Elizabeth , Moe David , Zhang Liyun , Simpson Pippa , Vo Nghia J.
Published: June 2016

Objectives:

The aim of the study was to determine whether embedding into the radiology report a patient‐specific plan in the event of gastrojejunostomy (GJ) tube dysfunction reduces the need for after‐hours utilization of pediatric interventional radiology resources for the replacement of GJ tubes.

Materials and Methods:

This is a Health Insurance Portability and Accountability Act compliant, institutional review board–approved retrospective repeated cross‐sectional study of patients requiring after‐hours (5 PM–7 AM) or weekend (Saturday and Sunday) GJ tube replacement at a dedicated children's hospital, before and after the inclusion of a patient‐specific plan in the radiology report as part of the electronic medical record.

Results:

During a 6‐month period before the inclusion of a patient‐specific plan, there were 242 total GJ tube changes performed by the pediatric interventional radiology service under image guidance. Twenty‐six (10.7%) of these procedures were performed outside of standard operating hours at the request of the emergency department (ED) (6/26), inpatient service (8/26), or patient/caregiver (12/26). Of the 8 inpatients, 3 were admitted from the ED for the sole purpose of tube replacement. Data were again collected for 6 months following inclusion of a patient‐specific plan during the same seasonal period of the following year. During this period, 240 total image‐guided changes were performed. Fifteen (6.2%) were performed outside of standard operating hours at the request of the ED (2/15), inpatient service (4/15), or patient/caregiver (9/15). No patients were admitted for GJ tube replacement procedures following implementation of the enhanced reporting policy. These data indicate a trend toward reduced after‐hours resource utilization for GJ tube replacement requests by the ED (23.1%–13.3%), inpatient service (30.8%–26.7%), and all patients (14.7%–11%). Fewer after‐hours GJ tube changes reduced cost by proportionately reducing hourly compensation for interventional radiology nurses and technicians.

Conclusions:

Our single‐center data suggest that the inclusion of patient‐specific recommendations at the end of each radiology GJ tube procedure note, generated in collaboration with the feeding service or primary medical provider, reduces off‐hour resource utilization in patients who could otherwise have their tubes replaced during standard operating hours with image guidance. Avoidance of tube‐related admissions is likely the greatest source of cost savings, followed by lower radiology technical support costs. Cost savings related to improved ED workflow and reduced patient/family anxiety are difficult to quantify, but likely significant. Future studies should be designed to quantify these savings and to assess the effect of this intervention on patient/caregiver satisfaction.
Pediatric Crohn Disease Clinical Outcome Assessments and Biomarkers
Authors: Sun Haihao , Vesely Richard , Lee Kerry Jo , Klein Agnes , Ikima Mutsuhiro , Mulberg Andrew E. ,   International Inflammatory Bowel Disease (i‐IBD) Working Group
Published: June 2016

Objective:

There is a pressing need for drug development in pediatric Crohn disease (CD). Our aim was to provide strategic approaches toward harmonization of current thinking about clinical outcome assessments (COAs) and biomarkers to facilitate drug development in pediatric CD.

Methods:

Scientists from the United States Food and Drug Administration, European Medicines Agency, Health Canada, and the Pharmaceuticals and Medical Devices Agency of Japan had monthly teleconferences from January 2014 through May 2015. A literature review was conducted to assess the measurement properties of all existing COA tools and to evaluate the current landscape of biomarkers used in pediatric CD. Based on the findings of literature review, we reached the consensus on the strategic approaches for evaluating outcomes in pediatric CD trials.

Results:

The pediatric Crohn's Disease Activity Index, Crohn's Disease Activity Index, and Harvey‐Bradshaw's index were used in pediatric CD clinical studies. But they lack adequate measurement properties (validity, reliability, and ability to detect change of the treatment) that are required to support approval of products intended to treat pediatric CD. Biomarkers (ie, fecal lactoferrin, osteoprotegerin, and calprotectin) have shown some promise for their potential as noninvasive surrogate endpoints in CD.

Conclusions:

Lack of well‐defined and reliable COAs presents a hurdle for global drug development in pediatric CD. It is essential to develop well‐defined and reliable COAs that can measure meaningful clinical benefit for patients in terms of how they feel, function, and survive. Development of noninvasive biomarkers as reliable surrogate endpoints needs to be further explored.
Diamond Blackfan Anemia: A Nonclassical Patient With Diagnosis Assisted by Genomic Analysis
Authors: Steinberg-Shemer Orna , Keel Siobán , Dgany Orly , Walsh Tom , Noy-Lotan Sharon , Krasnov Tanya , Yacobovich Joanne , Quarello Paola , Ramenghi Ugo , King Mary-Claire , Shimamura Akiko , Tamary Hannah
Published: June 2016

