bluuebunny/crossref_metadata_2025 huggingface dataset:
The Relationship Between Lumbar Lateral Listhesis and Radiculopathy in Adult Scoliosis
Authors: Kleimeyer John P. , Liu Ning , Hu Serena S. , Cheng Ivan , Alamin Todd , Grottkau Brian E. , Kukreja Sunil , Wood Kirkham B.
Published: January 2019

Study Design.

Retrospective review and prospective validation study.

Objective.

To develop a classification system of lumbar lateral listhesis that suggests different likelihoods of having radiculopathy in adult scoliosis.

Summary of Background Data.

The association of lumbar lateral listhesis with radiculopathy remains uncertain.

Methods.

A retrospective cohort of patients with adult scoliosis enrolled from 2011 to 2015 was studied to develop a classification system of lateral listhesis that can stratify the likelihood of having radiculopathy. Four radiological aspects of lateral listhesis, including Nash and Moe vertebral rotation, L4–L5 lateral listhesis, the number of consecutive listheses, and the presence of a contralateral lateral listhesis at the thoracolumbar junction above a caudal listhesis, were evaluated on radiographs. Their associations with the presence of radicular leg pain were evaluated using multivariable logistic regression. The classification system of lateral listhesis was thus developed using the most influential radiological factors and then validated in a prospective cohort from 2016 to 2017.

Results.

The retrospective cohort included 189 patients. Vertebral rotation is more than or equal to grade 2 (odds ratio [OR] = 9.45, 95% confidence interval [CI]: 4.07–25.14) and L4–5 listhesis (OR = 4.56, 95%CI: 1.85–12.35) were the two most influential listhesis factors associated with radiculopathy. The classification system of lateral listhesis was thus built based on the combinations of their respective presence: Type 0, 1, 2, 3 were defined as not having listhesis at all, none of the two factors present, one of the two presents, and both present, respectively. This classification significantly stratified the probability of radiculopathy, in both the retrospective cohort (0%, 6.4%, 33.8%, and 68.4% in Type 0, 1, 2, and 3, respectively; P < 0.001) and a prospective cohort of 105 patients (0%, 16.7%, 46.9%, and 72.7%; P < 0.001).

Conclusion.

Lumbar lateral listhesis is associated with the presence of radiculopathy in adult scoliosis. Types 2 and 3 lateral listhesis on radiographs may alert surgeons treating patients with spinal deformity.

Level of Evidence: 2
The Effect of Proton Pump Inhibitors on Bone Formation in a Rat Spinal Arthrodesis Model
Authors: Sonn Kevin A. , Wallace Stephen J. , Yuan Feng Ning F. , Schneider Andrew D. , Hsu Erin L. , Havey Robert M. , Patwardhan Avinash G. , Callaci John J.
Published: January 2019

Study Design.

Rat posterolateral arthrodesis model.

Objective.

Quantify the impact of administration of a proton pump inhibitor on spine fusion.

Summary of Background Data.

Proton pump inhibitors (PPIs) are widely used for gastrointestinal disorders and for ulcer prophylaxis in patients taking non-steroidal anti-inflammatory drugs. PPIs cause chronic acid suppression which has been found to result in decreased bone mineral density, increased fracture risk, and impaired fracture healing. Despite advances in surgical techniques, pseudarthrosis still occurs in up to 24% of patients requiring revision surgery following spinal fusion procedures. Thus, there are likely many unidentified risk factors. While PPIs have been hypothesized to impact fracture healing, no study has evaluated their effect on spine arthrodesis rates.

Methods.

Thirty-eight female rats underwent posterolateral lumbar spinal fusion. Rats were divided into two groups: normal saline control and pantroprazole, which was administered by daily intraperitoneal injections. At 8 weeks postoperative spines were evaluated with manual palpation, microCT, histologic analysis, and biomechanical testing.

Results.

