bluuebunny/crossref_metadata_2025 huggingface dataset:
Domperidone for Lactation
Authors: Sewell Catherine A. , Chang Christina Y. , Chehab Miriam M. , Nguyen Christine P.
Published: May 2017

This commentary serves to raise health care provider awareness about the regulatory status and available evidence regarding domperidone for insufficient lactation. Breastfeeding provides significant health benefits for mothers and infants, and insufficient milk production remains the most common reason for early weaning. Domperidone, a dopamine receptor antagonist that may increase milk production, is not approved for any human use in the United States. It is approved in some countries for certain gastrointestinal disorders, but is not approved in any country for lactation enhancement. Domperidone is associated with serious cardiac arrhythmias. The U.S. Food and Drug Administration (FDA) issued an import alert in 2004, updated in 2012, explaining that the importation of domperidone is illegal with limited exceptions, including when imported pursuant to an investigational new drug application. The FDA also issued a public safety warning regarding the use of domperidone for lactation. Nonetheless, domperidone is sometimes being obtained illegally and used in attempts to increase milk production in lactating mothers. There is limited quality evidence for the effectiveness of domperidone for lactation enhancement. In contrast, considerable information exists on domperidone's cardiac risks including QT prolongation, torsades de pointes, and sudden cardiac death, including among lactating women. In light of limited efficacy data that do not offset safety concerns from a public health perspective, we continue to caution against using domperidone for lactation enhancement. Research and drug development are needed to address the significant unmet medical need for lactation disorders.
Minimally Invasive Hysterectomy and Power Morcellation Trends in a West Coast Integrated Health System
Authors: Zaritsky Eve , Tucker Lue-Yen , Neugebauer Romain , Chou Tatiana , Flanagan Tracy , Walter Andrew J. , Raine-Bennett Tina
Published: May 2017

OBJECTIVE:

To examine trends in minimally invasive hysterectomy and power morcellation use over time and associated clinical characteristics.

METHODS:

We conducted a trend analysis and retrospective cohort study of all women 18 years of age and older undergoing hysterectomy for benign conditions at Kaiser Permanente Northern California collected from electronic health records. Generalized estimating equations and Cochran–Armitage testing were used to assess the primary outcomes, hysterectomy incidence, and proportion of hysterectomies by surgical route and power morcellation. Logistic regression analysis was used to assess secondary outcomes, clinical characteristics, and complications associated with surgical route.

RESULTS:

There were 31,971 hysterectomies from 2008 to 2015; the incidence decreased slightly from 2.86 (95% confidence interval [CI] 2.85–2.87) to 2.60 (95% CI 2.59–2.61) per 1,000 women (P<.001). Minimally invasive hysterectomies increased from 39.8% to 93.1%, almost replacing abdominal hysterectomies entirely (P<.001). Vaginal hysterectomies decreased slightly from 26.6% to 23.4% (P<.001). The proportion of nonrobotic laparoscopic hysterectomies with power morcellation increased steadily from 3.7% in 2008 to a peak of 11.4% in 2013 and decreased to 0.02% in 2015 (P<.001). Robot-assisted laparoscopic hysterectomies remained a small proportion of all hysterectomies comprising 7.8% of hysterectomies in 2015. Women with large uteri (greater than 1,000 g) were more likely to receive abdominal hysterectomies than minimally invasive hysterectomy (adjusted relative risk 11.62, 95% CI 9.89–13.66) and laparoscopic hysterectomy with power morcellation than without power morcellation (adjusted relative risk 5.74, 95% CI 4.12–8.00). Laparoscopic supracervical hysterectomy was strongly associated with power morcellation use (adjusted relative risk 43.89, 95% CI 37.55–51.31).

CONCLUSION:

A high minimally invasive hysterectomy rate is primarily associated with uterine size and can be maintained without power morcellation.
Changes in Myomectomy Practice After the U.S. Food and Drug Administration Safety Communication on Power Morcellation
Authors: Stentz Natalie C. , Cooney Laura G. , Sammel Mary , Shah Divya K.
Published: May 2017

OBJECTIVE:

To examine the association between the 2014 U.S. Food and Drug Administration (FDA) safety communication on power morcellation and surgical approach and morbidity after myomectomy.

METHODS:

In this retrospective cohort study, data were abstracted from the American College of Surgeons National Surgical Quality Improvement Program database on 3,160 myomectomies between April 2012 and December 2013 (pre-FDA) and 4,378 between April 2014 and December 2015 (post-FDA). Aims were to 1) compare rates of abdominal and laparoscopic myomectomy pre-FDA and post-FDA (primary outcome), 2) directly compare the morbidity of abdominal and laparoscopic myomectomy during each time period (secondary outcome 1), and 3) compare the morbidity after all myomectomies performed pre-FDA and post-FDA (secondary outcome 2). Adjusted means, odds ratios, and rate ratios with 95% confidence intervals were calculated using linear, logistic, and Poisson regression, respectively, adjusting for age, race, ethnicity, body mass index, and myoma burden.

RESULTS:

Myomectomies performed post-FDA were more likely to be abdominal (60.0%, 95% confidence interval [CI] 58.6–61.5%) than laparoscopic (40.0%, 95% CI 38.5–41.4%) as compared with myomectomies pre-FDA, which were equally divided between surgical approaches (49.1% abdominal, 95% CI 47.4–50.9% compared with 50.9% laparoscopic, 95% CI 49.1–52.6%; P<.001). When directly compared with laparoscopic myomectomy, abdominal myomectomy was associated with longer hospitalizations, higher readmission rates, and greater morbidity both pre-FDA and post-FDA (P<.05, all comparisons). Adjusted models demonstrated shorter operative times post-FDA for all myomectomies (P<.001), although composite morbidity was similar between myomectomies performed pre-FDA and post-FDA (P=.809).

