bluuebunny/crossref_metadata_2025 huggingface dataset:
Preoperative Prognostic Nutritional Index Predicts Long‐Term Surgical Outcomes in Patients with Esophageal Squamous Cell Carcinoma
Authors: Hirahara Noriyuki , Tajima Yoshitsugu , Fujii Yusuke , Kaji Shunsuke , Yamamoto Tetsu , Hyakudomi Ryoji , Taniura Takahito , Miyazaki Yoshiko , Kishi Takashi , Kawabata Yasunari
Published: December 2017

Background

The purpose of the present study is to investigate the utility of prognostic nutritional index (PNI) as a simple and readily available marker in esophageal squamous cell carcinoma (ESCC).

Methods

We retrospectively analyzed 169 patients who underwent potentially curative esophagectomy, for histologically verified ESCC. We decided to set the optimal cutoff value for preoperative PNI levels at 49.2, based on the cancer‐specific survival (CSS) and the overall survival (OS) by receiver operating characteristic curve analysis.

Results

Multivariate logistic regression analysis identified that TNM pStage III [hazard ratio (HR) 3.261, p < 0.0001] and PNI < 49.2 (HR 3.887, p < 0.0001) were confirmed as independent poor predictive factors for CSS, and age >70 (HR 2.024, p < 0.0042), TNM pStage III (HR 2.510, p = 0.0002), and PNI < 49.2 (HR 2.248, p = 0.0013) were confirmed as independent poor predictive factors for OS. In non‐elderly patients, TNM pStage III (CSS; HR 3.488, p < 0.0001, OS; HR 2.615, p = 0.0007) and PNI < 49.2 (CSS; HR 3.849, p < 0.0001, OS; HR 2.275, p = 0.001) were confirmed as independent poor predictive factors for CSS, and OS when multivariate logistic regression analysis was applied. But in elderly patients, univariate analyses demonstrated that the TNM pStage III was the only significant risk factor for CSS (HR 3.701, p = 0.0057) and OS (HR 1.974, p = 0.0224).

Conclusions

The PNI was a significant and independent predictor of CSS and OS of ESCC patients after curative esophagectomy. The PNI was cost‐effective and readily available, and it could act as a marker of survival.
Implementation of Trauma Center and Massive Transfusion Protocol Improves Outcomes for Major Trauma Patients: A Study at a Single Institution in Korea
Authors: Hwang Kyungjin , Kwon Junsik , Cho Jayun , Heo Yunjung , Lee John Cook‐Jong , Jung Kyoungwon
Published: December 2017

Background

This study evaluated the effectiveness and clinical outcomes of the implementation of a trauma center and massive transfusion protocol (TCMTP) in a developing country without a well‐established trauma system.

Methods

We included patients (1) aged >15 years, (2) with an Injury Severity Score >15, (3) who received ≥10 units of packed red blood cells (PRBCs) within 24 h, (4) who directly visited our institution from 2010 to 2016, and (5) who survived for ≥24 h. Patients treated during the post‐TCMTP period (2015–2016) were compared with historical groups treated pre‐TCMTP (2010–2012) and interim‐TCMTP (2013–2014). Demographics, transfusion and fluid therapy performance, and clinical outcomes were compared between the three groups.

Results

Overall, 190 patients were included: 64, 64, and 62 patients in the pre‐TCMTP, interim‐TCMTP, and post‐TCMTP groups, respectively. Comparison between the three groups revealed significant differences in the fresh‐frozen plasma/PRBC ratio (p = 0.001) and crystalloid infusion (p = 0.007); these variables gradually increased from pre‐ to post‐TCMTP. Conversely, colloid infusion showed a reduction post‐TCMTP (p < 0.001). Kaplan–Meier curves revealed that the 90‐day survival rate was significantly higher in the post‐TCMTP group (pre‐TCMTP: 45.3 vs. 75.8%, p = 0.001; interim‐TCMTP: 56.3 vs. 75.8%, p = 0.027). In Cox regression hierarchical survival analysis, TCMTP showed a hazard ratio for mortality of 0.380 after adjusting for all potentially confounding factors.

Conclusions

Our results suggest that building trauma centers and establishing a massive transfusion protocol according to the specific situations of a country will help improve outcomes for major trauma patients, even in developing countries without a well‐established trauma system.
One‐Hour Postoperative Parathyroid Hormone Levels Do Not Reliably Predict Hypocalcemia After Thyroidectomy
Authors: Sahli Zeyad , Najafian Alireza , Kahan Stacie , Schneider Eric B. , Zeiger Martha A. , Mathur Aarti
Published: December 2017

Introduction

Hypocalcemia is a well‐known complication after total thyroidectomy. Studies have indicated that the presence of low postoperative parathyroid hormone (PTH) levels can predict hypocalcemia. However, definitive study designs are lacking. The aim of this study was to determine whether postoperative PTH alone can accurately predict postoperative biochemical hypocalcemia.

Methods

Under IRB approval, a prospective study of 218 consecutive patients who underwent total or completion thyroidectomy by two surgeons between June 2014 and June 2016 was performed. Biochemical hypocalcemia was defined as ionized calcium <1.13 mmol/L or serum calcium <8.4 mg/dL at any time postoperatively. Three PTH thresholds, <10, <20 pg/mL, and >50% drop in PTH 1 h postoperatively from baseline were examined.