Diamond Blackfan anemia (DBA) is an inherited syndrome usually presenting with severe macrocytic anemia in infancy, paucity of erythroid precursors in the bone marrow, and congenital anomalies. We describe a child with mild, transfusion independent normocytic anemia whose diagnosis of DBA was established by identification of a novel de novo mutation disrupting normal splicing of the ribosomal protein RPL5. The diagnosis of DBA was confirmed by elevated erythrocyte adenosine deaminase levels and an abnormal ribosomal RNA profile. This case demonstrates the usefulness of genomic analysis in establishing the diagnosis of DBA in patients with a nonclassical presentation of the disease.
Empowering Staff Nurses With Essential Skills
Authors: Czekanski Elizabeth
Published: June 2016

Nurse leaders in the mental health field are challenged to ensure the mental health environment is safe and therapeutic. They must also continually evaluate whether nurses are effectively engaging therapeutically with patients in their care. Undergraduate nursing students and practicing nurses usually receive little or no training in facilitating nurse-led groups. Nurses who are trained and capable of facilitating groups may enhance therapeutic relationships and engage patients to improve treatment outcomes. Training staff and disseminating educational materials in an efficient manner are often challenges for nurse leaders. The Veterans Health Administration (VHA) Office of Nursing Services (ONS) Mental Health Field Advisory Committee (MH-FAC) developed a nursing guide for conducting psychoeducation groups. This was followed up with a complementary live virtual training with “on-demand” features that included discussion and demonstration of nurse-led group implementation strategies. Both products were disseminated to nurse leaders throughout the VHA ONS Web site. Responses to both the guide and video were overwhelmingly positive. This article discusses the importance of nurse-led psychoeducational groups and describes a project implemented by the ONS MH-FAC, which helped provide an essential training to more than 1100 RNs within the Veterans Affairs Health System nationally.
Interdisciplinary Shared Governance in Ambulatory Care
Authors: Powers Sharon , Bacon Cynthia Thornton
Published: June 2016

The implementation of shared governance structures in acute care has illustrated the positive relationship between shared decision making and nurse empowerment and positive nurse and patient outcomes. Little is known, however, about interdisciplinary shared governance, and even less is known about shared governance in ambulatory care. This article details one health system's experience with the implementation of an interdisciplinary shared governance structure in ambulatory care over a 4-year period. The authors report lessons learned, positive health system outcomes that resulted including improved communication, better preparedness for accreditation visits, improved assessment of fall risk, and a streamlined documentation system. Also discussed are mechanisms to enhance sustainability of the structure and discussion of future opportunities and challenges.
Features of Prolonged Grief Symptoms in Chinese and Swiss Bereaved Parents
Authors: Xiu Daiming , Maercker Andreas , Woynar Stefanie , Geirhofer Bettina , Yang Yuting , Jia Xiaoming
Published: June 2016

This study investigates clinical expressions of prolonged grief in samples of 32 Chinese and 33 Swiss bereaved parents, according to the proposed International Classification of Diseases, 11th Revision model of prolonged grief disorder (PGD). Sex differences and predictors (cultural attitudes, sense of coherence, and posttraumatic growth) of PGD were analyzed. In result, after controlling for sociodemographic and loss-related sample differences, both samples showed similar PGD symptom profiles, with Swiss parents exhibiting more severe grief-related preoccupation and Chinese parents exhibiting some accessory symptoms and functional impairment to a greater extent. Multivariate analyses revealed for the Chinese sample primary predictions of PGD by life satisfaction, general health and one’s world view (social cynicism) and for the Swiss sample by female sex, sense of coherence, and life satisfaction. The findings substantiate the basic appropriateness of the International Classification of Diseases, 11th Revision PGD in distinct cultural groups and may contribute to a better understanding of grief expression and its potential predictors across different cultures.
The Expression of B-Type Natriuretic Peptide After CaCl2-Induced Arrhythmias in Rats
Authors: Cao Zhi-Peng , Zhang Yuan , Mi Li , Luo Xin-Yi , Tian Mei-Hui , Zhu Bao-Li
Published: June 2016

To investigate the patterns of B-type natriuretic peptide (BNP) expression after arrhythmia, BNP was assessed at different time points (0 minute, 10 minutes, 30 minutes, 1 hour, 3 hours, and 6 hours) in CaCl2-induced arrhythmia in rats through various methods such as immunohistochemistry, Western blotting, quantitative real-time polymerase chain reaction, and enzyme-linked immunosorbent assay. Immunohistochemistry results showed that the expression of BNP in the endocardium was higher than that in the epicardium in rats undergoing sustained arrhythmias. The BNP-to-GAPDH (glyceraldehyde-3-phosphate dehydrogenase) ratios determined by Western blotting analysis revealed no change at 0 minute but increased at 10 minutes and reached the first peak (0.48 [0.03]) at 30 minutes. After a brief decline, the second peak was observed at 6 hours (0.54 [0.03]). Similar patterns of BNP messenger RNA expression were also observed by quantitative real-time polymerase chain reaction. The plasma BNP concentrations did not change after initial bouts of cardiac arrhythmias but significantly increased 30 minutes after CaCl2 injections. The results demonstrate that arrhythmia causes an elevation of BNP in the myocardium and blood, and BNP messenger RNA increases in initial arrhythmia while its protein in myocardium and plasma does not; however, both of them were elevated after sustained arrhythmia. Such an elevated BNP expression, which is directly related to the severity and duration of the arrhythmias, may suggest the existence of fatal arrhythmia in sudden cardiac death.
The Role of SATB2 as a Diagnostic Marker of Sinonasal Intestinal-type Adenocarcinoma
Authors: Skalova Alena , Sar Aylin , Laco Jan , Metelkova Alena , Miesbauerova Marketa , Steiner Petr , Švajdler Marian , Michal Michal
Published: June 2016