CONCLUSIONS:

The FDA safety communication on power morcellation was associated with an 11% absolute increase in the use of abdominal myomectomy. Although morbidity is consistently higher after abdominal as compared with laparoscopic myomectomy, the increased reliance on abdominal myomectomy post-FDA did not result in clinically significant changes in morbidity in this cohort.
Premature Thelarche and the PURA Syndrome
Authors: Rezkalla Joshua , Von Wald Tiffany , Hansen Keith A.
Published: May 2017

BACKGROUND:

Premature thelarche is a self-limited condition characterized by Tanner stage II–III breast development in girls younger than 8 years of age with no evidence of advancing puberty. Evaluation concentrates on excluding central or peripheral causes of precocious puberty.

CASE:

A girl aged 2 years 4 months with profound hypotonia and delayed developmental milestones presented with Tanner II breast development, elevated follicle-stimulating hormone levels, suppressed luteinizing hormone level, normal growth and skeletal development, and prepubertal uterine length and ovarian volume. Monitoring until 8 years of age revealed no pubertal progression. Whole exome sequencing at 8 years revealed an autosomal-dominant mutation in the purine-rich element-binding protein A (PURA) gene. Previous patients with PURA syndrome have had pituitary dysfunction and precocious puberty.

CONCLUSION:

Purine-rich element-binding protein A syndrome can be associated with premature thelarche.
Zika Risk and Pregnancy in Clinical Practice
Authors: Rao Rashmi , Gaw Stephanie L. , Han Christina S. , Platt Lawrence D. , Silverman Neil S.
Published: May 2017

OBJECTIVE:

To describe a single U.S. perinatal center's ongoing experience with evaluating pregnant patients with potential exposure to Zika virus infection.

METHODS:

This is an institutional review board-approved longitudinal observational study from January to August 2016 from a single perinatal referral center. Patients who had traveled to or had sexual contact with a person who traveled to a region with documented local Zika virus transmission were included in the study. The aim of the study was to identify the rate of confirmed infection among pregnant women referred to our center with established risk factors for Zika virus acquisition. We also sought to characterize travel patterns that constituted risk, to identify rates of symptoms suggesting infection, and to potentially describe findings suggestive of congenital Zika virus infection in prenatal ultrasound evaluations.

RESULTS:

We evaluated 185 pregnant women with potential Zika virus exposure. Testing was offered in accordance with the version of the Centers for Disease Control and Prevention guidelines in place at the time of the consultation visit. Geographic exposure data showed Mexico (44%), the Caribbean (17%), North America (16%), South America (13%), and Central America (9%) to be the most common areas in which potential exposure occurred. One hundred twenty-three (67%) patients reported insect bites and 19 (10%) patients reported symptoms. Overall, five (3% of all) patients had prenatal ultrasound findings suggestive of possible fetal Zika virus infection; all their Zika virus test results returned negative. These findings included microcephaly, echogenic intracardiac foci, and ventricular calcifications. Of the 153 Zika virus screening tests ordered, eight (5%) immunoglobulin M results returned positive or equivocal with only one positive through confirmatory testing. Overall, 1 of 185 (0.5%) of all those consulted and 1 of 153 (0.7%) of those tested had a confirmed Zika virus infection with no confirmed fetal or neonatal infections.

CONCLUSION:

We identified low rates of confirmed maternal Zika virus infection in our cohort, but the number of patients described here demonstrates the magnitude of concern existing among both patients and physicians regarding possible perinatal Zika virus infection. It also underscores the need for health care providers to be prepared to answer questions, explain laboratory and ultrasound results, and describe testing options for concerned patients and their families.
Practical Aspects of Posttrauma Reconstruction With an Intramedullary Lengthening Nail
Authors: Bernstein Mitchell
Published: May 2017

Limb equalization using the Ilizarov method has evolved and adapted the use of internal lengthening devices. One of the newest devices, termed “PRECICE,” is a magnetically controlled telescoping nail. Complications such as pin site infection and skin irritation are eliminated. Despite trauma surgeons’ familiarity with intramedullary nailing, the Ilizarov method requires sound knowledge of deformity analysis and awareness of specific complications associated with distraction osteogenesis. This manuscript discusses some of the practical preoperative and intraoperative components of limb lengthening.
Lengthening of newly formed humerus after autologous fibula graft transplantation following intercalary tumor resection
Authors: Pilge Hakan , Ruppert Martin , Bittersohl Bernd , Westhoff Bettina , Krauspe Rüdiger
Published: May 2017

