bluuebunny/crossref_metadata_2025 huggingface dataset:
Specialty Practice Situations
Authors: Riveros-Perez Efrain , Perilla Mauricio
Published: August 2018

Recent advances in surgical and interventional procedures have led to a significant and increased demand for anesthesia services in locations distant from the traditional operating room. Special settings such as ophthalmologic surgery, interventional radiology, and the electrophysiology lab present unique challenges to the anesthesia provider. In addition to the remote location of the procedure rooms, the lack of familiarity with the equipment and distance from emergency back-up make for a challenging situation. Judicious preparation and set up of anesthesia equipment and materials as well as communication between the anesthesiologist, proceduralist, technicians, and nursing staff are key to performing these procedures in a safe fashion. Finally, procedures involving radiation exposure require awareness of occupational and patient safety concerns. This chapter discusses relevant anesthetic considerations for interventions performed in special settings including ophthalmologic surgery, gastrointestinal endoscopy, interventional radiology, cardiac diagnostic, and magnetic resonance imaging suites.
Using qualitative research with different types of RCTs
Authors: O'Cathain Alicia
Published: August 2018

When researchers write methodological reflections on the use of qualitative research with RCTs, their focus is usually on individually randomized two-armed pragmatic full RCTs. However, qualitative research is used with a range of RCT types. The objectives, data collection, or analysis of the qualitative research may depend on the type of RCT. How qualitative research can be used with different types of RCT is described in this chapter. This includes explanatory and pragmatic RCTs; feasibility, pilot, or exploratory RCTs; cluster RCTs; N of 1 trials; and factorial RCTs. Where guidance is available about using qualitative research with a specific type of RCT, this is described along with any challenges specific to each type.
Selecting research questions
Authors: O'Cathain Alicia
Published: August 2018

Qualitative research can make a wide range of contributions to the generation of evidence of effectiveness. Researchers do not necessarily set out with the intention of addressing these issues. That is, researchers can start with a broader set of research questions, and then specific issues can emerge during the qualitative analysis that are considered to be important enough to become the focus of a journal article. In this chapter consideration is given to the research question, or set of research questions, articulated in the proposal or published protocol. Issues addressed in the chapter include the factors shaping the selection of research questions, examples of research questions used in proposals and publications, and challenges faced when selecting research questions.
Collecting data
Authors: O'Cathain Alicia
Published: August 2018

There are many issues to consider when collecting data in qualitative research with RCTs. In this chapter consideration is given to the range of methods that can be used, who to include in the data collection, how to identify people or places to include, how many people or places to include, when to undertake data collection, and who is best placed to undertake it.
Analysing the qualitative data
Authors: O'Cathain Alicia
Published: August 2018

Numerous books and journal articles have been written about how to analyse qualitative data. In this chapter the assumption has been made that readers know how to do this. The focus of the chapter is on how researchers have analysed qualitative data collected with RCTs. The chapter begins with a brief description of the range of approaches to analysis used in the context of qualitative research with RCTs, giving examples of how researchers describe their analysis. Consideration is then given to who can be involved in the analysis and the challenges researchers may face.
Integrating qualitative and quantitative data and findings
Authors: O'Cathain Alicia
Published: August 2018

Integration is where one method influences in some way the objectives, sampling, data collection, analysis, or interpretation of the other methods within a mixed methods study. Studies of qualitative research undertaken with RCTs have identified that publications often have no evidence of integration of findings. That is, the promise of qualitative research helping to explain the RCT results is simply not delivered in practice, or at least not in a way that is visible outside the original research team. The focus of this chapter is on where integration can occur within a study, the techniques that can facilitate integration, and examples of integration in the context of qualitative research and RCTs.
Team working
Authors: O'Cathain Alicia
Published: August 2018

The focus of this chapter is on team work. How a team works together can affect the value of the qualitative research for the RCT and the generation of evidence of effectiveness of the intervention. How a team works best together may depend on the phase of the study—whether it is a feasibility study or the full evaluation—and the timing of completion of the qualitative research in relation to the full RCT. The value of integrated team working for feasibility studies for RCTs is discussed. The challenges of integrated team working for full RCTs are discussed because care is needed in terms of when feedback should occur and to whom. Team members’ understandings of different approaches to research, and their beliefs about what is good research, can affect openness to taking actions from the qualitative research.
Having an impact on health, health care, and health policy
Authors: O'Cathain Alicia
Published: August 2018

The focus of this chapter is on the final stage of the research: facilitating the use of the findings of the qualitative research undertaken with RCTs by a variety of stakeholders. Researchers generate evidence to improve the health and health care of the population and specific patient groups. To do this, research needs to impact on the practice of research team members, other researchers undertaking related research, other researchers engaged in synthesizing evidence, and members of the population, patients, practitioners, and policy makers who want to make research evidence-informed decisions. In some countries, university-based research is judged partly by the amount of impact it has in the real world.
Neurological disorders
Authors: Manji Hadi , Connolly Seán , Kitchen Neil , Lambery Christian , Mehta Amrish
Published: August 2018

Abstracts and keywords to be supplied.
Neurosurgery
Authors: Manji Hadi , Connolly Seán , Kitchen Neil , Lambery Christian , Mehta Amrish , Grover Patrick
Published: August 2018

Abstracts and keywords to be supplied.
Clinical approach
Authors: Provan Drew , Baglin Trevor , Dokal Inderjeet , de Vos Johannes , Al-Sader Hassan
Published: August 2018

