bluuebunny/crossref_metadata_2025 huggingface dataset:
Combined medial malleoplasty and Taylor Spatial Frame after a supramalleolar osteotomy in the treatment of ankle deformity in skeletally immature patients: A prospective study of a novel technique and the short-term results
Authors: Meselhy Mohammed Anter , Elhammady Adel Samy
Published: March 2020

Background:

This study examined the effectiveness of the Taylor Spatial Frame (TSF) in the treatment of deformity and limb shortening caused by distal tibial physeal arrest and the effectiveness in maintaining alignment and stability by reconstruction of the medial malleolus and the medial collateral ligament using an autogenous iliac crest graft and attached sartorius muscle-tendon.

Methods:

Thirteen pediatric patients with angular deformity of the distal tibia were enrolled in this prospective study. The mean age was 8.3 yr (range, 6 to 12 yr). All patients had open fractures with skin loss. Ten patients had Salter-Harris type IV physeal fractures, while three had Salter-Harris type V physeal injury. All patients had a varus ankle deformity (range, 15 to 33 degrees) and limb shortening (range, 1.9-cm to 3.3-cm). All patients were treated by a supramalleolar osteotomy and TSF for deformity correction for limb-length equalization. The absent medial malleolus was treated by medial malleoplasty with a graft from the ipsilateral iliac crest.

Results:

The mean follow-up period was 30 mo. The mean preoperative shortening of the tibia in relation to the fibula was 2.6 cm (range, 1.9 cm to 3.3 cm). The length of the short tibia was restored in all patients, and correction of the ankle deformity and stability were restored with a satisfactory outcome.

Conclusions:

TSF is highly effective in the treatment of distal tibial deformity in pediatric patients due to traumatic physeal arrest. Reconstruction of the medial malleolus and its ligamentous attachment is crucial for ankle joint stability.

Level of Evidence:

Level IV.
Mortality Rate of Geriatric Acetabular Fractures Is High Compared With Hip Fractures. A Matched Cohort Study
Authors: Khoshbin Amir , Atrey Amit , Chaudhry Hasaan , Nowak Lauren , Melo Luana T. , Stavrakis Alexandra , Schemitsch Emil H. , Nauth Aaron
Published: March 2020

Objectives:

Compare acute complication and mortality rates of geriatric patients with acetabular fractures (AFs) matched to hip fractures (HFs).

Design:

Retrospective cohort study.

Setting:

American College of Surgeons National Surgical Quality Improvement Project.

Patients:

Using Current Procedural Terminology codes, the American College of Surgeons National Surgical Quality Improvement Project registry was used to identify all patients ≥60 years from 2011 to 2016 treated for AFs undergoing open reduction internal fixation (ORIF) and HFs (undergoing ORIF, hemiarthroplasty, or cephalomedullary nail).

Outcome Measurements:

Patient characteristics, comorbidities, functional status, acute complications, and mortality rates were recorded. Patients were matched 1:5 (AF:HF). Chi-square, Fisher exact, and Mann–Whitney U tests were used to compare groups, and multivariable logistic regression was used to compare the risk of complications or death while adjusting for relevant covariates.

Results:

A total of 303 AF patients (age: 78.2 ± 9.2 years/59.7% females/27.1% wall, 28.4% one column and 45.2% 2 columns ORIF) were matched to 1511 HF patients (age: 78.3 ± 9.1 years/60.2% females/37.2% hemiarthroplasty, 16.3% ORIF and 47.4% cephalomedullary nail). Length of stay (8.4 ± 7.1 vs. 6.4 ± 5.9 days) and time to surgery [(TS) 2.3 ± 1.8 versus 1.2 ± 1.4 days] were longer in the AF group (P < 0.01). Unadjusted mortality rates were nonsignificantly higher for AFs versus HFs (6.6% vs. 4.6%, P = 0.14). After covariable adjustment, the risk of mortality was significantly higher for AFs versus HFs (odds ratio: 1.89, 95% confidence interval: 1.07–3.35).

Conclusion:

Geriatric AFs pose a significantly higher adjusted mortality risk when compared with HF patients. Strategies to mitigate risk factors in this population are warranted.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
PROMIS Physical Function Predicts Postoperative Pain and Disability Following Anterior Cervical Discectomy and Fusion
Authors: Parrish James M. , Jenkins Nathaniel W. , Brundage Thomas S. , Hrynewycz Nadia M. , Yoo Joon S. , Singh Kern
Published: March 2020

Study Design:

This was a retrospective study.

Objective:

The objective of this study was to determine if preoperative Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) score is predictive of improvement in pain and physical function following anterior cervical discectomy and fusion (ACDF).

Summary of Background Data:

Few studies have investigated the predictive nature of PROMIS PF of patients undergoing spine surgery, such as ACDF.

Methods:

Patients undergoing a primary, 1–3-level ACDF were retrospectively reviewed and were stratified into 3 cohorts according to preoperative PROMIS PF scores: minimal disability (score 50–60), mild disability (score 40–50), moderate disability (score 30–40), and severe disability (score 20–30). Preoperative PROMIS PF cohorts were tested for an association with demographics, perioperative characteristics, and improvement in Neck Disability Index (NDI), 12-Item Short-Form Physical Component Score (SF-12 PCS), and Visual Analog Scale (VAS) neck and arm pain using χ2 analysis and multivariate linear regression.