Background:

Intestinal-type adenocarcinoma (ITAC) of the nasal cavity and paranasal sinuses is an uncommon tumor associated with exposure to wood and leather dust, nickel, and possibly smoking. ITAC shares phenotypical features with colorectal carcinoma. In contrast to most non–intestinal-type sinonasal adenocarcinomas, ITAC is an aggressive adenocarcinoma with poor clinical outcome; therefore, its reliable separation from non-ITAC is very important.

Aim:

The use of a combination of immunohistochemical markers of intestinal differentiation was tested in a cohort of sinonasal carcinomas of different types. The aim of this study was to explore a new intestinal marker, SATB2, in conjunction with CDX2 and CK20 in differential diagnosis of sinonasal adenocarcinomas.

Materials and Methods:

Seven ITACs, 66 non-ITACs, and 1 case of extensive intestinal metaplasia (IM) of the nasal mucosa were included in the study and stained with SATB2, CK20, CDX2, and CK7 antibodies. Detection of mismatch repair proteins was performed in all cases of ITAC. All 7 sinonasal ITACs have been tested for KRAS, NRAS, and BRAF gene mutations.

Results:

All ITACs showed positive expression for SATB2, whereas all non-ITAC cases were negative. The only 1 case of IM was found to be positive for SATB2, whereas the same case showed negative expression of CK20 and only focal immunostaining for CDX2. The genetic analysis showed that only 1 sinonasal ITAC (1/7) showed KRAS c.35G>C, p.(Gly12Ala) mutation, whereas BRAF and NRAS genes were wild type. Four ITACs revealed wild-type KRAS, NRAS, and BRAF, and 2 remaining cases were not analyzable. All ITACs showed preserved nuclear expression of mismatch repair proteins.

Conclusions:

SATB2 in combination with CDX2 and CK20 differentiates sinonasal ITAC from non-ITAC with increased diagnostic sensitivity and specificity and detects IM in the sinonasal tract more easily.
Overexpression of TACC3 in Breast Cancer Associates With Poor Prognosis
Authors: Song Haiping , Liu Chunping , Shen Na , Yi Pengfei , Dong Fang , Li Xueqin , Zhang Ning , Huang Tao
Published: June 2016

Increasing evidences suggest that transforming acidic coiled-coil protein 3 (TACC3) is associated with various types of human cancer. However, the expression of TACC3 in breast cancer tissues remains largely unknown. To identify whether TACC3 can serve as a biomarker for the diagnosis and prognosis of breast cancer, quantitative polymerase chain reaction, western blotting, and immunohistochemistry staining were utilized to detect the expression of TACC3. The mRNA and protein levels of TACC3 in breast cancer samples were novelty higher compared with nontumorous breast tissues. Immunohistochemistry results revealed TACC3 expression was significantly correlated to lymphoid nodal metastasis (P=0.035) and HER-2 status (P=0.021). The patients with high expression of TACC3 had a significantly poor prognosis compared with patients with low expression (P=0.017), especially in the patients with pathological tumor size 2-4 status (P=0.028). Furthermore, multivariate analysis indicated that TACC3 expression was an independent prognostic factor for breast cancer patients (P=0.029). This study, first, suggested TACC3 might be an important molecular marker for diagnosis and prognosis of breast cancer.
Gastrointestinal Stromal Tumor: Genotype Frequency and Prognostic Relevance
Authors: Kumari Niraj , Priyaa Valli , Shukla Pooja , Kumar Ashok , Aggarwal Rakesh , Krishnani Narendra
Published: June 2016

Background:

Genotyping has an important role in the prognosis and prediction of response to tyrosine kinase inhibitor therapy. KIT exon 11 deletions serve as an adverse prognostic marker. Gastrointestinal stromal tumor (GIST) genotype has been described in developed countries; however, data from India are lacking. The aim of this study was to determine the genotype frequency and its prognostic relevance.

Materials and Methods:

Eighty consecutive cases of resected GIST were evaluated for histologic and immunohistochemical findings. Mutation analysis for exons 9, 11, 13, and 17 of KIT and 12 and 18 of PDGFRA was carried out by PCR-Sanger sequencing. Genotypes were correlated with risk groups, recurrence, and imatinib therapy.

Results:

Forty-seven of 80 cases (58.7%) showed mutations, including 30 cases (37.5%) in KIT exon 11, 9 cases (11.2%) in KIT exon 9, and 8 cases (10%) in PDGFRA exon 18. Codon 557-558 deletion was present in 15 cases. D842E was the most common in PDGFRA, with similar histologic features as D842V. KIT exon 11 deletion had higher mitotic rate, larger tumor size, high-risk stratification, and lower recurrence-free survival. Recurrences were seen in 12 (16.4%) patients. Nine patients (75%) with recurrence were on imatinib therapy.