History taking in patients with haematological disease - Physical examination - Splenomegaly - Lymphadenopathy - Unexplained anaemia - Patient with elevated haemoglobin - Elevated white blood cell (WBC) count - Reduced WBC count - Elevated platelet count - Reduced platelet count - Easy bruising - Recurrent thromboembolism - Pathological fracture - Raised ESR - Serum or urine paraprotein - Anaemia in pregnancy - Thrombocytopenia in pregnancy - Prolonged bleeding after surgery - Positive sickle test (HbS solubility test)
Red cell disorders
Authors: Provan Drew , Baglin Trevor , Dokal Inderjeet , de Vos Johannes , Kaya Banu , Theodoulou Angela
Published: August 2018

The peripheral blood film in anaemias - Anaemia in renal disease - Anaemia in endocrine disease - Anaemia in joint disease - Anaemia in gastrointestinal disease - Anaemia in liver disease - Iron (Fe) deficiency anaemia - Vitamin B12 deficiency - Folate deficiency - Other causes of megaloblastic anaemia - Anaemia in other deficiency states - Haemolytic syndromes - Genetic control of haemoglobin production - Sickling disorders - HbS—sickle-modifying therapies - Sickle cell trait (HbAS) - Other sickling disorders - Other haemoglobinopathies - Unstable haemoglobins - Thalassaemias - α‎ thalassaemia - β‎ thalassaemia - Other thalassaemias - Hereditary persistence of fetal haemoglobin - Hb patterns in haemoglobin disorders - Non-immune haemolysis - Hereditary spherocytosis - Hereditary elliptocytosis - Glucose-6-phosphate dehydrogenase (G6PD) deficiency - Pyruvate kinase deficiency - Other red cell enzymopathies - Drug-induced haemolytic anaemia - Methaemoglobinaemia - Microangiopathic haemolytic anaemia - Acanthocytosis - Autoimmune haemolytic anaemia - Cold haemagglutinin disease - Leucoerythroblastic anaemia - Aplastic anaemia - Paroxysmal nocturnal haemoglobinuria - Pure red cell aplasia - Iron (Fe) overload - Transfusion haemosiderosis
Leukaemia
Authors: Provan Drew , Baglin Trevor , Dokal Inderjeet , de Vos Johannes , Al-Sader Hassan
Published: August 2018

Acute myeloblastic leukaemia (AML) - Acute lymphoblastic leukaemia (ALL) - Chronic myeloid leukaemia (CML) - Chronic lymphocytic leukaemia (B-CLL) - Prolymphocytic leukaemia (PLL) - Hairy cell leukaemia and variant - Large granular lymphocyte leukaemia (LGLL) - Adult T-cell leukaemia-lymphoma (ATLL)
Myelodysplasia
Authors: Provan Drew , Baglin Trevor , Dokal Inderjeet , de Vos Johannes , Kaur Mammit
Published: August 2018

Myelodysplastic syndromes (MDS) - Classification of MDS - Clinical features of MDS - Prognostic factors in MDS - Clinical variants of MDS - Management of MDS - Response criteria - Myelodysplastic/myeloproliferative diseases (MDS/MPD)
Paraproteinaemias
Authors: Provan Drew , Baglin Trevor , Dokal Inderjeet , de Vos Johannes , Kaur Mammit
Published: August 2018

Paraproteinaemias - Monoclonal gammopathy of undetermined significance (MGUS) - Asymptomatic multiple myeloma (‘smouldering’ myeloma) - Multiple myeloma - Variant forms of myeloma - Cryoglobulinaemia - POEMS syndrome (osteosclerotic myeloma) - Plasmacytoma - Waldenström macroglobulinaemia - Heavy chain disease - AL (1° systemic) amyloidosis
Paediatric haematology
Authors: Provan Drew , Baglin Trevor , Dokal Inderjeet , de Vos Johannes , Theodoulou Angela
Published: August 2018

Blood counts in children - Red cell transfusion and blood component therapy—special considerations in neonates and children - Polycythaemia in newborn and childhood - Neonatal anaemia - Anaemia of prematurity - Haemolytic anaemia in the neonate - Congenital red cell defects - Acquired red cell defects - Haemolytic disease of the newborn - Hyperbilirubinaemia - Neonatal haemostasis - Neonatal alloimmune thrombocytopenia - Congenital dyserythropoietic anaemias - Congenital red cell aplasia - Acquired red cell aplasia - Fanconi anaemia - Rare congenital marrow failure syndromes - Neutropenia in childhood - Disorders of neutrophil function - Childhood immune (idiopathic) thrombocytopenic purpura - Haemolytic uraemic syndrome - Childhood cancer and malignant blood disorders - Childhood lymphoblastic leukaemia - Childhood lymphomas - Childhood acute myeloid leukaemia - Childhood myelodysplastic syndromes and chronic leukaemias - Histiocytic syndromes - Haematological effects of systemic disease in children
Protocols and procedures
Authors: Provan Drew , Baglin Trevor , Dokal Inderjeet , de Vos Johannes , Kaur Mammit
Published: August 2018

