bluuebunny/crossref_metadata_2025 huggingface dataset:
Signature
Authors: Bantekas Ilias
Published: March 2019

This chapter examines Article 42 of the United Nations Convention on the Rights of Persons with Disabilities (CRPD). Multilateral treaties such as the CRPD, which are adopted after years of negotiation, are opened for signature either to all states or only those states that participated in the negotiations and the final conference. Signature clauses are typically distinct from accession and ratification clauses given their bifurcated legal nature and distinct legal effects. Multilateral treaties undergo a three-tier process: a) negotiation/discussion; b) signature of final text and; c) ratification, which is further distinguished by the deposit of an instrument of ratification and the adoption of implementing legislation at the domestic level. Article 42 states that present Convention shall be open for signature by all states and by regional integration organizations at United Nations Headquarters in New York as of 30 March 2007. By September 2017 there were approximately 175 ratifications and twelve signatories to the CRPD.
Model checking and validity in propositional and modal inclusion logics
Authors: Hella Lauri , Kuusisto Antti , Meier Arne , Virtema Jonni
Published: March 2019

Propositional and modal inclusion logic are formalisms that belong to the family of logics based on team semantics. This article investigates the model checking and validity problems of these logics. We identify complexity bounds for both problems, covering both lax and strict team semantics. By doing so, we come close to finalizing the programme that aims to completely classify the complexities of the basic reasoning problems for modal and propositional dependence, independence and inclusion logics.
The effects of surface fossil magnetic fields on massive star evolution: I. Magnetic field evolution, mass-loss quenching, and magnetic braking
Authors: Keszthelyi Z , Meynet G , Georgy C , Wade G A , Petit V , David-Uraz A
Published: March 2019

Surface magnetic fields have a strong impact on stellar mass loss and rotation and, as a consequence, on the evolution of massive stars. In this work, we study the influence of an evolving dipolar surface fossil magnetic field with an initial field strength of 4 kG on the characteristics of 15 M⊙ solar metallicity models using the Geneva stellar evolution code. Non-rotating and rotating models considering two different scenarios for internal angular momentum transport are computed, including magnetic field evolution, mass-loss quenching, and magnetic braking. Magnetic field evolution results in weakening the initially strong magnetic field; however, in our models, an observable magnetic field is still maintained as the star evolves towards the red supergiant phase. At the given initial mass of the models, mass-loss quenching is modest. Magnetic braking greatly enhances chemical element mixing if radial differential rotation is allowed for; on the other hand, the inclusion of surface magnetic fields yields a lower surface enrichment in the case of near solid-body rotation. Models including surface magnetic fields show notably different trends on the Hunter diagram (plotting nitrogen abundance versus vsin i) compared to those that do not. The magnetic models agree qualitatively with the anomalous ‘Group 2 stars’, showing slow surface rotation and high surface nitrogen enhancement on the main sequence.
Revealing the dust attenuation properties on resolved scales in NGC 628 with SWIFT UVOT data
Authors: Decleir Marjorie , De Looze Ilse , Boquien Médéric , Baes Maarten , Verstocken Sam , Calzetti Daniela , Ciesla Laure , Fritz Jacopo , Kennicutt Rob , Nersesian Angelos , Page Mathew
Published: March 2019

Understanding how dust attenuation laws vary between and within galaxies is a key question if we want to reliably measure the physical properties of galaxies at both global and local scales. To shed new light on this question, we present a detailed study of the slope and bump strength of the attenuation law in the nearby spiral galaxy NGC 628 at the resolved spatial scale of 325 pc. To do so, we have modelled a broad multiwavelength data set from the ultraviolet (UV) to the infrared (IR) with the state-of-the-art SED fitting code cigale, including SWIFT UVOT data for which we have developed a new optimized reduction pipeline. We find that the median dust attenuation curve of NGC 628 is fairly steep, but not as steep as the SMC curve, and has a sub-MW-type UV bump. We observe intriguing variations within the galaxy, with regions of high AV exhibiting a shallower attenuation curve. We argue that the flattening of the curve is due to a dominance of absorption over scattering events at higher AV. No trend between the bump strength and the IRAC 8.0 $\mu$m emission was found. However, this does not necessarily rule out polycyclic aromatic hydrocarbons as the main contributors to the UV bump.
A new hard X-ray-selected sample of extreme high-energy peaked BL Lac objects and their TeV gamma-ray properties
Authors: Foffano L , Prandini E , Franceschini A , Paiano S
Published: March 2019