Secondary limb lengthening after intercalary bone resection in pediatric patients is still challenging. After the resection, a free fibula autograft can be used to reconstruct the osseous gap. However, in particular in young pediatric patients, insufficient growth of the epiphyseal plate after transplantation may lead to a significant limb-length discrepancy (LLD). In this case, the autograft was used for limb lengthening. We report on the lengthening of a humerus regenerate after fibula autograft transplantation into a humeral defect in a pediatric/young adolescent patient. Because of LLD, she underwent callus distraction of the humerus regenerate after transplantation of a fibula autograft using a unilateral external fixator device. An 18-year-old female patient with status postintercalary proliferating chondroma resection (at the age of 7 years) required treatment for correction of a 13 cm humerus shortening. She reported no pain, had no functional limitations, and had a full range of motion of the shoulder and elbow joint. She complained about her short humerus and overall body scheme. A unilateral external fixator device for callus distraction was applied to the transplanted humerus regenerate after free fibula autograft transplantation. Bone lengthening was performed by distraction (2×0.5 mm/day). After 62 days and a lengthening of 6 cm in total, bone distraction was stopped mainly to avoid any complication. At this time, there was no limitation in the range of motion. No nerve palsy or other problems occurred at any time of the distraction. In pediatric patients, the transplantation of a fibula autograft is a well-established option to bridge an osseous gap after intercalary bone resection. This case report shows that even the humerus regenerate after fibula autograft transplantation has excellent potential for callotasis and bone remodeling and therefore bone lengthening in patients with LLD is an option even after transplantation of an autograft. This method provides a new therapeutic option for patients with LLD after fibula transplantation.
Futility of imaging to stage melanoma patients with a positive sentinel lymph node
Authors: Holtkamp Lodewijka H.J. , Read Rebecca L. , Emmett Louise , Thompson John F. , Nieweg Omgo E.
Published: May 2017

The use of staging imaging in melanoma patients with a positive sentinel lymph node (SLN) has been reported to be of limited value. Improved accuracy resulting from the development of time-of-flight positron emission tomography (PET) and ongoing image quality improvement of computed tomography (CT) may challenge this statement. Our retrospective study assessed the clinical value of routine staging CT and PET/CT imaging in a recent cohort of asymptomatic SLN-positive patients. Between January 2011 and April 2014, 143 patients with a positive SLN were routinely staged using CT of various parts of the body or whole-body PET/CT. Scores were assigned for level of certainty for regional or distant metastases and incidental second primary malignancies. Diagnostic test performance was assessed, as well as the number and nature of ensuing additional diagnostic actions. CT was performed in 102 of 143 (71%) patients and PET/CT in 41 (29%) patients. The use of PET/CT increased over the study period. Metastases were found in two of the 143 patients (true-positive yield 1.4%). Sensitivity, specificity and positive predictive value were 11, 73 and 4% for CT and 17, 57 and 6%, respectively, for PET/CT. None of the 143 patients had a change in AJCC stage. Two other primary malignancies were found. Twenty-one (15%) patients were subjected to 37 additional investigations, referrals or procedures. Routine staging imaging with CT or PET/CT in SLN-positive patients is not useful. The yield is low and the results are often false positive, leading to unnecessary additional tests, most of which are costly and some potentially morbid.
Biomechanical and Histopathologic Effects of Pulsed-Light Accelerated Epithelium-On/-Off Corneal Collagen Cross-Linking
Authors: Zhang Xiaoyu , Sun Ling , Shen Yang , Tian Mi , Zhao Jing , Zhao Yu , Li Meiyan , Zhou Xingtao
Published: May 2017

Purpose:

This study aimed to compare the biomechanical and histopathologic effects of transepithelial and accelerated epithelium-off pulsed-light accelerated corneal collagen cross-linking (CXL).

Methods:

A total of 24 New Zealand rabbits were analyzed after sham operation (control) or transepithelial or epithelium-off operation (45 mW/cm2 for both). The transepithelial group was treated with pulsed-light ultraviolet A for 5 minutes 20 seconds, and the epithelium-off group was treated for 90 seconds. Biomechanical testing, including ultimate stress, Young modulus, and the physiological modulus, was analyzed. Histological changes were evaluated by light microscopy and transmission electron microscopy.

Results:

The stress–strain curve was nonlinear in both accelerated transepithelial and epithelium-off CXL groups. The stress and elastic moduli were all significantly higher in both experimental groups compared with the control group (P < 0.05), whereas there were no significant differences between the 2 treatment groups (P > 0.05). Six months after the operation, hematoxylin and eosin staining and transmission electron microscopy showed that the subcutaneous collagen fibers were arranged in a regular pattern, and the fiber density was higher in the experimental groups.

Conclusions:

Both transepithelial and accelerated epithelium-off CXL produced biomechanical and histopathologic improvements, which were not significantly different between the 2 pulsed-light accelerated CXL treatments.
Free-Living Amoebae Keratitis
Authors: Pinna Antonio , Porcu Tiziana , Boscia Francesco , Cano Antonella , Erre Giuseppe , Mattana Antonella
Published: May 2017

Purpose:

To describe the diagnostic and clinical features and treatment results in 43 consecutive patients with microbiologically proven free-living amoebae (FLA) keratitis.

Methods:

In this hospital-based, prospective case series, corneal scrapings from 43 patients with presumed amoebic keratitis were plated on nonnutrient agar. Amoebic isolates were identified morphologically and by the polymerase chain reaction. All patients with culture-proven FLA keratitis were treated with polyhexamethylene biguanide (PHMB) 0.02% eye drops.

