bluuebunny/crossref_metadata_2025 huggingface dataset:
Spectroscopic studies of non-thermal plasma jet at atmospheric pressure formed in low-current nonsteady-state plasmatron for biomedical applications
Authors: Demkin V. P. , Melnichuk S. V. , Demkin O. V. , Kingma H. , Van de Berg R.
Published: April 2016

The optical and electrophysical characteristics of the nonequilibrium low-temperature plasma formed by a low-current nonsteady-state plasmatron are experimentally investigated in the present work. It is demonstrated that experimental data on the optical diagnostics of the plasma jet can provide a basis for the construction of a self-consistent physical and mathematical plasma model and for the creation of plasma sources with controllable electrophysical parameters intended for the generation of the required concentration of active particles. Results of spectroscopic diagnostics of plasma of the low-current nonsteady-state plasmatron confirm that the given source is efficient for the generation of charged particles and short-wavelength radiation—important plasma components for biomedical problems of an increase in the efficiency of treatment of biological tissues by charged particles. Measurement of the spatial distribution of the plasma jet potential by the probe method has demonstrated that a negative space charge is formed in the plasma jet possibly due to the formation of electronegative oxygen ions.
Thermoelectric effects in a rectangular Aharonov-Bohm geometry
Authors: Pye A. J. , Faux D. A. , Kearney M. J.
Published: April 2016

The thermoelectric transport properties of a rectangular Aharonov-Bohm ring at low temperature are investigated using a theoretical approach based on Green's functions. The oscillations in the transmission coefficient as the field is varied can be used to tune the thermoelectric response of the ring. Large magnitude thermopowers are obtainable which, in conjunction with low conductance, can result in a high thermoelectric figure of merit. The effects of single site impurities and more general Anderson disorder are considered explicitly in the context of evaluating their effect on the Fano-type resonances in the transmission coefficient. Importantly, it is shown that even for moderate levels of disorder, the thermoelectric figure of merit can remain significant, increasing the appeal of such structures from the perspective of specialist thermoelectric applications.
Gas cluster ion beam assisted NiPt germano-silicide formation on SiGe
Authors: Ozcan Ahmet S. , Lavoie Christian , Alptekin Emre , Jordan-Sweet Jean , Zhu Frank , Leith Allen , Pfeifer Brian D. , LaRose J. D. , Russell N. M.
Published: April 2016

We report the formation of very uniform and smooth Ni(Pt)Si on epitaxially grown SiGe using Si gas cluster ion beam treatment after metal-rich silicide formation. The gas cluster ion implantation process was optimized to infuse Si into the metal-rich silicide layer and lowered the NiSi nucleation temperature significantly according to in situ X-ray diffraction measurements. This novel method which leads to more uniform films can also be used to control silicide depth in ultra-shallow junctions, especially for high Ge containing devices, where silicidation is problematic as it leads to much rougher interfaces.
The effect of long term under- and overfeeding on the expression of genes related to glucose metabolism in the mammary tissue of goats
Authors: Tsiplakou E. , Flemetakis E. , Kouri E. D. , Zervas G.
Published: April 2016

The glucose metabolism in the mammary tissue (MT) is controlled by several genes whose nutritional regulation is poorly documented. In this study, the effect of long-term under- and overfeeding on the expression of glucose transporter 1 (GLUT1), glucose transporter 3 (GLUT3), sodium glucose contransporter 1 (SGLT1), two isoforms of β- (1, 4) galactosyltransferase [β- (1, 4) GAT1 and β- (1, 4) GAT3], and α-lactalbumin (LALBA), related to glucose metabolism in goat MT, was examined by using real-time RT-PCR. Twenty- four lactating goats were divided into three homogenous subgroups and fed the same ration in quantities covering 70% (underfeeding), 100% (control) and 130% (overfeeding) of their energy and crude protein requirements, respectively. The results showed that the feeding level did not affect the GLUT1, GLUT3 and SGLT1 genes expression in goats MT. On the contrary, a significant reduction and a trend for reduction on mRNA of β- (1, 4) GAT1 and on β- (1, 4) GAT3, respectively, in the MT of underfed goats, compared with the overfed ones, was observed. Moreover, a significant decrease in the LALBA mRNA accumulation in the MT of underfed goats compared with the overfed was found. In conclusion, the MT of goats, unlike cows, adapt to changes in glucose or energy supply from different levels of feeding by changing the utilisation of glucose for the synthesis of lactose.
Greenhouse gas emissions from dung, urine and dairy pond sludge applied to pasture. 1. Nitrous oxide emissions
Authors: Ward G. N. , Kelly K. B. , Hollier J. W.
Published: April 2016

