bluuebunny/crossref_metadata_2025 huggingface dataset:
Interferon Alpha-2b Eye Drops Prevent Recurrence of Pterygium After the Bare Sclera Technique: A Single-Center, Sequential, and Controlled Study
Authors: Yin Mingyang , Li Hang , Zhang Yingnan , Dai Honglei , Luo Fei , Pan Zhiqiang
Published: July 2019

Purpose:

To investigate the efficacy and safety of interferon (IFN) alpha-2b eye drops in preventing pterygium recurrence after the bare sclera technique.

Methods:

Sixty eyes in 53 patients who underwent treatment for primary pterygium (the length of corneal invasion ranged from 2 to 4 mm) were enrolled in this prospective study. All patients were divided in chronological sequence into 2 groups. The control group included the first 30 eyes, whereas the treatment group included the next 30 eyes. After treatment with the bare sclera technique, levofloxacin and 0.1% fluorometholone eye drops were used 4 times a day for 3 months after surgical excision in both groups. In addition, IFN alpha-2b eye drops were applied in the treatment group 4 times a day for 3 months. Throughout an 18-month follow-up period, all patients in both groups were examined 1 day, 10 days, 1 month, 3 months, 6 months, 12 months, and 18 months after surgery. The main outcome measures were pterygium recurrence, conjunctival redness and thickness, and neovascularization and complications (ie, delayed conjunctival healing, persistent corneal epithelial defection, conjunctival granuloma, and scleral melting and necrosis).

Results:

The recurrence rates in the control group and the treatment group at the end of the sixth month were 29.2% and 3.7%, respectively, and the rates were significantly different between the 2 groups (P = 0.019). Up to 12 months after surgeries, the recurrence rate was 33.3% in the control group and 7.4% in the treatment group, and the difference between the 2 groups was statistically significant (P = 0.048). The rates at the end of 18 months were the same. During the follow-up period, no complications were observed except for 1 conjunctival granuloma (in the treatment group) and 2 corneal epithelial defects (one in the control group and the other in the treatment group).

Conclusions:

Administration of IFN alpha-2b eye drops after the bare sclera technique appear safe and effective in reducing the recurrence of pterygium.
Short-Term Effects of Ground-Level Ozone in Patients With Dry Eye Disease: A Prospective Clinical Study
Authors: Kim Yewon , Paik Hae Jung , Kim Mee Kum , Choi Yoon-Hyeong , Kim Dong Hyun
Published: July 2019

Purpose:

To investigate changes in the clinical features of patients with dry eye disease (DED) according to short-term outdoor ground-level ozone exposure.

Methods:

This prospective observational study included patients with DED who were treated with the same topical drugs (0.05% cyclosporine or 3% diquafosol) and visited the hospital twice at 2-month intervals. Patients who showed a short tear film breakup time and positive ocular surface staining were assigned to the diquafosol and cyclosporine groups, respectively. The ocular surface disease index (OSDI) score, tear secretion, tear film breakup time, and corneal fluorescein staining score were measured at each visit. The mean ground-level ozone concentration for 1 week before the ocular examinations was used as the ozone exposure level. Changes in dry eye parameters according to changes in ozone concentration were analyzed using univariate and multivariate linear analyses.

Results:

Thirty-three patients were included in the analysis. The mean age was 55.2 ± 10.5 years. Ozone concentrations were significantly associated with increased OSDI scores (R = 0.304, P = 0.0006) and a decreased tear secretion (R = −0.355, P = 0.0012) in univariate models. In multivariate models, the results were consistent; the OSDI score increased by 3.43 points (β = 3.43, P = 0.002), and tear secretion decreased by 1.43 mm (β = −1.43, P = 0.015) per 0.01 ppm increase in ozone concentrations over a 2-month interval. Notably, the cyclosporine group showed more prominent changes in the OSDI score and tear secretion with changes in the ozone concentration (P < 0.05).

Conclusions:

Short-term exposure to increased ground-level ozone concentration led to increased ocular discomfort and decreased tear secretion in patients with DED.
Lyme Neuroborreliosis in Children
Authors: Rožič Mojca , Lah Liza Lea , Ružić-Sabljić Eva , Kastrin Andrej , Arnež Maja
Published: July 2019

Background:

Information on the etiology of Lyme neuroborreliosis (LNB) in children in Europe and the influence of Borrelia burgdorferi sensu lato species isolated from cerebrospinal fluid (CSF) on clinical presentation of LNB in children are limited.

Methods:

The study was monocentric. During its 17-year period, children younger than 15 years with presentation suggestive of LNB or confirmed Lyme borreliosis that had B. burgdorferi sensu lato isolated from CSF and had species of B. burgdorferi sensu lato identified by pulsed-field gel electrophoresis were included. Demographic and medical data were compared for children infected with Borrelia garinii to those infected with Borrelia afzelii.

Results:

One hundred and fifty-three children had B. burgdorferi sensu lato isolated from CSF. In 71/113 (62.8%) and 42/113 (37.2%) patients, B. garinii and B. afzelii, respectively, were identified. Patients infected with B. garinii did not report symptoms suggestive of central nervous system (CNS) involvement or any other symptoms more often than patients infected with B. afzelii. Compared with children infected with B. afzelii, children infected with B. garinii had erythema migrans less often (18.3% vs. 45.2%) but had positive meningeal signs (69.0% vs. 38.1%), CSF lymphocytic predominance (97.1% vs. 75.0%), and elevated albumin CSF/serum quotient (80.6% vs. 50.0%) more often.