Results

Postoperative PTH < 10 pg/mL had a sensitivity of 36.5% (95% CI 27.4–46.3%) and a specificity of 89.2% (95% CI 81.9–94.3%). Postoperative PTH < 20 pg/mL had a sensitivity of 66.4% (95% CI 56.6–75.2%) and a specificity of 67.6% (95% CI 58.0–76.2%). Postoperative PTH decrease >50% had a sensitivity of 63.4% (95% CI 53.2–72.7%) and a specificity of 72.5% (95% CI 62.5–81.0%). Across all PTH thresholds, the false‐negative rate was 33.6–63.5% indicating that up to 64% of patients with a normal PTH level could have been discharged without appropriate calcium supplementation. The false‐positive rate was 10.8–32.4% indicating that up to 32.4% of patients with low PTH could have been treated with calcium supplementation unnecessarily.

Conclusion

Following total thyroidectomy, PTH levels are unreliable in predicting hypocalcemia. Additional prospective studies are needed to understand the true utility of PTH levels post‐thyroidectomy.
Topical Minoxidil Versus Topical Diltiazem for Chemical Sphincterotomy of Chronic Anal Fissure: A Prospective, Randomized, Double‐Blind, Clinical Trial
Authors: Alvandipour Mina , Ala Shahram , Khalvati Mehdi , Yazdanicharati Jamshid , Koulaeinejad Neda
Published: December 2017

Background

Anal fissure is a common anorectal problem causing severe pain and discomfort to the patients. Chemical sphincterotomy has emerged as a noninvasive alternative to the surgical methods of fissure treatment. The objective of this study was evaluation of the efficacy and the adverse effects of topically applied minoxidil in chemical sphincterotomy of chronic anal fissure in comparison with topical diltiazem.

Methods

A total of 88 patients with chronic anal fissure aged between 15 and 65 years were included in this double‐blind, randomized clinical trial and were randomly assigned to either 0.5% minoxidil cream or 2% diltiazem cream twice daily for 2 weeks. The pain intensity, bleeding, wound healing, itching, headache, dizziness, significant drop in blood pressure, allergy and fissure relapse were assessed on a monthly basis for 2 months.

Results

Both diltiazem and minoxidil reduced the pain, bleeding and improved fissure healing with no significant difference. There were no between‐groups differences in the frequencies of adverse effects, except for itching which was slightly higher with minoxidil during the first month. Allergy occurred in two patients in the minoxidil group, which was not severe and did not lead to discontinuation of the trial.

Conclusion

Topically administered minoxidil is of equal efficacy as diltiazem in the treatment of chronic anal fissure with low frequency of adverse effects. Thus, it can be considered as an agent for chemical sphincterotomy of anal fissure, but the itching at the beginning of the treatment can affect the adherence of the patient to treatment.

Trial registration number IRCT2015041414483N6 (the full trial protocol could be accessed online at www.irct.ir).
A system for three-dimensional gaze fixation analysis using eye tracking glasses
Authors: Takahashi Ryo , Suzuki Hiromasa , Chew Jouh Yeong , Ohtake Yutaka , Nagai Yukie , Ohtomi Koichi
Published: December 2017

Eye tracking is a technology that has quickly become a commonplace tool for evaluating package and webpage design. In such design processes, static two-dimensional images are shown on a computer screen while a subject's gaze where he or she looks is measured via an eye tracking device. The collected gaze fixation data are then visualized and analyzed via gaze plots and heat maps. Such evaluations using two-dimensional images are often too limited to analyze gaze on three-dimensional physical objects such as products because users look at them not from a single point of view but rather from various angles. Therefore in this study we propose methods for collecting gaze fixation data for a three-dimensional model of a given product and visualizing corresponding gaze plots and heat maps also in three dimensions. To achieve our goals, we used a wearable eye-tracking device, i.e., eye-tracking glasses. Further, we implemented a prototype system to demonstrate its advantages in comparison with two-dimensional gaze fixation methods.

Highlights Proposing a method for collecting gaze fixation data for a three-dimensional model of a given product. Proposing two visualization methods for three dimensional gaze data; gaze plots and heat maps. Proposed system was applied to two practical examples of hair dryer and car interior.
Piomiosite do piriforme em um paciente com doença de Kikuchi-Fujimoto—relato de caso e revisão da literatura
Authors: Barros Antônio , Soares Cláudio , Temponi Eduardo , Barbosa Victor , Teixeira Luiz , Grammatopoulos George
Published: December 2017

A piomiosite primária é uma infecção bacteriana profunda do músculo esquelético. Quando não diagnosticada ou tratada, a infecção pode evoluir para sepse, choque séptico e até morte. Os autores relatam o caso de uma paciente do sexo feminino, 23 anos, apresentando piomiosite do músculo piriforme durante o tratamento da doença de Kikuchi-Fujimoto. A piomiosite é uma infecção rara, mas potencialmente grave, que pode levar ao choque séptico. Esse caso mostra a necessidade em se elevar o grau de suspeição clínica em pacientes com comprometimento do sistema imunológico, para que o tratamento seja iniciado em estágio precoce. A literatura mostra que os resultados do tratamento da piomiosite do piriforme são bons.
If Scientists Had a Time Machine: No. 1
Authors: Wendel JoAnna
Published: December 2017

Where would you go?
Recording Belgium’s Gravitational History
Authors: Van Camp Michel , Francis Olivier , Lecocq Thomas
Published: December 2017

Instruments at Belgium’s Membach geophysical station set a new record for monitoring gravitational fluctuations caused by storm surges, groundwater fluctuations, and the Moon’s tidal pull.
B-type Natriuretic Peptide and Other Risk Factors for Predicting Postoperative Atrial Fibrillation after Thoracic Surgery
Authors: Pu Zhenye , Qi Xiaotong , Xue Tao , Liu Zhiyong , Wu Yanhu
Published: December 2017

Background Postoperative atrial fibrillation (POAF) is associated with increased morality rate, prolonged hospitalization, and reduced long-term survival after surgery. Thus, prediction of POAF is important to assess surgical risk and provide prophylaxis.