Nitrous oxide (N2O) from excreta deposited by grazing ruminants is a major source of greenhouse gas emissions in Australia. Experiments to measure N2O emissions from dairy cow dung, urine and pond sludge applied to pasture, and the effectiveness of the nitrification inhibitor nitrapyrin in reducing these emissions, were conducted in south-western Victoria, Australia. In Experiment 1, emissions from urine, with and without nitrapyrin, and from dung were measured. Treatments applied in September 2013 resulted in cumulative emissions (245 days) of 0.60, 5.35, 4.15 and 1.02 kg N2O-nitrogen (N)/ha for the nil, urine (1000 kg N/ha), urine (1000 kg N/ha) + nitrapyrin (1 kg active ingredients/ha), and dung (448 kg N/ha) treatments, respectively, giving emission factors of 0.47% and 0.09% for urine and dung respectively. Nitrapyrin reduced N2O emissions from urine for 35 days, with an overall reduction in emissions of 25%. In Experiment 2, sludge, with and without nitrapyrin, was applied in May 2014, and dung was applied in May, August, November 2014 and January 2015. Cumulative emissions (350 days) were 0.19, 0.49, 0.31 and 0.39 kg N2O-N/ha for the nil, sludge (308 kg N/ha), sludge (308 kg N/ha) + nitrapyrin (1 kg active ingredients/ha), and dung (total 604 kg N/ha) treatments, respectively, giving emission factors of 0.10% and 0.03% for sludge and dung. Nitrapyrin reduced N2O emissions from sludge for 60 days, with an overall reduction in emissions of 59%. A third experiment on two soil types compared emissions from urine and dung, with and without nitrapyrin, applied in different seasons of the year. Emissions were highly seasonal and strongly related to soil water status. Emission factors (90 days) ranged from 0.02% to 0.19% for urine and 0.01% to 0.12% for dung. Nitrapyrin reduced emissions from urine by 0–35% and had little effect on emissions from dung. Overall, the experiments found that nitrapyrin was an effective tool in reducing emissions from urine, dung and sludge applied to pasture, but the magnitude varied across the year, with nitrapyrin being most effective when soils had >70% water-filled pore space when major emissions occurred.
Elongation factor 4 remodels the A-site tRNA on the ribosome
Authors: Gagnon Matthieu G. , Lin Jinzhong , Steitz Thomas A.
Published: April 2016

Significance

Many protein factors interact with the ribosome during protein synthesis. Elongation factor 4 (EF-4/LepA) is a widely distributed and highly conserved translational GTPase for which several physiological roles have been proposed. Despite this, the function of EF-4 remains unknown. We have determined a high-resolution crystal structure of the ribosome bound to EF-4 in its GTP-bound state and A-, P-, and E-site tRNAs. Notably, EF-4 induces a distinct conformation of the tRNA bound in the A site, which deviates substantially from that of a canonical A-tRNA. EF-4 interacts with both helical domains of the A-site tRNA, indicating that EF-4 recognizes the L-shaped conformation of tRNA. Our results provide insights into the tRNA remodeling capacity of EF-4 on the ribosome.
Dynamics of prebiotic RNA reproduction illuminated by chemical game theory
Authors: Yeates Jessica A. M. , Hilbe Christian , Zwick Martin , Nowak Martin A. , Lehman Niles
Published: April 2016

Significance

The origins of life required a means for information-containing molecules to compete with one another for survival and reproduction. Using an analysis based on game theory, we can predict the situations in which cooperation, selfishness, or a mixture of the two is beneficial to the future evolutionary success of RNAs.
Structures of the nucleoid occlusion protein SlmA bound to DNA and the C-terminal domain of the cytoskeletal protein FtsZ
Authors: Schumacher Maria A. , Zeng Wenjie
Published: April 2016

Significance

The bacterial protein FtsZ polymerizes into protofilaments to create the cytokinetic ring responsible for directing cell division. Cellular levels of FtsZ are above the concentration required for Z-ring formation. Hence, FtsZ-binding proteins have evolved that control its spatiotemporal formation. The SlmA protein is one such factor that, when bound to specific chromosomal DNA, inhibits FtsZ polymerization to prevent Z rings from forming through the bacterial chromosome. This inhibition depends on complex formation between SlmA-DNA and the FtsZ C-terminal domain (CTD). Here we describe SlmA–DNA–FtsZ CTD structures. These structures and complementary biochemistry unveil the molecular basis for the unique requirement that SlmA be DNA-bound to interact with FtsZ, a mechanism that appears to be conserved among SlmA-containing bacteria.
The Association between Benzodiazepine Prescription and Aberrant Drug-Related Behaviors in Primary Care Patients Receiving Opioids for Chronic Pain
Authors: Park Tae Woo , Saitz Richard , Nelson Kerrie P. , Xuan Ziming , Liebschutz Jane M. , Lasser Karen E.
Published: April 2016

