bluuebunny/crossref_metadata_2025 huggingface dataset:
Lumbar Spondylolisthesis
Authors: Desai Mehul J. , Sayal Puneet , Leong Michael S.
Published: June 2018

Lumbar spondylolisthesis typically presents as low back and/or lower extremity pain. Spondylolisthesis is most commonly observed in female patients and the elderly. Lumbar spondylolisthesis may result from congenital, isthmic, trauma-related, degenerative, and iatrogenic causes. Diagnostic imaging (radiographs, magnetic resonance imaging) and physical examination are needed to differentiate the categories of lumbar spondylolisthesis, which will assist in selecting the appropriate treatment. A customized interdisciplinary treatment plan tailored to the patient’s presentation and goals will produce clinical improvement. Surgical remediation is typically reserved for recalcitrant cases but can be effective.
Lumbar Radiculopathy and Radicular Pain
Authors: Goff Brandon J. , Guthmiller Kevin B. , Clapp Jamie C. , Lassiter William B. , Baldridge Morgan J. , Hochheimer Sven M. , Salas Margaux M.
Published: June 2018

Lumbar radicular pain is a significant burden for patients and is one of the most common complaints presented to spine practitioners. In the young, it is most often due to acute disc herniation, but in older patients, the onset is usually multifactorial. Most cases resolve on their own, but many patients experience recurrences. This chapter reviews a continuum of treatment options, from comprehensive physical rehabilitation to surgery. Understanding the pathophysiologic process may allow a more meaningful understanding of the development of chronic neuropathic pain of the extremity. A comprehensive history and physical examination, with findings confirmed by radiologic studies as warranted, may raise red flags early in the process and will facilitate efficient treatment of the underlying issues. An interdisciplinary approach may allow for earlier improvement and suitable treatment as needed.
Spinal Deformity and Scoliosis
Authors: Kainth Daraspreet Singh , Dhaliwal Karanpal Singh , Polly David W.
Published: June 2018

Spinal deformity can be present in children, adolescents, and adults. Early-onset scoliosis, which affects children less than 10 years of age, can be the result of congenital abnormalities or neuromuscular disease or can be idiopathic. Adolescents most commonly develop scoliosis as the result of adolescent idiopathic scoliosis. Adult deformity can be the result of progression of conditions present in childhood or adolescence, or from degenerative changes. Many conditions can lead to spine deformity, including congenital causes, trauma, cancer, osteoporosis, postsurgical, and idiopathic causes. Though deformity treatment needs to be tailored to the individual, there are many guiding principles and concepts that apply when treating patients with scoliosis and spinal deformity. This chapter reviews important concepts such the deformity classification systems, deformity parameters, treatment options, and associated risks and benefits.
Approaches and Relative Benefits of Open Versus Minimally Invasive Surgery for Degenerative Conditions
Authors: Rosenthal Brett D. , Mendoza Marco , Boody Barrett S. , Hsu Wellington K.
Published: June 2018

Minimally invasive techniques aim to improve upon traditional open surgeries by limiting the morbidity of the surgical approach. In doing so, soft tissue collateral injury is minimized, the midline is relatively spared, and the amount of osseous resection is reduced. Both open and minimal-access procedures are options for decompressing neural tissue, correcting spinal column malalignment, or stabilizing vertebral motion segments. Minimally invasive techniques reduce the necessary soft tissue retraction and surgical dissection with the goal of reducing postoperative pain and expediting recovery. However, the limited access afforded by these approaches can be challenging for complex and revision procedures, and the surgeon must be familiar with the specialized instrumentation and novel technologies. The decision to use minimally invasive techniques is multifactorial and is largely dependent on patient, surgeon, and hospital factors.
Biologic and Regenerative Therapies
Authors: Dworkin Ian , Fung Daniel A. , Davis Timothy T.
Published: June 2018

Low back pain is one of the most debilitating conditions worldwide, and a major cause is degenerative disc disease. Current therapies range from conservative treatments, such as medications, physical therapy, and other modalities, to more invasive treatments such as injections and surgery; however, these therapies neither stop the progression of degeneration nor restore function to the degenerating disc; they focus on symptom management, not on etiology. A novel approach to treating degenerative disc disease involves using regenerative therapies such as stem cells, growth factors, and gene therapy. The goal of these therapies is not just to decrease symptoms, but to reverse disc degeneration, while simultaneously enhancing current treatment modalities. Though clinical translation of regenerative therapies is in its infancy, in vitro and in vivo investigations have revealed these therapies’ potential in treating degenerative disc disease as well as a multitude of other musculoskeletal conditions.
Platelet-Rich Plasma Injections
Authors: Khwarg Juewon , Fung Daniel A. , Hunter Corey , Davis Timothy T.
Published: June 2018

Platelet-rich plasma (PRP) is an autologous plasma suspension enriched with a supraphysiologic concentrate of platelets, isolated through a process of centrifugation. Administered locally (usually by injection or direct application) to areas of injury, PRP contains a high density of growth factors, which are believed to potentiate the body’s natural regenerative processes. Over the past 20 years, interest in PRP therapy has grown exponentially, as it offers a relatively safe, autologous treatment modality. It has gained particular popularity for a wide variety of musculoskeletal pathologies. There is a growing body of scientific literature that is giving further insight into PRP’s therapeutic effects. This chapter will review the history, preparation techniques, basic science justifications, current clinical evidence, as well as procedural considerations for the therapeutic use of PRP.
Opioids in Spine Pain: Indications, Challenges, and Controversies
Authors: Sayal Puneet , Mao Jianren
Published: June 2018