Conclusions:

GIST genotype frequency is lower in Indians. KIT exon 11 deletion is associated with poor prognosis compared with wild-type and other missense mutations. D842E is a common PDGFRA mutation in Indian patients. Patients with a wild genotype are not suitable candidates for imatinib therapy. Genotyping can serve as an important prognostic marker.
Identification of New Biomarkers Associated With IDH Mutation and Prognosis in Astrocytic Tumors Using NanoString nCounter Analysis System
Authors: Zhang Ming , Pan Yi , Qi Xueling , Liu Yan , Dong Rongfang , Zheng Danfeng , Chang Qing , Zhang Jing , Fang Weigang , Zhong Yanfeng
Published: June 2016

Background:

Isocitrate dehydrogenase (IDH) mutations have been reported as biomarkers associated with tumorigenesis and prognosis in gliomas. However, genes affected by these mutations are still under investigation. The purpose of this study is to identify new molecular biomarkers associated with IDH mutation and prognosis in astrocytic tumors, which account for the largest proportion of gliomas.

Materials and Methods:

NanoString analysis was conducted on 40 astrocytic tumors. In total, 69 genes and 6 fusion genes were selected for screening. Quantitative real-time polymerase chain reaction and immunohistochemistry were used to validate the selected discriminatory genes. Kaplan-Meier survival curves and log-rank test were used to analyze the overall survival and progression-free survival.

Results:

mRNA levels of NTRK3, ERCC1, JAK2, AXL, BCL2, ESR1, HSP90AB1, TUBB3, RET, and ABCG2 were elevated in the IDH mutant group, whereas levels of POSTN and ERBB2 were elevated in the IDH wild-type group. Genes more highly expressed in the better prognosis group included NTRK3, ERCC1, ROS1, ERBB4, BCL2, CDKN2A, AXL, PI3KCA, HSP90AB1, ABCG2, JAK2, and RET. In the worse prognosis group, TIMP1, POSTN, and ERBB2 showed increased expressions. The elevated expression of HSP90AB1 was correlated with IDH mutation, long survival, and secondary glioblastomas. Elevated TIMP1 expression was related to high tumor grade and short patient survival. The results of NanoString were confirmed with quantitative real-time polymerase chain reaction and immunohistochemistry.

Conclusions:

HSP90AB1 is related to IDH mutation and the expressions of HSP90AB1 and TIMP1 can predict prognosis in astrocytic tumors. The NanoString analysis system is a precise and reliable method to detect mRNA expression in formalin-fixed paraffin-embedded samples.
Predicting Flow in the Pediatric Emergency Department
Authors: Krinsky-Diener Miriam , Agoritsas Konstantinos , Chao Jennifer H. , Sinert Richard
Published: June 2016

Objective

The aim of this study was to determine whether patient volume in an urban pediatric emergency department (ED) can be predicted based on holidays and thus aid in staffing and resource allocation.

Methods

Log-in dates and times were obtained for all patients seen in an urban pediatric ED between July 1, 2006, and June 30, 2013. Visits were coded for the day of the week, tour (ie, shift), and season and whether they occurred on a holiday or nonholiday. Comparisons between the median number of patient visits on holidays versus nonholidays by day of the week, tour, and season were performed. Additional comparisons on 5 Monday holidays as well as New Year's Day, Thanksgiving, and Christmas Day were also performed. Data were presented as medians with interquartile ranges. Group comparisons were performed via using Mann-Whitney U tests and Kruskal-Wallis tests (α = 0.05, 2 tailed).

Results

There were 223,677 total patient visits, with a mean yearly census of 31,954. The median daily volume was 85, peaking on Mondays (median, 99). The summer season demonstrated the fewest number of patient visits (median, 74) relative to the other seasons (medians, 89–91). Compared with nonholidays, there were fewer patient visits on Thanksgiving and Christmas Day and in the late afternoon and evening on other individual holidays.

Conclusions

Fewer patient visits on Thanksgiving and Christmas Days, as well as during the late afternoon/evening on several other holidays, point to the possibility of small adjustments to staffing in ways that can more efficiently balance demand with available resources.
Methemoglobinemia Following Monolinuron Ingestion
Authors: Mortamet Guillaume , Oualha Mehdi , Renolleau Sylvain , Moesch Christian , Treluyer Jean-Marc
Published: June 2016

Case

We describe a case report of a 2-year-old boy presenting to the emergency department with cyanosis and agitation. There was no suggestive history of poisoning but parents reported the presence of an aquarium at the family dinner the night before, with an aquarium cleaner beside it. Physical examination at admission revealed central cyanosis without signs of respiratory distress. Oxygen saturation measured by pulse oximetry (Spo

2
) was at 80% in room air. Plasma level of methemoglobin was measured at 11.8%. After 6 hours, methemoglobin decreased spontaneously to 5% and pulse oximetry saturation reached 98% in room air. Consciousness, weakness, and behavior were concomitantly improved. Because of rapid and spontaneous improvement, no specific treatment such as methylene blue was administered. A mass spectrometry toxicological analysis was performed in a blood sample taken the day of admission. Screening procedure of pesticides based on liquid chromatography coupled with mass spectrometry identified monolinuron, a phenylurea herbicide.