Background: Benzodiazepine use has been associated with addiction-related risks, but little is known about its association with aberrant drug-related behaviors in patients receiving opioids for chronic pain. The authors examined the association between receipt of a benzodiazepine prescription and 2 aberrant drug-related behaviors, early opioid refills and illicit drug (cocaine) use in patients receiving opioids for noncancer chronic pain. Methods: This was a retrospective cohort study of 847 patients with ≥1 visit to either a hospital-based primary care clinic or one of two community health centers between September 1, 2011, and August 31, 2012. All patients received ≥3 opioid prescriptions written at least 21 days apart within 6 months, and ≥1 urine drug screen during the study period. A Cox proportional hazards model estimated the hazard of a second early opioid refill, defined as an opioid prescription written 7–25 days after the previous prescription for the same drug, as a function of time-varying benzodiazepine prescription. A logistic regression model examined the relationship between benzodiazepine prescription and a positive urine test for cocaine. Models were adjusted for demographics and mental/substance use disorder diagnoses. Results: Twenty-three percent ( n = 196) of patients received ≥1 benzodiazepine prescription during the study period. Twenty-two percent ( n = 183) of patients had ≥2 early opioid refills, and 11% ( n = 93) had ≥1 positive urine drug tests for cocaine. Receipt of benzodiazepine prescription was associated with an increased hazard of having a second early opioid refill, adjusted hazard ratio = 1.54 (95% confidence interval [CI]: 1.09–2.18), but not associated with a positive cocaine test, adjusted odds ratio = 1.07 (95% CI: 0.55–2.23). Conclusions: Among primary care patients receiving chronic opioid therapy, benzodiazepine prescription was associated with early opioid refills but not with cocaine use. Further research should better elucidate the risks and benefits of prescribing benzodiazepines to patients receiving opioids for chronic pain.
High-precision measurement of weld seam based on narrow depth of field lens in laser welding
Authors: Wang P. J. , Shao W. J. , Gong S. H. , Jia P. J. , Li G.
Published: April 2016

In laser beam welding, when the width of weld seam is less than 0.1 mm, present vision sensor-based measurements can barely obtain the seam width and seam position stably and reliably. A seam measuring method based on narrow depth of field (NDOF) is proposed in this article, which aims to detect this kind of narrow and small weld seam with great accuracy. This measurement system consists of a multiple optical magnifier, a Charge-Coupled Device/Complementary Metal Oxide Semiconductors (CCD/CMOS) camera, and an external light-emitting diode lighting unit. First, the principle of the NDOF method is explained. Second, key features of weld seam are extracted by image-processing algorithm. Lastly, the result of experiment reveals that the NDOF method can meet the demanded detection precision. Measurement accuracy for the seam width and seam position is 6 and 8 μm, respectively.
Recrystallisation mechanism during friction stir welding of ultrafine- and coarse-grained AISI 304L stainless steel
Authors: Sabooni S. , Karimzadeh F. , Enayati M. H. , Ngan A. H. W.
Published: April 2016

Ultrafine-grained (UFG) and a coarse-grained (CG) 304L stainless steels were produced by a combination of cold rolling and annealing. Friction stir welding (FSW) was applied at the same welding conditions to study the effects of the grain size of the base metal on the grain structure of the weld nugget and its recrystallisation mechanism. The results showed that the recrystallisation mechanism changes with the grain size of the base metal. Continuous dynamic recrystallisation (CDRX) was found to be dominant at the FSW of the UFG sample while discontinuous dynamic recrystallisation is the main recrystallisation mechanism in the FSW of the CG sample. Although the weld nugget grain size of the UFG welded sample is slightly higher than that of the CG welded sample, its nanohardness was found to be higher. This behaviour is attributed to the higher dislocation densities of the austenite grains in the UFG welded sample produced through CDRX.
Shortening the Miles to the Milestones: Connecting EPA-Based Evaluations to ACGME Milestone Reports for Internal Medicine Residency Programs
Authors: Choe John H. , Knight Christopher L. , Stiling Rebekah , Corning Kelli , Lock Keli , Steinberg Kenneth P.
Published: April 2016

The Next Accreditation System requires internal medicine training programs to provide the Accreditation Council for Graduate Medical Education (ACGME) with semiannual information about each resident’s progress in 22 subcompetency domains. Evaluation of resident “trustworthiness” in performing entrustable professional activities (EPAs) may offer a more tangible assessment construct than evaluations based on expectations of usual progression toward competence. However, translating results from EPA-based evaluations into ACGME milestone progress reports has proven to be challenging because the constructs that underlay these two systems differ.

The authors describe a process to bridge the gap between rotation-specific EPA-based evaluations and ACGME milestone reporting. Developed at the University of Washington in 2012 and 2013, this method involves mapping EPA-based evaluation responses to “milestone elements,” the narrative descriptions within the columns of each of the 22 internal medicine subcompetencies. As faculty members complete EPA-based evaluations, the mapped milestone elements are automatically marked as “confirmed.” Programs can maintain a database that tallies the number of times each milestone element is confirmed for a resident; these data can be used to produce graphical displays of resident progress along the internal medicine milestones.

Using this count of milestone elements allows programs to bridge the gap between faculty assessments of residents based on rotation-specific observed activities and semiannual ACGME reports based on the internal medicine milestones. Although potentially useful for all programs, this method is especially beneficial to large programs where clinical competency committee members may not have the opportunity for direct observation of all residents.
Increasing Scholarly Activity Productivity During Residency: A Systematic Review
Authors: Stevenson Michelle D. , Smigielski Elizabeth M. , Naifeh Monique M. , Abramson Erika L. , Todd Christopher , Li Su-Ting T.
Published: April 2016

Purpose

Although resident participation in scholarly activity is mandated by the Accreditation Council for Graduate Medical Education, programmatic factors associated with success are not defined. This systematic review’s objective was to determine which interventions are effective in increasing resident scholarly activity productivity (RSAP), as measured by participation in scholarly activity, presentations, or publications.

Method

The PubMed, MEDLINE, Cochrane Library of Systematic Reviews, PsycINFO, CINAHL, and ERIC databases were searched through October 2013. English-language articles evaluating interventions to increase RSAP in U.S. or Canadian residency programs were included, without date limits. Two independent reviewers selected articles for inclusion and extracted data. Discrepancies were resolved by consensus.