Opioid medications are commonly used in the treatment of spine-mediated pain. They are used on a chronic, long-term basis, and their use is on the rise. The available evidence supports their use for short periods if much effort is put into patient and opioid selection, and with close monitoring. Challenges include numerous adverse effects, aberrant behaviors, and the comfort and skill set of providers. Controversies surrounding the chronic use of opioids center on the inconclusive evidence regarding long-term efficacy and safety. More research is necessary to determine whether these medications are appropriate, efficacious, and safe over the long term, and also to aid providers in managing patients on chronic opioids in terms of patient and opioid selection, risk stratification, monitoring, and discontinuation/weaning.
Intrathecal Pumps
Authors: Boortz-Marx Richard L. , Moyse Daniel , Qadri Yawar J.
Published: June 2018

Neuromodulation options that exist for chronic pain treatment include targeted intrathecal drug delivery, spinal cord stimulation, deep brain stimulation, cortical stimulation, and peripheral field stimulation. This chapter focuses on the neuromodulation technique of targeted intrathecal drug delivery. The chapter provides a brief overview of the history and focuses on clinically relevant discussion of patient selection, trialing, surgical technique, and other important topics for establishing a high-quality targeted intrathecal drug delivery program in this evolving age. The key to success with neuromodulation and targeted intrathecal drug delivery is patient selection. Appropriate pre-implantation screening and behavioral health assessment are critical. The choice of agent and route of delivery may play key roles in therapy success.
Peripheral Nerve Stimulation
Authors: Campos Lucas , Pope Jason E.
Published: June 2018

Neuromodulation is the process of altering nerve impulses through electrical or chemical mechanisms. Peripheral nerve stimulation (PNS) is one of the most diverse and rapidly expanding areas of neuromodulation. The goal of this chapter is to increase awareness of the theory, basic science, and ongoing clinical indications of PNS. The use of PNS is a natural outgrowth from traditional methods of using neurostimulation in the spinal canal. Various disease states are theoretically amenable to PNS, including headache disorders such as migraine and cluster headache. Significant and specific risks, safety concerns, and adverse events are possible with PNS, particularly without a focus on prevention.
Living the spectre of forced return: negotiating deportability in British immigration detention
Authors: Turnbull Sarah
Published: June 2018

Immigration detention and deportation are being increasingly utilised in many countries as key state responses to irregular migration. These practices work together to force migrants to their countries of origin or third countries, offering limited choice about whether to stay or leave. Drawing on a multi-sited ethnographic study of British immigration detention, this paper explores how detainees negotiate deportability and their accounts of the spectre of departing the United Kingdom, often against their wishes and occasionally by force. It analyses how deportability and the institutional structures and logics of immigration detention coalesce to shape detainees’ understandings of their positions and options as deportable subjects. The paper highlights the materiality of return from immigration detention and the complexities and multiplicities of how detainees account for their possible departures in relation to the themes of identity, belonging, and home. British immigration removal centres can be understood as ‘sites of struggle’ in which those subject to detention and deportation negotiate these interconnected practices, acting as best they can within coercive and isolating carceral institutions.
Observability of planet–disc interactions in CO kinematics
Authors: Pérez Sebastián , Casassus S , Benítez-Llambay P
Published: June 2018

Empirical evidence of planets in gas-rich circumstellar discs is required to constrain giant planet formation theories. Here we study the kinematic patterns which arise from planet–disc interactions and their observability in CO rotational emission lines. We perform 3D hydrodynamical simulations of single giant planets and predict the emergent intensity field with radiative transfer. Pressure gradients at planet-carved gaps, spiral wakes, and vortices bear strong kinematic counterparts. The isovelocity contours in the CO(2-1) line centroids $v$○ reveal large-scale perturbations, corresponding to abrupt transitions from below sub-Keplerian to super-Keplerian rotation along with radial and vertical flows. The increase in line optical depth at the edge of the gap also modulates $v$○, but this is a mild effect compared to the dynamical imprint of the planet–disc interaction. The large-scale deviations from the Keplerian rotation thus allow the planets to be indirectly detected via the first moment maps of molecular gas tracers, at Atacama Large Millimetre/submillimetre Array angular resolutions. The strength of these deviations depends on the mass of the perturber. This initial study paves the way to eventually determine the mass of the planet by comparison with more detailed models.
Exploring the roles of substrate‐binding surface of the chaperone site in the chaperone activity of trigger factor
Authors: Fan Dongjie , Cao Shunan , Zhou Qiming , Zhang You , Yue Lei , Han Chang , Yang Bo , Wang Yu , Ma Zhuo , Zhu Lingxiang , Liu Chuanpeng
Published: June 2018