Results:

A total of 126 patients were included: 11 had a minimal disability, 44 had mild disability, 54 had moderate disability, and 17 had severe disability. Patients with a severe disability experienced no statistically significant increase in their length of stay. Greater preoperative disability demonstrated lower NDI and SF-12 PCS scores preoperatively and at each postoperative timepoint. Greater preoperative disability had worse VAS neck and arm pain preoperatively and 6-week and 3-month postoperatively. Although patients with severe disability trended worse VAS neck and arm pain at the 6-month follow-up, this did not reach statistical significance.

Conclusions:

In this investigation, patients with worse PROMIS PF scores reported greater pain and disability in the preoperative period and experienced less improvement in NDI, SF-12 PCS, and VAS back and leg following ACDF. PROMIS PF is an efficient and accurate instrument that can effectively evaluate strength, mobility, and coordination in the preoperative period and may be used to predict clinical outcomes following ACDF.
Study on the Expression Levels and Clinical Significance of PD-1 and PD-L1 in Plasma of NSCLC Patients
Authors: He Jiabei , Pan Yuanqing , Guo Yang , Li Baolan , Tang Yu
Published: March 2020

As new members of the CD28/B7 costimulatory superfamily, PD-1 (programmed cell death 1) and its ligand PD-L1 (programmed cell death ligand 1) mediate a negative costimulatory signal, which inhibits functioning and proliferation of T and B cells, and reduce interleukin-2, interleukin-10, and interferon-γ secretion. This inhibitory pathway plays an important role in immune escape and the microenvironment of the tumor, and closely related to tumor progression. sPD-1 and sPD-L1 are the soluble form of PD-1 and PD-L1 in peripheral blood, which had not been well investigated. In this study, sPD-1 and sPD-L1 level in peripheral blood of non–small cell lung cancer (NSCLC) patients were determined, and their correlation to clinicopathologic features and long-term survival of these patients were analyzed, so as to provide references for further investigations. Plasma sPD-1 and sPD-L1 levels in 88 NSCLC patients and 40 healthy controls were determined by enzyme-linked immunosorbent assay, and their correlation to clinicopathologic features and long-term survival of these patients were analyzed. Our study showed that the plasma sPD-1 and sPD-L1 were higher in NSCLC patients than in healthy controls, and plasma sPD-L1 and sPD-L1/sPD-1 ratio independently and positively correlated with overall survival of NSCLC patients. This study provides a reference for the assessment of prognosis and risk stratification for NSCLC patients, as well as for immune treatment of cancer.
Targets of cGMP/cGKI in Cardiac Myocytes
Authors: Adler Julia , Kuret Anna , Längst Natalie , Lukowski Robert
Published: March 2020

The 3′,5′-cyclic guanosine monophosphate (cGMP)-dependent protein kinase type I (cGKIakaPKGI) is a major cardiac effector acting downstream of nitric oxide (NO)-sensitive soluble guanylyl cyclase and natriuretic peptides (NPs), which signal through transmembrane guanylyl cyclases. Consistent with the wide distribution of the cGMP-generating guanylyl cyclases, cGKI, which usually elicits its cellular effects by direct phosphorylation of its targets, is present in multiple cardiac cell types including cardiomyocytes (CMs). Although numerous targets of cGMP/cGKI in heart were identified in the past, neither their exact patho-/physiological functions nor cell-type specific roles are clear. Herein, we inform about the current knowledge on the signal transduction downstream of CM cGKI. We believe that better insights into the specific actions of cGMP and cGKI in these cells will help to guide future studies in the search for predictive biomarkers for the response to pharmacological cGMP pathway modulation. In addition, targets downstream of cGMP/cGKI may be exploited for refined and optimized diagnostic and therapeutic strategies in different types of heart disease and their causes. Importantly, key functions of these proteins and particularly sites of regulatory phosphorylation by cGKI should, at least in principle, remain intact, although upstream signaling through the second messenger cGMP is impaired or dysregulated in a stressed or diseased heart state.
Use of Treprostinil in Pediatric Pulmonary Hypertension: Case Reports and Review of the Literature
Authors: Gavotto Arthur , Thomas Fanny , Werner Oscar , Moreau Johan , Amedro Pascal
Published: March 2020

Background:

Add-on therapy with prostacyclin in pediatric refractory pulmonary hypertension (PH) poses a challenge, especially when considering continuous intravenous administration in younger children. A search for alternate routes of drug delivery has led to the clinical investigation of stable and long-acting prostacyclin analogues, such as subcutaneous treprostinil. We reported 2 pediatric cases of PH treated with subcutaneous treprostinil and reviewed the literature on treprostinil use in children.

Method:

The literature review used 3 electronic databases and a combination of terms (treprostinil, pediatric, PH, prostanoid, etc). We also searched for pediatric clinical trials on treprostinil registered on international clinical trial registries.