Results

Of the 6,248 records screened, 80 studies underwent data abstraction. Twenty-six described outcomes without a comparison group, leaving 54 studies representing 13 medical and surgical specialties. Interventions included required scholarly activity participation, protected research time, research curricula, research directors, dedicated research days, and research tracks. Focusing on the 35 studies reporting statistical analysis, RSAP was associated with all interventions. There were some differences in intervention effectiveness between medical and surgical specialties.

Conclusions

Interventions, including protected time, research curricula, or specialized research tracks, generally result in increased participation in scholarly activity in residency programs, with mixed effects on resident presentations or publications. In many studies, interventions were bundled, suggesting that programs may need to provide increased structure and rigor through multiple pathways. The findings highlight the need for a clear definition of resident scholarly activity success aligned specifically to individual program and resident aims.
Health Systems Science Curricula in Undergraduate Medical Education: Identifying and Defining a Potential Curricular Framework
Authors: Gonzalo Jed D. , Dekhtyar Michael , Starr Stephanie R. , Borkan Jeffrey , Brunett Patrick , Fancher Tonya , Green Jennifer , Grethlein Sara Jo , Lai Cindy , Lawson Luan , Monrad Seetha , O’Sullivan Patricia , Schwartz Mark D. , Skochelak Susan
Published: April 2016

Purpose

The authors performed a review of 30 Accelerating Change in Medical Education full grant submissions and an analysis of the health systems science (HSS)-related curricula at the 11 grant recipient schools to develop a potential comprehensive HSS curricular framework with domains and subcategories.

Method

In phase 1, to identify domains, grant submissions were analyzed and coded using constant comparative analysis. In phase 2, a detailed review of all existing and planned syllabi and curriculum documents at the grantee schools was performed, and content in the core curricular domains was coded into subcategories. The lead investigators reviewed and discussed drafts of the categorization scheme, collapsed and combined domains and subcategories, and resolved disagreements via group discussion.

Results

Analysis yielded three types of domains: core, cross-cutting, and linking. Core domains included health care structures and processes; health care policy, economics, and management; clinical informatics and health information technology; population and public health; value-based care; and health system improvement. Cross-cutting domains included leadership and change agency; teamwork and interprofessional education; evidence-based medicine and practice; professionalism and ethics; and scholarship. One linking domain was identified: systems thinking.

Conclusions

This broad framework aims to build on the traditional definition of systems-based practice and highlight the need for medical and other health professions schools to better align education programs with the anticipated needs of the systems in which students will practice. HSS will require a critical investigation into existing curricula to determine the most efficient methods for integration with the basic and clinical sciences.
The Two-Stage Examination: A Method to Assess Individual Competence and Collaborative Problem Solving in Medical Students
Authors: Lindsley Janet E. , Morton David A. , Pippitt Karly , Lamb Sara , Colbert-Getz Jorie M.
Published: April 2016

Problem

Effectively solving problems as a team under stressful conditions is central to medical practice; however, because summative examinations in medical education must test individual competence, they are typically solitary assessments.

Approach

Using two-stage examinations, in which students first answer questions individually (Stage 1) and then discuss them in teams prior to resubmitting their answers (Stage 2), is one method for rectifying this discordance. On the basis of principles of social constructivism, the authors hypothesized that two-stage examinations would lead to better retention of, specifically, items answered incorrectly at Stage 1.

In fall 2014, they divided 104 first-year medical students into two groups of 52 students. Groups alternated each week between taking one- and two-stage examinations such that each student completed 6 one-stage and 6 two-stage examinations. The authors reassessed 61 concepts on a final examination and, using the Wilcoxon signed ranked tests, compared performance for all concepts and for just those students initially missed, between Stages 1 and 2.

Outcomes

Final examination performance on all previously assessed concepts was not significantly different between the one-and two-stage conditions (P = .77); however, performance on only concepts that students initially answered incorrectly on a prior examination improved by 12% for the two-stage condition relative to the one-stage condition (P = .02, r = 0.17).

Next Steps

Team assessment may be most useful for assessing concepts students find difficult, as opposed to all content. More research is needed to determine whether these results apply to all medical school topics and student cohorts.
Disseminated Intravascular Coagulation
Authors: Thachil Jecko
Published: April 2016

Anesthesiologists may encounter patients with disseminated intravascular coagulation, a potential complication of severe sepsis or major trauma. This practical guide discusses the clinical approach, laboratory diagnosis, and current management of this condition.
Flexible Intramedullary Nailing of Unstable and/or Open Tibia Shaft Fractures in the Pediatric Population
Authors: Pandya Nirav K.
Published: April 2016

Tibial shaft fractures are common injuries in the pediatric population, and can be treated conservatively the vast majority of the time. Yet, it is important to recognize that open and/or unstable tibial shaft fractures represent a different entity. Rigid intramedullary devices are generally contraindicated because of the skeletal immaturity of these patients, and external fixation is associated with a high complication rate. As a result, flexible nailing is being utilized with increasing frequency. It is essential for the clinician to understand the pearls and pitfalls associated with the utilization of these flexible nails; particularly in regards to their immediate use in the context of open fractures and the risk of compartment syndrome postoperatively after fixation.
Curriculum Development and Evaluation of a Hemodynamic Critical Care Ultrasound: A Systematic Review of the Literature
Authors: Kanji Hussein D. , McCallum Jessica L. , Bhagirath Kapil M. , Neitzel Andrew S.
Published: April 2016

Objective:

The application of ultrasound to assess a patient’s cardiac function and volume status is becoming commonplace in the practice of critical care. These skills have been taught through varying curricula; however, no consensus on the optimal curriculum has been established. The purpose of this systematic review is to evaluate the literature regarding critical care ultrasound curriculum development and evaluation.