Conclusions:

In Slovenia, LNB in children is more often caused by B. garinii, followed by B. afzelii. The clinical picture of LNB in children caused by B. garinii is not more often suggestive of CNS involvement, but CNS inflammation is more pronounced in children infected with B. garinii, compared with children infected with B. afzelii.
Educational and Experiential Factors Associated With Physical Therapists' Diagnostic Reasoning
Authors: Souter Courtney , Musy Emily , Hartstein Aaron , Lievre Arthur , Fergus Andrea
Published: July 2019

Introduction.

The influence of education level, post-professional training, and experience on physical therapists' (PTs) diagnostic reasoning is unknown. The purpose of this study was to examine the influence of education, training, and experience on PTs' diagnostic reasoning through a series of musculoskeletal case-based surveys. While literature supports quality of care's influence on health care costs, the factors influencing PTs' quality of care are unclear. Literature suggests that surgeons with post-professional training and more experienced Emergency Room physicians demonstrate better patient outcomes, diagnostic accuracy, and efficiency.

Methods.

Five hundred and twenty-nine licensed PTs participated in this study. A series of 5 case-based electronic surveys assessed participants' diagnostic reasoning in orthopedic presentations. Response rates ranged from 55% to 40%. Accuracy, efficiency, and hypothesis-generation strategies were analyzed to examine diagnostic reasoning. Strength of associations, diagnostic accuracy, and hypothesis-generation strategies were examined via odds ratios; efficiency of determining the accurate diagnosis was examined via t tests.

Results.

Hypothetico-deductive reasoning by systematically eliminating competing diagnoses (funneling) demonstrated significant correlation with accuracy in 4 of the 5 cases (odds ratio [OR] 2.46 [1.19–5.10] to 13.9 [6.12–31.5]). Physical therapists with any American Board of Physical Therapy Specialities (ABPTS) certification demonstrated significantly greater diagnostic accuracy (OR 2.1 [1.41–3.807] to 3.00 [1.22–7.36]) and efficiency (P < .05) in 3 of the 5 cases compared to those without ABPTS certification. Board-Certified Orthopedic Clinical Specialists (OCS) demonstrated significantly greater diagnostic accuracy (OR 1.90 [1.08–3.34] to 3.42 [1.42–8.40]) and efficiency (P < .05) compared to those without ABPTS OCS certification. Residency-trained PTs demonstrated significantly greater diagnostic accuracy (OR 2.02 [1.03–3.96] to 2.84 [1.38–5.82]) and efficiency (P < .05) compared to those without residency training. Degree level, experience, and fellowship training were not related to accuracy, efficiency, or funneling hypotheses (P > .05).

Discussion and Conclusion.

American Board of Physical Therapy Specialities certification and American Board of Physical Therapy Residency and Fellowship Education training's significant association with both diagnostic accuracy and efficiency suggests the importance of PTs' pursuit of ABPTS certification and/or formal post-professional training in developing diagnostic reasoning and expertise. These post-professional endeavors may lead to appropriate care more quickly, improving patient outcomes, and decreasing health care costs.
Utilization of the Clinical Reasoning Assessment Tool Across a Physical Therapy Curriculum: Application for Teaching, Learning, and Assessment
Authors: McDevitt Amy , Rapport Mary Jane , Jensen Gail , Furze Jennifer
Published: July 2019

Introduction.

Clinical reasoning is a multifaceted skill set crucial to optimal patient care. The ability to assess development of clinical reasoning skills in entry-level physical therapist students continues to be challenging. The Clinical Reasoning Assessment Tool (CRAT) was developed in order to assess students' progress in the essential link between clinical reasoning and the development of knowledge. Based on a previously published tool (Clinical Reasoning Grading Rubric), the CRAT considers 3 domains representing clinical reasoning and knowledge development (content knowledge, procedural knowledge and psychomotor skills, and conceptual reasoning).

The purpose of this study was to determine whether the use of the CRAT would reliably reflect student progress in acquisition and application of clinical reasoning skills across didactic and clinical components of physical therapist education and to determine whether case context impacts performance.

Methods.

A cross-sectional study was performed using the CRAT to assess student performance at 4 specific time points across 2 years of a physical therapy curriculum. Fifty-five students from 2 consecutive class cohorts were assessed using the CRAT. Eleven assessors scored 172 completed tools using a visual analog scale representing a learner continuum (beginner, intermediate, competent, and proficient). Analysis of variance (ANOVA) was used to determine whether time and case context were predictors of performance in each of the 3 clinical reasoning domains.

Results.

Mean scores in each of the 3 domains steadily increased at each performance assessment point, and results of the ANOVA showed that each specified time point was significantly predictive of performance in each of the 3 domains of interest (P < .0001 for each). In addition, case context is predictive of procedural knowledge (P = .007) and conceptual reasoning (P = .0297).

Discussion and Conclusions.

The results of this study, and observations related to use of the tool, demonstrate the utility of the CRAT in measuring the performance of physical therapy students.
Emergency care: Operationalizing the practice through a concept analysis
Authors: Davis Wesley D. , Dowling Evans Dian , Fiebig William , Lewis Chrystal L.
Published: July 2019

Background and Purpose:

Current uses of emergency care are ambiguous and lack clarity, leading to imprecise use of the term in nursing practice. An explicit definition of emergency care is necessary to build and advance the field. An empirically driven definition of emergency care is lacking in the refereed literature. The purpose of this article was to present an in-depth inquiry of emergency care that contributes to the advancement of knowledge and to articulate a defensible definition of emergency care.