Trigger factor (TF) is a key component of the prokaryotic chaperone network, which is involved in many basic cellular processes, such as protein folding, protein trafficking, and ribosome assembly. The major chaperone site of TF has a cradle‐like structure in which protein substrate may fold without interference from other proteins. Here, we investigated in vivo and in vitro the roles of hydrophobic and charged patches on the edge and interior of cradle during TF‐assisted protein folding. Our results showed that most of the surface of the cradle was involved in TF‐assisted protein folding, which was larger than found in early studies. Although the inner surface of cradle was mostly hydrophobic, both hydrophobic and electrostatic patches were indispensable for TF to facilitate correct protein folding. However, hydrophobic patches were more important for the antiaggregation activity of TF. Furthermore, it was found that the patches on the surface of cradle were involved in TF‐assisted protein folding in a spatial and temporal order. These results suggest that the folding‐favorable interface between the cradle and substrate was dynamic during TF‐assisted protein folding, which enabled TF to be involved in the folding of substrate in an aggressive manner rather than acting as a classic holdase.—Fan, D., Cao, S., Zhou, Q., Zhang, Y., Yue, L., Han, C., Yang, B., Wang, Y., Ma, Z., Zhu, L., Liu, C. Exploring the roles of substrate‐binding surface of the chaperone site in the chaperone activity of trigger factor. FASEB J. 32, 6655–6665 (2018). www.fasebj.org
Angiotensin II receptor I blockade prevents stenosis of tissue engineered vascular grafts
Authors: de Dios Ruiz‐Rosado Juan , Lee Yong‐Ung , Mahler Nathan , Yi Tai , Robledo‐Avila Frank , Martinez‐Saucedo Diana , Lee Avione Y. , Shoji Toshihiro , Heuer Eric , Yates Andrew R. , Pober Jordan S. , Shinoka Toshiharu , Partida‐Sanchez Santiago , Breuer Christopher K.
Published: June 2018

We previously developed a tissue‐engineered vascular graft (TEVG) made by seeding autologous cells onto a biodegradable tubular scaffold, in an attempt to create a living vascular graft with growth potential for use in children undergoing congenital heart surgery. Results of our clinical trial showed that the TEVG possesses growth capacity but that its widespread clinical use is not yet advisable due to the high incidence of TEVG stenosis. In animal models, TEVG stenosis is caused by increased monocytic cell recruitment and its classic (“M1”) activation. Here, we report on the source and regulation of these monocytes. TEVGs were implanted in wild‐type, CCR2 knockout (Ccr2−/−), splenectomized, and spleen graft recipient mice. We found that bone marrow—derived Ly6C+hi monocytes released from sequestration by the spleen are the source of mononuclear cells infiltrating the TEVG during the acute phase of neovessel formation. Furthermore, short‐term administration of losartan (0.6 g/L, 2 wk), an angiotensin II type 1 receptor antagonist, significantly reduced the macrophage populations (Ly6C+/−/F480+) in the scaffolds and improved long‐term patency in TEVGs. Notably, the combined effect of bone marrow‐derived mononuclear cell seeding with short‐term losartan treatment completely prevented the development of TEVG stenosis. Our results provide support for pharmacologic treatment with losartan as a strategy to modulate monocyte infiltration into the grafts and thus prevent TEVG stenosis.—Ruiz‐Rosado, J. D. D., Lee, Y.‐U., Mahler, N., Yi, T., Robledo‐Avila, F.,Martinez‐Saucedo,D.,Lee,A.Y.,Shoji,T., Heuer, E.,Yates,A.R., Pober, J. S., Shinoka,T., Partida‐Sanchez, S., Breuer, C. K. Angiotensin II receptor I blockade prevents stenosis of tissue engineered vascular grafts. FASEB J. 32, 6822‐6832 (2018). www.fasebj.org
O‐Glycosylation‐mediated signaling circuit drives metastatic castration‐resistant prostate cancer
Authors: Tzeng Sheue‐Fen , Tsai Chin‐Hsien , Chao Tai‐Kuang , Chou Yu‐Ching , Yang Yu‐Chih , Tsai Mong‐Hsun , Cha Tai‐Lung , Hsiao Pei‐Wen
Published: June 2018

Disseminated castration‐resistant prostate cancer (CRPC) is a common disease in men that is characterized by limited survival and resistance to androgen‐deprivation therapy. The increase in human epidermal growth factor receptor 2 (HER2) signaling contributes to androgen receptor activity in a subset of patients with CRPC; however, enigmatically, HER2‐targeted therapies have demonstrated a lack of efficacy in patients with CRPC. Aberrant glycosylation is a hallmark of cancer and involves key processes that support cancer progression. Using transcriptomic analysis of prostate cancer data sets, histopathologic examination of clinical specimens, and in vivo experiments of xenograft models, we reveal in this study a coordinated increase in glycan‐binding protein, galectin‐4, specific glycosyltransferases of core 1 synthase, glycoprotein‐N‐acetylgalactosamine 3‐β‐galactosyltransferase 1 (C1GALT1) and ST3 β‐galactoside α‐2,3‐sialyltransferase 1 (ST3GAL1), and resulting mucin‐type O‐glycans during the progression of CRPC. Furthermore, galectin‐4 engaged with C1GALT1‐dependent O‐glycans to promote castration resistance and metastasis by activating receptor tyrosine kinase signaling and cancer cell sternness properties mediated by SRY‐box 9 (SOX9). This galectin‐glycan interaction up‐regulated the MYC‐dependent expression of C1GALT1 and ST3GAL1, which altered cellular mucin‐type O‐glycosylation to allow for galectin‐4 binding. In clinical prostate cancer, high‐level expression of C1GALT1 and galectin‐4 together predict poor overall survival compared with low‐level expression of C1GALT1 and galectin‐4. In summary, MYC regulates abnormal O‐glycosylation, thus priming cells for binding to galectin‐4 and downstream signaling, which promotes castration resistance and metastasis.—Tzeng, S.‐F., Tsai, C.‐H., Chao, T.‐K., Chou, Y.‐C., Yang, Y.‐C., Tsai, M.‐H., Cha, T.‐L., Hsiao, P.‐W. O‐Glycosylation‐mediated signaling circuit drives metastatic castration‐resistant prostate cancer. FASEB J. 32, 6869–6882 (2018). www.fasebj.org
CE: Original Research: The Efficacy and Safety of an RN-Driven Ketamine Protocol for Adjunctive Analgesia During Burn Wound Care
Authors: Baumgartner Laura , Townsend Nicole , Winkelman Katie , MacLaren Robert
Published: June 2018