Data Sources:

Studies were identified using MEDLINE, Embase, CINAHL, PsycInfo, the Cochrane Center Register of Controlled Trials, and ERIC according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through June 2014.

Study Selection:

Included studies were limited to those that described adult (age, > 16 yr) cardiac or hemodynamic critical care ultrasound curricula for physicians. Two reviewers independently screened studies based on predetermined exclusion criteria, and disagreements were resolved by a third reviewer.

Data Extraction:

Data were abstracted, and quality was assessed by two reviewers using the Newcastle-Ottawa Scale. Data abstracted from the studies included the learner population, examination type, duration, composition, and setting of the curriculum, means of evaluation, and outcomes.

Data Synthesis:

The search yielded 654 studies; of which, 15 met inclusion criteria. All curricula used a combination of didactic and hands-on components. The highest agreement between novice and experts, coupled with the most time-efficient application, was achieved when the study was limited to a basic qualitative approach for the assessment of global function or contractility and assessment of inferior vena cava collapsibility. The mode of delivery seemed most efficient when a hybrid method was used, including online instruction. Minimum scanning competency may be achieved with 30 scans although more rigorous study on this element is necessary.

Conclusions:

Assessment of cardiac function and volume assessment is becoming an essential skill in critical care medicine. Physicians can be taught bedside echocardiography in a time-effective manner with positive benefit to patients by applying a concise curriculum with limited content.
Low Tidal Volume Ventilation Use in Acute Respiratory Distress Syndrome*
Authors: Weiss Curtis H. , Baker David W. , Weiner Shayna , Bechel Meagan , Ragland Margaret , Rademaker Alfred , Weitner Bing Bing , Agrawal Abha , Wunderink Richard G. , Persell Stephen D.
Published: April 2016

Objective:

Low tidal volume ventilation lowers mortality in the acute respiratory distress syndrome. Previous studies reported poor low tidal volume ventilation implementation. We sought to determine the rate, quality, and predictors of low tidal volume ventilation use.

Design:

Retrospective cross-sectional study.

Setting:

One academic and three community hospitals in the Chicago region.

Patients:

A total of 362 adults meeting the Berlin Definition of acute respiratory distress syndrome consecutively admitted between June and December 2013.

Measurements and Main Results:

Seventy patients (19.3%) were treated with low tidal volume ventilation (tidal volume < 6.5 mL/kg predicted body weight) at some time during mechanical ventilation. In total, 22.2% of patients requiring an Fio
2 greater than 40% and 37.3% of patients with Fio
2 greater than 40% and plateau pressure greater than 30 cm H2O received low tidal volume ventilation. The entire cohort received low tidal volume ventilation 11.4% of the time patients had acute respiratory distress syndrome. Among patients who received low tidal volume ventilation, the mean (sd) percentage of acute respiratory distress syndrome time it was used was 59.1% (38.2%), and 34% waited more than 72 hours prior to low tidal volume ventilation initiation. Women were less likely to receive low tidal volume ventilation, whereas sepsis and Fio
2 greater than 40% were associated with increased odds of low tidal volume ventilation use. Four attending physicians (6.2%) initiated low tidal volume ventilation within 1 day of acute respiratory distress syndrome onset for greater than or equal to 50% of their patients, whereas 34 physicians (52.3%) never initiated low tidal volume ventilation within 1 day of acute respiratory distress syndrome onset. In total, 54.4% of patients received a tidal volume less than 8 mL/kg predicted body weight, and the mean tidal volume during the first 72 hours after acute respiratory distress syndrome onset was never less than 8 mL/kg predicted body weight.

Conclusions:

More than 12 years after publication of the landmark low tidal volume ventilation study, use remains poor. Interventions that improve adoption of low tidal volume ventilation are needed.
Routine Chest Radiography Is Not Necessary After Ultrasound-Guided Right Internal Jugular Vein Catheterization
Authors: Hourmozdi Justin J. , Markin Abraham , Johnson Brad , Fleming Patrick R. , Miller Joseph B.
Published: April 2016

Objectives:

Central venous catheter placement is a common procedure performed on critically ill patients. Routine postprocedure chest radiographs are considered standard practice. We hypothesize that the rate of clinically relevant complications detected on chest radiographs following ultrasound-guided right internal jugular vein catheterization is exceedingly low.

Design:

Retrospective chart review.

Setting:

Adult ICUs, emergency departments, and general practice units at an academic tertiary care hospital system.

Patients:

All 1,322 ultrasound-guided right internal jugular vein central venous catheter attempts at an academic tertiary care hospital system over a 1-year period.

Interventions:

None.