Fusion rates of the control group and PPI group were not significantly different (100% vs. 94%). Average fusion scores were significantly lower in the pantoprazole group. New bone formation identified on microCT imaging of bilaterally fused specimens demonstrated a lower average volume of newly generated bone in the PPI group, but this difference was not significant. Biomechanical testing demonstrated no significant difference in strength or stiffness of the fusion mass between the groups.

Conclusion.

This study demonstrates that administration of PPIs does not inhibit fusion rates, bone formation, or affect biomechanical integrity of fusion. However, lower fusion scores in the PPI group suggest that a negative impact may still exist. Future studies will explore growth factor and protein expression in the fusion masses as well as utilize higher doses of PPI to fully discern their effect on spine fusion.

Level of Evidence: N/A
Glenohumeral Arthrodesis With Reamer-Irrigator-Aspirator (RIA) Bone Grafting After Traumatic Proximal Humerus Bone Loss and Flail Shoulder
Authors: Puvanesarajah Varun , Shafiq Babar , Ingari John V.
Published: January 2019

Glenohumeral arthrodesis is a salvage procedure in the shoulder with few indications. However, in young patients with flail shoulder, shoulder arthrodesis is a durable, functional option. Allograft or autograft can be used to reconstruct the defect during glenohumeral arthrodesis. Autografts be vascularized or nonvascularized. The use of vascularized autograft can increase operative time and is associated with substantial donor-site morbidity. The reamer-irrigator-aspirator, a system that irrigates and aspirates reamed bone and medullary contents, including mesenchymal stem cells, isolating bone graft with little donor-site morbidity, is a potential solution. We used this system for glenohumeral arthrodesis in a 22-year-old man with massive proximal humeral bone loss, axillary nerve injury, deltoid muscle atrophy, and soft-tissue coverage needs complicated by infection. Isolated graft was placed in the bony defect, and the arthrodesis was stabilized with a 16-hole plate. There were no intraoperative or postoperative complications. At 3 months after surgery, his bone graft had incorporated, with no evidence of instrumentation loosening or breakage. Six months after surgery, he had good function of the operative extremity with consolidation of the fusion mass and no loss of fixation. This patient’s outcome highlights that this method has low donor-site morbidity, allows for rapid osseointegration and union, and preserves functional outcomes, despite necessary humeral shortening.
Sliding the Medial Pin: A Safer Approach to Cross-pinning Humerus Supracondylar Fractures?
Authors: Wong Kenneth Pak Leung , Chew Ee Ming , Mahadev Arjandas
Published: January 2019

Introduction:

Many methods have been described to minimize the risk of ulnar nerve injury during the insertion of a medial pin for the percutaneous pinning of pediatric supracondylar humerus fractures (SCHF). The most recent AAOS Clinical Practice Guidelines suggests that physicians might want to avoid the use of medial-entry pins due to considerations of potential injury to the ulnar nerve. However, there are circumstances whereby a cross pin configuration is required. These include cases where there is medial wall comminution or due to the obliquity of the fracture. In this study, we present a group of patients with SCHF in which the medial pin was inserted using a new technique.

Materials and Methods:

This is a retrospective case series approved by the local centralized institutional review board. The medical records of all patients who underwent closed reduction and percutaneous pinning for SCHF using a new technique—the sliding method—by a single pediatric orthopedic surgeon from August 2017 till January 2018 were reviewed. Patient demographics, fracture type, operative time, postoperative Baumann’s angle, postoperative lateral capitellohumeral angle, and the rate of ulnar nerve palsy were recorded.

Results:

This new technique was used in a total of 35 patients. Two patients were excluded as one had multiple same limb injuries, while another had a Gustilo 3A humerus supracondylar fracture. The average patient age at the time of surgery was 6.2 years (range: 2 to 12 y). There were 22 children with Gartland grade 3 fractures, 10 with grade 2b fractures, and 1 had a flexion type fracture. The average operative time was 21 minutes (range: 7 to 58 min). The average postoperative Baumann’s angle was 73.9 degrees (range: 63.8 to 79.6 degrees) and the average postoperative lateral capitellohumeral angle was 44.6 degrees (range: 31.1 to 56.8 degrees). There were no cases of ulnar nerve palsy.