Results:

Forty-three corneal scrapings from 43 patients were found to be culture positive for FLA; 41 (95%) were from contact lens wearers and 2 (5%) were from noncontact lens wearers. Microscopic examination identified 4 Acanthamoeba spp, 24 Hartmannella spp, 12 vahlkampfiid amoebae, and 3 mixed infections with Hartmannella/vahlkampfiid amoebae. Morphological results were confirmed by the polymerase chain reaction. Patients with Acanthamoeba, Hartmannella, and vahlkampfiid keratitis had indistinguishable clinical features. In 38 eyes with keratitis at an early stage, treatment with PHMB 0.02% eye drops was fully successful. In 5 patients with advanced keratitis, topical PHMB 0.02% controlled the infection, but all of them developed a central corneal scar with visual deterioration.

Conclusions:

Acanthamoeba is not the only cause of amoebic keratitis, because this condition may also be caused by other FLA, such as Hartmannella and vahlkampfiid amoebae. This finding is epidemiologically interesting, suggesting a possible different geographical prevalence of the different FLA responsible for keratitis. Early diagnosis and proper antiamoebic treatment are crucial to yielding a cure.
Comparison of 2 Different Methods of Transepithelial Corneal Collagen Cross-Linking: Analysis of Corneal Histology and Hysteresis
Authors: Park Young Min , Kim Ho Yoon , Lee Jong Soo
Published: May 2017

Purpose:

To compare the effect of 2 different methods of transepithelial corneal collagen cross-linking (CXL) on corneal histology and hysteresis.

Methods:

The right eyes of New Zealand white rabbits (n = 50) were treated using one of the 2 transepithelial CXL methods. The eyes were then divided into 2 groups: group 1, transepithelial CXL using continuous ultraviolet A (UVA); group 2, accelerated transepithelial CXL using pulsed UVA.

Results:

Both groups showed a postoperative increase in central corneal thickness. In both groups, an increase in corneal hysteresis was found after CXL, but the changes were not significant when compared with the baseline value. The corneal resistance factor and corneal-compensated intraocular pressure also remained unchanged in both groups after treatment. In both groups, the CXL effect reached the anterior–mid part of the corneal stroma. In group 1, CXL mostly affected the anterior–mid part stroma, whereas group 2 showed stromal keratocyte loss, and an acellular zone, in the deep stroma. More signs of keratocyte apoptosis were observed in group 2 than in group 1.

Conclusions:

Accelerated transepithelial CXL using pulsed UVA showed considerably deeper effect in the stroma with keratocyte loss than transepithelial CXL using continuous UVA.
Evaluation Tool for Assessing a Newly Implemented Massive Transfusion Protocol
Authors: Broxton Shannon , Medeiros Regina , Schumacher Autumn
Published: May 2017

Exsanguination requires massive blood product replacement and termination of the bleeding source to prevent hemorrhagic shock and death. Massive transfusion protocols (MTPs) are algorithms that allow the health care team to quickly stabilize the bleeding patient and guide blood product administration. However, no national MTP guidelines or a standardized evaluation tool exist for collecting and reporting MTP-related data. The purpose of this article is to describe an original MTP evaluation tool, how it was used, barriers encountered, and a framework for reporting the MTP evaluation data. The evidence-based Broxton MTP Evaluation Tool was developed to evaluate the use of a newly implemented MTP via a retrospective review of electronic medical records (EMRs). Although the instrument itself worked well, barriers were encountered while reviewing the EMRs for the MTP evaluation. These barriers included no institutional entity was charged with tracking MTP activations, no searchable database was established to collect data concerning the MTP-activated patients, and no standard location in the EMR was designated for documenting the MTP activation. When devising protocols such as an MTP, a priori strategies should be developed for its implementation, documentation, and evaluation. Research is needed to determine best practices for evaluating an MTP to ensure positive patient outcomes with this protocol.
The Trauma Time-Out: Evaluating the Effectiveness of Protocol-Based Information Dissemination in the Traumatically Injured Patient
Authors: Nolan Heather R. , Fitzgerald Michael , Howard Brett , Jarrard Joey , Vaughn Danny
Published: May 2017

Procedural time-outs are widely accepted safety standards that are protocolized in nearly all hospital systems. The trauma time-out, however, has been largely unstudied in the existing literature and does not have a standard protocol outlined by any of the major trauma surgery organizations. The goal of this study was to evaluate our institution's use of the trauma time-out and assess how trauma team members viewed its effectiveness. A multiple-answer survey was sent to trauma team members at a Level I trauma center. Questions included items directed at background, experience, opinions, and write-in responses. Most responders were experienced trauma team members who regularly participated in trauma codes. All respondents noted the total time required to complete the time-out was less than 5 min, with the majority saying it took less than 1 min. Seventy-five percent agreed that trauma time-outs should continue, with 92% noting that it improved understanding of patient presentation and prehospital evaluation. Seventy-seven percent said it improved understanding of other team member's roles, and 75% stated it improved patient care. Subgroups of physicians and nurses were statistically similar; yet, physicians did note that it improved their understanding of the team member's function more frequently than nurses. The trauma time-out can be an excellent tool to improve patient care and team understanding of the incoming trauma patient. Although used widely at multiple levels of trauma institutions, development of a documented protocol can be the next step in creating a unified safety standard.
Case Report and Review of Management of Penetrating Trauma and Cardiac Pericarditis
Authors: Thomas Elizabeth , Golden Pamela , Moran Vicki
Published: May 2017

Acute pericarditis is the most common form of pericardial disease worldwide and it has many potential etiologies. This case study examines a patient admitted for multiple gunshot wounds who developed acute pericarditis postpericardial drain removal. The initial penetrating abdominal trauma, along with facial injuries and a suspected myocardial infarction, led to confusion in which the initial etiology of pericarditis was missed, creating a delay in overall patient care and extended length of stay.
Tourniquets in Trauma Care: A Review of Application
Authors: Cornelius Brian , Campbell Ryan , McGauly Pat
Published: May 2017