Extreme high-energy peaked BL Lac objects (EHBLs) are an emerging class of blazars with exceptional spectral properties. The non-thermal emission of the relativistic jet peaks in the spectral energy distribution (SED) plot with the synchrotron emission in X-rays and with the gamma-ray emission in the TeV range or above. These high photon energies may represent a challenge for the standard modelling of these sources. They are important for the implications on the indirect measurements of the extragalactic background light, the intergalactic magnetic field estimate, and the possible origin of extragalactic high-energy neutrinos. In this paper, we perform a comparative study of the multiwavelength spectra of 32 EHBL objects detected by the Swift-BAT telescope in the hard X-ray band and by the Fermi-LAT telescope in the high-energy gamma-ray band. The source sample presents uniform spectral properties in the broad-band SEDs, except for the TeV gamma-ray band where an interesting bimodality seems to emerge. This suggests that the EHBL class is not homogeneous, and a possible subclassification of the EHBLs may be unveiled. Furthermore, in order to increase the number of EHBLs and settle their statistics, we discuss the potential detectability of the 14 currently TeV gamma-ray undetected sources in our sample by the Cherenkov telescopes.
GMRT 610 MHz observations of galaxy clusters in the ACT equatorial sample
Authors: Knowles Kenda , Baker Andrew J , Bond J Richard , Gallardo Patricio A , Gupta Neeraj , Hilton Matt , Hughes John P , Intema Huib , López-Caraballo Carlos H , Moodley Kavilan , Schmitt Benjamin L , Sievers Jonathan , Sifón Cristóbal , Wollack Edward
Published: March 2019

We present Giant Metrewave Radio Telescope (GMRT) 610 MHz observations of 14 Atacama Cosmology Telescope (ACT) clusters, including new data for nine. The sample includes 73 per cent of ACT equatorial clusters with M500 > 5 × 1014 M⊙. We detect diffuse emission in three of these (27$^{+20}_{-14}$ per cent): we detect a radio minihalo in ACT-CL J0022.2–0036 at z = 0.8, making it the highest redshift minihalo known; we detect potential radio relic emission in ACT-CL J0014.9–0057 (z = 0.533); and we confirm the presence of a radio halo in low-mass cluster ACT-CL J0256.5+0006, with flux density S610 = 6.3 ± 0.4 mJy. We also detect residual diffuse emission in ACT-CL J0045.9–0152 (z = 0.545), which we cannot conclusively classify. For systems lacking diffuse radio emission, we determine radio halo upper limits in two ways and find via survival analysis that these limits do not significantly affect radio power scaling relations. Several clusters with no diffuse emission detection are known or suspected mergers, based on archival X-ray and/or optical measures; given the limited sensitivity of our observations, deeper observations of these disturbed systems are required in order to rule out the presence of diffuse emission consistent with known scaling relations. In parallel with our diffuse emission results, we present catalogues of individual radio sources, including a few interesting extended sources. Our study represents the first step towards probing the occurrence of diffuse emission in high-redshift (z ≳ 0.5) clusters, and serves as a pilot for statistical studies of larger cluster samples with the new radio telescopes available in the pre-SKA era.
Respiratory rates observed over 15 and 30 s compared with rates measured over 60 s: practice-based evidence from an observational study of acutely ill adult medical patients during hospital admission
Authors: Rimbi M , Dunsmuir D , Ansermino J M , Nakitende I , Namujwiga T , Kellett J
Published: March 2019

Background

Respiratory rate is often measured over a period shorter than 1 min and then multiplied to produce a rate per minute. There are few reports of the performance of such estimates compared with rates measured over a full minute.

Aim

Compare performance of respiratory rates calculated from 15 and 30 s of observations with measurements over 1 min.

Design

A prospective single center observational study

Methods

The respiratory rates calculated from observations for 15 and 30 s were compared with simultaneous respiratory rates measured for a full minute on acutely ill medical patients during their admission to a resource poor hospital in sub-Saharan Africa using a novel respiratory rate tap counting software app.

Results

There were 770 respiratory rates recorded on 321 patients while they were in the hospital. The bias (limits of agreement) between the rate derived from 15 s of observations and the full minute was −1.22 breaths per minute (bpm) (−7.16 to 4.72 bpm), and between the rate derived from 30 s and the full minute was −0.46 bpm (–3.89 to 2.97 bpm). Rates observed over 1 min that scored 3 National Early Warning Score points were not identified by half the rates derived from 15 s and a quarter of the rates derived from 30 s.

Conclusion

Practice-based evidence shows that abnormal respiratory rates are more reliably detected with measurements made over a full minute, and respiratory rate measurement ‘short-cuts’ often fail to identify sick patients.
Infinitesimal Automorphisms of VB-Groupoids and Algebroids
Authors: Esposito Chiara , Vitagliano Luca , Tortorella Alfonso Giuseppe
Published: March 2019

VB-groupoids and algebroids are vector bundle objects in the categories of Lie groupoids and Lie algebroids, respectively, and they are related via the Lie functor. VB-groupoids and algebroids play a prominent role in Poisson and related geometries. Additionally, they can be seen as models for vector bundles over singular spaces. In this paper we study their infinitesimal automorphisms, i.e. vector fields on them generating a flow by diffeomorphisms preserving both the linear and the groupoid/algebroid structures. For a special class of VB-groupoids/algebroids coming from representations of Lie groupoids/algebroids, we prove that infinitesimal automorphisms are the same as multiplicative sections of a certain derivation VB-groupoid/algebroid.
Service Use Following First-Episode Schizophrenia Among Commercially Insured Youth
Authors: Gilmer Todd P , van der Ven Els , Susser Ezra , Dixon Lisa B , Olfson Mark
Published: March 2019

Objective

To investigate patterns of mental health service and antipsychotic use following a first-episode schizophrenia (FES) and to examine the role of the treatment setting in which individuals are first diagnosed.