Acute leukaemia: investigations - Platelet reactions and refractoriness - Prophylactic regimen for neutropenic patients - Guidelines for use of IV antibiotics in neutropenic patients - Treatment of neutropenic sepsis: source unknown - Treatment of neutropenic sepsis: source known/suspected - Prophylaxis for patients treated with purine analogues - Tumour lysis syndrome - Administration of chemotherapy - Antiemetics for chemotherapy - Intrathecal chemotherapy - Management of extravasation - Specific procedures after extravasation of cytotoxics commonly used in haematology - Anticoagulation therapy: heparin - Oral anticoagulation with VKA - Oral anticoagulation with NOAC - Management of needlestick injuries - Chemotherapy protocols - ABVD - BEACOPP/escalated BEACOPP - BEAM/LEAM - Bortezomib/dexamethasone - CHOP 21 and CHOP 14 - ChlVPP - CODOX-M/IVAC ± R - CTD and CTDa - DHAP ± R - ESHAP ± R - FC ± R - ICE ± R - Lenalidomide/dexamethasone - MPT - Mini-BEAM ± R - Nordic schedule (R-maxi-CHOP and R-high-dose cytarabine for MCL) - PMitCEBO - R-Bendamustine - R-CHOP - R-CVP and CVP - Rituximab: monotherapy and maintenance therapy - Stanford V
Preparations
Authors: Anderson Sarah R. , Moore James , Anderson Sarah R. , Dallimore Jon , Davies Claire , Dawood Richard , Harvey Peter , McIntosh Iain , Moore James , Roberts Barry , Warrell David A. , Wilson-Howarth Jane , Winser Shane , Qureshi Tariq
Published: August 2018

Joining an expedition - Role of the expedition medical officer - Creating expedition teams - Immunization - Medical kits and supplies - Medical and first-aid training - Medical screening - Advising those with common pre-existing conditions - The older traveller - Child health in remote areas - Risk management - Medical insurance - Legal liabilities and professional insurance
Crisis management
Authors: Winser Shane , Johnson Chris , Birch Kristina , Drew Rose , Harvey Peter , Jones Stephen , Morgan Clare , Shaw Marc
Published: August 2018

Medical crisis management - Emergency response plan - Missing persons - Scene management - Evacuation - Moving an injured person - Repatriation - Telemedicine and communications - Sexual assault - Death on an expedition
Emergencies: collapse and serious illness
Authors: Dallimore Jon , Johnson Chris , Albert Edi , Briggs Spike , Dallimore Jon , Warrell David A. , Dhillon Sundeep , Grocott Mike , Hearns Stephen , Montgomery Hugh , Thompson Julian
Published: August 2018

The collapsed patient - Medical emergencies - Resuscitation in the wilderness - Basic life support (CPR) - Choking - Recovery position - Shock - Management of the shocked patient - Types of shock - Chest pain - Shortness of breath (dyspnoea) - Coma - Headache - Delirium/confusion - Convulsions - Diabetic emergencies - Gastrointestinal bleeding - Fever
Treatment: infectious diseases
Authors: Warrell David A. , Dryden Matthew , Miller Alastair , Morgan Clare , Warrell David A.
Published: August 2018

Introduction: infectious diseases - Viral infections - Bacterial infections - Malaria - Other protozoal infections - Filarial worms - Worm infections - Flukes - Emerging infections - Sexually transmitted infections
Psychological and psychiatric problems
Authors: Moore James , Davies Claire , Forbes Karen , Hawker Debbie , Moore James , Shaw Marc , Dallimore Jon , Jones Michael E. , Palmer Ian
Published: August 2018

Introduction: psychological and psychiatric problems - Stressors in the wilderness - Considerations before departure - Psychiatric conditions - Psychological reactions to traumatic events - Post-traumatic stress disorder - Serious psychological threats - Recreational drugs and alcohol - After the expedition - P—assess perception - I—obtain the person’s invitation - K—give knowledge and information - E—address emotions with empathic responses - S—strategy and summary
Plants and fungi
Authors: Warrell David A.
Published: August 2018

Dangers of living off the land - Effects of contact with skin - Effects of ingestion - Fungal poisoning - Treating plant and fungal ingestion
Caving
Authors: Johnson Chris , Cooper Paul
Published: August 2018

The underground environment - Humans underground - Risk management underground - Specific medical problems for cavers
Multiplicity of disc-bearing stars in Upper Scorpius and Upper Centaurus-Lupus
Authors: Kuruwita Rajika L , Ireland Michael , Rizzuto Aaron , Bento Joao , Federrath Christoph
Published: August 2018

We present observations of disc-bearing stars in Upper Scorpius (US) and Upper Centaurus-Lupus (UCL) with moderate resolution spectroscopy in order to determine the influence of multiplicity on disc persistence after ${\sim }5\hbox{--}20\, \mathrm{Myr}$. Discs were identified using infrared (IR) excess from the Wide-field Infrared Survey Explorer (WISE) survey. Our survey consists of 55 US members and 28 UCL members, using spatial and kinematic information to assign a probability of membership. Spectra are gathered from the ANU 2.3 m telescope using the Wide Field Spectrograph (WiFeS) to detect radial velocity variations that indicate the presence of a companion. We identify two double-lined spectroscopic binaries, both of which have strong IR excess. We find the binary fraction of disc-bearing stars in US and UCL for periods up to 20 yr to be $0.06^{+0.07}_{-0.02}$ and $0.13^{+0.06}_{-0.03}$, respectively. Based on the multiplicity of field stars, we obtain an expected binary fraction of ${\sim }0.12^{+0.02}_{-0.01}$. The determined binary fractions for disc-bearing stars do not vary significantly from the field, suggesting that overall lifetime of discs may not differ between single and binary star systems.
On estimating the atomic hydrogen column density from the H i 21 cm emission spectra
Authors: Saha Preetha , Roy Nirupam , Bhattacharya Mukul
Published: August 2018