Conclusions:

The sliding method is a novel technique of protecting the ulnar nerve during closed reduction percutaneous pinning of SCHF.

Level of Evidence:

Level IV.
Hip Resurfacing Utilizing the Direct Anterior Approach
Authors: Goltzer Oren , Guild George N.
Published: January 2019

Background:

The direct anterior approach (DAA) has been used successfully in total hip arthroplasty with many benefits including improved radiographic positioning of components, earlier ambulation, as well as decreased narcotic consumption, length of stay, dislocation rate, discharge to rehabilitation facility (vs. home) and 30-day readmission. Hip resurfacing can be a successful surgical option for the properly selected patient as it can preserve bone stock and provide excellent function including improved activity levels as compared with total hip arthroplasty. Traditionally hip resurfacing has been performed via an extensile posterior approach, but the benefits of DAA can be applied to resurfacing though not without a learning curve.

Case Presentation:

Here we report the surgical technique of hip resurfacing performed supine on a Hana table via the DAA and include key steps to ensure adequate exposure and minimize complications.
Improved Guideline Adherence and Reduced Brain Dysfunction After a Multicenter Multifaceted Implementation of ICU Delirium Guidelines in 3,930 Patients
Authors: Trogrlić Zoran , van der Jagt Mathieu , Lingsma Hester , Gommers Diederik , Ponssen Huibert H. , Schoonderbeek Jeannette F. J. , Schreiner Frodo , Verbrugge Serge J. , Duran Servet , Bakker Jan , Ista Erwin
Published: January 2019

Objectives:

Implementation of delirium guidelines at ICUs is suboptimal. The aim was to evaluate the impact of a tailored multifaceted implementation program of ICU delirium guidelines on processes of care and clinical outcomes and draw lessons regarding guideline implementation.

Design:

A prospective multicenter, pre-post, intervention study.

Setting:

ICUs in one university hospital and five community hospitals.

Patients:

Consecutive medical and surgical critically ill patients were enrolled between April 1, 2012, and February 1, 2015.

Interventions:

Multifaceted, three-phase (baseline, delirium screening, and guideline) implementation program of delirium guidelines in adult ICUs.

Measurements and Main Results:

The primary outcome was adherence changes to delirium guidelines recommendations, based on the Pain, Agitation and Delirium guidelines. Secondary outcomes were brain dysfunction (delirium or coma), length of ICU stay, and hospital mortality. A total of 3,930 patients were included. Improvements after the implementation pertained to delirium screening (from 35% to 96%; p < 0.001), use of benzodiazepines for continuous sedation (from 36% to 17%; p < 0.001), light sedation of ventilated patients (from 55% to 61%; p < 0.001), physiotherapy (from 21% to 48%; p < 0.001), and early mobilization (from 10% to 19%; p < 0.001). Brain dysfunction improved: the mean delirium duration decreased from 5.6 to 3.3 days (–2.2 d; 95% CI, –3.2 to –1.3; p < 0.001), and coma days decreased from 14% to 9% (risk ratio, 0.5; 95% CI, 0.4–0.6; p < 0.001). Other clinical outcome measures, such as length of mechanical ventilation, length of ICU stay, and hospital mortality, did not change.

Conclusions:

This large pre-post implementation study of delirium-oriented measures based on the 2013 Pain, Agitation, and Delirium guidelines showed improved health professionals’ adherence to delirium guidelines and reduced brain dysfunction. Our findings provide empirical support for the differential efficacy of the guideline bundle elements in a real-life setting and provide lessons for optimization of guideline implementation programs.
The Cost-Effectiveness of Interventions to Increase Utilization of Prone Positioning for Severe Acute Respiratory Distress Syndrome
Authors: Baston Cameron M. , Coe Norma B. , Guerin Claude , Mancebo Jordi , Halpern Scott
Published: January 2019

Objectives:

Despite strong evidence supporting proning in acute respiratory distress syndrome, few eligible patients receive it. This study determines the cost-effectiveness of interventions to increase utilization of proning for severe acute respiratory distress syndrome.