Results:

The reported cases highlighted the multifactorial nature of PH in pediatrics: a female child with a giant omphalocele, and intracardiac and extracardiac shunts; and a male premature child with a congenital diaphragmatic hernia and long-term PH. The literature review identified 19 studies reporting treprostinil use in 421 children with various types of PH (groups 1 and 3). Subcutaneous treprostinil was the most administered formulation, at a mean dose of 40 ng/kg/min. Overall, 12 clinical trials on treprostinil for children with PH were registered on the clinical trial registries. Most authors concluded that subcutaneous treprostinil was effective, well tolerated, and represented an alternative to intravenous epoprostenol.

Conclusions:

Subcutaneous treprostinil may be a useful adjunct in the therapeutic algorithm for children with severe PH, refractory to oral drugs, and after a complete check-up for all PH etiologies.
Higenamine Improves Cardiac and Renal Fibrosis in Rats With Cardiorenal Syndrome via ASK1 Signaling Pathway
Authors: Deng Ting , Wei Zhenming , Gael Akindavyi , Deng Xiaofang , Liu Yunfeng , Lai Jun , Hang Liwei , Yan Quanneng , Fu Qiang , Li Zhiliang
Published: March 2020

The pathogenesis of cardiorenal syndrome (CRS) is very complex, and currently there is no effective treatment for CRS. Higenamine (HI) has been shown to improve cardiac function in rats with heart failure. However, the role of higenamine in CRS remains unknown. Here, in vitro, higenamine treatment markedly reduced neonatal rat cardiac fibroblast collagen synthesis and inhibited neonatal rat cardiac myocyte hypertrophy. In our study, a rat model of type 2 CRS was induced by left anterior descending coronary artery ligation combined with 5/6 subtotal nephrectomy (STNx). Higenamine treatment decreased serum creatinine (Scr), blood urea nitrogen, and brain natriuretic peptide levels and was capable of improving left ventricular remodeling and systolic function in CRS rats, accompanied with decreased expression of transforming growth factor-β1 (TGF-β1), α–smooth muscle actin (α-SMA) and collagen I (Col1A1). Moreover, higenamine significantly inhibited the protein expression of phosphorylated apoptosis signal-regulated kinase 1 (p-ASK1) and downstream mitogen-activated protein kinases (MAPK) (ERK, P38)/NF-κB in cardiorenal tissues of CRS rats and neonatal rat cardiac fibroblast/neonatal rat cardiac myocyte cells. Our study demonstrated that higenamine improved cardiorenal function in CRS rats and attenuated heart and kidney fibrosis possibly via targeting ASK1/MAPK (ERK, P38)/NF-κB signaling pathway. This finding extends our knowledge on the role of higenamine in cardiorenal fibrosis, providing a potential target to prevent the progression of CRS.
Surgical Management of Hand Deformity in Epidermolysis Bullosa: Initial Experience and Technique
Authors: Anstadt Erin E. , Turer David M. , Spiess Alexander M. , Manders Ernest K.
Published: March 2020

Epidermolysis bullosa describes a rare group of genetic mucocutaneous disorders characterized by excessive epithelial fragility resulting in mechanically induced blistering and abnormal wound healing.
1,2
Its prevalence and incidence are 8.2 and 19.6 per 1,000,000 live births, respectively.
2
Gene therapy, protein replacement, and cell therapy strategies have been investigated, but there is currently no cure.
2
The Application of Posttransfer Free Flap Expansion for Management of Severe Foot Crush Injury with Extensive Soft Tissue Loss: A Case Report
Authors: Radwan Mohammad S. , Mashal Ashraf A.
Published: March 2020

Reconstruction of posttraumatic soft tissue defects has been revolutionized after the application of microvascular free flaps. However, standard flaps are limited in size and may not completely cover the defect. Flap expansion which is indicated in large defects with extensive soft tissue loss or shortage of donor tissue enables tension-free closure of large defects, minimal donor site morbidity, and better aesthetic outcomes. The literature review revealed a higher complication rate in the expansion of free flaps implanted in the extremities. A 7-year-old Palestinian girl presented with right foot crush injury and open multiple metatarsal and tarsal bone fractures with significant soft tissue loss. She underwent free latissimus dorsi flap transfer and overlying skin graft island application followed months later by expander implantation within the flap. This flap was serially expanded once a week for 4 months, until its dimension was declared to be large enough to cover the foot defect. We successfully transferred a free flap to a foot with extensive tissue loss. The overlying skin island contracted and minimized the defect size. The flap was serially expanded until completely covered the defect. No features of vascular compromise or other complications occurred; the flap remained viable with good aesthetic outcome. Posttransfer free flap expansion in lower limb defects can be utilized with meticulous care and follow-up for reconstruction of large defects.
Diagnostic Imaging and Outcomes for Nonobstetric Surgery During Pregnancy
Authors: TOLCHER MARY C. , CLARK STEVEN L.
Published: March 2020

A surgical disease occurring during pregnancy can present a diagnostic dilemma due to the desire to make a timely and accurate diagnosis within the constraints of limiting radiation exposure to the fetus. However, required diagnostic imaging should be pursued when indicated and attempts made to minimize the radiation dose by utilizing abdominal shielding and low-dose protocols when feasible. When surgery is indicated due to disease processes, treatment should not be altered or delayed due to pregnancy as the evidence for adverse pregnancy outcomes including early pregnancy loss and preterm delivery are overall of low quality due to substantial confounding by the disease process itself.
Of barriers and bridges: Buyer–supplier relationships in health care
Authors: Abdulsalam Yousef J. , Schneller Eugene S.
Published: March 2020

Background

As the second largest expense category after labor, supply expense has received more strategic attention in recent years. Collaborative buyer–supplier relationships play a significant role in strategic supply chain management. In the health sector, however, buyer–supplier relationships are generally perceived as adversarial and distrusting.