Methods:

This concept analysis was performed using the eight-step approach of Walker and Avant. A database search within the disciplines of nursing, medicine, education, and social sciences was conducted using the keyword emergency care. Databases of refereed literature were reviewed. Additional searches of nonrefereed literature, such as dictionaries and thesauri, were also examined.

Conclusions:

Based on this concept analysis, the attributes of emergency care include the immediate evaluation and treatment of an unexpected illness or injury. Emergency care is not specific to a setting or location. Antecedents to emergency care consist of a precipitating event, recognition that medical help is required, and access to emergency care. A model, borderline, related, and contrary cases of emergency care are presented.

Implications for practice:

The identification of emergency care attributes in this concept analysis contributes to the body of knowledge in emergency care and clarifies the ambiguity of the concept to prompt developments in practice, theory, and research with implications for emergency nurse practitioner clinical education, and scope of practice regulation.
The Changing Distribution of Length of Hospitalization at Academic Medical Centers 2007–2016
Authors: Doctoroff Lauren , Mukamal Kenneth J.
Published: July 2019

Background:

Length of stay (LOS) remains a primary focus for hospitals, and patients with prolonged LOS disproportionately affect hospital capacity and costs. We recently showed that long LOS patients are increasingly hospitalized at academic centers, but their effect on the distribution of LOS is unknown.

Methods:

Using the Vizient Clinical Data Base/Resource Manager (CDB/RM), which includes over 90% of the academic medical centers in the United States, we examined trends in the distributions of LOS for acute medical/surgical hospitalizations from 2007 to 2016 in 117 hospitals. We excluded patients under 18 years and those with primary psychiatry, obstetric or rehabilitation diagnoses.

Results:

Two separate trends were evident during this time period. Mean LOS decreased steadily from 2007 to 2010, but then rose steadily from 2011 and reached its maximum in 2016. Median LOS remained consistent at 3 days from 2007 to 2013 but it too rose from 2014 to 2016. As expected from the difference between the mean and median values, LOS at the 99th percentile dropped from 2007 to 2010 but then rose back by 2016. Gini coefficient values, used to measure inequalities in distribution, declined modestly from 2007 to 2010 but then remained unchanged through 2016. Results were similar in analyses adjusted for age, sex, and case-mix index.

Conclusions:

The beginning of the study period was characterized by a reduction in mean LOS, driven largely by decreases of the longest hospitalizations and greater uniformity in LOS. The latter portion saw steady increases in LOS that were similar across the entire distribution of hospitalizations. If the nadir in LOS has truly been reached, these trends will complicate the long-term health of academic medical centers and their staff, faculty, and trainees.
Maximizing Effectiveness of the Holistic Admission Process
Authors: Wagner Robin , Maddox Krista R. , Glazer Greer , Hittle Beverly M.
Published: July 2019

Background

Nursing programs have responsibility to become more holistic in admission practices, ensuring they admit applicants based on more than grades and test scores to determine the best fit for their program.

Problem

One frequently cited holistic admissions barrier is incorporating qualitative measurement of applicant characteristics through interviews. Finding the best interview model is a challenge, depending on a program's intent to learn about applicants.

Approach

This article describes the planning and implementation process for incorporating the Multiple Mini Interview (MMI) model into an existing holistic nursing program admission process.

Outcomes

MMI model implementation resulted in more congruency in student attributes with the college vision, mission, and values and increased diversity.

Conclusion

An efficient, well-organized MMI interview model was implemented, allowing achievement of overall admission goals and ensuring selected applicants demonstrate attributes aligned with college values and vision and increased diversity.
Spectral Evaluation of Eyeglass Blocking Efficiency of Ultraviolet/High-energy Visible Blue Light for Ocular Protection
Authors: Giannos Steven A. , Kraft Edward R. , Lyons Lance J. , Gupta Praveena K.
Published: July 2019

SIGNIFICANCE

We investigated, for safety and awareness, ultraviolet and high-energy violet light–blocking protection provided by assorted types of eyewear. Ultraviolet and high-energy violet light–filtering efficiency varied and did not correlate with price or advertised claims. Standardization of methods and specifications for lens spectral transmission evaluation is recommended.

PURPOSE

Studies have linked exposure of high-energy visible blue light to effect and damage on retinal epithelial cells, photoreceptors, and ganglion cells. “Blue light” is more accurately differentiated into “high-energy visible blue-violet light” and “circadian rhythm blue-turquoise light.” This study measured and compared spectral transmission of ultraviolet and high-energy violet light of low-, medium-, and high-priced sunglasses.

METHODS

Sunglasses and lens blanks were obtained from the University of Texas Medical Branch Optical Shop and vendors. Groups were based on promotional, retail, designer sunglasses, or “blue blocker” lenses. The percent transmittance of ultraviolet/visible spectral scans (800 to 350 nm) was measured using an Agilent Cary 50 spectrophotometer. High-energy violet/blue light was defined as 400 to 450 nm.

RESULTS

Promotional sunglasses (tinted polycarbonate) blocked 100% ultraviolet and 67 to 99.8% high-energy violet blue light. Retail sunglasses filtered out 95 to 100% ultraviolet A and 67% high-energy violet light. The tested designer sunglasses varied widely in their optical transmissibility with respect to their ultraviolet A and high-energy violet light–blocking properties, with some not blocking ultraviolet A. Clear and colorless Kodak Total Blue provided maximal high-energy violet protection, whereas clear Essilor Crizal Prevencia provided less high-energy violet blocking between 400 and 450 nm.