Methods It was a prospective study of 207 consecutive patients who underwent a routine preoperative laboratory testing before thoracic surgery from October 2016 to May 2017. Comprehensive data were collected. Then stepwise multivariate logistic regression analysis was adopted to identify significant risk factors associated with POAF from various variables.

Results As results, three variables as follows: male gender, open thoracotomy, and B-type natriuretic peptide (BNP) exceeding 59 pg/mL were considered as independent risk factors associated with POAF (p < 0.05).

Conclusion In patients undergoing noncardiac thoracic surgery, we found that an elevated preoperative BNP level (with the level of 59 pg/mL as a cutoff), male gender, and open-chest surgeries were significant risk factors for POAF. The identification of patients who are prone to develop POAF will provide prevention strategies to reduce this complication.
Buckberg versus Calafiore Cardioplegia in Patients with Acute Coronary Syndromes
Authors: Liakopoulos Oliver , Slottosch Ingo , Deppe Antje , Choi Yeong-Hoon , Madershahian Navid , Wahlers Thorsten , Kuhn Elmar
Published: December 2017

Background Choice of cardioplegic solution plays a pivotal role in special subgroups of patients referred for on-pump cardiac surgery. This retrospective analysis aimed to assess the impact of intermittent warm (Calafiore, Cala) versus intermittent cold blood cardioplegia (Buckberg, Buck) in patients referred to coronary artery bypass graft (CABG) surgery due to acute coronary syndromes (ACS).

Methods From 2008 to 2015, all consecutive patients undergoing urgent on-pump CABG surgery due to ACS (n = 950) were retrospectively analyzed. Intraoperative cardiac arrest was achieved using Buck (n = 273) or Cala (n = 677). Patients were compared regarding clinical outcomes and perioperative myocardial injury (PMI). Propensity score matching was performed to control for differences in preoperative patient characteristics.

Results Prevalences of left main stenosis >50%, COPD, and advanced New York Heart Association (NYHA) class were higher for intermittent warm blood cardioplegia (IWC)-patients while more Buck-patients had preoperative intra-aortic balloon pump (IABP) and redo procedures. Buck-patients needed more intraoperative defibrillations and showed longer cardiopulmonary bypass (CPB) and aortic clamping times. 30-day all-cause mortality (10.6 versus 9.3%), major adverse cardiac events (MACE) (52.7 versus 48.6%), and PMI (50.5 versus 55.7%; all p > 0.05) rates were comparable for Buck- and Cala-patients. Propensity score matching resulted in equal group sizes (n = 212 each) and balanced distribution of preoperative covariates. Although more Buck-patients still needed inotropic support >24 hours postoperatively (25.7 versus 14.7%; p = 0.005) compared with Cala-group, outcome variables of interest did not differ between treatment groups (30-day mortality: 7.5 versus 9.0%; MACE: 49.5 versus 40.6%; PMI: 48.1 versus 37.3%; all p > 0.05).

Conclusion Buckberg and Calafiore cardioplegia offer comparable myocardial protection and similar postoperative results in patients undergoing CABG surgery due to ACS.
Robust processing of the Dutch verb phrase
Authors: Van Eecke Paul
Published: December 2017

The Dutch verb phrase (VP) is notorious for its syntactic intricacies. There are
three main reasons why it is difficult to robustly handle its complexity in a
processing model. First of all, a single VP can contain multiple modal
auxiliaries (‘modal stacking’). Second, perfect auxiliaries can not only take a
past participle as their argument but also a modal auxiliary in the infinitive
form. Finally, there are various word orders in which the verb forms can appear.
The first part of this paper presents a fully operational precision processing
model of the Dutch VP in Fluid Construction Grammar. The model shows that the
aforementioned challenges can be overcome by carefully managing the hierarchical
relations between the elements of the VP. The second part introduces a robust
comprehension method, which can process VPs containing morphological and word
order errors. This method allows in many cases to recover the intended meaning
of an erroneous VP, as well as to correct its form, using a strategy that
exploits the deep semantic analyses and the bidirectional nature of the
model.
The colour of Dutch
Authors: Jaspers Jürgen
Published: December 2017

Many studies in recent years identify and discuss Dutch ethnolects. Generally this work takes linguistic phenomena as directly reflective of speakers’ ethnic identity. But if ethnicity is an inherent speaker feature, the absence of white ethnolect descriptions is difficult to explain. In this paper, therefore, I wish to judge the appeal of the notion of ethnolect against itsusefulness for explaining language use. I argue that ethnolect can usefully label everyday ethnicisations of language, but that such evaluations generally compress a more complex reality in which so-called ethnolectal features are recruited for other purposes than (un)marking one’s ascribed ethnicity. Crucial to unpacking this reality is the distinction of an intermediary step, the construction of interactional stance, between the use of linguistic features and their association with common-sense identity categories.
The attrition of Turkish as a third language
Authors: Yildiz Yasemin , Koyuncuoglu Hande
Published: December 2017