The 21 cm hyperfine transition of the atomic hydrogen (H i) in ground state is a powerful probe of the neutral gas content of the Universe. This radio frequency transition has been used routinely for decades to observe, both in emission and absorption, H i in the Galactic interstellar medium as well as in extragalactic sources. In general, however, it is not trivial to derive the physically relevant parameters like temperature, density, or column density from these observations. Here, we have considered the issue of column density estimation from the H i 21 cm emission spectrum for sightlines with a non-negligible optical depth and a mix of gas at different temperatures. The complicated radiative transfer and a lack of knowledge about the relative position of gas clouds along the sightline often make it impossible to uniquely separate the components, and hinders reliable estimation of column densities in such cases. Based on the observed correlation between the 21 cm brightness temperature and optical depth, we propose a method to get an unbiased estimate of the H i column density using only the 21 cm emission spectrum. This formalism is further used for a large sample to study the spin temperature of the neutral interstellar medium.
Effects of two feeding periods of tiamulin fed in combination with chlortetracycline for control and treatment of swine respiratory and enteric disease and subsequent growth performance of growing-finishing pigs
Authors: Puls Christopher L , Hammer James M , Eggers Kevin , Graham Amanda , Knopf Brandon , Greiner Laura , Carr Scott N
Published: August 2018

The objective of this study was to evaluate the effects of two dietary feeding periods of tiamulin in combination with chlortetracycline for the control and treatment of swine respiratory and enteric disease and subsequent growth performance. The study used 1,151 commercial crossbred barrows and gilts in a randomized complete block design. Pigs were housed in single-sex groups of 25 at a floor space of 0.69 m2/pig. There were two dietary treatments: 1) nonmedicated controls and 2) 39 mg/kg tiamulin + 441 mg/kg chlortetracycline (TIACTC) fed from days 7 to 20 and again days 49 to 62. There were 23 pens per treatment group. Daily observations were made throughout the study, including the number of pigs in each pen coughing, with diarrhea, or showing signs of lameness as well as the number of pigs in each pen requiring individual therapy treatment for each symptom. Pigs were weighed as a group on days 0 (for allocation purposes), 7, 21, 49, 61, 89 (start of marketing), and at time of slaughter. Within pen, animals were selected by visual appraisal and sent for slaughter over 4 wk to a commercial slaughter facility where HCW was collected and used to calculate carcass yield. There was no difference (P > 0.05) between treatments for the incidence of morbidity or mortality. Pigs fed TIACTC tended to have less coughing observations (P = 0.10) and less diarrhea observations (P = 0.08) during the study period, and had less observations of lameness (P < 0.001) and required less treatments than nonmedicated controls (P < 0.001). For the overall study period, pigs fed TIACTC had greater (P < 0.05) total BW gain (43.3 kg greater/pen) and greater (P < 0.05) ADG and ADFI than controls. There was no effect (P > 0.05) of treatment on G:F. Overall, pigs fed TIACTC weighed 1.3 kg heavier (P < 0.05) at the start of marketing and completed the study with an overall BW advantage of 1.6 kg (P < 0.05) compared to controls. The difference between treatments for live BW increased with marketing group (1.0 kg in marketing group 1 and 3.3 kg in marketing group 4). Pigs fed TIACTC had greater (P < 0.05) HCW (1.0 kg) than controls; however, there was no difference (P > 0.05) between treatments for carcass yield. The results of this study suggest that feeding TIACTC was successful at controlling respiratory and enteric disease and, consequently, improved growth performance and carcass weight of grow-finish pigs.
A Review of High Density Material in the Lungs
Authors: Mehta Samir D. , Zigmund Beth
Published: August 2018

High density material, including calcium and a variety of other substances, can be seen in the lungs in the setting of many iatrogenic, metabolic, infectious, neoplastic, occupational, and idiopathic disorders. The high density substance in the lungs typically is inconsequential, but it can be an important diagnostic clue to the cause of underlying pulmonary disease. High density material in the lungs can be confusing to radiologists, either due to similar appearances of imaging patterns or to the rare occurrence of some responsible entities. Chest CT is suited uniquely to characterize these patterns, with its high intrinsic contrast of dense material against the lung parenchyma. This review examines chest radiographic and chest CT patterns of high density material in the lungs and provides an approach to the differential diagnosis to familiarize radiologists with these disorders and improve diagnostic accuracy.
Hematopoietic stem-cell transplantation in systemic sclerosis: an update
Authors: Spierings Julia , van Rhijn-Brouwer Femke C.C. , van Laar Jacob M.
Published: August 2018

Purpose of review

To provide an overview of recently published work on autologous hematopoietic stem-cell transplantation (HSCT) in patients with systemic sclerosis (SSc).

Recent findings

Superiority of HSCT vs. intravenous cyclophosphamide pulses was demonstrated in the randomized controlled American Scleroderma: Cyclophosphamide or Transplantation (SCOT) Trial (n = 75), supporting the results from earlier studies. In the SCOT Trial, total body irradiation was used instead of the nonmyeloablative regimens used in other trials, and considered well tolerated during a follow-up time of 4.5 years. Three small uncontrolled prospective cohorts (n = 4, 14 and 18) and one retrospective analyses (n = 18), using various nonmyeloablative regimens, also showed improvement in skin involvement and lung volumes post-HSCT. Transplant-related toxicity and mortality remain an essential issue in HSCT. High treatment-related mortality was reported in one prospective cohort (n = 18), using alemtuzumab as a conditioning agent. Furthermore, cardiac complications, either treatment or disease related, require special attention. In translational studies, trends are reported in number of regulatory T cells and diversity of T-cell receptor repertoire at baseline and post-HSCT correlating with treatment response.