Traumatic hemorrhage has been identified as the leading cause of battlefield death in recent conflicts. Although injury patterns are not directly reproducible to the civilian world, treatment advancements can be used to provide care to patients worldwide. Long-standing dogma regarding the use of tourniquets has been disproved, and there is now recognition of the critical role that tourniquets play in trauma care. The history and evolution of tourniquets, including the identification of previous faults in application, will lead to an examination of the current devices in use along with evidence-based recommendations for use. A review of ongoing programs to reduce hemorrhage as a cause of death in civilian and law enforcement medicine promotes the application analysis. Tourniquets, as simple technology, have the potential to save many lives through appropriate use, but preconceived myths and notions have limited its use to combat medicine. An increase in utilization could have a much greater impact in areas other than combat.
Rasch validation and comparison of Slovenian, Croatian, and Italian versions of the Mini-BESTest in patients with subacute stroke
Authors: Goljar Nika , Giordano Andrea , Schnurrer Luke Vrbanić Tea , Rudolf Marko , Banicek-Sosa Ivanka , Albensi Caterina , Burger Helena , Franchignoni Franco
Published: May 2017

We aimed to verify by Rasch analysis whether the Mini-BESTest, a balance measure, confirms its main psychometric properties in patients with subacute stroke undergoing rehabilitation in three different countries (Slovenia, Croatia, and Italy), and to examine the stability of item hierarchy and difficulty across the three national versions through a differential item functioning analysis. We investigated 159 patients with subacute stroke consecutively admitted to three rehabilitation facilities after screening for an intensive, tailored rehabilitation program. Balance function was tested within 36 h from admission and after ∼25 days. As no differential item functioning was found between admission and discharge data or among countries, all data were pooled. Rasch criteria for the functioning of rating scale categories were fulfilled. In terms of internal construct validity, all items except item #14 (Cognitive Get Up & Go; infit value=1.42) showed an acceptable fit to the Rasch model. The patient ability–item difficulty matching was very good. Reliability indices were high. The Principal Component Analysis of standardized residuals confirmed the unidimensionality of the test. On the basis of the item calibration, raw scores of the Mini-BESTest were transformed into linear estimates of dynamic balance and six statistically detectable levels of balance ability were defined. Good psychometric features of the Mini-BESTest were confirmed. The three different national versions showed stability in item hierarchy, indicating equivalence of their cross-cultural adaptations. Problems with item #14 in these patients warrant further study.
Validation of the Vasoactive-Inotropic Score in Pediatric Sepsis*
Authors: McIntosh Amanda M. , Tong Suhong , Deakyne Sara J. , Davidson Jesse A. , Scott Halden F.
Published: May 2017

Objectives:

To assess the validity of Vasoactive-Inotropic Score as a scoring system for cardiovascular support and surrogate outcome in pediatric sepsis.

Design:

Secondary retrospective analysis of a single-center sepsis registry.

Setting:

Freestanding children’s hospital and tertiary referral center.

Patients:

Children greater than 60 days and less than 18 years with sepsis identified in the emergency department between January 2012 and June 2015 treated with at least one vasoactive medication within 48 hours of admission to the PICU.

Interventions:

None.

Measurements and Main Results:

Vasoactive-Inotropic Score was abstracted at 6, 12, 24, and 48 hours post ICU admission. Primary outcomes were ventilator days and ICU length of stay. The secondary outcome was a composite outcome of cardiac arrest/extracorporeal membrane oxygenation/in-hospital mortality. One hundred thirty-eight patients met inclusion criteria. Most common infectious sources were pneumonia (32%) and bacteremia (23%). Thirty-three percent were intubated and mortality was 6%. Of the time points assessed, Vasoactive-Inotropic Score at 48 hours showed the strongest correlation with ICU length of stay (r = 0.53; p < 0.0001) and ventilator days (r = 0.52; p < 0.0001). On multivariable analysis, Vasoactive-Inotropic Score at 48 hours was a strong independent predictor of primary outcomes and intubation. For every unit increase in Vasoactive-Inotropic Score at 48 hours, there was a 13% increase in ICU length of stay (p < 0.001) and 8% increase in ventilator days (p < 0.01). For every unit increase in Vasoactive-Inotropic Score at 12 hours, there was a 14% increase in odds of having the composite outcome (p < 0.01).

Conclusions:

Vasoactive-Inotropic Score in pediatric sepsis patients is independently associated with important clinically relevant outcomes including ICU length of stay, ventilator days, and cardiac arrest/extracorporeal membrane oxygenation/mortality. Vasoactive-Inotropic Score may be a useful surrogate outcome in pediatric sepsis.
Predicting Thoracic Injury in Children With Multitrauma
Authors: Weerdenburg Kirstin D. , Wales Paul W. , Stephens Derek , Beno Suzanne , Gantz Jessica , Alsop Jessie , Schuh Suzanne
Published: May 2017

Objectives

Previous pediatric trauma studies focused on predictors of abnormal chest radiographs or included patients with low injury severity. This study identified predictors of thoracic injury (TI) diagnoses in a high-risk population and determined TI rate without predictors.