Measurements and Main Results:

Data from standardized procedure notes and postprocedure chest radiographs were extracted and individually reviewed to verify the presence of pneumothorax or misplacement, and any intervention performed for either complication. The overall success rate of ultrasound-guided right internal jugular vein central venous catheter placement was 96.9% with an average of 1.3 attempts. There was only one pneumothorax (0.1% [95% CI, 0–0.4%]), and the rate of catheter misplacement requiring repositioning or replacement was 1.0% (95% CI, 0.6–1.7%). There were no arterial placements found on chest radiographs. Multivariate regression analysis showed no correlation between high-risk patient characteristics and composite complication rate.

Conclusions:

In a large teaching hospital system, the overall rate of clinically relevant complications detected on chest radiographs following ultrasound-guided right internal jugular vein catheterization is exceedingly low. Routine chest radiograph after this common procedure is an unnecessary use of resources and may delay resuscitation of critically ill patients.
Signatures of Subacute Potentially Catastrophic Illness in the ICU: Model Development and Validation*
Authors: Moss Travis J. , Lake Douglas E. , Calland J. Forrest , Enfield Kyle B. , Delos John B. , Fairchild Karen D. , Moorman J. Randall
Published: April 2016

Objectives:

Patients in ICUs are susceptible to subacute potentially catastrophic illnesses such as respiratory failure, sepsis, and hemorrhage that present as severe derangements of vital signs. More subtle physiologic signatures may be present before clinical deterioration, when treatment might be more effective. We performed multivariate statistical analyses of bedside physiologic monitoring data to identify such early subclinical signatures of incipient life-threatening illness.

Design:

We report a study of model development and validation of a retrospective observational cohort using resampling (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis type 1b internal validation) and a study of model validation using separate data (type 2b internal/external validation).

Setting:

University of Virginia Health System (Charlottesville), a tertiary-care, academic medical center.

Patients:

Critically ill patients consecutively admitted between January 2009 and June 2015 to either the neonatal, surgical/trauma/burn, or medical ICUs with available physiologic monitoring data.

Interventions:

None.

Measurements and Main Results:

We analyzed 146 patient-years of vital sign and electrocardiography waveform time series from the bedside monitors of 9,232 ICU admissions. Calculations from 30-minute windows of the physiologic monitoring data were made every 15 minutes. Clinicians identified 1,206 episodes of respiratory failure leading to urgent unplanned intubation, sepsis, or hemorrhage leading to multi-unit transfusions from systematic individual chart reviews. Multivariate models to predict events up to 24 hours prior had internally validated C-statistics of 0.61–0.88. In adults, physiologic signatures of respiratory failure and hemorrhage were distinct from each other but externally consistent across ICUs. Sepsis, on the other hand, demonstrated less distinct and inconsistent signatures. Physiologic signatures of all neonatal illnesses were similar.

Conclusions:

Subacute potentially catastrophic illnesses in three diverse ICU populations have physiologic signatures that are detectable in the hours preceding clinical detection and intervention. Detection of such signatures can draw attention to patients at highest risk, potentially enabling earlier intervention and better outcomes.
Inhibition of Intestinal Thiamin Transport in Rat Model of Sepsis
Authors: Sassoon Catherine S. , Zhu Ercheng , Fang Liwei , Subramanian Veedamali S. , Said Hamid M.
Published: April 2016

Objectives:

Thiamin deficiency is highly prevalent in patients with sepsis, but the mechanism by which sepsis induces thiamin deficiency is unknown. This study aimed to determine the influence of various severity of sepsis on carrier-mediated intestinal thiamin uptake, level of expressions of thiamin transporters (thiamin transporter-1 and thiamin transporter-2), and mitochondrial thiamin pyrophosphate transporter.

Design:

Randomized controlled study.

Setting:

Research laboratory at a Veterans Affairs Medical Center.

Subjects:

Twenty-four Sprague-Dawley rats were randomized into controls, mild, moderate, and severe sepsis with equal number of animals in each group.

Interventions:

Sepsis was induced by cecal ligation and puncture with the cecum ligated below the cecal valve at 25%, 50%, and 75% of cecal length, defined as severe, moderate, and mild sepsis, respectively. Control animals underwent laparotomy only.

Measurements and Main Results:

After 2 days of induced sepsis, carrier-mediated intestinal thiamin uptake was measured using [3H]thiamin. Expressions of thiamin transporter-1, thiamin transporter-2, and mitochondrial thiamin pyrophosphate transporter proteins and messenger RNA were measured. Proinflammatory cytokines (interleukin-1β and interleukin-6) and adenosine triphosphate were also measured. Sepsis inhibited [3H]thiamin uptake, and the inhibition was a function of sepsis severity. Both cell membrane thiamin transporters and mitochondrial thiamin pyrophosphate transporter expression levels were suppressed; also levels of adenosine triphosphate in the intestine of animals with moderate and severe sepsis were significantly lower than that of sham-operated controls.