There is increasing evidence that patients with rapidly progressive SSc may benefit from HSCT. However, optimal patient selection, pretransplantation workup and posttransplant management, still have to be established.
Measurement Techniques and Utility of Hounsfield Unit Values for Assessment of Bone Quality Prior to Spinal Instrumentation
Authors: Zaidi Qasim , Danisa Olumide A. , Cheng Wayne
Published: August 2018

Study Design.

A systematic review.

Objective.

The aim of this study was to evaluate the clinical utility of assessing bone quality using computed tomography (CT) attenuation in Hounsfield units (HU).

Summary of Background Data.

Assessing bone quality before spine instrumentation is an essential step of preoperative planning. Dual energy x-ray absorptiometry (DEXA) has been the gold standard for assessing bone mineral density (BMD); however, DEXA can result in spuriously elevated BMD measurements in patients with degenerative disease, compression fractures, and/or vascular calcifications. Measuring vertebral HU values has been proposed as an alternate method of assessing BMD and bone quality.

Methods.

We searched MEDLINE, Cochrane Library, and EMBASE for studies correlating HU to BMD and to spine surgery outcomes.

Results.

HU measurements correlate with success of lumbar interbody fusion (133.7 vs. 107.3 HU) and posterolateral fusion (167 vs. 139.8 HU), cage subsidence (112.4 vs. 140.2 HU), adjacent segment fractures (145.6 vs. 199.4 HU), pedicle screw loosening (116.4 vs. 132.7 HU) and (99.1 vs. 141.2 HU), and risk of incidental durotomy (149.2 vs. 177.0 HU). Intra and inter-rater reliability coefficients are 0.964 and 0.975. The correlation between HU values and BMD in nondegenerative patients is r
2 = 0.52 compared with HU versus BMD in degenerative patients r
2 = 0.18.

Conclusion.

HU value measurement is a simple and rapid technique to assess bone quality that should be performed in all patients with pre-existing CT scans. HU measurement has excellent inter and intra-rater reliability and can be performed on axial or sagittal images. L1 HU threshold values of 110 HU for detecting osteoporosis, and 135 HU for detecting osteopenia are 90% specific. In patients with significant degenerative disease, HU values should be given more credence. Additional high-quality prospective studies comparing HU and DEXA values to patient outcomes are necessary to validate the role of CT measurements in preoperative evaluation.

Level of Evidence: 4
Preparing for Bundled Payments in Cervical Spine Surgery
Authors: Kalakoti Piyush , Gao Yubo , Hendrickson Nathan R. , Pugely Andrew J.
Published: August 2018

Study Design.

Retrospective, observational study.

Objective.

To examine the influence of patient, hospital, and procedural characteristics on hospital costs and length hospital of stay (LOS).

Summary of Background Data.

Successful bundled payment agreements require management of financial risk. Participating institutions must understand potential cost input before entering into these episodes-of-care payment contracts. Elective anterior cervical discectomy and fusion (ACDF) has become a popular target for early bundles given its frequency and predictability.

Methods.

A national discharge database was queried to identify adult patients undergoing elective ACDF. Using generalized linear models, the impact of each patient, hospital, and procedures characteristic on hospitalization costs and the LOS was estimated.

Results.

In 2011, 134,088 patients underwent ACDF in the United States. Of these 31.6% had no comorbidities, whereas 18.7% had three or more. The most common conditions included hypertension (44.4%), renal disease (15.9%), and depression (14.7%). Mean hospital costs after ACDF was $18,622 and mean hospital LOS was 1.7 days. With incremental comorbidities, both hospital costs and LOS increased. Both marginal costs and LOS rose with inpatient death (+$17,181, +2.0 days), patients with recent weight loss (+$8351, +1.24 days), metastatic cancer (+$6129 +0.80 days), electrolyte disturbances (+$4175 +0.8 days), pulmonary-circulatory disorders (+$4065, +0.6 days), and coagulopathies (+$3467, +0.58 days). Costs and LOS were highest with the following procedures: addition of a posterior fusion/instrumentation ($+11,189, +0.9 days), revision anterior surgery (+$3465, +0.3 days), and fusion of more than three levels (+$3251, +0.2 days). Patients treated in the West had the highest costs (+$9300, +0.3 days). All P values were less than 0.05.

Conclusion.

Hospital costs and LOS after ACDF rise with increasing patient comorbidities. Stakeholders entering into bundled payments should be aware of that certain patient, hospital, and procedure characteristics will consume greater resources.

Level of Evidence: 3
Continued Inpatient Care After Elective 1- to 2-level Posterior Lumbar Fusions Increases 30-day Postdischarge Readmissions and Complications
Authors: Malik Azeem T. , Jain Nikhil , Kim Jeffery , Yu Elizabeth , Khan Safdar N.
Published: August 2018

Study Design:

This was a retrospective cohort study.

Objective:

The main objective of this article was to investigate the impact of discharge destination on postdischarge outcomes following an elective 1- to 2-level posterior lumbar fusion (PLF) for degenerative pathology.