Method

Analysis of de-identified administrative claims data from the OptumLabs Data Warehouse was used to identify 1450 privately insured youth and young adults aged 14 through 30 with FES from January 1, 2011 through December 31, 2015. Regression analysis was used to estimate the use of mental health services during the year following FES, by type of service and by site of index diagnosis.

Results

In the year following FES, 79.7% of youth received outpatient mental health services and 35.8% filled a prescription for antipsychotic medication. Among service users, mean outpatient visits were 15.9 and mean antipsychotic fills were 8.3. Youth who received an index diagnosis of FES in an inpatient setting were more likely to fill an antipsychotic medication than youth with FES in other settings. Youth who received an index diagnosis of FES during a specialty mental health outpatient visit had greater use of outpatient mental health than youth who received their diagnosis during a primary care visit.

Conclusions

Despite evidence-based guidelines supporting outpatient psychosocial care and antipsychotic treatment for FES, one-fifth of this cohort did not use outpatient services and the majority did not fill any prescriptions for antipsychotic medications during the year following FES. Our findings provide renewed urgency to ongoing efforts to accelerate early identification and care coordination for youth with FES.
Tracking the Pendulum Swing on Legislative Entrenchment in New Zealand
Authors: Shiels Timothy , Geddis Andrew
Published: March 2019

When New Zealand’s Parliament legislates to the effect that law on some particular matter may only be enacted using a mandated procedure, can the New Zealand judiciary enforce this provision against a future Parliament that fails to comply with it? Following the Supreme Court’s recent refusal to conclusively decide this question, we examine why it still remains controversial in New Zealand. We first set the issue in a wider constitutional framework, explaining how such judicial enforcement requires considering the nature of parliamentary sovereignty and the role of the courts in defining this. The way in which the matter has been addressed over time in New Zealand and elsewhere—the pendulum swing of constitutional understandings, to use the Supreme Court’s term—is then outlined. We draw on this analysis to examine why the Supreme Court felt unable to resolve the particular question of enforceability, while also raising an as-yet unexamined question as to how such enforcement implicates the statutorily guaranteed parliamentary privilege of non-interference in the internal affairs of the House. We conclude that because it is unlikely this issue will come before the courts again in the near term, continued uncertainty over the law in this area is set to continue.
Species diversity of Marmosa subgenus Micoureus (Didelphimorphia, Didelphidae) and taxonomic evaluation of the white-bellied woolly mouse opossum, Marmosa constantiae
Authors: Lima Silva Luan Gabriel De , Ferreira Daniela Cristina , Rossi Rogério Vieira
Published: March 2019

Marmosa subgenus Micoureus contains six currently recognized species, distributed from southern Belize to northern Argentina. Although recent studies have demonstrated the monophyly of the subgenus, the species have not been recently revised. Except for M. phaea, we evaluated the species diversity in this subgenus of mouse opossums using integrated morphological, morphometric and molecular data, with emphasis on M. constantiae. We used a total of 700 specimens for morphological and morphometric analyses. For phylogenetic, species delimitation, molecular variance and population structuring analyses (the latter two only for M. constantiae), we used the mitochondrial cytochrome b gene. Morphometric variation patterns were evaluated through Principal Component Analysis and Discriminant Function Analysis. Our results indicate that there are seven species in our samples. Among the species analysed morphologically, some can be discriminated by craniodental measurements and all can be discriminated through morphology. Marmosa constantiae is polyphyletic, composed of two lineages, one of which is correctly named M. budini. Marmosa constantiae (s.s.) has a well-known genetic structure, with no clear geographic structure and no consistent morphological patterns. Several records of M. demerarae in the literature correspond to M. constantiae. Marmosa demerarae may thus represent a complex formed of at least two species.
Acute neurological adverse events during immune checkpoint inhibition therapy in patients with melanoma brain metastases
Authors: Grätz Victoria , Langan Ewan A. , Neumann Alexander , Zillikens Detlef , Terheyden Patrick
Published: March 2019

The common adverse effects of immune checkpoint blockade therapy are well recognised. However, neurological adverse effects of checkpoint inhibitor therapy are less widely appreciated, and their clinical management remains challenging. Therefore, we report our experience of managing acute, life-threatening neurological toxicity during immune checkpoint inhibitor therapy. Five male patients with stage IV melanoma underwent anti-programmed cell death protein 1 therapy (monotherapy or combination therapy with anti-cytotoxic T-lymphocyte antigen-4 antibodies) and developed severe neurological symptoms and signs including headache, hemiparesis and dysarthria. The initial diagnosis of brain metastases actually occurred after initiation of checkpoint inhibitor therapy in three of the patients, whereas two patients had pre-existing central nervous metastases and developed cerebral oedema and haemorrhage during immunotherapy. A rapidly fatal outcome occurred in two patients treated with immunotherapy following the development of BRAF-inhibitor and MEK-inhibitor resistance. Four of the patients died owing to neurological complications, and one achieved a complete cerebral response. Immunotherapy and tumour progression can both result in the development of neurological symptoms and signs, making it difficult to determine causality. However, the temporal relationship between the development of neurological symptoms and the first administration of therapy means that patients should be closely monitored for the development of neurological sequelae, which may even herald the presence of occult brain metastases. The decision on whether to continue immunotherapy must balance the risks of symptom – versus disease progression. However, in our case series, it is encouraging to note that the initial acute neurological symptoms were often transient. Nevertheless, pretherapeutic brain imaging to exclude occult brain metastases and stratify the risk of intracerebral oedema and haemorrhage should be considered.
Ra-223 Treatment for Bone Metastases in Castrate-Resistant Prostate Cancer
Authors: Den Robert B. , George Daniel , Pieczonka Christopher , McNamara Megan
Published: March 2019