Purpose

The aim of this study was to investigate the major buyer–supplier relationship barriers, with an emphasis on the role of the physician as a surrogate buyer in the hospital’s procurement process.

Methodology

Semistructured interviews were conducted with informants from six health systems and five medical device manufacturers in the United States. Additional data were gathered through a focus group consisting of 10 senior-level physicians. A structured qualitative analysis identified important themes in buyer–supplier relationship factors.

Results

From the data, four major themes emerged regarding the barriers to collaborative buyer–supplier relationships: lack of information sharing, opportunistic pricing behavior, changing regulations, and physician–supplier alliances. Further investigation regarding the role of the physician in purchasing reveals triadic implications.

Conclusions

The medical device market continues to exhibit strained buyer–supplier relationships. The physician’s professional role in supply selection can undermine the hospital’s strategic supply management efforts.

Practice Implications

Both buyers and suppliers need to exhibit more information transparency in order to develop collaborative relationships with at least a small number of strategic partners. Supply chain executives at hospitals need to play a more active role in facilitating the link between the hospital’s physicians and suppliers. Alternatively, hospitals can provide physicians with substitute services to curb supplier influences on physician preferences.
The Shadow Rule, the UV Index, and the 5S Steps in the Tropics
Authors: Silva Abel Antônio
Published: March 2020

Solar ultraviolet radiation (UVR) induces the production of vitamin D (VD), but it also causes erythema and skin cancer among other diseases. The amount of UVR to get benefit and avoid harm is unknown. Some principles were proposed to provide accessible information on how to avoid overexposure to the Sun. They are (1) the Shadow Rule (SR); (2) the UV Index (UVI); and (3) the Slip, Slop, Slap, Seek, Slide (5S) steps. This work discusses these principles in the tropics, considering measurements of solar UVR, total ozone column, and cloudiness. Indeed, the SR leads to overexposures. The UVI is adequate for cloudless skies, but it does not consider radiation enhancement events by clouds. “Seek shade” in the 5S steps should be more emphasized as it is both the most efficient step in terms of avoiding direct sun and the friendliest step toward the environment. Therefore, photoprotection attitudes in the tropics should focus on the UVI and the 5S steps in addition to considering both VD sufficiency and environmental outcomes. The SR is clearly inaccurate.
Perimyocarditis Is a Rare Complication After Campylobacter-Associated Gastroenteritis
Authors: Mortensen Kasper Kjersgaard , Würtz Morten , Mohey Rajesh
Published: March 2020

Campylobacter species are a common cause of gastroenteritis globally, and the incidence is increasing worldwide. We present a rare case of perimyocarditis following Campylobacter-associated gastroenteritis. A 22-year-old man presented with diarrhea after returning from a vacation in the Philippines. Few days later, he developed chest pain, and based on biochemical measures, electrocardiography, and echocardiography, he was diagnosed with perimyocarditis. With this case story, we wish to emphasize that development of cardiac symptoms in patients with gastroenteritis should warrant clinicians to supplement the clinical assessment with cardiac measures. Perimyocarditis is a serious inflammation of the heart, and although perimyocarditis is rarely caused by Campylobacter infections, the potential severity makes the association between the 2 conditions important.
Impact of a Structured Response and Evidence-Based Checklist on In-hospital Stroke Outcomes
Authors: Snavely Joshua , Thompson Hilaire , Bridges Elizabeth , Fathi Joelle
Published: March 2020

BACKGROUND

In-hospital stroke events account for 2% to 17% of all ischemic strokes in the United States. Current stroke guidelines do not provide guidance on how to care for in-hospital stroke. Use of checklists during high-acuity events reduces error and provides clarity for responding staff. We sought to determine whether the use of an evidence-based checklist to guide in-hospital stroke response improved intervention times and patient outcomes.

METHODS

This study used a retrospective chart review of patients hospitalized between January 1, 2016, and December 31, 2018, at a community hospital certified as a primary stroke center with the Joint Commission. Encounters were sorted into preintervention and postintervention groups to evaluate for change in treatment rates, new or worsened disability, and mortality. Nursing staff who respond to in-hospital stroke calls (“response staff”) were also surveyed regarding their perception of benefit and firsthand experience when using the checklist.

RESULTS

A total of 168 patient charts were reviewed (18 prechecklist, 150 postchecklist). After checklist implementation, treatment with intravenous thrombolytics for in-hospital stroke events increased from 0% to 11%. All-cause mortality decreased from 23.1% to 15.0%, whereas ambulatory disability at discharge increased from 38.0% to 62.1%. The increase in disability likely reflects the reduction in mortality, improved data collection, and the increase in postimplementation reporting.