CONCLUSIONS

The ultraviolet and high-energy violet (400 to 450 nm) light–filtering efficiency varied between sunglasses and clear lenses and did not correlate with price or advertised claims. Standardization of methods and specifications for lens spectral transmission evaluation is recommended.
Combined Topical Anti-inflammatory and Oral Acetazolamide in the Treatment of Central Serous Chorioretinopathy
Authors: Wuarin Raphael , Kakkassery Vinodh , Consigli Andrea , Roquelaure Daniel , Papanastasiou Athanasios , Schutz James Scott , Thumann Gabriele , Chronopoulos Argyrios
Published: July 2019

SIGNIFICANCE

Central serous chorioretinopathy (CSCR) is still a therapeutic challenge with no criterion standard treatment. However, anatomic changes at the level of the retinal pigment epithelium could prove of predictive value in the course of the disease for selective treatment in cases of increased risk of chronicity.

PURPOSE

This pilot study analyzes the efficacy for treating acute CSCR with combined systemic acetazolamide 250 mg twice a day and nepafenac 0.1% eye drops three times a day in comparison with an untreated control group. It also evaluates the presence a pigment epithelial detachment (PED) as a risk factor for chronic CSCR.

METHODS

Nineteen consecutive patients (group 1) with new or new onset of recurrent CSCR were treated with oral acetazolamide and nepafenac eye drops for at least 2 months. A control group of 14 patients (group 2) with new or new onset of recurrent CSCR were untreated while under regular observation for 4 months. Primary end points were central macular thickness and best-corrected visual acuity after 4 months. Secondary end points were complete regression of subretinal fluid at 3 months and association of PED at baseline with recurrent or chronic CSCR imaged by optical coherence tomography.

RESULTS

Group 1 showed significantly faster resolution of subretinal fluid with a mean central macular thickness at 4 months of 271 ± 85 μm compared with 322 ± 79 μm for group 2 (P < .05), but with no functional benefit with a best-corrected visual acuity at 4 months of 0.8 ± 0.2 for group 1 compared with 0.9 ± 0.1 for the control group (P < .05). Patients with a small flat PED were at a higher risk of developing chronic CSCR compared with patients with a dome-shaped or no PED (P < .05).

CONCLUSIONS

Central serous chorioretinopathy remains a therapeutic challenge. This pilot study shows faster resolution of subretinal fluid with treatment but without functional benefit compared with observation. The presence of small, flat PED was associated with development of chronic CSCR.
Celiac Disease: Updates on Pathology and Differential Diagnosis
Authors: Dai Yinghuan , Zhang Qin , Olofson Andrea M. , Jhala Nirag , Liu Xiuli
Published: July 2019

Celiac disease is a gluten-triggered immune-mediated disorder, characterized by inflammation of the enteric mucosa following lymphocytic infiltration and eventually resulting in villous blunting. There have been many developments in refining diagnostic laboratory tests for celiac disease in the last decade. Biopsy-sparing diagnostic guidelines have been proposed and validated in a few recent prospective studies. However, despite these developments, histologic evaluation of duodenal mucosa remains one of the most essential diagnostic tools as it helps in the diagnosis of celiac disease in individuals who do not fulfill the biopsy-sparing diagnostic criteria and in those not responding to a gluten-free diet. Histologic evaluation also allows for the assessment of mucosal recovery after treatment and in the identification of concurrent intestinal diseases. Therefore, pathologists should be familiar with the histologic spectrum of celiac disease and need to be aware of other disorders with similar symptoms and histopathology that may mimic celiac disease. This review aims to provide pathologists with updates on celiac laboratory testing, biopsy-sparing diagnostic criteria, histopathology, complications, and differential diagnoses of celiac disease.
Simulation-Based Curricula for Enhanced Retention of Pediatric Resuscitation Skills
Authors: Jani Priti , Blood Angela D. , Park Yoon Soo , Xing Kuan , Mitchell Diana
Published: July 2019

Introduction

Resuscitation skills decay as early as 4 months after course acquisition. Gaps in research remain regarding ideal educational modalities, timing, and frequency of curricula required to optimize skills retention. Our objective was to evaluate the impact on retention of resuscitation skills 8 months after the Pediatric Advanced Life Support (PALS) course when reinforced by an adjunct simulation-based curriculum 4 months after PALS certification. We hypothesized there would be improved retention in the intervention group.

Methods

This is a partial, double-blind, randomized controlled study. First-year pediatric residents were randomized to an intervention or control group. The intervention group participated in a simulation-based curriculum grounded in principles of deliberate practice and debriefing. The control group received no intervention. T-tests were used to compare mean percent scores (M) from simulation-based assessments and multiple-choice tests immediately following the PALS course and after 8 months.

Results

Intervention group (n = 12) had overall improved retention of resuscitation skills at 8 months when compared with the control group (n = 12) (mean, 0.57 ± 0.05 vs 0.52 ± 0.06; P = 0.037). No significant difference existed between individual skills stations. The intervention group had greater retention of cognitive knowledge (mean, 0.78 ± 0.09 vs 0.68 ± 0.14; P = 0.049). Residents performed 61% of assessment items correctly immediately following the PALS course.