Bone metastases are common in men with metastatic castrate-resistant prostate cancer (mCRPC), occurring in 30% of patients within 2 years of castrate resistance and in >90% of patients over the disease course. There are 6 US Food and Drug Administration-approved therapies for mCRPC with demonstrated survival benefit. Of these, only radium-223 (Ra-223) specifically targets bone metastases, delays development of skeletal-related events, and improves survival. This review discusses key data from the ALSYMPCA trial, which contributed to the approval of Ra-223. Data from other trials are highlighted to provide further insight into which patients might benefit from Ra-223. Special patient populations are described, as well as other considerations for the administration of Ra-223. Finally, ongoing trials of Ra-223 combined with other therapies for mCRPC are discussed. These include combining Ra-223 with sipuleucel-T or immunooncology agents, to enhance immune responses, and trials in mildly symptomatic or asymptomatic patients. To date, the optimal timing, sequence, and combinations of Ra-223 with other agents are yet to be determined. The goals of this review are to provide insight into practical aspects of patient selection for Ra-223 treatment and to discuss key therapeutic strategies using the 6 approved mCRPC agents in patients with bone metastases. Results from ongoing trials should help guide the practitioner in using Ra-223 in patients with mCRPC.
Pharmacodynamic Therapeutic Drug Monitoring for Cancer: Challenges, Advances, and Future Opportunities
Authors: Veal Gareth J. , Amankwatia Edward B. , Paludetto Marie-Noëlle , Möcklinghoff Till , Thomson Fiona , André Nicolas , Ciccolini Joseph , Chatelut Etienne
Published: March 2019

In the modern era of cancer treatment, with targeted agents superseding more traditional cytotoxic chemotherapeutics, it is becoming increasingly important to use stratified medicine approaches to ensure that patients receive the most appropriate drugs and treatment schedules. In this context, there is significant potential for the use of pharmacodynamic biomarkers to provide pharmacological information, which could be used in a therapeutic drug monitoring setting. This review focuses on discussing some of the challenges faced to date in translating preclinical pharmacodynamic biomarker approaches to a clinical setting. Recent advances in important areas including circulating biomarkers and pharmacokinetic/pharmacodynamic modeling approaches are discussed, and selected examples of anticancer drugs where there is existing evidence to potentially advance pharmacodynamic therapeutic drug monitoring approaches to deliver more effective treatment are discussed. Although we may not yet be in a position to systematically implement therapeutic drug monitoring approaches based on pharmacodynamic information in a cancer patient setting, such approaches are likely to become more commonplace in the coming years. Based on ever-increasing levels of pharmacodynamic information being generated on newer anticancer drugs, facilitated by increasingly advanced and accessible experimental approaches available to researchers to collect these data, we can now look forward optimistically to significant advances being made in this area.
Improving Therapeutic Decisions: Pharmacodynamic Monitoring as an Integral Part of Therapeutic Drug Monitoring
Authors: Shipkova Maria , Christians Uwe
Published: March 2019

Although the monitoring of drug therapies based on the determination of drug concentrations in biological materials is certainly an important instrument for individualized dosing and dose adjustment with a broad variety of pharmaceuticals, its role is limited by the fact that it does not reflect pharmacodynamic (PD) and toxicodynamic interactions such as those caused by individual and environment-related factors. However, these interactions are important for both the efficacy and the safety of the drug therapy. Therefore, during recent years, there is an increased interest in personalized drug therapy as reflected by the development and clinical implementation of molecular “biomarkers” that are direct or surrogate markers of pharmacological effects [PD therapeutic drug monitoring (TDM)]. Moreover, this process is driven by new developments in instrumentation, such as mass spectrometry and array technologies, and in computational biology/pharmacology, databases, and bioinformatics. This Focus Issue of the journal focuses on current achievements in and status of PD TDM with different classes of drugs. The contributions to the present issue of Therapeutic Drug Monitoring provide a critical analysis of current practices of TDM with their limitations, introduce newer promising biomarkers in the field of PD TDM, discuss the challenges faced to date in translating preclinical tools into clinical settings, and point out recent advances in the establishment of modeling approaches that apply to pharmacokinetics (PK)/PD as well as pharmacogenetic information.
Echocardiographic assessment of left ventricular diastolic pressure
Authors: McLean Anthony S.
Published: March 2019

Purpose of review

Knowledge of the left ventricular pressures throughout the cardiac cycle is of considerable assistance in managing a haemodynamically unstable patient. Invasive pressure measurement is the only accurate way to analyze ventricular diastolic pressures but this is not feasible outside the catheterization laboratory, whereas the use of a pulmonary artery catheter or Doppler echocardiography, using surrogate measurements, is available at the bedside. The ever-increasing trend toward noninvasive monitoring puts echocardiography at the forefront and considerable effort has been made to define its role in this setting.