Conclusions

We recommend considering acquired methemoglobinemia after ingestion of industrial products and drugs in children with cyanosis, mental status alteration, and without respiratory distress symptoms.
Are We Adequately Treating Pain in Children Who Present to US Emergency Departments?
Authors: Yackey Katelyn Johnson , Rominger Annie Heffernan
Published: June 2016

Objectives

There are no recent national data on analgesic use for pain treatment in children. Our objective was to determine if there is adequate pain treatment for children in US emergency departments (EDs) and determine predictors of nonopioid and opioid analgesic administration.

Methods

Children younger than 18 years with the diagnosis of extremity fracture, appendicitis, or urinary tract stones were obtained from the National Health Ambulatory Medical Care Survey (NHAMCS) (2006–2010) and analyzed using logistic regression for complex samples. There were 2 analyses: (1) those who received analgesics versus those who did not; and (2) of those who received analgesics, opioid versus nonopioid analgesic use.

Results

There were 1341 records analyzed representing 4.5 million ED visits. Those who received analgesics were more likely to be older than age of 3 years (P = 0.05), be discharged from the hospital (odds ratio [OR], 1.72; 95% confidence interval [CI], 1.04–2.94), arrive between noon and midnight (OR, 0.1.85; CI, 1.12–3.03), and have a higher pain rating (P < 0.01). Children who received opioid analgesics were more likely to live outside the Northeast (P = 0.04), require admission (OR, 2.95; CI, 1.09–7.98), have a higher acuity triage level (OR, 1.79; CI, 1.04–3.06), have higher pain scores (P < 0.01), and have private insurance (OR, 1.75; CI, 1.06–2.94).

Conclusions

There is still a lot of room for improvement of pediatric pain control in US EDs. We aim to apply this information toward direct physician and nursing education interventions, including the recognition of age appropriate pain cues, and parental information and guidance to improve pediatric pain treatment in US EDs.
Back Pain in a Pediatric Emergency Department: Etiology and Evaluation
Authors: Brooks Talia M. , Friedman Lana M. , Silvis Renee M. , Lerer Trudy , Milewski Matthew D.
Published: June 2016

Objectives

Back pain is an uncommon chief complaint in the pediatric emergency department (ED). However, there are serious underlying conditions requiring prompt diagnosis and treatment. While the etiology is usually benign, variation exists in the evaluation. The study purpose was to describe pediatric patients who presented to the ED with back pain and evaluate for associations with laboratory and radiologic abnormalities indicative of underlying musculoskeletal pathology.

Methods

A retrospective review was conducted of patients aged birth to 18 years who presented to a pediatric ED with a chief complaint of back pain during a 1-year period. Primary outcome was discharge diagnosis, categorized as nonpathologic back pain, pathologic back pain, and other etiologies. Descriptive statistics were used.

Results

Two-hundred thirty-two patient encounters were reviewed, with 177 included in data analysis. A nonpathologic diagnosis of back pain was found in 76.8% of visits. Back pain and back or muscle strain were the most common diagnoses. Pathologic back pain diagnoses represented 2.3% of visits. Radiologic imaging was performed in 37.9%. Positive findings were noted in 16.9% of radiographs; no abnormalities were noted on computed tomography scan or magnetic resonance imaging. Laboratory studies were conducted in 35%. Abnormal plain radiographs were associated with a pathologic diagnosis of back pain (P < 0.001).

Conclusions

Most pediatric patients presenting to the ED with back pain were found to have a nonpathologic etiology and were discharged. Among those with a pathologic back pain diagnosis, abnormal radiograph findings were the only statistically significant factor, whereas laboratory studies, computed tomography scans, and magnetic resonance imaging scans were less indicative.
Acute Genitourinary Swelling and Erythema as Presenting Symptoms of Henoch-Schonlein Purpura
Authors: Hewett Kathryn M. , Titus M. Olivia
Published: June 2016

Henoch-Schonlein purpura (HSP) may present in a variety of ways, most commonly with joint pain or the distinctive palpable purpura. Genitourinary manifestations of HSP are less common and may precede the classic signs and symptoms of HSP, making the diagnosis difficult. We report a case of a 19-month-old boy with penile and scrotal erythema and swelling at presentation who was later diagnosed with HSP.
Strategies to prevent BK virus infection in kidney transplant recipients
Authors: Wright Alissa J. , Gill John S.
Published: June 2016

Purpose of review

Despite improvements in posttransplant care, BK virus (BKV) remains one of the most challenging posttransplant infections in kidney transplant recipients with high rates of allograft failure. In the absence of well tolerated and efficacious viral specific therapeutics, treatment is primarily focused on reduction of immunosuppression, which poses a risk of rejection and fails to lead to viral clearance in a number of patients.