This longitudinal study investigates an English-French-Turkish-speaking seven-years-old female child’s repertoire combining two Indo-European languages, English and French, and Turkish, which is an Altaic language. Language attrition has mostly focused on first language (L1) attrition, and to a lesser extent on second language (L2) attrition. Third language (L3) attrition, however, has been mostly overlooked, and more attention has gone to adult language attrition after migration or after institutional language learning. Most research has in addition focused on only a subset of target languages (TL). This paper therefore addresses the attrition of child L3 (Turkish) attrition ‘after remigration’. The findings show selective regression with structurally assigned morphology and confirm the findings of previous studies showing that the younger the informant, the more attrition is likely to occur.
Procedural repetition in task-based interaction among young EFL learners
Authors: Lázaro-Ibarrola Amparo , Hidalgo María Ángeles
Published: December 2017

Interactive tasks are valuable tools for L2 learners and have long made their way into language lessons. Among the different task conditions, only few studies have dealt with procedural repetition, which consists of repeating the same task type with different contents and which is frequently used in schools. In this study we explore the effects of procedural repetition on the oral interactions of ten pairs of English learners (age 11) who had to repeat a task three times. Their negotiation strategies and general performance (accuracy, fluency and complexity) were analysed. Results show that, in the third repetition, the amount of confirmation checks and repetitions decreased significantly and accuracy timidly improved. All other aspects remained unaffected. The pedagogical implications of these results are also discussed.
Correlating elastic and plastic deformation with magnetic permeability values
Authors: Papadopoulou S
Published: December 2017

This paper investigates the utilization of magnetic permeability method in determining elastic and plastic deformation state of ferromagnetic steels. The results have shown a strong degradation of the magnetic values on plastically region due to the irreversible movements of the magnetic domain walls.
The Vulnerability Formation Mechanism and Control Strategy of the Oil and Gas Pipeline City
Authors: Chen Y L , Han L
Published: December 2017

Most of the pipelines of oil and gas pipelines in our country have been for more than 25 years. These pipes are buried underground and was difficult to daily test. In addition, it was vulnerable to environmental, corrosion and natural disasters, So there is a hidden nature of accidents. The rapid development of urbanization, population accumulation, dense building and insufficient safety range are all the reasons for the frequent accidents of oil and gas pipelines. Therefore, to appraise and know the safe condition of the city various regions oil and gas pipelines is vital significant. In order to ensure the safety of oil and gas pipeline city, this paper defines the connotation of oil and gas pipeline city vulnerability according to the previous research on vulnerability. Then from three perspectives of environment, structure and behavior, based on the analytical paradigm of “structure—vulnerability conduct—performance” about oil and gas, the influential indicators of vulnerable oil and gas pipelines were analysed, the vulnerability mechanism framework of Oil and gas pipeline city was also constructed. Finally, the paper proposed the regulating strategy of the vulnerability of the oil and gas pipeline city to decrease its vulnerability index, which can be realize the city’s vulnerability evaluation and provides new ideas for the sustainable development of the city.
The Bidirectional Relationship Between Depressive Symptoms and Homebound Status Among Older Adults
Authors: Xiang Xiaoling , An Ruopeng , Oh Hyunsung
Published: December 2017

Objectives

This study aimed to examine the bidirectional relationship between depressive symptoms and homebound status among older adults.

Method

The study sample included 7,603 community-dwelling older adults from the National Health and Aging Trends Study. A bivariate latent state-trait model of depressive symptoms and homebound status was estimated via structural equation modeling.

Results

The model fit the data well (Root Mean Square Error of Approximation = .02, Comparative Fit Index = .97, Standardized Root Mean Square Residual = .06). The relationship between homebound status and depressive symptoms can be decomposed into three parts: a moderate correlation between the stable trait components (r = .56, p <.001); a contemporary association of the state components (b = .17, p <.001); and bidirectional lagged effects between the state components. Change in homebound status was as a stronger predictor of depressive symptoms (b = .19, p < .001) than change in depressive symptoms was of homebound status (b = .06, p < .001; test of difference: Δ scaled χ2(1) = 24.2, p < .001).

Discussion

Homebound status and depressive symptoms form a feedback loop to influence each other. Improving the outdoor mobility of older adults may have immediate benefits for reducing depressive symptoms.
Dose effect of patient–care team communication via secure portal messaging on glucose and blood pressure control
Authors: Price-Haywood Eboni G , Luo Qingyang , Monlezun Dominique
Published: December 2017

Objectives

Organizational strategies for implementing eHealth tools influence patient and provider use of portal technology. This study examines whether the intensity of bidirectional secure portal messaging is associated with improved clinical outcomes.

Material and Methods

This is a retrospective cohort analysis of 101 019 patients with diabetes or hypertension (11 138 active portal users) who received primary care within the Ochsner Health System between 2012 and 2014. Propensity score–adjusted multivariable fixed effects regression panel analysis was used to examine associations between intensity of “medical advice” portal messaging and glucose/blood pressure control.

Results

Most portal users rarely used medical advice messaging. A higher proportion of patients who were age 50 years and older, female, white non-Hispanic, and with co-morbid diabetes and hypertension had higher frequency and intensity of medical advice messaging. Study findings revealed a dose-response effect of the intensity of messaging on glucose control, whereby, compared to nonportal users, each level of messaging among portal users was associated with greater decreases in HbA1c (β estimate [95% CI]: none −0.28 (−0.34 to −0.22); low −0.28 (−0.32 to −0.24); medium −0.41 (−0.52 to −0.31); high −0.43 (−0.60 to −0.27), all P ≤ .001). There was no observed effect on blood pressure.