Recent findings

Ongoing refinement of guidelines used to evaluate left ventricular diastolic function have provided a pathway for critical care physicians to better understand how to evaluate left ventricular end-diastolic pressure and/or left atrial pressures. A number of recent studies have investigated the accuracy of combined or single echocardiographic parameters in determining left ventricular diastolic pressures as compared to those obtained invasively. Specifically selected combined parameters have moderate accuracy.

The recent literature on the clinical application of echocardiography on the accuracy in determining left ventricular noninvasively demonstrates that although far from perfect, it can be a very useful tool.
Nurses' Views on Using Pasteurized Donor Human Milk for Hypoglycemic Term Infants
Authors: Ferrarello Debi , Froh Elizabeth B. , Hinson Tyonne D. , Spatz Diane L.
Published: March 2019

Purpose:

The purpose of this study was to explore maternal child nurses' knowledge and beliefs about using pasteurized donor human milk (PDHM) to treat newborns with hypoglycemia. Pasteurized donor human milk has been used for decades in neonatal intensive care units, but its use is relatively new in the well-baby population.

Study Design and Methods:

Focus groups of maternal child nurses were conducted to explore this topic.

Results:

Six focus groups that included a total 20 nurses were held. Four themes were identified: 1) nurses presumed safety of PDHM but lacked knowledge, 2) nurses' role as patient–family advocate, 3) nurses' logistical concerns about implementation of PDHM, and 4) nurses lacked clarity on formal milk sharing versus PDHM.

Clinical Implications:

As the use of PDHM increases for well babies, nurses will need more education about PDHM, its safety profile, its use in breastfeeding support and protection of the infant microbiome, and how PDHM differs from informal milk sharing. Nurses play an important role in helping parents weigh risks and benefits of using PDHM or formula when supplementation is needed during the hospital stay. It is important that nurses feel confident in their own knowledge and ability to address parental concerns so they can advocate for their patients and support parental decision-making.
A Tablet-Based Tool for Accurate Measurement of Hand Proprioception After Stroke
Authors: Block Hannah J. , Mirdamadi Jasmine L. , Ryckman Sydney , Lynch Anna K. , Wilson Reid , Udayan Divya , Massie Crystal L.
Published: March 2019

Background and Purpose:

Proprioceptive deficits in the hand are common following stroke, but current clinical measurement techniques are too imprecise to detect subtle impairments or small changes. We developed a tablet-based tool to measure static hand proprioception using an adaptive staircase procedure.

Methods:

In 16 individuals with chronic stroke and age-matched controls, we quantified proprioception at the metacarpophalangeal joint of the index finger using 3 methods: the tablet task, a custom passive movement direction discrimination test (PMDD), and a manual assessment similar to the Fugl-Meyer (F-M) proprioception subsection.

Results:

The tablet-based measure and the PMDD both identified impaired proprioception in the affected hand relative to the unaffected hand (P = 0.024 and 0.028), and relative to the control group (P = 0.040 and 0.032), while manual assessment did not. The PMDD had a ceiling effect as movement excursions greater than 15^ were not biomechanically feasible. The tablet-based measure and the PMDD detected impaired proprioception in 56% to 75%, and the F-M in only 29%, of patients. PMDD and tablet-based measures were both correlated with primary tactile sensation, but not manual dexterity.

Discussion and Conclusions:

Both the tablet-based tool and the custom PMDD performed better than manual assessment. The PMDD may be useful when the deficit is mild or assessment of dynamic proprioception is desired. As the tablet-based measure does not have the ceiling effect that is associated with the PMDD, it may be useful with any level of proprioceptive impairment, and may be preferable if testing or clinician training time needs to be minimized, or pain or spasticity is present.

Video Abstract available for more insights from the authors (see the Video, Supplementary Digital Content 1, available at: http://links.lww.com/JNPT/A256).
Approach to the Examination and Classification of Nystagmus
Authors: Eggers Scott D. Z.
Published: March 2019

Background and Purpose:

Physical therapists caring for patients with neurologic or vestibular disorders must routinely examine and characterize nystagmus and other oscillatory eye movements. Often, the diagnosis hinges on proper interpretation of the nystagmus pattern. This requires understanding the terminology surrounding the numerous attributes and influencing factors of nystagmus, a systematic approach to the examination, and a classification structure that guides practitioners to the specific nystagmus type and subsequent evaluation and management.

Summary of Key Points:

Nystagmus is an involuntary, rapid, rhythmic, oscillatory eye movement with at least 1 slow phase. Jerk nystagmus has a slow phase and a fast phase. Pendular nystagmus has only slow phases. Nystagmus is distinguished from other types of oscillatory eye movements, such as saccadic intrusions or oscillations. Characterizing nystagmus requires clearly describing its trajectory. This includes choosing a reference frame to describe the axes or planes and direction of eye movements. Several attributes are used to describe nystagmus: binocularity, conjugacy, velocity, waveform, frequency, amplitude, intensity, temporal profile, and age at first appearance. Several factors may influence nystagmus, including gaze position, visual fixation, vergence, and a variety of provocative maneuvers. Classification of nystagmus may be organized by physiologic or pathologic nystagmus versus other nystagmus-like movements. Pathologic nystagmus may be spontaneous, gaze-evoked, or triggered by provocative maneuvers. The combination of attributes allows differentiation between the many peripheral and central forms.