Recent findings

Recent work has turned toward preventive therapies analogous to those used for other infections like cytomegalovirus. These efforts have focused on the use of quinolone antibiotic prophylaxis to prevent BKV infection and pretransplant vaccination to boost humoral and cellular immunity.

Despite promising in-vitro and observational data, quinolone antibiotic prophylaxis has not been effective in preventing BKV infection in prospective studies. However, prophylaxis with newer less toxic viral specific agents such as brincidofovir – the lipid oral formulation of cidofovir – may yet prove effective. Strategies focused on eliciting a humoral immune response to recombinant virus-like particles or using adoptive transfer of BKV-specific T cells have also shown significant potential to prevent BKV infection in organ transplant recipients.
‘No touch’ technologies for environmental decontamination: focus on ultraviolet devices and hydrogen peroxide systems
Authors: Weber David J. , Kanamori Hajime , Rutala William A.
Published: June 2016

Purpose of review

This article reviews ‘no touch’ methods for disinfection of the contaminated surface environment of hospitalized patients’ rooms. The focus is on studies that assessed the effectiveness of ultraviolet (UV) light devices, hydrogen peroxide systems, and self-disinfecting surfaces to reduce healthcare-associated infections (HAIs).

Recent findings

The contaminated surface environment in hospitals plays an important role in the transmission of several key nosocomial pathogens including methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus spp., Clostridium difficile, Acinetobacter spp., and norovirus. Multiple clinical trials have now demonstrated the effectiveness of UV light devices and hydrogen peroxide systems to reduce HAIs. A limited number of studies have suggested that ‘self-disinfecting’ surfaces may also decrease HAIs.

Many studies have demonstrated that terminal cleaning and disinfection with germicides is often inadequate and leaves environmental surfaces contaminated with important nosocomial pathogens. ‘No touch’ methods of room decontamination (i.e., UV devices and hydrogen peroxide systems) have been demonstrated to reduce key nosocomial pathogens on inoculated test surfaces and on environmental surfaces in actual patient rooms. Further UV devices and hydrogen peroxide systems have been demonstrated to reduce HAI. A validated ‘no touch’ device or system should be used for terminal room disinfection following discharge of patients on contact precautions. The use of a ‘self-disinfecting’ surface to reduce HAI has not been convincingly demonstrated.
Colonoscopy Comfort
Authors: McCommons Robin , Wheeler Megan , Houston Susan
Published: June 2016

Decreased discomfort after colonoscopy is a high priority for patients. Typically, air is used to insufflate the bowel during colonoscopy, but emerging literature shows that carbon dioxide insufflation decreases postoperative discomfort and flatus. An evidence-based practice project was developed and implemented by a surgical department at a community hospital. The Director of Surgical Services brought the evidence to the staff, secured agreement from a physician champion, and the new process was quickly adopted. Patients experienced less discomfort and flatus postprocedure with carbon dioxide insufflation, and were able to be discharged expediently. These patient outcomes validated the literature and confirmed the success of the practice change.
Applying Judgment Analysis Theory and Methods to Obtain an Insight Into Clinical Judgments
Authors: Nadler Izhak , Globus Omer , Pessach-Gelblum Liat , Strauss Zipora , Sela Rina , Ziv Amitai
Published: June 2016

Introduction

Clinicians who provide acute care are required to quickly identify and judge the illness severity of patients who experience deterioration in their clinical state. Accuracy of judgments can only be tested with respect to a valid reference, but in most health care areas, there is no such score. Judgment analysis theory and methods are presented and proposed as a framework to obtain insight into clinical judgments. A study in a simulated neonatal intensive care unit setup is described to demonstrate the applicability of the proposed methodology.

Methods

Sixteen participants from a neonatal intensive care unit department reviewed 31 clips of simulated cases. The participants were directed to use a 5-point scale to rate their personal interpretation regarding the illness severity of the simulated patient. Judgment analysis techniques were used to identify the judgment capabilities of the participants and to determine factors that influence those capabilities.

Results

Most participants interpreted the clinical signs information consistently, but interpretation varied remarkably between clinicians, providing possible explanation to the differences between the clinicians’ judgments. Significant correlations were found between the doctors’ years of medical experience and attributes of their judgments.

Conclusions

Judgment analysis can be used to obtain insight into clinical judgments and to identify and quantify factors that affect clinicians’ judgments. Judgment analysis can promote health care by enhancing clinical assessment teaching, by providing objective and personalized feedback to team members about their judgment performance, and by introducing a unified and objective method to study elements that affect clinical judgments.
Laparoscopic Sleeve Gastrectomy and Nutrient Deficiencies: A Prospective Study
Authors: Al-Mulhim Abdulrahman S.
Published: June 2016

Background:

Laparoscopic sleeve gastrectomy (LSG) is being increasingly established as a definitive procedure for weight loss. The mechanism for weight loss in LSG is gastric restriction and neurohormonal changes, but there is deficient information on its nutritional effect. The aim of this prospective study was to assess vitamin and micronutrient deficiencies following LSG (whats and when) in organized follow-up visits.