CONCLUSIONS

Use of a checklist during inpatient stroke events can potentially increase adherence to guidelines for appropriate treatment and reduce mortality. Hospital response teams should consider use of a structured response system with an evidence-based checklist for high-acuity, low-frequency events such as in-hospital stroke.
High Cost for Low Yield
Authors: Evans Gretchen , Barker Abigail , Simon Laura , Kushnir Vladmir
Published: March 2020

Routine esophagogastroduodenoscopy (EGD) is an area of continued controversy in the preoperative evaluation for bariatric surgery; more information is needed regarding its impact on surgical management and associated costs. This systematic review and meta-analysis reports rates of abnormalities detected on preoperative EGD that changed operative management or delayed bariatric surgery. Sensitivity analysis examined the impact of controversial findings of hiatal hernia, Helicobacter pylori, gastritis, peptic ulcer disease. Data were used to calculate the cost per surgical alteration made due to abnormalities detected by routine EGD, compactly termed “cost-of-routine-EGD.” Thirty-one retrospective observational studies were included. Meta-analysis found 3.9% of EGDs resulted in a change in operative management; this proportion decreased to 0.3% after sensitivity analysis, as detection of hiatal hernia comprised 85.7% of findings that changed operative management. Half of the 7.5% of cases that resulted in surgical delay involved endoscopic detection of H. pylori. Gastric pathology was detected in a significantly greater proportion of symptomatic patients (65.0%) than in asymptomatic patients (34.1%; P<0.001). Cost-of-routine-EGD to identify an abnormality that changed operative management was $601,060, after excluding controversial findings. The cost-of-routine-EGD to identify any abnormality that led to a change in type of bariatric operation was $281,230 and $766,352 when controversial findings were included versus excluded, respectively. Cost-of-routine-EGD to identify a malignancy was $2,554,506. Cost-of-routine-EGD is high relative to the low proportion of abnormalities that alter bariatric surgery. Our results highlight the need to develop alternative strategies to preoperative screening, in order to improve access and decrease cost associated with bariatric surgery.
The Relationship between Corneal Nerve Morphology and Inflammatory Mediators and Neuropeptides in Healthy Individuals
Authors: Markoulli Maria , Colorado Luisa H. , Edwards Katie
Published: March 2020

SIGNIFICANCE

This study set out to explore the relationship between the ocular surface immune and nervous systems by exploring corneal nerve structure and the presence of inflammatory mediators and neuropeptides in the tear film.

PURPOSE

The purpose of this study was to determine the association between corneal nerve morphology and tear film inflammatory mediators and a neuropeptide in healthy individuals.

METHODS

Flush tears were collected from both eyes of 21 healthy participants aged 39.7 ± 9.9 years (10 females, 11 males) and analyzed for substance P, matrix metalloproteinase-9, tissue inhibitor of matrix metalloproteinase-1 (TIMP-1), tumor necrosis factor α, and interleukin 6. In vivo central corneal confocal microscopy was performed on the right eye, and eight images were captured. Variables measured were corneal nerve fiber length (CNFL), corneal nerve density (CNFD), corneal nerve branch density, fiber total branch density, corneal nerve fiber area, corneal nerve fiber width (CNFW), and corneal nerve fractal dimension (CNFrac). For each eye, the average across the images and the maximum and minimum values were determined for each variable. Pearson correlation analysis was performed to test for associations.

RESULTS

Substance P correlated with CNFrac (max) (r = −0.48, P = .03) and CNFW (min) (r = −0.52, P = .02). TIMP-1 correlated with CNFD (average) (r = −0.53, P = .03), CNFL (average) (r = −0.49, P = .05), CNFrac (max) (r = −0.49, P = .05), and CNFD (min) (r = −0.55, P = .02). Interleukin 6 correlated with CNFW (average) (r = −0.49, P = .05), the standard deviation of CNFL (r = −0.51, P = .04), CNFL (max) (r = −0.50, P = .04), CNFrac (max) (r = −0.50, P = .04), and CNFW (min) (r = −0.55, P = .02). Tumor necrosis factor α, matrix metalloproteinase-9, and its ratio with TIMP-1 did not correlate with any corneal nerve parameters.

CONCLUSIONS

Both inflammatory mediators and neuropeptides correlated with measures of corneal nerve morphology, supporting the link between the inflammatory and nervous systems.
Glycogen-rich Clear Cell Carcinoma of the Breast: A Comprehensive Review
Authors: Vranic Semir , Skenderi Faruk , Beslagic Vanesa , Gatalica Zoran
Published: March 2020

Glycogen-rich clear cell carcinoma (GRCC) is a very rare form of primary breast cancer (<0.1% of all breast cancers). It is characterized by the presence of neoplastic cells with a glycogen-abundant clear cytoplasm (the Periodic Acid Schiff–positive, diastase-sensitive). The expression of steroid receptors (estrogen and progesterone receptors) has been variably reported (35% to 100% of the cases), whereas most studies reported low human epidermal growth factor receptor 2 positivity in GRCC. High androgen receptor positivity without androgen receptor splice variant-7 was reported in one recent study. Although sparse, the preliminary theranostic data on GRCC indicate the potential of targeted treatments in selected cases (antiandrogen, PIK3CA, and immune checkpoint inhibitors). Because of its rarity, the prognosis for GRCC patients remains controversial. Herein, we comprehensively appraise the epidemiological, morphologic, molecular, and clinical characteristics of this rare mammary malignancy.
Population Pharmacokinetics of IV Phenobarbital in Neonates After Congenital Heart Surgery
Authors: Thibault Céline , Massey Shavonne L. , Naim Maryam Y. , Abend Nicholas S. , Zuppa Athena F.
Published: March 2020

Objectives:

To develop a population pharmacokinetic model for IV phenobarbital in neonates following cardiac surgery and perform simulations to identify optimal dosing regimens.