Objective: Traditional analgesic regimens often fail to control the severe pain patients experience during burn wound care, and the drugs are frequently administered at doses that can cause oversedation and respiratory depression. Ketamine may be an ideal agent for adjunctive analgesia in such patients because of its unique mechanism of action and lack of association with respiratory depression. This study evaluated the efficacy and safety of a critical care RN–driven protocol for IV ketamine administration during burn wound care.

Methods: This retrospective cohort study examined all adult burn patients who received ketamine as part of a critical care RN–driven ketamine protocol for burn wound care from September 2011 through September 2013. Efficacy outcomes were opioid and benzodiazepine requirements (expressed as fentanyl and midazolam equivalents, respectively) four hours after ketamine administration compared with four hours before such administration. Safety parameters assessed were neurologic, hemodynamic, and respiratory effects.

Results: Twenty-seven patients received 56 ketamine doses as part of this protocol; the mean (SD) dose was 0.75 (0.35) mg/kg. Twenty patients (74%) were male and seven (26%) were female; mean age was 39 years. The average percentage of total body surface area burned was 23.4%. With the protocol, opioid and benzodiazepine requirements were reduced by 29% and 20%, respectively. One patient experienced an episode of oversedation after concomitant administration of ketamine and fentanyl. No patients experienced neurologic or hemodynamic complications following ketamine administration.

Conclusions: The administration of ketamine during burn wound care using a critical care RN–driven protocol was associated with reduced opioid and benzodiazepine requirements and few adverse effects. Prospective studies are needed to investigate additional patient outcomes and the independent administration of ketamine by critical care RNs.
Mechanisms leading to T-cell activation in drug hypersensitivity
Authors: Meng Xiaoli , Yerly Daniel , Naisbitt Dean J.
Published: June 2018

Purpose of review

Delayed-type or nonimmediate drug hypersensitivity reactions often involve the activation of drug-specific T cells. As such, the molecular initiating event is an interaction between HLA proteins, HLA-binding peptides and the drug. For many years, the formation of covalently modified drug protein adducts was assumed to be a prerequisite for T-cell activation. The purpose of this article is to review recent studies using human PBMC, T-cell lines and clones, which show that drugs are in fact loaded onto HLA molecules in different forms to activate T cells.

Recent findings

We now know that protein-reactive drugs such as β-lactam antibiotics activate T cells via direct noncovalent interactions with HLA or HLA-binding peptides, direct covalent modification of HLA-binding peptides and covalent binding of non-HLA associated proteins. Adducts formed inside and outside of the cells undergo protein processing to generate HLA-binding peptides that are assumed to contain the drug modification. Studies using synthetic stable (e.g. oxypurinol) and reactive (e.g. nitroso sulfamethoxazole) metabolites show that metabolites activate T cells via the same pathways. A variety of drugs with different structural features have also been shown to activate T cells though a direct HLA-binding interaction. Of note, abacavir behaves in an unexpected way, binding deep in the peptide binding cleft of one HLA, selectively activating CD8+ T cells.

In-vitro studies have revealed that a number of drug HLA-binding interactions lead to the activation of T cells. These can be categorized according to two hypotheses, namely hapten and pharmacological interactions. As we move forward with the development of diagnostic and predictive T-cell assays, it is critical to reach a consensus that direct drug HLA binding and the formation of drug protein adducts are important events for T-cell activation.
Etiology of Global Corneal Blindness and Current Practices of Corneal Transplantation: A Focused Review
Authors: Mathews Priya M. , Lindsley Kristina , Aldave Anthony J. , Akpek Esen K.
Published: June 2018

Purpose:

The purpose of this focused review was to explore the etiologies of corneal blindness worldwide and compare them with the indications and type of keratoplasties (eg, full-thickness penetrating keratoplasty, anterior lamellar keratoplasty, or endothelial keratoplasty) performed.

Methods:

A literature search of the articles published in the top 10 journals (based on the Altmetrics score) relevant to corneal transplantation within the past 20 years was performed to determine how the focus within corneal transplantation has changed over time. These data were compared with the prevalence and etiology of corneal blindness in each respective region worldwide.

Results:

The leading etiologies of corneal blindness worldwide are primarily due to anterior corneal pathology with a normal endothelium, and the prevalence is highest in developing countries. In addition, the number and type of corneal transplantations performed globally indicate that current practices are disproportionately skewed in favor of endothelial keratoplasty, which is targeted for the pathology prevalent in developed countries. Despite the large number of individuals who would benefit from anterior lamellar keratoplasty, this technique seems to be infrequently performed.