Conclusions

The digital divide exists not only between portal users and nonusers but also among portal users. Research exploring the relationship between intensity of bidirectional secure messaging and health outcomes for a broader scope of chronic conditions is needed. Future implementation research must also elucidate best practices that enhance not only the use of portals by patients and providers, but how they use portals.
A 2–3 billion year old major merger paradigm for the Andromeda galaxy and its outskirts
Authors: Hammer F , Yang Y B , Wang J L , Ibata R , Flores H , Puech M
Published: December 2017

Recent observations of our neighbouring galaxy M31 have revealed that its disc was shaped by widespread events. The evidence for this includes the high dispersion (V/σ ≤ 3) of stars older than 2 Gyr, and a global star formation episode, 2–4 Gyr ago. Using the modern hydrodynamical code, gizmo, we have performed 300 high-resolution simulations to explore the extent to which these observed properties can be explained by a single merger. We find that the observed M31 disc resembles models having experienced a 4:1 merger, in which the nuclei coalesced 1.8–3 Gyr ago, and where the first passage took place 7–10 Gyr ago at a large pericentre distance (32 kpc). We also show that within a family of orbital parameters, the Giant Stream (GS) can be formed with various merger mass ratios, from 2:1 to 300:1. A recent major merger may be the only way to create the very unusual age–dispersion relation in the disc. It reproduces and explains the long-lived 10 kpc ring, the widespread and recent star formation event, the absence of a remnant of the GS progenitor, the apparent complexity of the 3D spatial distribution of the GS, the NE and G Clumps and their formation process, and the observed slope of the halo profile. These modelling successes lead us to propose that the bulk of the substructure in the M31 halo, as well as the complexity of the inner galaxy, may be attributable to a single major interaction with a galaxy that has now fully coalesced with Andromeda.
Activity of (2060) Chiron possibly caused by impacts?
Authors: Cikota Stefan , Fernández-Valenzuela Estela , Ortiz Jose Luis , Morales Nicolás , Duffard René , Aceituno Jesus , Cikota Aleksandar , Santos-Sanz Pablo
Published: December 2017

The centaur 95P/(2060) Chiron is showing comet-like activity since its discovery, but the mass-loss mechanisms triggering its activity remained unexplained. Although the collision rates in the centaur region are expected to be very low, and impacts are thought not to be responsible for the mass-loss, since the recent indications that Chiron might possess a ring similar to Chariklo's, and assuming that there is debris orbiting around, the impact triggered mass-loss mechanism should not be excluded as a possible cause of its activity. From time series observations collected on Calar Alto Observatory in Spain between 2014 and 2016, we found that the photometric scatter in Chiron's data is larger than a control star's scatter, indicating a possible microactivity, possibly caused by debris falling back to Chiron's surface and lifting small clouds of material. We also present rotational light curves, and measurements of Chiron's absolute magnitudes, which are consistent with the models supporting the presumption that Chiron possesses rings. By co-adding the images acquired in 2015, we have detected an ∼5 arcsec long tail, showing a surface brightness of 25.3 mag(V) arcsec−2.
Treatment of an Anterior Inferior Cerebellar Artery Aneurysm With Microsurgical Trapping and In Situ Posterior Inferior Cerebellar Artery to Anterior Inferior Cerebellar Artery Bypass: Case Report
Authors: Lee Bryan S , Witek Alex M , Moore Nina Z , Bain Mark D
Published: December 2017

BACKGROUND

Anterior inferior cerebellar artery (AICA) aneurysms are rare lesions whose treatment can involve microsurgical and/or endovascular techniques. Such treatment can be challenging and may carry a significant risk of neurological morbidity.

OBJECTIVE

To demonstrate a case involving a complex AICA aneurysm that was treated with a unique microsurgical approach involving trapping the aneurysm and performing in Situ bypass from the posterior inferior cerebellar artery (PICA) to the distal AICA. The nuances of AICA aneurysms and revascularization strategies are discussed.

METHODS

The aneurysm and the distal segments of AICA and PICA were exposed with a retrosigmoid and far lateral approach. A side-to-side anastomosis was performed between the adjacent caudal loops of PICA and AICA. The AICA aneurysm was then treated by trapping the aneurysm-bearing segment of the parent vessel between 2 clips.

RESULTS

A postoperative angiogram demonstrated a patent PICA-AICA bypass and complete occlusion of the AICA aneurysm. There were no complications, and the patient made an excellent recovery.

CONCLUSION

The combination of parent vessel sacrifice and bypass remains an excellent option for certain difficult-to-treat aneurysms. This case involving PICA-AICA bypass to treat an AICA aneurysm serves as an example of the neurosurgeon's ability to develop unique solutions that take advantage of individual anatomy.
2017 Visionary Leader
Authors: Floyd Tara
Published: December 2017

The following manuscript is the winning 2017 Richard Hader Visionary Leader Award entry submitted to Nursing Management in recognition of Maureen Maurano, BSN, RN, nurse manager of the neonatal intensive care unit at Children's National Health System in Washington, D.C. Ms. Maurano was formally recognized for her achievements before the Keynote Address at Congress2017, October 4, in Las Vegas, Nev. There, she received the award, sponsored by Hackensack Meridian Health.
Culture-Negative Septic Shock Compared With Culture-Positive Septic Shock: A Retrospective Cohort Study
Authors: Kethireddy Shravan , Bilgili Beliz , Sees Amanda , Kirchner H. Lester , Ofoma Uchenna R. , Light R. Bruce , Mirzanejad Yazdan , Maki Dennis , Kumar Aseem , Layon A. Joseph , Parrillo Joseph E. , Kumar Anand
Published: December 2017

Objectives:

To determine the clinical characteristics and outcomes of culture-negative septic shock in comparison with culture-positive septic shock.

Design:

Retrospective nested cohort study.