Design:

Retrospective single-center pharmacokinetic study.

Setting:

Cardiac ICU at Children’s Hospital of Philadelphia.

Patients:

Consecutive neonates who received greater than or equal to one dose of IV phenobarbital and had greater than or equal to one phenobarbital concentration drawn per standard of care from June 15, 2012, to October 15, 2018.

Interventions:

None.

Measurements and Main Results:

A population pharmacokinetic model was developed using nonlinear mixed-effects modeling. Simulations were performed using the final model variables. Optimal phenobarbital loading doses were determined based on attainment of peak and maintenance concentrations between 20 and 40 mg/L. A total of 37 neonates contributed 159 pharmacokinetic samples. The median (range) weight, postmenstrual age, and postnatal age were 3.2 kg (1.3–3.8), 39 2/7 weeks (28 2/7 to 42 6/7), and 5 days (0–26 d), respectively. Twelve patients (32%) were on extracorporeal membrane oxygenation. An one-compartment model best described the data. The final population pharmacokinetic model included (1) weight and postnatal age for clearance and (2) weight, extracorporeal membrane oxygenation, and albumin for volume of distribution. In neonates not on extracorporeal membrane oxygenation, loading doses of 30 and 20 mg/kg reached goal concentration with albumin values less than or equal to 3 and 3.5 mg/dL, respectively. Loading doses of 30 mg/kg reached goal concentration on extracorporeal membrane oxygenation regardless of albumin values. Maintenance doses of 4–5 mg/kg/d reached goal concentration in all neonates.

Conclusions:

In neonates following cardiac surgery, phenobarbital clearance increased with postnatal age. Volume of distribution increased with extracorporeal membrane oxygenation and lower albumin values. Loading doses of 30 mg/kg on extracorporeal membrane oxygenation and 20–30 mg/kg without extracorporeal membrane oxygenation were needed to reach goal concentration based on simulations.
The Swedish SPinal Cord Injury Study on Cardiopulmonary and Autonomic Impairment
Authors: Hill Mattias , Jörgensen Sophie , Engström Gunnar , Persson Margaretha , Lexell Jan
Published: March 2020

Objective

The aim of the study was to present the methodology, cohort demographics, and initial results of the Swedish SPinal Cord Injury Study on Cardiopulmonary and Autonomic Impairment (SPICA).

Design

The SPICA is based on the Swedish CArdioPulmonary BioImage Study, a study on cardiopulmonary diseases in a cohort of 30,000 people. The assessments in the SPICA cover the structure and function of the cardiopulmonary and autonomic systems using bioimaging and functional analyses, together with a study-specific questionnaire and generic and spinal cord injury–specific assessment tools. The inclusion criteria were as follows: age 50–65 yrs, traumatic spinal cord injury of 5 yrs or more, and injury levels C1-T6, American Spinal Injury Association Impairment Scale A–C.

Results

Of 38 potential participants, 25 comprised the final sample (20% women, mean age 58 yrs, mean time since injury 28 yrs). Eight percent had sustained a cardiovascular event, and 72% were classified as a high risk for cardiovascular disease. Asthma was previously diagnosed in only 8%, and none had chronic obstructive pulmonary disease.

Conclusions

The risk for cardiovascular disease in people with severe high-level spinal cord injury is a major clinical concern. Forthcoming studies in the SPICA will provide new knowledge of cardiopulmonary health in this cohort, which can guide future research and be used to develop long-term management.
Associations Between Physical Activity Intensities and Physical Function in Stroke Survivors
Authors: Gothe Neha P. , Bourbeau Kelsey
Published: March 2020

Purpose

Impairment caused by stroke is a major cause of disablement in older adults. Physical activity has been shown to improve physical functioning; however, little research has been done to explore how physical activity of different intensities may affect physical function among stroke survivors. The purpose of this study was to examine the patterns of accelerometer-measured physical activity and the relationship between physical activity intensities and objective physical functioning and perceived functional limitations in stroke survivors.

Methods

Stroke survivors (N = 30, mean age = 61.77 ± 11.17) completed the Short Physical Performance Battery and the Late-Life Function and Disability Instrument. Physical activity intensities were measured objectively using a 7-day actigraph accelerometer wear period and scored using the National Health and Nutrition Examination Survey cutoffs for sedentary (counts/minute ≤100), light (counts/minute 101–2019), and moderate to vigorous (moderate to vigorous physical activity counts/minute ≥2020) activity.

Results

Multiple linear regressions controlling for age and time since stroke demonstrated that higher levels of moderate to vigorous physical activity predicted better Short Physical Performance Battery performance (β = .43, P = 0.04). For self-reported physical function, light physical activity predicted better basic lower limb function (β = .45, P = 0.009), better advanced lower limb function (β = .53, P = 0.003), better upper limb function (β = .37, P = 0.04), and higher total function score (β = .52, P = 0.002) on the Late-Life Function and Disability Instrument.