Conclusions

Resuscitation skills acquisition from the PALS course and retention are suboptimal. These findings support the use of simulation-based curricula as course adjuncts to extend retention beyond 4 months.
Frequent Emergency Department Use by Children
Authors: Vivier Patrick M. , Rogers Michelle L. , Gjelsvik Annie , Linakis James G. , Schlichting Lauren E. , Mello Michael J.
Published: July 2019

Objectives

Frequent use of the emergency department (ED) is often targeted as a quality improvement metric. The objective of this study was to assess ED visit frequency by the demographic and health characteristics of children who visit the ED to better understand risk factors for high ED utilization.

Methods

The majority of pediatric ED services in Rhode Island are provided by a hospital network that includes the state's only children's hospital. Using 10 years of data (2005–2014) from this statewide hospital network, we examined ED use in this network for all children aged 0 to 17 years. Patients' home addresses were geocoded to assess their neighborhood characteristics.

Results

Between 2005 and 2014, 17,844 children visited 1 or more of the network EDs at least once. In their year of maximum use, 67.8% had only 1 ED visit, 20.1% had 2 visits, 6.9% had 3 visits, and 5.2% had 4 or more visits. In the adjusted multinomial logistic regression model, age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the ED were found to be significantly associated with increased visit frequency.

Conclusions

Risk factors for frequent ED use by children include age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the hospital. To decrease frequent pediatric ED use, improved medical management of complex medical problems is needed, but it is also essential to address modifiable social determinants of health care utilization in this population.
Clinical Indicators of Pediatric Shunt Malfunction
Authors: Razmara Ashkaun , Jackson Eric M.
Published: July 2019

Objectives

The majority of the previous literature on clinical predictors of shunt malfunction is from the neurosurgical data, looking at the symptoms of patients who had surgery. Because common childhood illnesses are filtered from these samples, the prevalence of shunt malfunction is markedly higher than it would be for the pediatrician's office or emergency department (ED). Clinical predictive values obtained from a representative population can better inform clinical judgment in these environments.

Methods

A retrospective analysis of the Nationwide Emergency Department Sample (2006–2015) was performed. International Classification of Diseases, Ninth Revision, Clinical Modification Diagnosis/Procedure Codes were used to identify pediatric (≤20 years of age) ED visits with the presence of a cerebrospinal fluid (CSF) shunt (V45.2). Shunt malfunction was defined as any condition resulting in surgical revision (02.41, 02.42, 02.43). Multivariable logistic regression was used to examine the associations between shunt malfunction, demographic factors, and clinical presentation.

Results

There were 74,552 observations for ED visits by pediatric patients with a CSF shunt between 2006 and 2015, of which 12.8% (9,560) required shunt revision. Positive predictive values for clinical indicators were reported along with the results of multivariable logistic regression.

Conclusions

We identified peritonitis, papilledema, and oculomotor palsies as the strongest clinical indicators for shunt malfunction in pediatric ED visits with a CSF shunt. We found that patients presenting with headache, nausea/vomiting, convulsions, or fever were more likely to have an etiology other than shunt malfunction. Thus, after an appropriate shunt evaluation, other sources of symptoms should be investigated.
Otherwise Healthy 15-Month-Old With Rapid-Onset Soft Tissue Swelling
Authors: Anderson Julie Jelaine , Avendano Pablo , Kaila Rahul
Published: July 2019

Necrotizing soft tissue infections are a serious medical emergency that involve necrosis within the soft tissue space including the dermis, subcutaneous tissue, superficial fascia, deep fascia, and muscle. Inciting factors include recent varicella infection, omphalitis, trauma, intramuscular injections, perianal trauma, and surgery. Unlike adult cases, children presenting with necrotizing soft tissue infections are more likely to be immunocompetent and without underlying chronic illnesses. Although rare in children, familiarity with the clinical manifestations of necrotizing soft tissue infections is essential for early diagnosis and surgical debridement, as significant mortality is associated with advanced disease.
Point-of-Care Ultrasound for Targeted Assessment of Shock
Authors: Weberding Nathaniel T. , Marin Jennifer R.
Published: July 2019

The differential diagnosis for patients presenting in shock can be broad, making rapid diagnosis and management challenging. We present a case of a medically complex patient with presumed septic shock, diagnosed with a large pericardial effusion with evidence of tamponade using the rapid ultrasound in shock and hypotension protocol. The point-of-care ultrasound examination allowed for more timely and definitive management.
Intralymphatic Rosai-Dorfman Disease Associated With Vulvar Lymphedema: A Case Report of an Extremely Rare Phenomenon
Authors: Saleem Atif , Hoffmann Jenny , Warnke Roger , Rieger Kerri E. , Longacre Teri
Published: July 2019