Setting:

ICUs of 28 academic and community hospitals in three countries between 1997 and 2010.

Subjects:

Patients with culture-negative septic shock and culture-positive septic shock derived from a trinational (n = 8,670) database of patients with septic shock.

Interventions:

None.

Measurements and Main Results:

Patients with culture-negative septic shock (n = 2,651; 30.6%) and culture-positive septic shock (n = 6,019; 69.4%) were identified. Culture-negative septic shock compared with culture-positive septic shock patients experienced similar ICU survival (58.3% vs 59.5%; p = 0.276) and overall hospital survival (47.3% vs 47.1%; p = 0.976). Severity of illness was similar between culture-negative septic shock and culture-positive septic shock groups ([mean and sd Acute Physiology and Chronic Health Evaluation II, 25.7 ± 8.3 vs 25.7 ± 8.1]; p = 0.723) as were serum lactate levels (3.0 [interquartile range, 1.7–6.1] vs 3.2 mmol/L [interquartile range, 1.8–5.9 mmol/L]; p = 0.366). As delays in the administration of appropriate antimicrobial therapy after the onset of hypotension increased, patients in both groups experienced congruent increases in overall hospital mortality: culture-negative septic shock (odds ratio, 1.56; 95% CI [1.47–1.66]; p < 0.0001) and culture-positive septic shock (odds ratio, 1.65; 95% CI [1.59–1.71]; p < 0.0001).

Conclusions:

Patients with culture-negative septic shock behave similarly to those with culture-positive septic shock in nearly all respects; early appropriate antimicrobial therapy appears to improve mortality. Early recognition and eradication of infection is the most obvious effective strategy to improve hospital survival.
Predictors of In-Hospital Mortality After Rapid Response Team Calls in a 274 Hospital Nationwide Sample*
Authors: Shappell Claire , Snyder Ashley , Edelson Dana P. , Churpek Matthew M.
Published: December 2017

Objectives:

Despite wide adoption of rapid response teams across the United States, predictors of in-hospital mortality for patients receiving rapid response team calls are poorly characterized. Identification of patients at high risk of death during hospitalization could improve triage to intensive care units and prompt timely reevaluations of goals of care. We sought to identify predictors of in-hospital mortality in patients who are subjects of rapid response team calls and to develop and validate a predictive model for death after rapid response team call.

Design:

Analysis of data from the national Get with the Guidelines-Medical Emergency Team event registry.

Setting:

Two-hundred seventy four hospitals participating in Get with the Guidelines-Medical Emergency Team from June 2005 to February 2015.

Patients:

282,710 hospitalized adults on surgical or medical wards who were subjects of a rapid response team call.

Interventions:

None.

Measurements and Main Results:

The primary outcome was death during hospitalization; candidate predictors included patient demographic- and event-level characteristics. Patients who died after rapid response team were older (median age 72 vs 66 yr), were more likely to be admitted for noncardiac medical illness (70% vs 58%), and had greater median length of stay prior to rapid response team (81 vs 47 hr) (p < 0.001 for all comparisons). The prediction model had an area under the receiver operating characteristic curve of 0.78 (95% CI, 0.78–0.79), with systolic blood pressure, time since admission, and respiratory rate being the most important variables.

Conclusions:

Patients who die following rapid response team calls differ significantly from surviving peers. Recognition of these factors could improve postrapid response team triage decisions and prompt timely goals of care discussions.
Optimal Cerebral Perfusion Pressure in Centers With Different Treatment Protocols
Authors: Howells Tim , Smielewski Peter , Donnelly Joseph , Czosnyka Marek , Hutchinson Peter J. A. , Menon David K. , Enblad Per , Aries Marcel J. H.
Published: December 2017

Objectives:

The three centers in this study have different policies regarding cerebral perfusion pressure targets and use of vasopressors in traumatic brain injury patients. The aim was to determine if the different policies affected the estimation of cerebral perfusion pressure which optimizes the strength of cerebral autoregulation, termed “optimal cerebral perfusion pressure.”

Design:

Retrospective analysis of prospectively collected data.

Setting:

Three neurocritical care units at university hospitals in Cambridge, United Kingdom, Groningen, the Netherlands, and Uppsala, Sweden.

Patients:

A total of 104 traumatic brain injury patients were included: 35 each from Cambridge and Groningen, and 34 from Uppsala.

Interventions:

None.

Measurements and Main Results:

In Groningen, the cerebral perfusion pressure target was greater than or equal to 50 and less than 70 mm Hg, in Uppsala greater than or equal to 60, and in Cambridge greater than or equal to 60 or preferably greater than or equal to 70. Despite protocol differences, median cerebral perfusion pressure for each center was above 70 mm Hg. Optimal cerebral perfusion pressure was calculated as previously published and implemented in the Intensive Care Monitoring+ software by the Cambridge group, now replicated in the Odin software in Uppsala. Periods with cerebral perfusion pressure above and below optimal cerebral perfusion pressure were analyzed, as were absolute difference between cerebral perfusion pressure and optimal cerebral perfusion pressure and percentage of monitoring time with a valid optimal cerebral perfusion pressure. Uppsala had the highest cerebral perfusion pressure/optimal cerebral perfusion pressure difference. Uppsala patients were older than the other centers, and age is positively correlated with cerebral perfusion pressure/optimal cerebral perfusion pressure difference. Optimal cerebral perfusion pressure was significantly lower in Groningen than in Cambridge. There were no significant differences in percentage of monitoring time with valid optimal cerebral perfusion pressure. Summary optimal cerebral perfusion pressure curves were generated for the combined patient data for each center. These summary curves could be generated for Groningen and Cambridge, but not Uppsala. The older age of the Uppsala patient cohort may explain the absence of a summary curve.