Conclusions

These findings suggest that light activity as well as moderate to vigorous physical activity may contribute to better physical functioning in stroke survivors. Although moderate to vigorous physical activity significantly predicted the objective measure of physical function (Short Physical Performance Battery), light physical activity consistently predicted higher scores on all subscales of the Late-Life Function and Disability Instrument. Disabilities resulting from stroke may limit this population from engaging in moderate to vigorous physical activity, and these findings highlight the importance of light physical activity, which may offer similar perceived functional benefits. Future studies should focus on development of effective exercise interventions for stroke survivors by incorporating and comparing both moderate to vigorous physical activity and light-intensity physical activity.
Marital Status, Close Relationships, and All-Cause Mortality: Results From a 10-Year Study of Nationally Representative Older Adults
Authors: Manvelian Atina , Sbarra David A.
Published: March 2020

Objective

Becoming widowed is associated with an increased risk of early mortality. Drawing on theoretical literature related to social support and health, the present study evaluated whether the quantity of close relationships might differentially moderate the relationship between marital status (widowed versus married) and mortality risk 10 years later.

Method

Data were obtained from the National Social Life Health and Aging Project. A diverse group of older adults (n = 2347) were interviewed three times for 10 years. Information on close friends/family, marital status, and mortality was gathered. Logistic regression and moderation analyses were used to test whether the quantity of close relationships conditioned the risk of death for married and widowed adults 10 years later.

Results

The quantity of close relationships moderated the association between marital status and mortality risk (B = −0.35, SE = 0.11, p = .002). Compared with their married counterparts, widowed older adults who had fewer than four to six close relationships had an increased risk of death 10 years later (B = −0.35, SE = 0.09, p < .001); similarly, among people who reported few close relationships, widowed adults had an increased risk of death compared with their married counterparts (B = 0.54, SE = 0.15, p < .001). These findings remained significant after accounting for demographics, health behaviors/chronic health conditions, and psychological distress. This effect is comparable to the increased mortality risk associated with smoking cigarettes.

Conclusions

Having fewer than four to six close relationships is associated with an increased mortality risk for widowed older adults.
The Incidence and Nature of Adverse Medical Device Events in Dutch Hospitals: A Retrospective Patient Record Review Study
Authors: Porte Petra J. , Smits Marleen , Verweij Lisanne M. , de Bruijne Martine C. , van der Vleuten Cees P. M. , Wagner Cordula
Published: March 2020

Objectives

Despite widespread use of medical devices and their increasing complexity, their contribution to unintended injury caused by healthcare (adverse events, AEs) remains relatively understudied. The aim of this study was to gain insight in the incidence and types of AEs involving medical devices (AMDEs).

Methods

Data from two patient record studies for the identification of AEs were used. Identification of AMDEs was part of these studies. Patient records of 6894 admissions of a random sample of 20 hospitals in 2011/2012 and 19 hospitals in 2015/2016 were reviewed for AMDEs by trained nurses and physicians.

Results

In 98.7% of the admissions, a medical device was used. Adverse events involving medical devices were present in 2.8% of the admissions, with 24% of the AMDEs being potentially preventable. Of all AEs, in 40%, medical devices were involved. Of all potentially preventable AEs, in 44%, medical devices were involved. Implants were most often involved in potentially preventable AMDEs.

Conclusions

Medical devices are substantially involved in potentially preventable AEs in hospitals. Research into AMDEs is of great importance because of the increasing use and complexity of medical devices. Based on patient records, most improvements could be made for placement of implants and prevention of infections related to medical devices. Safety and safe use of medical devices should be a subject of attention and further research.
Intersystem Medical Error Discovery: A Document Analysis of Ethical Guidelines
Authors: Duffy Blake , Miller Jacquelyn , Vitous C. Ann , Dossett Lesly A.
Published: March 2020

Objectives

Patient safety programs aim to improve transparency regarding medical errors, and there is broad consensus on how providers should communicate about their own errors. How providers should respond to other providers’ errors is less clear, especially when they occur outside the provider’s facility or system (intersystem medical error discovery [IMED]). To understand what guidance is available to healthcare professionals in this scenario, we conducted a document analysis of ethical guidelines.

Methods

We searched for ethics codes primarily using databases and lists of professional associations. We used thematic analysis to examine documents in relation to our research questions: is there guidance on (a) what a provider should do after discovering another provider’s error that occurred in a different health system, (b) interacting with other providers, or (c) other subjects relevant to IMED?

Results

Our search identified 150 documents from 120 organizations. These documents contained ambiguous terminology and guidance limiting practical application to IMED scenarios, with most guidance potentially applicable to IMED rendered irrelevant to most IMED scenarios by its restriction to incompetence. In addition, guidelines often sent conflicting signals about prioritizing honesty with and autonomy of patients versus not criticizing the care provided by a fellow practitioner.

Conclusions

Ethics codes provide little guidance on communication regarding IMED scenarios, and in some cases, the guidance is internally conflicting. National professional and patient safety organizations should work to provide a framework for providers and facilities to communicate regarding these ethically and professionally challenging scenarios.
In-Hospital Fall and Fracture Risk With Conditions in the Elixhauser Comorbidity Index: An Analysis of State Inpatient Data
Authors: Davis Jonathan , Casteel Carri , Peek-Asa Corinne
Published: March 2020

Objective

In-hospital falls (IHFs) are a significant burden to the healthcare industry and patients seeking inpatient care. Many falls lead to injuries that could be considered a hospital-acquired condition (HAC). We demonstrated how administrative data can be used to quantify how many IHFs occur and identify what conditions increase the risk for these falls.