Sinus histiocytosis with massive lymphadenopathy, also known as Rosai-Dorfman disease (RDD), is a self-limited histiocytic disorder of unclear etiology which most commonly presents with cervical lymphadenopathy. Purely extranodal presentation of RDD is uncommon, and isolated intralymphatic/intravascular confinement of this entity has not previously been described. We report a 16-yr-old female who presented with vaginal swelling and mass-like enlargement of the right labia. The mass had been present for nearly a year without pain or tenderness. Clinically, the lesion was thought to be a Bartholin gland cyst. Following surgical resection, histologic examination demonstrated a hypocellular myxedematous stroma with a mixture of ectatic thin and thick-walled vessels within which there were numerous collections of histiocytes, lymphocytes, and plasma cells. The histopathologic differential diagnosis included localized vulvar lymphedema, a specialized genital tract neoplasm, and childhood asymmetric labium majus enlargement. The histiocytes showed occasional plasma cells and lymphocytes within their cytoplasm, consistent with emperipolesis. Immunohistochemical studies showed that the histiocytes expressed CD163 and S100, while ERG and D2-40 highlighted their intralymphatic confinement, ultimately leading to the diagnosis of intralymphatic RDD. Intralymphatic RDD may present as vulvar lymphedema and can potentially mimic other myxedematous neoplasms of the vulvovaginal region.
HPV-independent Vulvar Squamous Cell Carcinoma is Associated With Significantly Worse Prognosis Compared With HPV-associated Tumors
Authors: Allo Ghassan , Yap Mei Ling , Cuartero Julie , Milosevic Michael , Ferguson Sarah , Mackay Helen , Kamel-Reid Suzanne , Weinreb Ilan , Ghazarian Danny , Pintilie Melania , Clarke Blaise A.
Published: July 2019

Vulvar squamous cell carcinomas (VSCC) represent the most common carcinoma of the female external genitalia, with increasing incidence. Although high-risk human papillomavirus (HPV) infection has long been implicated in the majority of cervical and anal squamous cell carcinomas, there is uncertainty about its prevalence and prognostic impact in VSCC. In this study, we conducted a retrospective integrated morphologic and multimodal HPV analysis of a cohort of 114 VSCC cases treated at the Princess Margaret Cancer Centre/University Health Network, Toronto, Canada between 2000 and 2010. VSCC histology was reviewed. We analyzed the cohort for HPV using polymerase chain reaction based method, and tissue microarray DNA and RNA in situ hybridization (ISH), and p16 immunohistochemistry. Among the 114 cases (age 70±16 yr), 36.7% of cases were classified as having histomorphology of HPV infection. HPV was detected in 31.9% (polymerase chain reaction), 14.0% (DNA ISH), and 27.3% (RNA ISH) of cases. p16 immunohistochemistry was positive in 37.8% of cases. On univariate analysis, HPV morphology (P=0.009), p16+ (P=0.00013), DNA ISH+ (P=0.021), and RNA ISH+ (P=0.00061) were associated with better 5-yr progression-free survival. DNA ISH+ (P=0.049) was associated with better 5-yr overall survival. On multivariate analysis, HPV morphology (P=0.033), p16+ (P=0.01), and RNA ISH+ (P=0.035) were associated with better 5-yr progression-free survival. In conclusion, a subset of VSCC is associated with HPV, which correlates with better outcome. Relatively inexpensive tests such as histomorphologic evaluation, p16 immunohistochemistry, and HPV RNA ISH can be used to predict outcome in VSCC. Therefore, routine reporting of HPV status in VSCC is recommended.
Primary Peritoneal Low-grade Serous Carcinoma in a Patient With Lynch Syndrome: A Case Report
Authors: Makiuchi Satomi , Yoshida Hiroshi , Ishikawa Mitsuya , Kojima Naoki , Kanai Yae , Kato Tomoyasu
Published: July 2019

Lynch syndrome (LS) is an autosomal dominant disease caused by a germline mutation in DNA mismatch repair genes which increases the risk of several cancers such as endometrial and colorectal cancers. However, there are only a few reports of peritoneal malignancies in patients with LS. Herein, we report the first case of a primary peritoneal low-grade serous carcinoma in a woman with LS and provide a literature review of peritoneal malignancies in patients with LS. The patient was a 72-yr-old gravid 2 para 2 Japanese woman with a germline mutation in MLH1. She had a history of colon cancer and endometrial cancer and was treated with total hysterectomy and bilateral salpingo-oophorectomy 14 yr ago. During the follow-up, peritoneal nodules were detected by abdominal computed tomography which were surgically resected. Pathologic examination revealed a low-grade serous carcinoma with cells positive for BerEP4, MOC31, CEA, and WT-1 and negative for BAP1, PAX8, MLH1, and PMS2, by immunohistochemistry. This case report and literature review show that peritoneal low-grade serous carcinoma can occur in patients with LS and that LS-related cancers usually precede primary peritoneal malignancies. The differential diagnosis for peritoneal nodules in patients with LS should, therefore, include peritoneal serous carcinoma and malignant mesothelioma besides metastasis of LS-related cancers. Considering the ambiguous immunophenotypes, a combination of immunohistologic markers would be useful for an accurate diagnosis of such cases.
Reconstruction of Gustilo Type IIIC Injuries of the Lower Extremity
Authors: Ricci Joseph A. , Abdou Salma A. , Stranix John T. , Lee Z-Hye , Anzai Lavinia , Thanik Vishal D. , Saadeh Pierre B. , Levine Jamie P.
Published: July 2019

Background:

Gustilo type IIIC open tibia fractures are characterized by an ischemic limb requiring immediate arterial repair. In this patient population, the decision between primary amputation and limb salvage can be challenging. This study aims to evaluate the reconstructive outcomes of patients with Gustilo type IIIC injuries.

Methods:

A single-center retrospective review of 806 lower extremity free flaps from 1976 to 2016 was performed. Flap loss and salvage rates for patients with Gustilo type IIIC injuries were determined. To determine the utility of performing salvage in this group, outcomes of the IIIC reconstructions were compared to those of similar patients with Gustilo I type IIB injuries with only a single patent vessel.