Conclusions:

Most corneal blindness worldwide is secondary to anterior corneal pathology because of infections and trauma. However, this does not align with the current trends and practices in the field of corneal transplantation. We discuss potential solutions to address the current leading causes of global corneal blindness, including increasing the number of anterior lamellar keratoplasties performed, using long-term preserved corneas by trained surgeons, and improving eye bank handling and distribution of procured tissues.
Combined Hookwire and Methylene Blue Localization of Pulmonary Nodules
Authors: Joseph Brady John , Hirsch Reilly Christie , Guay Robert , Dasika Uday
Published: June 2018

Objective

Because of decreased tactile sensation with thoracoscopic approaches to biopsy, localization preoperatively and intraoperatively is important for successful biopsy. Our study evaluated the technique of combined computed tomography-guided hookwire and methylene blue localization.

Methods

Seventy-five patients from November 2007 to August 2013 who underwent combined Hawkins hookwire and methylene blue localization of 76 total pulmonary nodules before video-assisted thoracic surgery-guided wedge resection were retrospectively reviewed. Multiple patient, nodule, and procedural characteristics were analyzed for correlation with successful wire localization and wire dislodgement. Successful wire localization was defined as absence of lesions requiring re-resection, wire dislodgement necessitating re-resection, or conversion to thoracotomy for localization.

Results

Seventy-four patients were included in the study (75 pulmonary nodules - 1 patient had 2 lesions localized) and mean ± SD patient age was 65.8 ± 12.1 years and 50% were male. The mean ± SD largest nodule diameter was 14.6 ± 7.4 mm and 29.3% of these were subcentimeter pulmonary nodules. Increased age and history of malignancy were associated with malignant diagnoses ( P = 0.037 and 0.009, respectively) Successful wire localization was present in 86.4% of patients. Lesions with lower mean distance to the pleura correlated with successful localization ( P = 0.002). Wire dislodgement was present in 9.3% (7 patients) with 4 (5.3%) of these necessitating need for re-resection to establish pathologic diagnosis. Albeit wire dislodgement, 57.4% (4/7) still had successful thoracoscopic localization.

Conclusions

This study demonstrates that utilization of Hawkins hookwire in combination with methylene blue injection is an effective method to successfully localize pulmonary nodules for thoracoscopic wedge resection and should prompt further investigation for its utilization.
Three-Year Survival Comparison between Transcatheter and Surgical Aortic Valve Replacement for Intermediate- and Low-Risk Patients
Authors: Siordia Juan A. , Loera Jackquelin M. , Scanlon Matt , Evans Jessie , Knight Peter A.
Published: June 2018

Transcatheter aortic valve implantation is a suitable therapeutic intervention for patients deemed inoperable or high risk for surgical aortic valve replacement. Current investigations question whether it is a suitable alternative to surgery for intermediate- and low-risk patients. The following meta-analysis presents a comparison between transcatheter versus surgical aortic valve replacement in patients that are intermediate and low risk for surgery. Articles were collected via an electronic search using Google Scholar and PubMed. Articles of interest included studies comparing the survival of intermediate- and low-risk patients undergoing transcatheter aortic valve implantation to those undergoing surgical aortic valve replacement. Primary end points included 1-, 2-, and 3-year survival. Secondary end points included postintervention thromboembolic events, stroke, transient ischemic attacks, major vascular complications, permanent pacemaker implantation, life-threatening bleeding, acute kidney injury, atrial fibrillation, and moderate-to-severe aortic regurgitation. Six studies met the criteria for the meta-analysis. One- and two-year survival comparisons showed no difference between the two interventions. Surgical aortic valve replacement, however, presented with favorable 3-year survival compared with the transcatheter approach. Transcatheter aortic valve implantation had more major vascular complications, permanent pacemaker implantation, and moderate-to-severe aortic regurgitation rates compared with surgery. Surgical aortic valve replacement presented more life-threatening bleeding, acute kidney injury, and atrial fibrillation compared with a transcatheter approach. There was no statistical difference between the two approaches in terms of thromboembolic events, strokes, or transient ischemic attack rates. Surgical aortic valve replacement presents favorable 3-year survival rates compared with transcatheter aortic valve implantation.
Using Lean to Enhance Heart Failure Patient Identification Processes and Increase Core Measure Scores
Authors: Hunt Jennifer R. , Ouellette Kelli Jo , Reece Michelle
Published: June 2018

Background:

Heart failure (HF) is the leading cause of hospitalization among older adults in the United States. Health systems target readmission rates for quality improvement and cost reduction.

Local Problem:

Heart failure core measure (CM) scores at our medical center were lower than the national average, and methods for capturing the appropriate documentation on HF patients to ensure CM compliance were not clear.

Methods:

An interdisciplinary team determined barriers to increasing CM scores, gathered baseline data, and identified gaps in the existing process.

Interventions:

The team implemented an accurate reporting system and error-proofing process, redesigned the process for identifying patients admitted with a HF diagnosis, and developed a patient appointment section before discharge in the electronic medical record.

Results:

There was a decrease in readmissions within 30 days of implementation from 12% to 8%, and HF CM compliance score increased from 88% to 100%. The percentage of HF patients not identified during hospitalization decreased from 17% to 0%. Heart failure patients discharged with a 7-day follow-up appointment increased from 88% to 98%.