Methods

Iowa State Inpatient Database records from 2008 to 2014 for adults older than 50 years were used to quantify IHFs, falls resulting in an HAC (HAC IHFs), and fractures during in-hospital treatment. The medical conditions used in the Elixhauser Comorbidity Index were evaluated for the risk of the separate fall-related outcomes using Poisson regression.

Results

There were 1770 records that had an IHF for an IHF rate of 0.26 per 1000 patient days. Psychoses (rate ratio = 1.95, 95% confidence interval = 1.63–2.34) and alcohol abuse (rate ratio = 1.77, 95% confidence interval = 1.40–2.24) showed the greatest increase in IHF risk. These conditions also increased the risk of HAC IHFs and in-hospital fractures. Fluid and electrolyte disorders, deficiency anemias, and chronic pulmonary disease increased the risk for IHFs/HAC IHFs but did not increase the risk of in-hospital fractures.

Conclusions

Administrative data can be used to track various fall-related outcomes occurring during inpatient treatment. Several conditions of the Elixhauser Comorbidity Index were identified as increasing the risk of fall-related outcomes and should be considered when evaluating a patient’s risk of falling.
Factors Related to Medication Administration Incidents in England and Wales Between 2007 and 2016: A Retrospective Trend Analysis
Authors: Härkänen Marja , Vehviläinen-Julkunen Katri , Franklin Bryony Dean , Murrells Trevor , Rafferty Anne Marie
Published: March 2020

Objectives

The aims of the study were to describe medication administration incidents reported in England and Wales between 2007 and 2016, to identify which factors (reporting year, type of incident, patients’ age) are most strongly related to reported severity of medication administration incidents, and to assess the extent to which relevant information was underreported or indeterminate.

Methods

Medication administration incidents reported to the National Reporting & Learning System between January 1, 2007, and December 31, 2016 were obtained. Characteristics of the data were described using frequencies, and relationships between variables were explored using cross-tabulation.

Results

A total of 517,384 incident reports were analyzed. Of these, 97.1% (n = 502,379) occurred in acute/general hospitals, mostly on wards (69.1%, n = 357,463), with medicine the most common specialty area (44.5%, n = 230,205). Medication errors were most commonly omitted doses (25.8%, n = 133,397). The majority did not cause patient harm (83.5%, n = 432,097). When only incidents causing severe harm or death (n = 1,116) were analyzed, the most common type of error was omitted doses (24.1%). Most incidents causing severe harm or death occurred in patients aged 56 years or older. For the 10-year period, the percentage of incidents with “no harm” increased (74.1% in 2007 to 86.3% in 2016). For some variables, data were often missing or indeterminate, which has implications for data analysis.

Conclusions

Medication administration incidents that do not cause harm are increasingly reported, whereas incidents reported as severe harm and death have declined. Data quality needs to be improved. Underreporting and indeterminate data, inaccuracies in reporting, and coding jeopardize the overall usefulness of these data.
Predictors of Seclusion and Restraint Following Injurious Assaults on Psychiatric Units
Authors: Staggs Vincent S.
Published: March 2020

Objectives

The aim of this study was to describe use of seclusion and restraint after injurious assaults by psychiatric inpatients in U.S. hospitals, including examination of hospital, unit, assaultive patient, and assault characteristics as predictors of seclusion/restraint use.

Methods

Data from 2004 to 2017 on 23,630 injurious assaults reported by 747 psychiatric units in 482 general hospitals were analyzed. Odds of seclusion, odds of three restraint types (device, hold, pharmacological), and duration of seclusion and device restraint were modeled as functions of hospital, unit, assaultive patient, and assault characteristics.

Results

Compared with teaching hospitals, nonteaching hospitals had lower rates of seclusion but higher rates of all three types of restraint. Seclusion and restraint rates were lower in government hospitals and hospitals in metropolitan settings. Pharmacological restraint was most common in for-profit hospitals; seclusion was most common in nonprofit hospitals. Episodes of seclusion and device restraint were approximately 20% shorter in teaching hospitals than in nonteaching hospitals and lasted markedly longer in federal government hospitals. Hospitals in metropolitan settings reported 30% longer time spent in seclusion, on average. Involuntary admission was associated with higher odds of seclusion, device restraint, and hold. Female patients were less likely than males to be restrained with a device, and their seclusion and device restraint episodes tended to be shorter. The number of persons injured in an assault predicted odds of seclusion and all three types of restraint. The maximum level of injury sustained predicted odds of seclusion, device restraint, and hold, as well as duration of both seclusion and device restraint. Odds of seclusion/restraint were lower when the most severely injured person was a patient rather than a clinical health care worker.

Conclusions

Inconsistencies were observed in seclusion and restraint use, which varied by hospital type, patient sex and admission status, maximum level of injury sustained, and type of person most severely injured. Thus, there may be room for improvement in hospital and unit policies and practices. More comprehensive data are needed for further research on use of seclusion and restraint in response to incidents other than injurious assault.