Results:

A total of 32 patients with Gustilo type IIIC injuries underwent reconstruction after traumatic injury. Ten patients (31.3 percent) experienced a perioperative complication, including seven unplanned returns to the operating room (21.9 percent), three partial flap losses (9.4 percent), and five complete flap losses (15.6 percent). When type IIIC injuries were compared with single-vessel Gustilo type IIIB injuries, no statistically significant differences were noted with respect to major perioperative complications (p = 0.527), unplanned return to the operating room (p = 0.06), partial flap loss (p = 0.209), complete flap loss (p = 0.596), or salvage rate (p = 0.368). Although this result was not statistically significant, Gustilo type IIIC injuries trended toward lower take-back rates and higher salvage rates compared with single-vessel Gustilo type IIIB injuries.

Conclusion:

Patients with Gustilo type IIIC open tibia fractures should be considered candidates for limb salvage, as flap loss and reconstruction of these injuries are comparable to those of the routinely reconstructed single-vessel runoff type IIIB injuries.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Ultrasound Time-Harmonic Elastography of the Aorta
Authors: Schaafs Lars-Arne , Tzschätzsch Heiko , Reshetnik Alexander , van der Giet Markus , Braun Jürgen , Hamm Bernd , Sack Ingolf , Elgeti Thomas
Published: July 2019

Objectives

The aim of this study was to investigate ultrasound time-harmonic elastography for quantifying aortic stiffness in vivo in the context of aging and arterial hypertension.

Materials and Methods

Seventy-four participants (50 healthy participants and 24 participants with long-standing hypertension) were prospectively included between January 2018 and October 2018, and underwent ultrasound time-harmonic elastography of the upper abdominal aorta. Compound maps of shear-wave speed (SWS) as a surrogate of tissue stiffness were generated from multifrequency wave fields covering the full field-of-view of B-mode ultrasound. Blood pressure and pulse wave velocity were measured beforehand. Interobserver and intraobserver agreement was determined in 30 subjects. Reproducibility of time-harmonic elastography was assessed in subgroups with repeated measurements after 20 minutes and after 6 months. Linear regression analysis, with subsequent age adjustment of SWS obtained, receiver operating characteristic analysis, and intraclass correlation coefficients (ICCs) were used for statistical evaluation.

Results

Linear regression analysis revealed a significant effect of age on SWS with an increase by 0.024 m/s per year (P < 0.001). Age-adjusted SWS was significantly greater in hypertensives (0.24 m/s; interquartile range [IQR], 0.17–0.40 m/s) than in healthy participants (0.07 m/s; IQR, −0.01 to 0.06 m/s; P < 0.001). A cutoff value of 0.15 m/s was found to differentiate best between groups (area under the receiver operating characteristic curve, 0.966; 95% confidence interval, 0.93–1.0; P < 0.001; 83% sensitivity and 98% specificity). Interobserver and intraobserver variability was excellent (ICC, 0.987 and 0.937, respectively). Reproducibility was excellent in the short term (ICC, 0.968; confidence interval, 0.878–0.992) and good in the long term (ICC, 0.844; confidence interval, 0.491–0.959).

Conclusions

Ultrasound time-harmonic elastography of the upper abdominal aorta allows quantification of aortic wall stiffness in vivo and shows significantly higher values in patients with arterial hypertension.
Nasoplatine Island Advancement Flap for Closure of Anterior Palatal Fistula in Patient With Isolated Cleft Palate
Authors: Rahpeyma Amin , DDS Saeedeh Khajehahmadi
Published: July 2019

Palatal fistula is common in cleft patients. Palatal fistula repair is difficult, and there is 10% to 30% recurrence rate. Application of nasopalatine Island advancement flap for easy closure of medium size anterior palatal fistula in isolated cleft patient is demonstrated. Anatomic basis, advantages, and limitations of this new flap are explained. Nasopalatine Island advancement flap is a useful aid for easy closure of medium size anterior palatal fistula in isolated cleft patient.
Evaluation of the Spatial Position and Correlation of Mandibular Ramus in Skeletal Class III Patients With Mandibular Asymmetry
Authors: Qu Guan-Lin , Xu Jing , Zhou Qing
Published: July 2019

Purpose:

To evaluate the position and bilateral difference of mandibular ramus region, specifically the condyle, sigmoid notch, and mandibular angle in skeletal class III patients with mandibular asymmetry.

Materials and Methods:

3D-CT images were performed in 50 patients with skeletal class III malocclusion. According to the severity of mandibular asymmetry, 22 cases were included in the control group and 28 cases were included in the symmetry group. The 3D landmarks were measured relative to 6 reference planes and the outcomes among different groups were compared.

Results:

There are significant differences in the position of mandibular ramus region between both sides in the asymmetry group. The position of condyle was more posterior and internal on the deviated side; and the positions of sigmoid notch and gonion were more posterior, superior, and lateral on the deviated side. Furthermore, the degree of mandibular asymmetry was more highly correlated with the height of ramus and the position of mandibular angle than it was with the height of condyle and the position of sigmoid notch.

Conclusion:

When evaluating mandibular asymmetry and making surgical plans, the position of mandibular ramus should be taken into consideration.
The Upper Third in Facial Gender Confirmation Surgery: Forehead and Hairline
Authors: Capitán Luis , Simon Daniel , Bailón Carlos , Bellinga Raúl J. , Gutiérrez-Santamaría Javier , Tenório Thiago , Capitán-Cañadas Fermín
Published: July 2019

The upper third of the face contains 2 features that are particularly important for facial gender recognition: the frontonasoorbital region and the hairline. The supraorbital ridge, which determines the position and exposure of the eyebrows, is almost invariably more developed in the male than in the female. Surgical modification of the frontonasoorbital complex, considered a standard procedure in facial feminization, is reliable and predictable, and also delivers satisfactory results that are stable over time.