Conclusions:

Differences in optimal cerebral perfusion pressure calculation were found between centers due to demographics (age) and treatment (cerebral perfusion pressure targets). These factors should be considered in the design of trials to determine the efficacy of autoregulation-guided treatment.
Treatment of Paraquat-Induced Lung Injury With an Anti-C5a Antibody: Potential Clinical Application*
Authors: Sun Shihui , Jiang Yuting , Wang Renxi , Liu Chenfeng , Liu Xiaoling , Song Nianping , Guo Yan , Guo Renfeng , Du Lanying , Jiang Shibo , Li Yan , Qiu Zewu , Zhao Guangyu , Zhou Yusen
Published: December 2017

Objectives:

Complement activation product C5a plays a critical role in systemic inflammatory response syndrome induced by viruses, bacteria, and toxic agents including paraquat poisoning. This study is to explore the efficiency of anti-C5a–based intervention on systemic inflammatory responses induced by paraquat poisoning.

Design:

Study of cynomolgus macaque model and plasma from paraquat-poisoning patients.

Setting:

Laboratory investigation.

Subjects:

Cynomolgus macaque (n = 12) and samples of plasma from patients (n = 16).

Interventions:

The neutralizing antihuman C5a antibody (IFX-1) was administered to investigate the new treatment strategy for paraquat-induced systemic inflammatory responses in cynomolgus macaque model. In addition, C5a activation in plasma of paraquat patients was blocked by IFX-1 to investigate the blockade role of anti-C5a antibody in activation of inflammatory cells.

Measurements and Main Results:

Dysregulated complement activation and the subsequent cytokine storm were found in patients with acute lung injury and in a primate model of paraquat poisoning. Targeted inhibition of C5a by IFX-1 led to marked alleviation of systemic inflammatory responses and multiple organ damage in the primate model. In addition, blockade of C5a activity in plasma from patients completely inhibited activation of CD11b on blood granulocytes from normal donors, suggesting that IFX-1 may alleviate the excessive activation of inflammatory responses and have clinical utility for patients with acute lung injury.

Conclusions:

Anti-C5a antibodies such as IFX-1 may be used as effective therapeutics for treatment of those suffering from systemic inflammatory responses induced by chemical poisoning like paraquat.
Risk Stratification Using Oxygenation in the First 24 Hours of Pediatric Acute Respiratory Distress Syndrome*
Authors: Yehya Nadir , Thomas Neal J. , Khemani Robinder G.
Published: December 2017

Objective:

Oxygenation measured 24 hours after acute respiratory distress syndrome onset more accurately stratifies risk, relative to oxygenation at onset, in both children and adults. However, waiting 24 hours is problematic, especially for interventions that are more efficacious early in the disease course. We aimed to delineate whether oxygenation measured at timepoints earlier than 24 hours would retain predictive validity in pediatric acute respiratory distress syndrome.

Design:

Observational cohort study.

Setting:

Two large, academic PICUs.

Patients:

Invasively ventilated children with acute respiratory distress syndrome.

Interventions:

None.

Measurements and Main Results:

Pao2
/Fio2
and oxygenation index (mean airway pressure × Fio2
× 100)/Pao2
) were measured at acute respiratory distress syndrome onset, at 6, 12, 18, and 24 hours after in 459 children at the Children’s Hospital of Philadelphia. Neither Pao2
/Fio2
nor oxygenation index at acute respiratory distress syndrome onset discriminated outcome. Between 6 and 24 hours, both Pao2
/Fio2
(area under receiver operating curve for mortality between 0.57 and 0.62; p = 0.049–0.002) and oxygenation index (area under receiver operating curve, 0.60–0.62; p = 0.006–0.001) showed good discrimination and calibration across multiple outcomes, including mortality, ventilator-free days at 28 days, ventilator days in survivors, and probability of extubation, given competing risk of death. The utility of oxygenation at 12 hours was confirmed in an independent cohort from the Children’s Hospital of Los Angeles.

Conclusion:

Oxygenation measured between 6 and 12 hours of acute respiratory distress syndrome onset accurately stratified outcomes in children. Our results have critical implications for the design of trials, especially for interventions with greater impact in early acute respiratory distress syndrome.
Cutaneous Metaplastic Carcinoma: Report of a Case With Sebaceous Differentiation
Authors: Pazzini Renato , Pereira Gustavo A. , Macarenco Ricardo S.
Published: December 2017

In this study, a case of a 56-year-old woman with cutaneous metaplastic carcinoma in the neck is reported. It harbored basal cell carcinoma, squamous cell carcinoma, and sebaceous carcinoma, as well as osteosarcoma (with fibroblastic, osteoblastic, aneurysmal bone cyst-like, and chondroblastic patterns). To our knowledge, the literature does not mention sebaceous carcinoma in cutaneous metaplastic carcinoma. Epidemiology and intact mismatch repair proteins of this case support sporadic pathogenesis for this neoplasm. The patient has been followed up for 3 years after surgery with free margins, and no local recurrence or distant metastases have been observed.
Naked Hair Shafts as a Marker of Cicatricial Alopecia
Authors: Doytcheva Kristina , Tan Timothy , Guitart Joan , Gerami Pedram , Yazdan Pedram
Published: December 2017