Background Data:

Discharge to an inpatient care facility may be associated with adverse outcomes as compared with home discharge.

Materials and Methods:

The 2012-2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was used to query for patients undergoing PLFs using Current Procedural Terminology (CPT) codes (22612, 22630, and 22633). Additional levels were identified using CPT-22614, CPT-22632, and CPT-22634. Records were filtered to include patients undergoing surgery for degenerative spine pathologies. Only patients undergoing a single-level or 2-level PLF were included in the study. A total of 23,481 patients were included in the final cohort.

Results:

A total of 3938 (16.8%) patients were discharged to a skilled care or rehabilitation facility following the primary procedure. Following adjustment for preoperative, intraoperative, and predischarge clinical characteristics, discharge to a skilled care or rehabilitation facility was associated with higher odds of any complication [odds ratio (OR), 1.70; 95% confidence interval (CI), 1.43–2.02], wound complications (OR, 1.73; 95% CI, 1.36–2.20), sepsis-related complications (OR, 1.64; 95% CI, 1.08–2.48), deep venous thrombosis/pulmonary embolism complications (OR, 1.72; 95% CI, 1.10–2.69), urinary tract infections (OR, 1.96; 95% CI, 1.45–2.64), unplanned reoperations (OR, 1.49; 95% CI, 1.23–1.80), and readmissions (OR, 1.29; 95% CI, 1.10–1.49) following discharge.

Conclusions:

After controlling for predischarge characteristics, discharge to skilled care or rehabilitation facilities versus home following 1- to 2-level PLF is associated with higher odds of complications, reoperations, and readmissions. These results stress the importance of careful patient selection before discharge to inpatient care facilities to minimize the risk of complications. Furthermore, the results further support the need for uniform and standardized care pathways to promote home discharge following hospitalization for elective PLFs.

Level of Evidence:

Level III.
Arthroscopy-assisted Treatment of Displaced Distal Clavicle Fractures Utilizing Curved Buttons and Suture Tape With a Single Coracoclavicular Tunnel
Authors: Rose Mark T. , Noyes Matthew P. , Denard Patrick J.
Published: August 2018

Background:

Distal third clavicle fractures are associated with high rates of nonunion. Acceptable healing rates have been reported; however, complications and the need for additional procedures are a concern. The purpose of this study was to evaluate the functional outcomes and healing rates of an arthroscopy-assisted technique for fixation of unstable distal third clavicle fractures.

Methods:

Seven patients presenting to a single surgeon with displaced distal clavicle fractures were included. A curved suspensory button and suture tape construct with a single coracoclavicular tunnel was used. Visual Analog Scale, American Shoulder and Elbow Surgeons scores, Simple Shoulder Test, and Subjective Shoulder Value scores were analyzed preoperatively and at final follow-up. Radiographic evidence of union, maintenance of reduction and complications were recorded. All patients were available for 1-year follow-up.

Results:

Mean Visual Analog Scale pain score improved from 6.1±1.1 to 1.1±1.0 (P=0.022). American Shoulder and Elbow Surgeons scores increased from 40.3±17.2 to 86.7±13.7 (P≤0.001). The mean Simple Shoulder Test score increased from 2.7±1.1 to 11.0±1.8 (P≤0.001). The Subjective Shoulder Value improved from 41.6±19.1 to 91.4±7.6 (P=0.210). Fracture united in 6 of 7 patients and reduction was maintained in all patients. Six patients were satisfied and returned to previous activity level.

Conclusions:

Arthroscopy-assisted fixation of unstable displaced distal clavicle fractures demonstrates improved functional outcomes and high patient satisfaction. This construct avoids many of the previously reported complications associated with other methods of fixation, while minimizing the amount of soft tissue dissection.
Betrixaban
Authors: Lee Katie , Cham Samantha , Lam Sum
Published: August 2018

Venous thromboembolism (VTE) is a common and preventable cause of morbidity and mortality in hospitalized patients. Low-molecular-weight heparin, low-dose unfractionated heparin, fondaparinux, and warfarin have been the mainstay options for the prevention and treatment of VTE before the emergence of nonvitamin K antagonist oral anticoagulants (NOACs) such as dabigatran, rivaroxaban, apixaban, and edoxaban. Despite the advantages of NOACs in improving patient adherence, none of them are approved for the prevention of VTE in acutely ill medical patients at high risk of thromboembolism. Betrixaban is a new NOAC and a factor Xa inhibitor that was approved for extended-duration thromboprophylaxis in these high-risk patients. The approval was based on the results of the APEX (Acute Medically Ill VTE Prevention with Extended Duration Betrixaban) study. In this Phase III randomized controlled trial, once-daily oral betrixaban (35 to 42 days extended duration) was associated with a reduction of composite VTE with no difference in major bleeding when compared to once-daily subcutaneous enoxaparin (6 to 14 days standard duration). Betrixaban differs from other NOACs by having a longer half-life, minimal CYP450 interactions, and minimal renal clearance. This article provides an overview of betrixaban’s pharmacological profile, clinical trial results, and potential roles in therapy.
Ewing-Like Sarcoma: A Case of a Primary Cutaneous Primitive Neuroectodermal Tumor With Atypical Immunohistochemistry and Lack of Fusion Oncogene Detection
Authors: Labadie Jessica G. , Florek Aleksandra G. , VandenBoom Timothy , Yazdan Pedram , Krunic Aleksandar L.
Published: August 2018