A prototypical male hairline has an M-shaped pattern compared to the more rounded shape often seen in female hairlines. Feminization of the hairline requires minimizing the temples as well as rounding out the overall shape, optimizing hair density, and occasionally changing the height of the hairline.

This article provides an update on our forehead reconstruction technique and our experience in the treatment of hairline redefinition.
Artifacts That Can Be Misinterpreted as Interictal Discharges
Authors: Mathias Sally V. , Bensalem-Owen Meriem
Published: July 2019

It is presumed that the EEG records only cerebral activity. However, frequently it can include other electrical activities, referred to as noise or artifact, which are not of cerebral origin. In the last few decades, evolution in digital technology has greatly improved the ability to record and display interpretable EEG. With the widespread availability of prolonged EEG recording, new artifacts have been described. The addition of concomitant video with audio during recordings has allowed in most instances to determine the source of certain artifacts. One of the challenges of interpreting EEGs consists of identifying artifacts correctly. Some of the EEG artifacts are so distinctive in appearance that the experienced reader can readily identify them. It is not uncommon for normal EEGs to be overinterpreted, especially by inexperienced readers. Failing to identify artifacts correctly can lead to “over reading” a study and doing so can result in misdiagnosis of epilepsy. This in turn can result in inappropriate treatments that ultimately can have serious clinical implications. This review will provide a description of the most commonly encountered artifacts that mimic spike or sharp waves, also referred to as interictal epileptiform discharges. In addition, we will describe troubleshooting approaches to eliminate these artifacts whenever possible. Artifacts that mimic ictal discharges will be reviewed in a different section.
Normal Variants Are Commonly Overread as Interictal Epileptiform Abnormalities
Authors: Kang Joon Y. , Krauss Gregory L.
Published: July 2019

Electroencephalographers may misclassify benign variant EEG patterns as epileptiform discharges, resulting in delays in the diagnosis and appropriate treatment of other paroxysmal disorders, such as psychogenic nonepileptic seizures, anxiety/panic disorders, and near syncope. These benign variant patterns include wicket spikes, small sharp spikes, and rhythmic mid-temporal theta of drowsiness. Cautious interpretations of semi-rhythmic sharp transients, usually gradually rising from the EEG background in drowsiness, can help avoid misdiagnosing patients as having seizures. Viewing the EEG as confirmatory for a clear clinical diagnosis is also helpful—elderly patients with syncope, for example, often have microvascular disease and EEG wicket rhythms in drowsiness—a careful review of the clinical history and the paroxysmal EEG pattern usually help distinguish normal variant patterns from interictal sharp waves and spikes and avoid misdiagnosing epilepsy.
Phased diploid genome assemblies for three strains ofCandida albicansfrom oak trees
Authors: Hamlin Jennafer A. P. , Dias Guilherme , Bergman Casey M. , Bensasson Douda
Published: July 2019

Although normally a harmless commensal,Candida albicanshas the potential to generate a wide range of infections including systemic candidaemia, making it the most common cause of bloodstream infections worldwide with a high rate of mortality.C. albicanshas long been considered an obligate commensal, however, recent studies suggest it can live outside animal hosts. Here, we have generated PacBio sequencing and phased genome assemblies for threeC. albicansstrains from oak trees in the United Kingdom (NCYC 4144, NCYC 4145, and NCYC 4146). Our results provide phasedde novodiploid assemblies forC. albicansand provide a framework to study patterns of genomic variation within and among strains of an important fungal pathogen.
Inflammasome-mediated antagonism of type I interferon enhancesRickettsiapathogenesis
Authors: Burke Thomas P. , Engström Patrik , Chavez Roberto A. , Fonbuena Joshua A. , Vance Russell E. , Welch Matthew D.
Published: July 2019

Inflammasomes and interferons constitute two critical arms of innate immunity. Most facultative bacterial pathogens that inhabit the host cell cytosol avoid activating inflammasomes and are often resistant to killing by type I interferon (IFN-I). We report that the human pathogenRickettsia parkeri,an obligate intracellular pathogen that resides in the cytosol, is sensitive to IFN-I. The mechanism of IFN-I-dependent restriction requires the transcription factor IRF5, which upregulates anti-rickettsial factors including guanylate-binding proteins and iNOS. However,R. parkericurtails cGAS-dependent IFN-I production by causing caspase-11-dependent pyroptosis.In vivo, inflammasome activation antagonizes IFN-I production, enhancingR. parkeriabundance in the spleen. Mice lacking either IFN-I or IFN-γ signaling are resistant to infection, but mice lacking both rapidly succumb, revealing that both interferons are required to controlR. parkeri. This study illuminates how an obligate cytosolic pathogen exploits the intrinsic trade-off between cell death and cytokine production to escape killing by innate immunity.

Highlights

Rickettsiakilled by GBPs activates caspase-11 and GSDMD, promoting pyroptosis

Rickettsiaexploits pyroptosis to avoid cGAS-dependent type I interferon

IRF5, GBPs, and iNOS contribute to controllingR. parkeriinfection

Ifnar-/-Ifngr-/-mice succumb to infection, uncovering a mouse model to studyR. parkeri