Recommendations for Clinical Practice:

Therapists should carefully examine and characterize the trajectory and other attributes and influencing factors of nystagmus to accurately classify it and arrive at the correct diagnosis.
Update on HINTS Plus, With Discussion of Pitfalls and Pearls
Authors: Kattah Jorge C.
Published: March 2019

Background and Purpose:

The team that manages acute vertigo in patients requires multispecialty skills. This special interest article offers a simplified list of common pitfalls to be avoided when applying the HINTS (Head-Impulse, Nystagmus, Test-of-Skew) Plus examination protocol in patients with acute vertigo. Benign paroxysmal positional vertigo is the most frequent cause of positional vertigo. The lack of systematic evaluation of symptom duration and triggers, and/or incomplete target examination, leads to improper diagnosis and management. Pitfalls to avoid and pearls to apply are offered to avoid misclassification of acute vertigo.

Summary of Key Points:

Appropriate, expeditious treatment implemented upon diagnostic certainty by the first health professional evaluating the patient is key to a good outcome. The absence of a typical positional nystagmus is particularly concerning for an alternative diagnosis. Misclassification of the type of vertigo leads to potential diagnostic error. The HINTS Plus examination is useful when applied to the correct clinical scenario. The most common misclassification of vertigo relates to an inability to detect spontaneous nystagmus suppressed by visual fixation and subsequent classification and treatment for positional vertigo. The second most common classification relates to inadequate evaluation of the HINTS Plus examination.

Recommendations for Clinical Practice:

Through an organized evaluation of the acutely vertiginous patient, common pitfalls in the classification of vertigo can be avoided. Such an evaluation leads to identification of those patients who require canal repositioning maneuvers and those who need referral for evaluation of other causes.
The Utility of the Focused Assessment With Sonography in Trauma Examination in Pediatric Blunt Abdominal Trauma
Authors: Liang Tian , Roseman Eric , Gao Melanie , Sinert Richard
Published: March 2019

Objective

To evaluate the utility of the Point of Care Ultrasound (POCUS) Focused Assessment with Sonography for Trauma (FAST) examination for diagnosis of intra-abdominal injury (IAI) in children presenting with blunt abdominal trauma.

Methods

We searched medical literature from January 1966 to March 2018 in PubMed, EMBASE, and Web of Science. Prospective studies of POCUS FAST examinations in diagnosing IAI in pediatric trauma were included. Sensitivity, specificity, and likelihood ratios (LR) were calculated using a random-effects model (95% confidence interval). Study quality and bias risk were assessed, and test-treatment threshold estimates were performed.

Results

Eight prospective studies were included encompassing 2135 patients with a weighted prevalence of IAI of 13.5%. Studies had variable quality, with most at risk for partial and differential verification bias. The results from POCUS FAST examinations for IAI showed a pooled sensitivity of 35%, specificity of 96%, LR+ of 10.84, and LR− of 0.64. A positive POCUS FAST posttest probability for IAI (63%) exceeds the upper limit (57%) of our test-treatment threshold model for computed tomography of the abdomen with contrast. A negative POCUS FAST posttest probability for IAI (9%) does not cross the lower limit (0.23%) of our test-treatment threshold model.

Conclusions

In a hemodynamically stable child presenting with blunt abdominal trauma, a positive POCUS FAST examination result means that IAI is likely, but a negative examination result alone cannot preclude further diagnostic workup for IAI. The need for computed tomography scan may be obviated in a subset of low-risk pediatric blunt abdominal trauma patients presenting with a Glasgow Coma Scale of 14 to 15, a normal abdominal examination result, and a negative POCUS FAST result.
Atraumatic Spinal Epidural Hematoma as Initial Presentation of Hemophilia A in an Infant
Authors: Crumm Caitlin E. , Crotty Erin E. , Albert Catherine M. , Blair Amanda B. , Otjen Jeffrey P. , Feldman Kenneth W.
Published: March 2019

Hemophilia A is characterized by deficiency of factor VIII. We present a unique, illustrative case of an infant with a short history of neck pain and irritability without neurological deficits who was found to have a spinal epidural hematoma. The subsequent investigation for the etiology, including workup for nonaccidental trauma, led to a diagnosis of severe hemophilia A.
3 Cases of Inflicted Skull Crush Injuries in Infants
Authors: Brown Emily C.B. , Donaruma-Kwoh Marcella M. , Otjen Jeffrey P. , Feldman Kenneth W.
Published: March 2019

We describe 3 infants with skull fractures that involved more than 1 skull bone. On further evaluation, 2 of the 3 infants had additional fractures at other sites of the body and the third infant had concerning bruising of the face. Although an accidental mechanism of injury was initially given as the history in each case, law enforcement investigations led all 3 fathers to confess to crushing their infants' skulls out of frustration. These crushes were caused by their arms or hands. Bilateral skull fractures or those involving more than 1 skull bone can be seen in falls as well as in crush injuries. A crush-like pattern of injury, in the absence of a clear and plausible accidental mechanism, should raise concerns for possible physical abuse especially in nonambulatory infants.
Roller Coaster–Induced Subdural Hematoma in a Previously Healthy Teenager
Authors: Tseng Peggy , Kearl Yvette Liza , Ansari Ashkon
Published: March 2019

Of the multitude of neurologic injuries related to roller-coaster rides, a majority of them are reported about adults. In this case, we present a patient who presented to the pediatric emergency department with new-onset seizure and hemiplegia 2 days after a roller-coaster ride. She was ultimately diagnosed with a subdural hematoma. The acceleration and G forces of roller coasters are hypothesized to cause enough stress and shearing forces that are thought to directly cause subdural hemorrhage.