Patients and Methods:

LSG was performed in 112 consecutive patients between June 2010 and December 2013. In all patients, the vitamin and micronutrient deficiencies were corrected before the LSG procedure. Patients were investigated for vitamin and micronutrient concentrations 2, 4, 6, 9, and 12 months after surgery.

Results:

During the study time, 112 patients (65% female) underwent LSG. The mean age was 26 years (range: 20 to 37 y), and the mean preoperative body mass index was 41 (range: 35 to 52). Complications and nutrient deficiencies were observed and analyzed throughout the follow-up period.

Conclusions:

The appearance of vitamin and nutritional deficiencies after LSG is a common phenomenon. Correction of the deficiencies before surgery, sufficient supplementation immediately after the procedure, and routine long follow-up are important to avoid the serious consequences of the deficiencies.
Learning Curve for Laparoscopic Major Hepatectomy: Use of the Cumulative Sum Method
Authors: Chan Fiona Ka-Man , Cheng Kai-Chi , Yeung Yuk-Pang , Ho Kit-Man
Published: June 2016

Background:

Laparoscopic liver resection (LLR) has now become a worldwide practice. However, the adoption of laparoscopic major hepatectomy (LMH) was slow. We report our center’s experience in laparoscopic major resections.

Method:

A total of 156 LLRs from 2002 to 2014 were studied. The clinical parameters of LMHs were compared with those of minor resections. The learning curve of LMHs was investigated using the cumulative sum (CUSUM) analysis of operative time. Subgroup analysis of right posterior sectionectomies against anterolateral hepatectomies was conducted.

Results:

Among the 156 LLRs, 49 (31%) were LMHs. CUSUM analysis showed that operative time improved after the 25th LMH. Beyond that proportion of pure laparoscopic LMHs increased (18/25 vs. 24/24, P=0.005); Pringle maneuver was not required (4/25 vs. 0/24, P=0.041). Blood loss (800 vs. 500 mL, P=0.034) and transfusion rate (13/25 to 3/24, P=0.003) improved in latter LMHs. Right posterior sectionectomies had significantly more blood loss than anterolateral LMHs (500 vs. 1500 mL, P=0.034).

Conclusion:

Laparoscopic major resection is safe and feasible; operative outcomes improved after overcoming the learning curve. Right posterior sectionectomy, however, should be further evaluated for its cost-effectiveness.
Consequences of Lost Gallstones During Laparoscopic Cholecystectomy: A Review Article
Authors: Jabbari Nooghabi Azadeh , Hassanpour Masoumeh , Jangjoo Ali
Published: June 2016

Background:

Laparoscopic cholecystectomy (LC) has become a popular and widespread procedure for the treatment of gallstone disease. There is still an increasing concern about specific complications of LC due to gallbladder perforation and spillage of bile and stones. Although unretrieved intraperitoneal gallstones rarely become symptomatic, their infective complications may cause serious morbidities even after a long interval from LC.

Methods:

We performed a review of the literature on the diagnosis, prevention, consequences, and management of lost gallstones. All studies with a focus on lost gallstones or perforated gallbladder were analyzed to evaluate the postoperative complications.

Results:

Between 1991 and 2015, >250 cases of postoperative complications of spilled gallstones were reviewed in the surgical literature. The most common complications are intraperitoneal abscesses and fistulas. Confusing clinical pictures due to gallstones spreading in different locations makes diagnosis challenging. Even asymptomatic dropped gallstones may masquerade intraperitoneal neoplastic lesions.

Conclusions:

Every effort should be made to prevent gallbladder perforation; otherwise, they should be retrieved immediately during laparoscopy. In cases with multiple large spilled stones or infected bile, conversion to open surgery can be considered. Documentation in operative notes and awareness of patients about lost gallstones are mandatory to early recognition and treatment of any complications.
The Effect of Equal Ratio Ventilation on Oxygenation, Respiratory Mechanics, and Cerebral Perfusion Pressure During Laparoscopy in the Trendelenburg Position
Authors: Jo Youn Yi , Kim Ji Young , Chang Young Jin , Lee Sehwan , Kwak Hyun Jeong
Published: June 2016

The aim of this study was to investigate the effects of equal ratio ventilation (ERV) on oxygenation, respiratory mechanics, and the cerebral perfusion pressure during pneumoperitoneum in the Trendelenburg position. Thirty patients undergoing laparoscopic low anterior resection (25 to 65 y) were enrolled. Mechanical ventilator was set to volume-controlled mode at an inspiratory to expiratory (I:E) ratio of 1:2 with a tidal volume of 8 mL/kg of ideal body weight with a 5 cm H2O positive end-expiratory pressure. Twenty minutes after pneumoperitoneum in the Trendelenburg position, the I:E ratio was changed to 1:1 for 20 minutes and then restored to 1:2. No significant changes in arterial oxygen tension and respiratory compliance after adopting ERV. Mean arterial pressure and cerebral perfusion pressure decreased significantly over time after adopting the Trendelenburg position during pneumoperitoneum (P=0.014 and 0.005, respectively). In conclusion, there was no improvement in oxygenation or respiratory mechanics with ERV.
Outcomes From an Enhanced Recovery Program for Laparoscopic Gastric Surgery
Authors: Wong-Chong Nathalie , Kehlet Henrik , Grantcharov Teodor P.
Published: June 2016

Purpose:

To examine the outcomes from an enhanced recovery after surgery (ERAS) program for laparoscopic gastric surgery.