Naked hair shafts (NHS) are free-floating hair shafts devoid of surrounding epithelium, supporting structures, and/or embedded in inflammation that may result from destruction of hair follicles by scarring processes such as inflammation and fibroplasia. Extensive examination of NHS has not been performed in scalp biopsies of alopecia. We retrospectively evaluated 622 scalp biopsies of alopecia [345 cicatricial alopecias (central centrifugal cicatricial alopecia, lichen planopilaris, discoid lupus erythematosus, acne keloidalis nuchae, and folliculitis decalvans] and 277 non–cicatricial alopecias [alopecia areata, androgenic alopecia, telogen effluvium, and psoriatic alopecia)] for the presence of NHS. NHS occurred in 0.72% (2/277) of non–cicatricial alopecias (1/102 of alopecia areata, 1/150 of androgenic alopecia, 0/17 of telogen effluvium, and 0/8 of psoriatic alopecia) and 20% (72/345) of cicatricial alopecias (27/118 of central centrifugal cicatricial alopecia, 29/109 of lichen planopilaris, 2/75 of discoid lupus erythematosus, 11/16 of acne keloidalis nuchae, and 3/27 of folliculitis decalvans). The presence of NHS was significantly increased in cicatricial alopecias in comparison with non–cicatricial alopecias; P value <0.0001. Among the cicatricial alopecias, 26% (92/345) had mild inflammation and/or fibrosis, of which 9% (9/92) had NHS. There were 73% (253/345) that had moderate to severe inflammation and/or fibrosis, of which 24% (63/253) had NHS, indicating that as the severity of inflammation and fibrosis increases, so does the presence of NHS. NHS rarely occurs in non–cicatricial alopecias. This variation may result from destruction of hair follicles by the inflammatory and scarring processes. The presence of NHS may be a useful adjunctive histopathologic feature in the diagnosis of cicatricial alopecia.
Cuticular Poroma: A Poroma Mostly Composed of Cuticular Cells (Cuticuloma)
Authors: Alegría-Landa Victoria , Kutzner Heinz , Requena Luis
Published: December 2017

Poromas are benign cutaneous adnexal neoplasms with differentiation toward excretory ducts of eccrine and apocrine glands. They are mainly composed of solid aggregates of small, monomorphous, round, and basophilic poroid cells, with a lower proportion of larger, squamous, eosinophilic cuticular cells, which are lining ductal structures with an eosinophilic luminal cuticle. In most cases of poromas, cuticular cells represent a small proportion of the neoplastic aggregates. We report 2 poromas mostly composed of cuticular cells, and on the basis of these findings, we have named cuticuloma to this histopathologic variant of poroma.
SUBRETINAL TRANSPLANTATION OF AN AUTOLOGOUS RETINAL FREE FLAP FOR CHRONIC RETINAL DETACHMENT WITH PROLIFERATIVE VITREORETINOPATHY WITH AND WITHOUT MACULAR HOLE
Authors: Thomas Akshay S. , Mahmoud Tamer H.
Published: December 2017

Purpose:

To describe the surgical technique for subretinal transplantation of an autologous retinal free flap in cases of chronic retinal detachment with proliferative vitreoretinopathy with and without a macular hole.

Methods:

Descriptive case series.

Results:

Two patients with recurrent retinal detachment with proliferative vitreoretinopathy were referred for surgical evaluation. The first patient had high myopia and a macular hole. Acuity at the last time of sustained retinal reattachment was 20/400 for the first patient and counting fingers for the second patient and, in both cases, declined to light perception in the months after redetachment. Despite membrane/internal limiting membrane peeling, surgical repair required an inferior retinectomy in both cases. A retinal free flap was placed subfoveally. In the first patient, the flap was placed with the photoreceptors facing bare retinal pigment epithelium. In the second patient, the flap was inverted so its photoreceptors faced residual macular photoreceptors. The retina was flattened over the flap. Postoperatively, vision improved to 20/160 and 20/400 in the first and second patient respectively.

Conclusion:

Subretinal placement of a retinal flap is possible in eyes with retinal detachment and proliferative vitreoretinopathy with and without macular hole. Whether such a flap results in superior visual and anatomical outcomes remains to be seen.
Excellent Outcomes Following Response-based Omission of Radiotherapy in Children and Adolescents With Intermediate or High-risk Hodgkin Lymphoma
Authors: Ozuah Nmazuo W. , Marcus Karen J. , LaCasce Ann S. , Billett Amy L.
Published: December 2017

Several pediatric Hodgkin lymphoma (HL) consortia have demonstrated safe omission of radiotherapy (RT) in early stage HL, whereas feasibility of omitting RT in advanced HL is still under investigation. This is a single institution retrospective analysis of 27 patients with intermediate-risk or high-risk HL (age 22 y and younger), treated with a modification of the dose-intensive OEPA-COPDAC (vincristine, etoposide, prednisone, doxorubicin—cyclophosphamide, vincristine, prednisone, dacarbazine) regimen, with radiation restricted to only sites of inadequate early response (Deauville ≥3 and/or ≤75% tumor shrinkage). Their outcome was compared with a historical cohort (n=42) treated with Stanford V or ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine), who received consolidative involved-field RT. RT was omitted in 15 of 27 (56%) of patients treated with OEPA-COPDAC, majority of whom (67%) had high-risk disease. At a median follow-up of 3.1 years, the 3-year progression-free survival was 100% in patients who received OEPA-COPDAC, versus 83.3% (95% confidence interval, 68.2%-91.7%) in the historical cohort, P=0.03. Our analysis demonstrates excellent survival with omission of RT in more than 50% of patients with pediatric advanced HL, treated with a dose-intensive chemotherapy regimen. When administered, RT was restricted to only sites of inadequate early response. Results of large prospective studies are needed to validate these findings.