We present a 25-year-old male patient with a primary cutaneous primitive neuroectodermal tumor (cPNET) with unusual immunohistochemistry and lack of fusion oncogene generation. The lesion expressed CD99 and WT-1, and the histological features were consistent with cPNET. Differential diagnoses such as rhabdomyosarcoma, desmoplastic small round blue cell tumor, hematolymphoid neoplasm, neuroblastoma, and CIC-DUX round cell sarcoma were ruled out based on immunohistochemistry, genetic studies, and histology. Previous cPNET cases have been published detailing abnormal immunochemistry and genetic expression. However, to our knowledge, fusion oncogene negativity in cPNET tumors has only been reported in one other published case series. These reports, including this study, reinforce the fact that a high index of suspicion should be used when diagnosing these tumors, regardless of immunohistochemical and genetic variability. This case highlights that the typical genetic and immunohistochemical features of cPNET may be more variable than previously thought. Future studies are needed to better understand these variations of cPNET.
Mental Health of Children of Deployed and Nondeployed US Military Service Members: The Millennium Cohort Family Study
Authors: Fairbank John A. , Briggs Ernestine C. , Lee Robert C. , Corry Nida H. , Pflieger Jacqueline C. , Gerrity Ellen T. , Amaya-Jackson Lisa M. , Stander Valerie A. , Murphy Robert A.
Published: August 2018

Objective:

Families experience multiple stressors as a result of military service. The purpose of this study was to investigate the associations among service member deployment experiences, family and military factors, and children's mental health using baseline data from the Millennium Cohort Family Study, a study designed to evaluate the health and mental health effects of military service on families, including children.

Method:

This study examined administrative data on deployment status (combat, noncombat, and no deployments), as well as service member– and spouse-reported data on deployment experiences and family functioning in relation to the mental health of children in the family who were aged 9 to 17 years.

Results:

Most children were not reported to have mental health, emotional, or behavioral difficulties regardless of parental deployment status. For an important minority of children, however, parental deployments with combat, compared with those with no deployment, were associated with a parental report of attention-deficit disorder/attention-deficit hyperactivity disorder and depression as diagnosed by a clinical provider, after accounting for demographics, psychosocial context, and military factors. Children's odds of a parental report of depression were significantly higher in both the combat and the noncombat deployment groups than in the no deployment group.

Conclusion:

These findings extend our understanding of the association between parental deployments and children's mental health, with implications for services and training mental health providers serving military families.
Critical Care Nurses’ Qualitative Reports of Experiences With Family Behaviors as Obstacles in End-of-Life Care
Authors: Beckstrand Renea L. , Mallory Caitlin , Macintosh Janelle L.B. , Luthy Karlen E.
Published: August 2018

Background

Critical care nurses (CCNs) frequently provide end-of-life (EOL) care for critically ill patients. Critical care nurses may face many obstacles while trying to provide quality EOL care. Some research focusing on obstacles CCNs face while trying to provide quality EOL care has been published; however, research focusing on family behavior obstacles is limited. Research focusing on family behavior as an EOL care obstacle may provide additional insight and improvement in care.

Objectives

We wanted to gather firsthand experiences of CCNs regarding working with families of dying patients. We then wanted to determine the predominant obstacle themes noted when CCNs share these rich experiences in EOL care.

Methods

A random geographically dispersed sample of 2000 members of the American Association of Critical-Care Nurses was surveyed. Responses from a qualitative question on the questionnaire were analyzed.

Results

Sixty-seven EOL obstacle experiences surrounding issues with families’ behavior were analyzed for this study. Experiences were categorized into 8 themes. Top 3 common obstacle experiences included families in denial, families going against patient wishes and advanced directives, and families directing care that negatively impacted patients.

Conclusions

In overcoming EOL obstacles, it may be beneficial to have proactive family meetings to align treatment goals and to involve palliative care earlier in the ICU stay.
Optimal Gender-Specific Strategies for the Secondary Prevention of Heart Disease in Women
Authors: Rao Angela , Newton Phillip J. , DiGiacomo Michelle , Hickman Louise D. , Hwang Christine , Davidson Patricia M.
Published: August 2018

Background:

There is a paucity of evidence on gender-specific, individually tailored secondary prevention (cardiac rehabilitation [CR]) services for women with heart disease. Women participate less in CR programs, thus increasing their risk of further cardiac events. This review aims to (1) determine the effectiveness of gender-specific interventions specifically designed for women with heart disease, delivered in outpatient CR settings; and (2) classify key elements of effective CR strategies/models for women with heart disease.

Methods:

Using the PRISMA guidelines, this is a systematic review of CR models tailored to women to improve cardiovascular risk. Four databases were searched for randomized controlled trials (RCTs) between January 1974 and July 2017 published in peer-reviewed English language journals.

Results:

Three RCTs comprising 725 women of gender-specific CR strategies were identified. Significant improvements were found in one-third (1 study) of the included multicomponent CR strategies for outcomes including general health, social functioning, vitality, mental health, depression, and quality of life.

Conclusion:

Further large-scale RCTs are required to replicate positive findings and accurately assess the capacity for gender-specific multicomponent CR programs that incorporate participant-driven collaborative models to moderate psychological risk and improve functional capacity and quality of life for women with heart disease.
MACULAR CHOROIDAL THICKNESS IN UNILATERAL COMMOTIO RETINAE
Authors: Burke Marie , Lieu Philip , Abrams Gary , Boss Joseph
Published: August 2018

Purpose:

To investigate the choroidal thickness (CT) and choroidal area (CA) in patients with unilateral commotio retinae of the macula using spectral domain optical coherence tomography with enhanced-depth imaging.