Materials and Methods:

This was a prospective study of patients undergoing elective laparoscopic gastric resection in an ERAS protocol at a single institution between 2008 and 2012. Outcomes included the length of hospital stay, intraoperative and postoperative complications, the readmission rate, the reoperation rate, and the 30-day mortality.

Results:

Of the 86 patients, 60 underwent partial gastrectomy and 26 underwent total gastrectomy. Median lymph nodes sampled was 15 (range, 9 to 47). The median length of hospital stay was 4 (range, 1 to 44) days. The conversion rate to open surgery was 11.6%. Four patients (4.7%) had an anastomotic leak. Three patients had postoperative bleeding (4.7%). About 4.7% (n=4) of the patients required readmission and 8.1% required reoperation (n=7). The 30-day mortality rate was 2.3% (n=2) due to complications from anastomotic leak.

Conclusions:

Laparoscopic gastrectomy within an ERAS protocol results in a short hospital stay with an acceptable morbidity and mortality rate.
Preoperative Very Low-Calorie Diet Reduces Technical Difficulty During Laparoscopic Cholecystectomy in Obese Patients
Authors: Jones Alexander D. , Waterland Peter W. , Powell-Brett Sarah , Super Paul , Richardson Martin , Bowley Douglas
Published: June 2016

This study investigates the effectiveness of preoperative very low-calorie diet (VLCD) in laparoscopic cholecystectomy. A prospective observational study of consecutive patients undergoing laparoscopic cholecystectomy was undertaken. At the preoperative visit, all patients were advised to adhere to VLCD for 2 weeks before surgery (<800 kcal/d). Patients were judged to have complied with the VLCD if weight loss >2 kg. Technical difficulty was assessed using questionnaires. A total of 38 patients met the inclusion criteria. Difficulty of visualization and dissection of Calot’s triangle in obese patients was twice that of nonobese patients (P=0.01). In 62% of procedures involving obese VLCD noncompliant patients, the surgeon experienced ≥1 area of technical difficulty, compared with 0% of procedures on obese, compliant patients (P=0.018). Difficulty of dissection of the gallbladder bed was 3 times higher in obese, noncompliant patients, compared with obese, compliant patients (P=0.07). Adherence to a 2-week preoperative VLCD may reduce technical difficulty of laparoscopic cholecystectomy in obese patients.
Late Postoperative Complications in Laparoscopic Sleeve Gastrectomy (LVSG) Versus Laparoscopic Roux-en-y Gastric Bypass (LRYGB): Meta-analysis and Systematic Review
Authors: Osland Emma , Yunus Rossita M. , Khan Shahjahan , Memon Breda , Memon Muhammed A.
Published: June 2016

Aims and Objectives:

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic vertical sleeve gastrectomy (LVSG), have been proposed as cost-effective strategies to manage obesity-related chronic disease. The objectives of this meta-analysis and systematic review were to analyze the “late postoperative complication rate (>30 days)” for these 2 procedures.

Materials and Methods:

Randomized controlled trials (RCTs) published between 2000 and 2015 comparing the late complication rates, that is, >30 days following LVSG and LRYGB in adult population (ie, 16 y and above) were selected from PubMed, Medline, Embase, Science Citation Index, Current Contents, and the Cochrane database. The outcome variables analyzed included mortality rate, major and minor complications, and interventions required for their management and readmission rates. Random effects model was used to calculate the effect size of both binary and continuous data. Heterogeneity among the outcome variables of these trials was determined by the Cochran Q statistic and I
2 index. The meta-analysis was prepared in accordance with the Preferred Reporting of Systematic Reviews and Meta-Analyses guidelines.

Results:

Six RCTs involving a total of 685 patients (LVSG, n=345; LRYGB, n=340) reported late major complications. A nonstatistical reduction in relative odds favoring the LVSG procedure was observed [odds ratio (OR), 0.64; 95% confidence interval (CI), 0.21-1.97; P=0.4]. Four RCTs representing 408 patients (LVSG, n=208; LRYGB, n=200) reported late minor complications. A nonstatistically significant reduction of 36% in relative odds favoring the LVSG procedure was observed (OR, 0.64; 95% CI, 0.28-1.47; P=0.3). A 37% relative reduction in odds was observed in favor of the LVSG for the need for additional interventions to manage late postoperative complications that did not reach statistical significance (OR, 0.63; 95% CI, 0.19-2.05; P=0.4). No study specifically reported readmissions required for the management of late complication.

Conclusions:

This meta-analysis and systematic review of RCTs shows that the development of late (major and minor) complications is similar between LVSG and LRYGB procedures, 6 months to 3 years postoperatively, and they do not lead to higher readmission rate or reoperation rate for either procedure. However longer-term surveillance is required to accurately describe the patterns of late complications in these patients.