Conclusion:

Through implementation of an interdisciplinary-led process improvement and lean methodologies, metrics and CMs were achieved.
Longer Duration of Urinary Catheterization Increases Catheter-Associated Urinary Tract Infection in PICU
Authors: Fukuoka Kahoru , Furuichi Mihoko , Ito Kenta , Morikawa Yoshihiko , Watanabe Ichiro , Shimizu Naoki , Horikoshi Yuho
Published: June 2018

Objectives:

Catheter-associated urinary tract infections account for 30% of healthcare-associated infections. To date, few studies have addressed pediatric catheter-associated urinary tract infection in PICUs. The aim of our study was to assess the risk of catheter-associated urinary tract infection in relation to the duration of catheterization in the PICU.

Design:

Retrospective cohort study.

Setting:

PICU at a tertiary children’s hospital.

Patients:

Our study was conducted between April 2012 and June 2015 at Tokyo Metropolitan Children’s Medical Center in Japan. Children in the PICU with an urethral catheter were included. Catheter-associated urinary tract infection cases were defined according to the National Healthcare Safety Network criteria. The patients’ demographic data and isolated organisms were reviewed. Duration of catheterization and the catheter-associated urinary tract infection occurrence rate were analyzed.

Interventions:

None.

Measurements and Main Results:

Among 1,890 catheterizations, 23 catheter-associated urinary tract infection cases were identified. The overall occurrence rate was 2.35/1,000 catheter-days. Among the patients with catheter-associated urinary tract infection, 13 were boys. The median age was 11 months (interquartile range, 7–35 mo), and the median duration of catheterization was 7 days (interquartile range, 5–12 d). The isolated bacteria were Escherichia coli (26.5%), Enterococcus faecalis (17.6%), and Klebsiella pneumoniae (11.8%). Two species were isolated in each of 11 cases (47.8%). Each additional day of catheterization increased the risk of catheter-associated urinary tract infection (odds ratio, 1.06; 95% CI, 1.02–1.10, and odds ratio adjusted for contact precaution status and surgical procedures was 1.05; 95% CI, 1.01–1.09).

Conclusions:

Longer duration of catheterization increased the risk of catheter-associated urinary tract infection by 5% each day at the PICU. Prompt removal of the urethral catheter is strongly recommended whenever feasible.
Caring for Pediatric Patients With Epidermolysis Bullosa in the Emergency Department
Authors: Jenkinson Helena A. , Lundgren Ashley D. , Levy Moise L. , Diaz Lucia Z.
Published: June 2018

Epidermolysis bullosa (EB) refers to a heterogeneous group of genetic disorders characterized by epithelial fragility. We provide guidelines for management of pediatric patients with EB in the emergency department based on a review of literature, as well as insights from our own experiences caring for patients with EB. The purpose of the guidelines proposed is prevention of avoidable iatrogenic trauma to the skin and mucosa of patients with EB who are presenting to the emergency department for a variety of reasons.
Just-in-Time Training for Intraosseous Needle Placement and Defibrillator Use in a Pediatric Emergency Department
Authors: Itoh Taichi , Lee-Jayaram Jannet , Fang Rui , Hong Travis , Berg Benjamin
Published: June 2018

Objectives

Just-in-time training (JITT) is a method of simulation-based training where the training occurs within the clinical environment in a concise manner. Just-in-time training has shown effects at the learner, patient, and system-wide levels. We evaluated a JITT curriculum for the procedures of intraosseous (IO) needle placement and defibrillator use in a pediatric emergency department (ED) by comparing the trainees' comfort level in performing those procedures independently (Kirkpatrick level 2a) and trainees' knowledge of the procedures/equipment (Kirkpatrick level 2b) before and after the JITT.

Methods

The study enrolled all fourth year medical students and residents (family medicine and pediatrics) who rotated through a children's hospital ED. The JITT curriculum included group discussion on storage locations of procedure equipment in the ED and clinical indications/contraindications followed by hands-on procedure training. One of 2 attending physicians facilitated the 10- to 20-minute JITT in the ED during their shifts. Trainees completed an anonymous survey to delineate medical training level, previous procedure experiences, procedure-related knowledge, and comfort level to perform the procedures independently. Identical surveys were completed before and after the JITT. The data were analyzed using percentage for categorical variables. For comparisons between pre-JITT and post-JITT survey data, χ2tests or Fisher exact tests were used.

Results

There were 65 surveys included (34 pre-JITT and 31 post-JITT surveys). The comfort level to perform procedures independently increased from pre-JITT 0% to post-JITT 48% (P< 0.001) for IO needle placement and from pre-JITT 3% to post-JITT 32% (P= 0.0016) for defibrillator use. The procedure-related knowledge also increased by ##greater than or equal to 50% post-JITT (P< 0.0001).

Conclusions

Our JITT curriculum significantly increased the comfort level of the trainees to perform IO needle insertion and defibrillator use independently. Procedure-related knowledge also increased. By increasing their comfort to perform these procedures independently, we aim to increase the likelihood that trainees can be competent contributing members of an acute medical response team in these respective roles.
Translational models of infection prevention and control: lessons from studying high risk aging populations
Authors: Mody Lona
Published: June 2018

Purpose of review

The present review describes our research experiences and efforts in advancing the field of infection prevention and control in nursing facilities including postacute and long-term care settings.