Methods:

This is a retrospective review of 16 eyes of 8 consecutive patients with unilateral macular commotio retinae within 7 days of blunt ocular trauma that underwent optical coherence tomography with enhanced-depth imaging seen at our institution. The contralateral, nontraumatized eye served as the control group. All patients underwent spectral domain optical coherence tomography imaging with enhanced-depth imaging protocol. Using the electronic caliper within the Zeiss optical coherence tomography review software, CT was measured from the outer portion of the retinal pigment epithelium band to the inner surface of the sclera. The central horizontal and vertical rasters were averaged to calculate the final CT measurement of each eye. The final CA reading of each eye was obtained by averaging the central 1,500 μm2 of subfoveal CA using the same rasters. The researchers compared the CT, CA, and best-corrected visual acuity in traumatized eyes with macular commotio with their fellow nontraumatized control eyes.

Results:

Traumatized eyes with macular commotio retinae had greater subfoveal CT and CA (P = 0.0027, P = 0.0279) compared with the normal fellow eye. An increase in CT and CA in the subfoveal area in the presence of commotio retinae was associated with worse visual acuity (P = 0.0180).

Conclusion:

Subfoveal CT and CA were greater in eyes with commotio retinae when compared with normal fellow eyes. Increased CT and CA in macular commotio retinae were associated with decreased visual acuity.
Novel Technique for Improving Graft Unfolding in Vitrectomized Eyes Using a Temporary Diaphragm in Descemet Membrane Endothelial Keratoplasty
Authors: Yoeruek Efdal , Bartz-Schmidt Karl U.
Published: August 2018

Purpose:

To describe a new surgical technique for performing Descemet membrane endothelial keratoplasty (DMEK) using a temporary hydrophilic methacrylate sheet in the anterior chamber in cases of previous vitrectomy with complete removal of the vitreous body.

Methods:

Medical records were reviewed for baseline and follow-up best spectacle-corrected visual acuity, endothelial cell count, and indication for DMEK using a temporary hydrophilic methacrylate sheet. Operative notes were analyzed in all cases to identify any specific intraoperative event.

Results:

Seven eyes of 7 patients were included in this analysis. Mean age was 65.7 ± 18.2 years, and the mean follow-up duration was 11.5 months. All 7 patients had previously received pars plana vitrectomy with complete vitreous removal. All patients were pseudophakic. For 5 patients, it was their first DMEK surgery and 2 patients had DMEK surgery for a second time, due to a failed outcome in previous surgery. Best spectacle-corrected visual acuity improved from 1.5 ± 0.5 logMAR before surgery to 0.76 ± 0.37 logMAR after surgery during follow-up (P < 0.001). The mean endothelial cell count was 2442 ± 304 cells/mm2 and decreased to 1484 ± 279 cells/mm2 during follow-up (P < 0.001). No complications were observed in any of the cases at the unfolding stage using this method. All grafts remained clear at the last follow-up visit.

Conclusions:

This modified approach of DMEK surgery, using a temporary hydrophilic methacrylate sheet for flattening the anterior chamber and facilitating graft unfolding, could help overcome possible complications of DMEK in completely vitrectomized eyes.
Population-based Incidence of Childhood Pneumonia Associated With Viral Infections in Bangladesh
Authors: Havers Fiona P. , Fry Alicia M. , Goswami Doli , Nahar Kamrun , Sharmin Amina Tahia , Rahman Mustafizur , Brooks W. Abdullah
Published: August 2018

Background:

The contribution of respiratory viruses to childhood pneumonia in tropical low- and middle-income countries is poorly understood. We used population-based respiratory illness surveillance in children 5 years of age or younger in Dhaka, Bangladesh, to characterize these illnesses.

Methods:

We conducted weekly home visits to children who were referred to clinic for fever or respiratory symptoms. Standardized clinical data were collected. Nasopharyngeal washes were collected for one fifth of children diagnosed with a febrile or respiratory syndrome, with virus isolation testing for influenza and reverse transcription polymerase chain reaction testing for other viruses. Pneumonia was defined as age-specific tachypnea and crepitations on chest auscultation by study physicians.

Results:

From April 2004 to February 2008, 17,584 children were followed for 17,644 child-years; 6335 children had 12,499 clinic visits with eligible illnesses, including 6345 pneumonia episodes (incidence of 36 episodes/100 child-years). Annual incidence of pneumonia/100 child-years ranged from 88.3 for children 0–6 months of age to 13.1 for those 36–60 months of age. Of 1248 pneumonia visits with laboratory testing, 803 (64%) had detection of viral pathogens, including 274 respiratory syncytial virus (22% of pneumonia visits with laboratory testing; incidence 7.9/100 child-years), 244 adenovirus (19%; 7.0/100 child-years), 198 human metapneumovirus (16%; 5.7/100 child-years), 174 parainfluenza (14.0%; 5.0/100 child-years), and 81 influenza (6.5%; 2.3/100 child years).

Conclusions:

Viral pathogens contribute to a majority of childhood pneumonia episodes in Bangladesh, a setting with high pneumonia rates, especially in children 2 years of age or younger. Developing effective prevention strategies targeting these children is a high priority. Given less sensitive laboratory method used for influenza detection, influenza rates may be underestimated.