Methods

This study was a retrospective trauma registry analysis of previously healthy children aged 0 to 17 years with multisystem blunt trauma requiring trauma team activation and chest radiography who were divided into those with and without TI. Plausible TI predictors included Glasgow Coma Scale score of 13 or less, abnormal thoracic symptoms/signs, abnormal chest auscultation, respiratory distress/ rate higher than the 95th percentile, oxygen saturation less than 95%, abnormal abdominal signs/symptoms, tachycardia higher than the 95th percentile, blood pressure lower than the 5th percentile, and femur fracture.

Results

One hundred forty-one (29%) of 493 eligible patients had TI. Independent TI predictors include thoracic symptoms/signs (odds ratio [OR], 6.0; 95% confidence interval [CI], 3.6–10.1), abnormal chest auscultation (OR, 3.5; 95% CI, 2.0–6.2), saturation less than 95% (OR, 3.1; 95% CI, 1.8–5.5), blood pressure lower than the 5th percentile (OR, 3.7; 95% CI, 1.1–12.2), and femur fracture (OR, 2.5; 95% CI, 1.2–5.4). Six (5%) of 119 children (95% CI, 0.01–0.09) without predictors had TI.

Conclusions

Predictors of TI include thoracic symptoms/signs, abnormal chest auscultation, saturation less than 95%, blood pressure lower than the 5th percentile, and femur fracture. Because an important portion of children without predictors had TI, chest radiography should remain part of pediatric trauma resuscitation.
HIV and Obesity Comorbidity Increase Interleukin 6 but Not Soluble CD14 or D-Dimer
Authors: Taylor Barbara S. , So-Armah Kaku , Tate Janet P. , Marconi Vincent C. , Koethe John R. , Bedimo Roger J. , Butt Adeel A. , Gibert Cynthia L. , Goetz Matthew B. , Rodriguez-Barradas Maria C. , Womack Julie A. , Gerschenson Mariana , Lo Re Vincent , Rimland David , Yin Michael T. , Leaf David , Tracy Russell P. , Justice Amy C. , Freiberg Matthew S.
Published: May 2017

Objectives:

Obesity prevalence among people living with HIV (HIV+) is rising. HIV and obesity are proinflammatory states, but their combined effect on inflammation (measured by interleukin 6, IL-6), altered coagulation (D-dimer), and monocyte activation (soluble CD14, sCD14) is unknown. We hypothesized inflammation increases when obesity and HIV infection co-occur.

Methods:

The Veterans Aging Cohort Study survey cohort is a prospective, observational study of predominantly male HIV+ veterans and veterans uninfected with HIV; a subset provided blood samples. Inclusion criteria for this analysis were body mass index ≥ 18.5 kg/m2 and biomarker measurement. Dependent variables were IL-6, sCD14, and D-dimer quartiles. Obesity/HIV status was the primary predictor. Unadjusted and adjusted logistic regression models were constructed.

Results:

Data were analyzed for 1477 HIV+ and 823 uninfected participants. Unadjusted median IL-6 levels were significantly higher and sCD14 levels significantly lower in obese/HIV+ compared with nonobese/uninfected (P <0.01 for both). In adjusted analyses, the odds ratio for increased IL-6 in obese/HIV+ patients was 1.76 (95% confidence interval: 1.18 to 2.47) compared with nonobese/uninfected, and obesity/HIV+ remained associated with lower odds of elevated sCD14. We did not detect a synergistic association of co-occurring HIV and obesity on IL-6 or sCD14 elevation. D-dimer levels did not differ significantly between body mass index/HIV status groups.

Conclusions:

HIV–obesity comorbidity is associated with elevated IL-6, decreases in sCD14, and no significant difference in D-dimer. These findings are clinically significant, as previous studies associated these biomarkers with mortality. Future studies should assess whether other biomarkers show similar trends and potential mechanisms for unanticipated sCD14 and D-dimer findings.
Minimally Invasive Versus Open Pancreaticoduodenectomy
Authors: Nassour Ibrahim , Wang Sam C. , Christie Alana , Augustine Mathew M. , Porembka Matthew R. , Yopp Adam C. , Choti Michael A. , Mansour John C. , Xie Xian-Jin , Polanco Patricio M. , Minter Rebecca M.
Published: May 2017

Objective:

To compare the perioperative outcomes of minimally invasive pancreaticoduodenectomy (MIPD) in comparison with open pancreaticoduodenectomy (OPD) in a national cohort of patients.

Background:

Limited well-controlled studies exist comparing perioperative outcomes between MIPD and OPD.

Methods:

Patients who underwent MIPD and OPD were abstracted from the 2014 to 2015 pancreas-targeted American College of Surgeons National Surgical Quality Improvement Program. OPD and MIPD patients were matched 3:1 using propensity score, and perioperative outcomes were compared.

Results:

A total of 4484 patients were identified with 334 (7.4%) undergoing MIPD. MIPD patients were younger, more likely to be White, and had a lower rate of weight loss. They were more likely to undergo classic Whipple and to have a drain placed. After 3:1 matching, 1002 OPD patients were compared with 334 MIPD patients. MIPD was associated with longer mean operative time (426.6 vs 359.6 minutes; P < 0.01), higher readmission rate (19.2% vs 14.3%; P = 0.04) and lower rate of prolonged length of stay >14 days (16.5% vs 21.6%; P = 0.047). The 2 groups had a similar rate of 30-day mortality (MIPD 1.8% vs OPD 1.3%; P = 0.51), overall complications, postoperative pancreatic fistula, and delayed gastric emptying. A secondary analysis comparing MIPD without conversion or open assist with OPD showed that MIPD patients had lower rates of overall surgical site infection (13.4% vs 19.6%; P = 0.04) and transfusion (7.9% vs 14.4%; P = 0.02).