Recent findings

There are over two million infections in postacute and long-term care settings each year in the United States and $4 billion in associated costs. To define a target group most amenable to infection prevention and control interventions, we sought to quantify the relation between indwelling device use and microbial colonization in nursing facility patients. Using various methodologies including survey methods, observational epidemiology, randomized controlled studies, and collaboratives, we showed that (1) indwelling device type is related to the site of multidrug-resistant organism (MDRO) colonization; (2) multianatomic site colonization with MDROs is common; (3) community-associated methicillin-resistant Staphylococcus aureus (MRSA) appeared in the nursing facility setting almost immediately following its emergence in acute care; (4) MDRO prevalence and catheter-associated infection rates can be reduced through a multimodal targeted infection prevention intervention; and (5) using a collaborative approach, such an intervention can be successfully scaled up.

Our work advances the infection prevention field through translational research utilizing various methodologies, including quantitative and qualitative surveys, patient-oriented randomized controlled trials, and clinical microbiologic and molecular methods. The resulting interventions employ patient-oriented methods to reduce infections and antimicrobial resistance, and with partnerships from major national entities, can be implemented nationally.
Liver Perfusate Natural Killer Cells From Deceased Brain Donors and Association With Acute Cellular Rejection After Liver Transplantation: A Time-to-Rejection Analysis
Authors: Pagano Duilio , Badami Ester , Conaldi Pier Giulio , Seidita Aurelio , Tuzzolino Fabio , Barbàra Marco , di Francesco Fabrizio , Tropea Alessandro , Liotta Rosa , Chiarello Gaia , Luca Angelo , Gruttadauria Salvatore
Published: June 2018

Background

The ability to predict which recipients will successfully complete their posttransplant clinical course, which is crucial for liver transplant (LT) programs. The assessment of natural killer (NK) cell subset determined by flow cytometry from a monocentric series of consecutive liver perfusates could help identify risk factors portending adverse LT outcomes.

Methods

Liver perfusates were collected during the back-table surgical time after the procurement procedures for donors after brain death. Lymphocytic concentrations and phenotypes were matched with donors after brain death characteristics and indications, timing, surgical techniques, outcomes, and biopsy-proven acute cellular rejections (ACRs) in 46 adult recipients who underwent LT between 2010 and 2014 at our institute. Cox regression models were used to study relevant risk factors in order to estimate hazard ratios for episodes of rejection after LT.

Results

Percentage of NK cells was significantly associated with donor age (P = 0.05) and the percentage of NK T cellular subset (P = 0.001). The length of follow-up after LT was 41.0 ± 20.9 months, and 11 (23.9%) recipients experienced biopsy-proven ACR. At time-to-rejection proportional regression analysis, a cutoff value of 33.7% was optimal, with a sensitivity of 1, specificity of 0.57, and positive and negative predictive values of 0.42 and 1, respectively. The liver perfusate NK cell subset was strongly associated with biopsy-proven ACR (hazard ratio, 10.7; P = 0.02).

Conclusions

Liver perfusate cytofluorimetric phenotyping may contribute as a targeted preoperative tool to predict the risk of ACR, and as clinical test in translational studies that aim to improve donor allograft procurement and transplant outcomes.
Changes in Utilization and Discard of HCV Antibody-Positive Deceased Donor Kidneys in the Era of Direct-Acting Antiviral Therapy
Authors: Bowring Mary G. , Kucirka Lauren M. , Massie Allan B. , Ishaque Tanveen , Bae Sunjae , Shaffer Ashton A. , Garonzik Wang Jacqueline , Sulkowski Mark , Desai Niraj , Segev Dorry L. , Durand Christine M.
Published: June 2018

Background

The availability of direct-acting antiviral (DAA) therapy might have impacted use of hepatitis C virus (HCV)-infected (HCV+) deceased donor kidneys for transplantation.

Methods

We used 2005 to 2018 Scientific Registry of Transplant Recipients data to identify 18 936 candidates willing to accept HCV+ kidneys and 3348 HCV+ recipients of HCV+ kidneys. We compared willingness to accept, utilization, discard, and posttransplant outcomes associated with HCV+ kidneys between 2 treatment eras (interferon [IFN] era, January 1, 2005 to December 5, 2013 vs DAA era, December 6, 2013 to August 2, 2018). Models were adjusted for candidate, recipient, and donor factors where appropriate.

Results

In the DAA era, candidates were 2.2 times more likely to list as willing to accept HCV+ kidneys (adjusted odds ratio,2.072.232.41;P< 0.001), and HCV+ recipients were 1.95 times more likely to have received an HCV+ kidney (adjusted odds ratio,1.761.952.16;P< 0.001). Median Kidney Donor Profile Index of HCV+ kidneys decreased from 77 (interquartile range [IQR], 59-90) in 2005 to 53 (IQR, 40-67) in 2017. Kidney Donor Profile Index of HCV− kidneys remained unchanged from 45 (IQR, 21-74) to 47 (IQR, 24-73). After adjustment, HCV+ kidneys were 3.7 times more likely to be discarded than HCV− kidneys in the DAA era (adjusted relative rate,3.363.674.02;P< 0.001); an increase from the IFN era (adjusted relative rate,2.783.023.27;P< 0.001). HCV+ kidney use was concentrated within a subset of centers; 22.5% of centers performed 75% of all HCV+ kidney transplants in the DAA era. Mortality risk associated with HCV+ kidneys remained unchanged (aHR,1.071.191.32in both eras).