Advances in roller-coaster technology may surpass the passenger's physical capacity for acceleration and rotary forces, and we may see an increased number of medical complications after these rides. We recommend that emergency and pediatric health care providers consider amusement park thrill rides as a possible cause of subdural hematomas in previously healthy patients with new neurologic complaints.
Austere Foreign Body Injuries in Children and Adolescents
Authors: Fischer Julie , Krishnamurthy Jayasree , Hansen Shana , Reeves Patrick T.
Published: March 2019

Background

Pediatric foreign body (FB) injuries to the nasal, aural, and/or oral cavities are well documented. Description of austere foreign body (AFB) injuries involving the rectum, vagina, or penis eludes the current pediatric literature. Austere FBs can be difficult to identify and have the potential to cause serious consequences. We aim to characterize AFB injuries by children and adolescents presenting to emergency departments (EDs) in the United States.

Methods

The National Electronic Injury Surveillance System was queried to include subjects aged 0 to 25 years using a primary search term for diagnosis of foreign body from the period of January 2008 to January 2017. The consumer product and the body part involved (ie, rectal, vaginal, penile) were analyzed. Taylor series linearization generated national estimates. A trend analysis was performed using the Cochrane Armitage test of trend.

Results

There were 27,755 (95% confidence interval, 21,170–34,338) national estimated childhood ED visits for suspected AFB injuries during 2008 to 2017 including an estimated 7756 vaginal FBs, 7138 penile FBs, and 8359 rectal FBs (RFBs). Over the timeline, there was a significant up trend in the frequency of annual RFBs (P < 0.01).

Conclusion

Austere FB injuries appear to cluster around age of 7 years. Most AFB injuries are able to be treated and released from the ED. It appears that RFB injury frequencies are rising and tend to require more frequent admission. Providers must be vigilant in the diagnosis and management of these potentially hazardous injury types.
Hypertrophic Herpes Simplex With Subsequent Development of Plasma Cell Vulvitis: A Potential Diagnostic Pitfall
Authors: Elghobashy Maiar , Elgaly Maher , Salmons Nabeel , El-Ghobashy Alaa
Published: March 2019

A 37-yr-old patient previously diagnosed with human immunodeficiency virus initially presented with a genital lesion which upon histologic assessment was diagnosed as a pseudotumor associated with herpes simplex virus infection. The pseudotumor responded to initial treatment with Acyclovir, however, the lesion recurred 2 yr later and was diagnosed as plasma cell vulvitis. We discuss the clinical presentation, diagnostic work up and treatment options of such a rare lesion.
Capturing Patients' Perspectives on Medication Safety: The Development of a Patient-Centered Medication Safety Framework
Authors: Giles Sally J. , Lewis Penny J. , Phipps Denham L. , Mann Faith , Avery Anthony J. , Ashcroft Darren M.
Published: March 2019

Objectives

Medication safety incidents are common in primary care and contributory factors frameworks can assist in our understanding of their causes. A framework that is positioned from the perspective of patients would be advantageous in practice when seeking patient insights into medication safety. The aim of this study was to develop a patient-centered contributory factors framework for examining medication safety incidents.

Methods

A purposive sample of 106 members of the public, patients, and carers were recruited to take part in focus groups (n = 18). Focus groups were audio recorded, transcribed, and analyzed using a thematic framework. A patient and public involvement group was set up to undertake multiple roles in the research process, including the development of the focus group schedule, analysis of the data, and the construction of a patient-centered framework of contributory factors (patient-centered medication safety) and implementation checklist.

Results

The findings highlighted the importance of communication, supplies of medication and appliances, patient- and carer-related factors, healthcare professional factors, and computer systems and programs in the safe use of medicines. Some contributory factors were unique to primary care patients such as access to services and continuity of care. In conjunction with a patient and public involvement group, a framework of factors that patients believe contribute to medication safety incidents in primary care was developed that could be used by patients and healthcare professionals.

Conclusions

The patient-centered medication safety framework and implementation checklist provides a novel tool to examine contributory factors that can lead to medication safety incidents from patients' perspective.
Differential Uptake of 68Ga-PSMA-HBED-CC (PSMA-11) in Low-Grade Versus High-Grade Gliomas in Treatment-Naive Patients
Authors: Verma Priyanka , Malhotra Gaurav , Goel Atul , Rakshit Sutapa , Chandak Ashok , Chedda Rupal , Banerjee Sharmila , Asopa Ramesh V.
Published: March 2019

Purpose of the Report

Prostate-specific membrane antigen (PSMA) is a type II membrane glycoprotein, which is not only overexpressed in prostate cancers but also in variety of solid tumors including glioblastoma multiforme. The aim of the present study was to demonstrate PSMA expression in gliomas using 68Ga-PSMA-HBED-CC(PSMA 11) PET/CT.