Conclusions:

For the first time, we demonstrated that sepsis inhibited carrier-mediated intestinal thiamin uptake as a function of sepsis severity, suppressed thiamin transporters and mitochondrial thiamin pyrophosphate transporter, leading to adenosine triphosphate depletion.
Faecal occult blood screening for colorectal cancer in Serbia: a pilot study
Authors: Scepanovic Milena , Jovanovic Olivera , Keber Dusan , Jovanovic Ivan , Miljus Dragan , Nikolic Goran , Kovacevic Bojan , Pavlovic Aleksandra , Dugalic Predrag , Nagorni Aleksandar , Grgov Sasa , Knezevic Slavko , Milenkovic Predrag , Perisic Nenad , Faivre Jean
Published: April 2016

Colorectal cancer (CRC) is becoming a major public health problem in the Republic of Serbia. Organized mass screening has been shown to decrease CRC mortality and even its incidence. The aim of this study was to assess the acceptability of a faecal immunochemical test for haemoglobin proposed by primary care physicians. From August to November 2013, a pilot study for CRC screening was organized in individuals aged 50 to 74 years. The study included 50 primary healthcare centres from all 25 administrative regions of Serbia. A qualitative immunochromatographic faecal immunochemical test for human haemoglobin detection was used. Overall, 50 894 individuals were invited. The participation rate was 67.8 and 3.4% of the tests were positive. Among individuals with a positive test, 69.7% agreed to undergo colonoscopy. The positive predictive value was 27.1% for adenoma and 14.6% for carcinoma. This was the first CRC screening project encompassing approximately one-third of primary healthcare facilities in all regions across the country. It showed a good response of the target population and satisfactory cooperation of the healthcare professionals involved.
Management of Skin Reactions During Cetuximab Treatment in Association With Chemotherapy or Radiotherapy
Authors: Pinto Carmine , Barone Carlo A. , Girolomoni Giampiero , Russi Elvio G. , Merlano Marco C. , Ferrari Daris , Maiello Evaristo
Published: April 2016

Objectives:

Cetuximab was shown in phase III clinical trials to improve chemotherapy efficacy in patients with advanced colorectal and head-neck cancer. Appropriate management of skin reactions associated with epidermal growth factor receptor inhibitor therapy is necessary to allow adequate drug compliance and to improve patient quality of life and outcomes.

Methods:

The RAND/UCLA Appropriateness Method was used by a group of experts to produce new Italian recommendations on the management of skin reactions in this setting. Statements were generated on the basis of an updated systematic review of the literature and rated twice by a panel of 38 expert physicians. A meeting of the panel was held after the first rating session.

Results:

Skin reactions included acneiformic rash, skin dryness (xerosis), pruritus, paronychia, hair abnormalities, mucositis, and increased growth of eyelashes or facial hair. Updates of the previous recommendations on the prevention and treatment of each type of reaction were proposed.

Conclusions:

This updated Expert Opinion focuses on how to assess and correctly grade skin reactions according to the latest National Cancer Institute Common Terminology Criteria for Adverse Events and on how to manage these adverse events in clinical practice.
Attention-Deficit/Hyperactivity Disorder, Behavior Regulation and Virtual School Support
Authors: Wallace Claire , Ievers-Landis Carolyn E. , Scherer Catherine , Roizen Nancy , Augustyn Marilyn
Published: April 2016

CASE:

Tony is a 6-year-old multiracial boy diagnosed as having attention-deficit/hyperactivity disorder—combined type who is followed in your primary care practice and has started on a stimulant medication. Tony continues to have difficulty with emotion regulation and impulse control both at home and at school. He was asked to leave his private school soon after beginning first grade because of physical fighting, emotional outbursts, and arguing with teachers.

His mother made the decision to enroll Tony in online virtual schooling for the remainder of the academic year, with the plan to transition back to traditional school for the next academic year. They have enrolled in a program that offers lessons online and sends materials to the home for the child to use to complete certain types of assignments (e.g., science experiments). Virtual schools are different from traditional home schooling because children receive their instruction from teachers online with parental assistance as opposed to parents being responsible for teaching all material. Tony's mother comes to your practice requesting assistance with setting up an appropriate school environment for her son at home, where she can monitor and support his academic progress.

Tony is a bright child, with an Intelligence Quotient in the superior range. He has advanced academic skills, but he becomes dysregulated if he is told he is wrong or that he has answered a question incorrectly. For example, if he answered a question incorrectly in class, he would become verbally abusive toward his teacher and often have temper tantrums. This challenging behavior occurred daily at school and was one of the factors leading to his expulsion. The behavior had predated the introduction of stimulant medication and had remained consistent after he began medication.

Tony's parents are highly educated, and both parents hold professional jobs with steady income. His parents have good command of typical behavior management strategies such as the use of rewards, time out, and behavioral contingencies to target noncompliance and temper tantrums. However, Tony's difficulty identifying and regulating his emotions leads to emotional outbursts and shutdowns that have thus far been unresponsive to standard behavior management techniques. Tony continued to have outbursts even when the behavior was ignored. His mother is concerned not only about his learning during the coming year but also about his social relationships and the family dynamic. Tony's outbursts cause significant disruption in the home and are a source of tension among parents and siblings.