Conclusions:

MIPD had an equivalent morbidity and mortality rate to OPD, with the benefit of a decreased rate of prolonged length of stay, though this is partially offset by an increased readmission rate.
Myocardial Injury After Noncardiac Surgery (MINS) in Vascular Surgical Patients
Authors: Biccard Bruce M. , Scott David Julian Ashbridge , Chan Matthew T. V. , Archbold Andrew , Wang Chew-Yin , Sigamani Alben , Urrútia Gerard , Cruz Patricia , Srinathan Sadeesh K. , Szalay David , Harlock John , Tittley Jacques G. , Rapanos Theodore , Elias Fadi , Jacka Michael J. , Malaga German , Abraham Valsa , Berwanger Otavio , Montes Félix R. , Heels-Ansdell Diane M. , Hutcherson Matthew T. , Chow Clara K. , Polanczyk Carisi A. , Szczeklik Wojciech , Ackland Gareth L. , Dubois Luc , Sapsford Robert J. , Williams Colin , Cortés Olga L. , Le Mananch Yannick , Devereaux P. J.
Published: May 2017

Objective:

To determine the prognostic relevance, clinical characteristics, and 30-day outcomes associated with myocardial injury after noncardiac surgery (MINS) in vascular surgical patients.

Background:

MINS has been independently associated with 30-day mortality after noncardiac surgery. The characteristics and prognostic importance of MINS in vascular surgery patients are poorly described.

Methods:

This was an international prospective cohort study of 15,102 noncardiac surgery patients 45 years or older, of whom 502 patients underwent vascular surgery. All patients had fourth-generation plasma troponin T (TnT) concentrations measured during the first 3 postoperative days. MINS was defined as a TnT of 0.03 ng/mL of higher secondary to ischemia. The objectives of the present study were to determine (i) if MINS is prognostically important in vascular surgical patients, (ii) the clinical characteristics of vascular surgery patients with and without MINS, (iii) the 30-day outcomes for vascular surgery patients with and without MINS, and (iv) the proportion of MINS that probably would have gone undetected without routine troponin monitoring.

Results:

The incidence of MINS in the vascular surgery patients was 19.1% (95% confidence interval (CI), 15.7%–22.6%). 30-day all-cause mortality in the vascular cohort was 12.5% (95% CI 7.3%–20.6%) in patients with MINS compared with 1.5% (95% CI 0.7%–3.2%) in patients without MINS (P < 0.001). MINS was independently associated with 30-day mortality in vascular patients (odds ratio, 9.48; 95% CI, 3.46–25.96). The 30-day mortality was similar in MINS patients with (15.0%; 95% CI, 7.1–29.1) and without an ischemic feature (12.2%; 95% CI, 5.3–25.5, P = 0.76). The proportion of vascular surgery patients who suffered MINS without overt evidence of myocardial ischemia was 74.1% (95% CI, 63.6–82.4).

Conclusions:

Approximately 1 in 5 patients experienced MINS after vascular surgery. MINS was independently associated with 30-day mortality. The majority of patients with MINS were asymptomatic and would have gone undetected without routine postoperative troponin measurement.
Behavioural, ecological and evolutionary responses to extreme climatic events: challenges and directions
Authors: van de Pol Martijn , Jenouvrier Stéphanie , Cornelissen Johannes H. C. , Visser Marcel E.
Published: May 2017

More extreme climatic events (ECEs) are among the most prominent consequences of climate change. Despite a long-standing recognition of the importance of ECEs by paleo-ecologists and macro-evolutionary biologists, ECEs have only recently received a strong interest in the wider ecological and evolutionary community. However, as with many rapidly expanding fields, it lacks structure and cohesiveness, which strongly limits scientific progress. Furthermore, due to the descriptive and anecdotal nature of many ECE studies it is still unclear what the most relevant questions and long-term consequences are of ECEs. To improve synthesis, we first discuss ways to define ECEs that facilitate comparison among studies. We then argue that biologists should adhere to more rigorous attribution and mechanistic methods to assess ECE impacts. Subsequently, we discuss conceptual and methodological links with climatology and disturbance-, tipping point- and paleo-ecology. These research fields have close linkages with ECE research, but differ in the identity and/or the relative severity of environmental factors. By summarizing the contributions to this theme issue we draw parallels between behavioural, ecological and evolutionary ECE studies, and suggest that an overarching challenge is that most empirical and theoretical evidence points towards responses being highly idiosyncratic, and thus predictability being low. Finally, we suggest a roadmap based on the proposition that an increased focus on the mechanisms behind the biological response function will be crucial for increased understanding and predictability of the impacts of ECE.

This article is part of the themed issue ‘Behavioural, ecological and evolutionary responses to extreme climatic events’.
On detecting ecological impacts of extreme climate events and why it matters
Authors: Solow Andrew R.
Published: May 2017

There is growing interest in identifying the impacts of extreme climate events on natural systems. Two principles of such detection are that it should be based on a scientific understanding of the processes by which climate affects the system of interest and that non-climate factors that also affect the system should be controlled for. Using a simple temperature-dependent predator–prey model, this paper illustrates the importance of these principles in the context of establishing a link between temperature and population extremes. The results suggest that a naive approach based only on the co-occurrence of temperature and population extremes may fail. In the second part of the paper, some reasons for focusing attention on the ecological impacts of extreme climate events are briefly reviewed. It is suggested that, while extreme ecological events may be important for society, this does not imply that an analysis aimed at connecting them to extreme climate events should necessarily be based on extreme events themselves.