Patients and Methods

Ten patients with initially MRI suspected and eventually histopathologically proven gliomas [8 males (age range 30–73 yr; mean age 51.8 yr); 2 females aged 39 and 55 years] were subjected preoperatively to regional brain PET scan with 68Ga-PSMA-11 and 18F-FDG PET/CT. Final histopathology of brain lesions, their MIB-1 proliferation index (MIB-1 PI) were compared with PSMA and FDG PET findings.

Results

FDG PET/CT showed distinct FDG uptake in high-grade gliomas, whereas low-grade gliomas were non-FDG-avid amidst physiological tracer uptake. In vivo PSMA expression was seen in all patients with glioma. Of these, the 7 patients of glioblastoma harboring 8 lesions showed significantly higher PSMA expression than those with low-grade gliomas, average SUVmax being 16.93 and 2.93, respectively. Similarly, average tumor-to-background ratios (13.95 and 3.42, respectively) and MIB-1 PI (17.31 and 3.3, respectively) were substantially more in high-grade versus low-grade gliomas.

Conclusions

The results of this pilot study show that 68Ga-HBED-CC-PSMA PET/CT can be used to characterize the PSMA expression in gliomas, high-grade ones demonstrating higher SUVmax, MIB-1 PI tumor-to-background ratio than the low-grade ones. With these results as basis, certain patients may benefit from potential PSMA-targeted radionuclide therapy.
68Ga-DOTANOC PET/CT in an Atypical Extraskeletal Paravertebral Hemangioma Mimicking as Neurogenic Tumor in a Known Case of Breast Cancer
Authors: Vadi Shelvin Kumar , Mittal Bhagwant Rai , Parihar Ashwin Singh , Kumar Rajender , Singh Harmandeep , Singh Gurpreet
Published: March 2019

68Ga-DOTANOC PET/CT is well documented in evaluation of well-differentiated neuroendocrine tumors and in other lesions with somatostatin receptor expression such as pheochromocytoma, paraganglioma, neuroblastoma, meningioma, and mesenchymal tumors causing oncogenic osteomalacia. Causes of interpretative pitfalls include prominent pancreatic uncinate process activity, inflammation, osteoblastic activity (degenerative bone disease/fracture/vertebral hemangioma), splenunculi/splenosis, and others. We present a case of extraskeletal paravertebral lesion detected in a known case of breast cancer with increased 68Ga-DOTANOC uptake later proved to be hemangioma. This is a novel finding and should be kept as a rare benign differential in evaluation of lesions with somatostatin receptor expression.
Intravesical Extrusion of a Single-Incision Midurethral Sling Anchor With a Simple Transurethral Resection Technique: A Case Report
Authors: Gabriel Iwona M. , Chiang H. Abraham , Kalousdian Anthony , Minassian Vatche A.
Published: March 2019

Single-incision midurethral slings were introduced in 2006 with the goal of providing shorter operative time, less postoperative pain, and decreased rates of injury to surrounding structures (eg, bladder and/or obturator nerve). Although unrecognized bladder injury during SIMS placement is a rare complication, it can lead to irritative voiding symptoms and recurrent urinary tract infections. We present the case of minimally invasive approach to remove an extruded sling.
Increasing Age Predicts Increasing Residual Urine Volume
Authors: Wolff Birte Johanna , Brennan Katelyn , Joyce Cara Jean , Shannon Megan B. , Brincat Cynthia Ann
Published: March 2019

Objectives

To determine reference values for postvoid residual (PVR) volume for patients referred to a tertiary urogynecology center.

Methods

After Institutional Review Board approval, we performed a retrospective chart review of all new patients presenting to our referral center. We assessed associations between PVR and patient demographics, pelvic floor symptoms, and physical examination by Wilcoxon rank sum or Kruskal-Wallis tests as appropriate. A multivariable logistic regression model was used to calculate odds ratios for patient characteristics associated with PVR in the top age range-specific decile.

Results

Three hundred sixty-one patients were included in the analysis. The median PVR was 20 mL (interquartile range, 1st, 3rd quartiles, 10, 50). Older age was associated with higher PVR (P < 0.001). The median PVR in participants younger than 40 years was 10 mL, ages 40 to 49 years was 18 mL, 50 to 69 years was 20 mL, 70 to 79 years was 38 mL and in women older than 79 years was 50 mL. A multivariable analysis showed that prolapse stage (odds ratio [OR], 3.46 with prolapse stage 2–4 vs stage 0–1; P = 0.001), history of stroke (OR, 7.62; [95% CI 2.17–26.77, P = 0.002]), narcotic use (OR, 2.45; [95% CI 1.01–5.92; P = 0.047]), and urinary frequency (OR, 2.61; [95% CI, 1.14–5.98; P = 0.024]) were risk factors for increased PVR (as defined at >90%ile for age), independent of the age-related elevation.

Conclusions

The majority of patients presenting for urogynecologic evaluation had a low PVR with a median of 20 mL. Postvoid residual was higher for older age groups but nearly all volumes were less than 100 mL. The utility of a PVR measurement is highest for patients with pelvic organ prolapse, urinary frequency, narcotic use, or history of stroke.