His mother is asking for advice on how to support his behavior better at home now that he will be spending his entire day there. How might you assist this child and his mother by helping to integrate therapeutic goals into the academic environment?
Profiling of plasma metabolites in postmenopausal women with metabolic syndrome
Authors: Iida Miho , Harada Sei , Kurihara Ayako , Fukai Kota , Kuwabara Kazuyo , Sugiyama Daisuke , Takeuchi Ayano , Okamura Tomonori , Akiyama Miki , Nishiwaki Yuji , Suzuki Asako , Hirayama Akiyoshi , Sugimoto Masahiro , Soga Tomoyoshi , Tomita Masaru , Banno Kouji , Aoki Daisuke , Takebayashi Toru
Published: April 2016

Objective:

The aim of the study was to investigate the associations of amino acids and other polar metabolites with metabolic syndrome (MetS) in postmenopausal women in a lean Asian population.

Methods:

The participants were 1,422 female residents enrolled in a cohort study from April to August 2012. MetS was defined according to the National Cholesterol Education Program Adult Treatment Panel III modified for Japanese women. Associations were examined between MetS and 78 metabolites assayed in fasting plasma samples using capillary electrophoresis-mass spectrometry. Replication analysis was performed to confirm the robustness of the results in a separate population created by random allocation.

Results:

Analysis was performed for 877 naturally postmenopausal women, including 594 in the original population and 283 in the replication population. The average age, body mass index, and levels of high- and low-density lipoprotein cholesterol of the entire population were 64.6 years, 23.0 kg/m2, 72.1 mg/dL, and 126.1 mg/dL, respectively. There was no significant difference in low-density lipoprotein cholesterol levels between women with and without MetS. Thirteen metabolites were significantly related to MetS: multiple plasma amino acids were elevated in women with MetS, including branched-chain amino acids, alanine, glutamate, and proline; and alpha-aminoadipate, which is generated by lysine degradation, was also significantly increased.

Conclusions:

Our large-scale metabolomic profiling indicates that Japanese postmenopausal women with MetS have abnormal polar metabolites, suggesting altered catabolic pathways. These results may help to understand metabolic disturbance, including in persons with normal body mass index and relatively high levels of high-density lipoprotein cholesterol, and may have clinical utility based on further studies.
Limbal and Conjunctival Epithelial Cell Cultivation on Contact Lenses—Different Affixing Techniques and the Effect of Feeder Cells
Authors: Tóth Enikö , Beyer Dániel , Zsebik Barbara , Vereb György , Takács Lili
Published: April 2016

Objectives:

Corneal blindness due to limbal stem-cell deficiency can be treated by transplantation of cultivated limbal epithelial stem cells (LESCs). We examined LESC cultivation on a contact lens (CL) carrier. Our goal was to optimize explant affixation and assess the possible benefit of 3T3 feeder cells.

Methods:

Human cadaver limbal and conjunctival explants were allowed to attach to CLs under the airflow of the laminar box (dried group) or affixed on CLs using suturing (sutured group) or tissue adhesives (glued group), then cultivated with or without 3T3 feeder cells. Outgrowth efficiency was statistically analyzed. CEBPδ, p63, CK3/12, and CK13 were detected by immunofluorescence in expanded cells.

Results:

Suturing and gluing provided excellent sample attachment, whereas drying was less effective. Cell expansion was better in sutured than in dried or glued samples. Presence of 3T3 feeder resulted in significantly better cell growth (P=0.048), most importantly in dried samples (P=0.008). Stepwise regression analysis indicated that cell expansion was dependent on the affixing method (P<0.001) and the presence of feeder layer (P=0.003). Expanded cells maintained their CK expression profiles and expressed putative stem-cell markers p63 and CEBPδ. The 3T3 feeder did not influence the expression of putative LESC markers or growth rate.

Conclusions:

Suturing is an effective way to fasten explants to CLs. 3T3 fibroblasts are not necessary in this system, although they may enhance cell outgrowth when samples are exposed to stress. However, once cells begin to expand, neither expression of putative stem-cell markers nor growth rate is influenced by feeder cells.
Axillary Artery Access for Combined Endoaortic Balloon Occlusion and Perfusion during Robotic Mitral Valve Surgery
Authors: Ambur Vishnu V. , Kadakia Sagar S. , Taghavi Sharven , Jayarajan Senthil N. , Kashem Mohammed Abul , McCarthy James , Shiose Akira , Wheatley Grayson H. , Toyoda Yoshiya , Guy T. Sloane
Published: April 2016

We aimed to develop a method that provides an alternative cannulation site in robotic mitral valve surgery that allows simultaneous endo-occlusion and antegrade perfusion. A 71-year-old man with severe mitral regurgitation and history of coronary artery bypass grafting underwent totally endoscopic robotic mitral valve repair. A 23-mm endoreturn cannula was placed through a 10-mm graft that was sewn to the left axillary artery. An endoballoon was passed through the Dacron/cannula complex and into the ascending aorta. This complex was used for simultaneous antegrade perfusion, endoballoon occlusion, and antegrade cardioplegia. Completion transesophageal echocardiography showed no evidence of mitral regurgitation. The patient had an uneventful postoperative course and was doing well at his 2-month follow-up appointment. The left axillary artery is a viable option for simultaneous endoballoon occlusion, antegrade perfusion, and antegrade cardioplegia in robotic mitral valve surgery. This has the potential benefit of providing antegrade perfusion, which some studies have shown to be associated with a decreased risk of complications when compared with retrograde perfusion specifically inpatients with severe peripheral vascular disease.