Conclusions

Given the elevated risk of death on dialysis facing HCV+ candidates, improving quality of HCV+ kidneys, and DAA availability, broader utilization of HCV+ kidneys is warranted to improve access in this era of organ shortage.
The perception of colour and material in naturalistic tasks
Authors: Brainard David H. , Cottaris Nicolas P. , Radonjić Ana
Published: June 2018

Perceived object colour and material help us to select and interact with objects. Because there is no simple mapping between the pattern of an object's image on the retina and its physical reflectance, our perceptions of colour and material are the result of sophisticated visual computations. A long-standing goal in vision science is to describe how these computations work, particularly as they act to stabilize perceived colour and material against variation in scene factors extrinsic to object surface properties, such as the illumination. If we take seriously the notion that perceived colour and material are useful because they help guide behaviour in natural tasks, then we need experiments that measure and models that describe how they are used in such tasks. To this end, we have developed selection-based methods and accompanying perceptual models for studying perceived object colour and material. This focused review highlights key aspects of our work. It includes a discussion of future directions and challenges, as well as an outline of a computational observer model that incorporates early, known, stages of visual processing and that clarifies how early vision shapes selection performance.
The functional neuroanatomy of face perception: from brain measurements to deep neural networks
Authors: Grill-Spector Kalanit , Weiner Kevin S. , Gomez Jesse , Stigliani Anthony , Natu Vaidehi S.
Published: June 2018

A central goal in neuroscience is to understand how processing within the ventral visual stream enables rapid and robust perception and recognition. Recent neuroscientific discoveries have significantly advanced understanding of the function, structure and computations along the ventral visual stream that serve as the infrastructure supporting this behaviour. In parallel, significant advances in computational models, such as hierarchical deep neural networks (DNNs), have brought machine performance to a level that is commensurate with human performance. Here, we propose a new framework using the ventral face network as a model system to illustrate how increasing the neural accuracy of present DNNs may allow researchers to test the computational benefits of the functional architecture of the human brain. Thus, the review (i) considers specific neural implementational features of the ventral face network, (ii) describes similarities and differences between the functional architecture of the brain and DNNs, and (iii) provides a hypothesis for the computational value of implementational features within the brain that may improve DNN performance. Importantly, this new framework promotes the incorporation of neuroscientific findings into DNNs in order to test the computational benefits of fundamental organizational features of the visual system.
Colour, contours, shading and shape: flow interactions reveal anchor neighbourhoods
Authors: Kunsberg Benjamin , Holtmann-Rice Daniel , Alexander Emma , Cholewiak Steven , Fleming Roland , Zucker Steven W.
Published: June 2018

Two dilemmas arise in inferring shape information from shading. First, depending on the rendering physics, images can change significantly with (even) small changes in lighting or viewpoint, while the percept frequently does not. Second, brightness variations can be induced by material effects—such as pigmentation—as well as by shading effects. Improperly interpreted, material effects would confound shading effects. We show how these dilemmas are coupled by reviewing recent developments in shape inference together with a role for colour in separating material from shading effects. Aspects of both are represented in a common geometric (flow) framework, and novel displays of hue/shape interaction demonstrate a global effect with interactions limited to localized regions. Not all parts of an image are perceptually equal; shape percepts appear to be constructed from image anchor regions.
Soil viruses are underexplored players in ecosystem carbon processing
Authors: Trubl Gareth , Jang Ho Bin , Roux Simon , Emerson Joanne B. , Solonenko Natalie , Vik Dean R. , Solden Lindsey , Ellenbogen Jared , Runyon Alexander T. , Bolduc Benjamin , Woodcroft Ben J. , Saleska Scott R. , Tyson Gene W. , Wrighton Kelly C. , Sullivan Matthew B. , Rich Virginia I.
Published: June 2018

Rapidly thawing permafrost harbors ~30–50% of global soil carbon, and the fate of this carbon remains unknown. Microorganisms will play a central role in its fate, and their viruses could modulate that impact via induced mortality and metabolic controls. Because of the challenges of recovering viruses from soils, little is known about soil viruses or their role(s) in microbial biogeochemical cycling. Here, we describe 53 viral populations (vOTUs) recovered from seven quantitatively-derived (i.e. not multiple-displacement-amplified) viral-particle metagenomes (viromes) along a permafrost thaw gradient. Only 15% of these vOTUs had genetic similarity to publicly available viruses in the RefSeq database, and ~30% of the genes could be annotated, supporting the concept of soils as reservoirs of substantial undescribed viral genetic diversity. The vOTUs exhibited distinct ecology, with dramatically different distributions along the thaw gradient habitats, and a shift from soil-virus-like assemblages in the dry palsas to aquatic-virus-like in the inundated fen. Seventeen vOTUs were linked to microbial hosts (in silico), implicating viruses in infecting abundant microbial lineages fromAcidobacteria, Verrucomicrobia, andDeltaproteoacteria, including those encoding key biogeochemical functions such as organic matter degradation. Thirty-one auxiliary metabolic genes (AMGs) were identified, and suggested viral-mediated modulation of central carbon metabolism, soil organic matter degradation, polysaccharide-binding, and regulation of sporulation. Together these findings suggest that these soil viruses have distinct ecology, impact host-mediated biogeochemistry, and likely impact ecosystem function in the rapidly changing Arctic.