This article is part of the themed issue ‘Behavioural, ecological and evolutionary responses to extreme climatic events’.
Evolution of phenotypic plasticity in extreme environments
Authors: Chevin Luis-Miguel , Hoffmann Ary A.
Published: May 2017

Phenotypic plasticity, if adaptive, may allow species to counter the detrimental effects of extreme conditions, but the infrequent occurrence of extreme environments and/or their restriction to low-quality habitats within a species range means that they exert little direct selection on reaction norms. Plasticity could, therefore, be maladaptive under extreme environments, unless genetic correlations are strong between extreme and non-extreme environmental states, and the optimum phenotype changes smoothly with the environment. Empirical evidence suggests that populations and species from more variable environments show higher levels of plasticity that might preadapt them to extremes, but genetic variance for plastic responses can also be low, and genetic variation may not be expressed for some classes of traits under extreme conditions. Much of the empirical literature on plastic responses to extremes has not yet been linked to ecologically relevant conditions, such as asymmetrical fluctuations in the case of temperature extremes. Nevertheless, evolved plastic responses are likely to be important for natural and agricultural species increasingly exposed to climate extremes, and there is an urgent need to collect empirical information and link this to model predictions.

This article is part of the themed issue ‘Behavioural, ecological and evolutionary responses to extreme climatic events'.
No phenotypic plasticity in nest-site selection in response to extreme flooding events
Authors: Bailey Liam D. , Ens Bruno J. , Both Christiaan , Heg Dik , Oosterbeek Kees , van de Pol Martijn
Published: May 2017

Phenotypic plasticity is a crucial mechanism for responding to changes in climatic means, yet we know little about its role in responding to extreme climatic events (ECEs). ECEs may lack the reliable cues necessary for phenotypic plasticity to evolve; however, this has not been empirically tested. We investigated whether behavioural plasticity in nest-site selection allows a long-lived shorebird (
Haematopus ostralegus
) to respond to flooding. We collected longitudinal nest elevation data on individuals over two decades, during which time flooding events have become increasingly frequent. We found no evidence that individuals learn from flooding experiences, showing nest elevation change consistent with random nest-site selection. There was also no evidence of phenotypic plasticity in response to potential environmental cues (lunar nodal cycle and water height). A small number of individuals, those nesting near an artificial sea wall, did show an increase in nest elevation over time; however, there is no conclusive evidence this occurred in response to ECEs. Our study population showed no behavioural plasticity in response to changing ECE patterns. More research is needed to determine whether this pattern is consistent across species and types of ECEs. If so, ECEs may pose a major challenge to the resilience of wild populations.

This article is part of the themed issue ‘Behavioural, ecological and evolutionary responses to extreme climatic events’.
Learning from single extreme events
Authors: Altwegg Res , Visser Vernon , Bailey Liam D. , Erni Birgit
Published: May 2017

Extreme climatic events (ECEs) have a disproportionate effect on ecosystems. Yet much of what we know about the ecological impact of ECEs is based on observing the effects of single extreme events. We examined what characteristics affect the strength of inference that can be drawn from single-event studies, which broadly fell into three categories: opportunistic observational studies initiated after an ECE, long-term observational studies with data before and after an ECE and experiments. Because extreme events occur rarely, inference from such single-event studies cannot easily be made under the usual statistical paradigm that relies on replication and control. However, single-event studies can yield important information for theory development and can contribute to meta-analyses. Adaptive management approaches can be used to learn from single, or a few, extreme events. We identify a number of factors that can make observations of single events more informative. These include providing robust estimates of the magnitude of ecological responses and some measure of climatic extremeness, collecting ancillary data that can inform on mechanisms, continuing to observe the biological system after the ECE and combining observational data with experiments and models. Well-designed single-event studies are an important contribution to our understanding of biological effects of ECEs.

This article is part of the themed issue ‘Behavioural, ecological and evolutionary responses to extreme climatic events’.
Integrating plant ecological responses to climate extremes from individual to ecosystem levels
Authors: Felton Andrew J. , Smith Melinda D.
Published: May 2017

Climate extremes will elicit responses from the individual to the ecosystem level. However, only recently have ecologists begun to synthetically assess responses to climate extremes across multiple levels of ecological organization. We review the literature to examine how plant responses vary and interact across levels of organization, focusing on how individual, population and community responses may inform ecosystem-level responses in herbaceous and forest plant communities. We report a high degree of variability at the individual level, and a consequential inconsistency in the translation of individual or population responses to directional changes in community- or ecosystem-level processes. The scaling of individual or population responses to community or ecosystem responses is often predicated upon the functional identity of the species in the community, in particular, the dominant species. Furthermore, the reported stability in plant community composition and functioning with respect to extremes is often driven by processes that operate at the community level, such as species niche partitioning and compensatory responses during or after the event. Future research efforts would benefit from assessing ecological responses across multiple levels of organization, as this will provide both a holistic and mechanistic understanding of ecosystem responses to increasing climatic variability.

This article is part of the themed issue ‘Behavioural, ecological and evolutionary responses to extreme climatic events’.