Design:

We created decision trees to model severe acute respiratory distress syndrome from ICU admission through death (societal perspective) and hospital discharge (hospital perspective). We assumed patients received low tidal volume ventilation. We used short-term outcome estimates from the PROSEVA trial and longitudinal cost and benefit data from cohort studies. In probabilistic sensitivity analyses, we used distributions for each input that included the fifth to 95th percentile of its CI.

Setting:

ICUs that care for patients with acute respiratory distress syndrome.

Subjects:

Patients with moderate to severe acute respiratory distress syndrome.

Interventions:

The implementation of a hypothetical intervention to increase the appropriate utilization of prone positioning.

Measurements and Main Results:

In the societal perspective model, an intervention that increased proning utilization from 16% to 65% yielded an additional 0.779 (95% CI, 0.088–1.714) quality-adjusted life years at an additional long-term cost of $31,156 (95% CI, –$158 to $92,179) (incremental cost-effectiveness ratio = $38,648 per quality-adjusted life year [95% CI, $1,695–$98,522]). If society was willing to pay $100,000 per quality-adjusted life year, any intervention costing less than $51,328 per patient with moderate to severe acute respiratory distress syndrome would represent good value. From a hospital perspective, the intervention yielded 0.072 (95% CI, 0.008–0.147) more survivals-to-discharge at a cost of $5,242 (95% CI, –$19,035 to $41,019) (incremental cost-effectiveness ratio = $44,615 per extra survival [95% CI, –$250,912 to $558,222]). If hospitals were willing to pay $100,000 per survival-to-discharge, any intervention costing less than $5,140 per patient would represent good value.

Conclusions:

Interventions that increase utilization of proning would be cost-effective from both societal and hospital perspectives under many plausible cost and benefit assumptions.
Toward Gender Equity in Critical Care Medicine: A Qualitative Study of Perceived Drivers, Implications, and Strategies*
Authors: Leigh Jeanna Parsons , Grood Chloe de , Ahmed Sofia B. , Ulrich Ania C. , Fiest Kirsten M. , Straus Sharon E. , Stelfox Henry T.
Published: January 2019

Objectives:

Critical care medicine is a medical specialty where women remain underrepresented relative to men. The purpose of this study was to explore perceived drivers (i.e., influencing factors) and implications (i.e., associated consequences) of gender inequity in critical care medicine and determine strategies to attract and retain women.

Design:

Qualitative interview-based study.

Setting:

We recruited participants from the 13 Canadian Universities with adult critical care medicine training programs.

Participants:

We invited all faculty members (clinical and academic) and trainees to participate in a semistructured telephone interview and purposely aimed to recruit two faculty members (one woman and one man) and one trainee from each site. Interviews were transcribed verbatim, and two investigators conducted thematic analysis.

Interventions:

Not applicable.

Measurements and Main Results:

Three-hundred seventy-one faculty members (20% women, 80% men) and 105 trainees (28% women, 72% men) were invited to participate, 48 participants were required to achieve saturation. Participants unanimously described critical care medicine as a specialty practiced predominantly by men. Most women described experiences of being personally or professionally impacted by gender inequity in their group. Postulated drivers of the gender gap included institutional and interpersonal factors. Mentorship programs that span institutions, targeted policies to support family planning, and opportunities for modified role descriptions were common strategies suggested to attract and retain women.

Conclusions:

Participants identified a gender gap in critical care medicine and provided important insight into the impact for personal, professional, and group dynamics. Recommended improvement strategies are feasible, map broadly onto reported drivers and implications, and are applicable to critical care medicine and more broadly throughout medical specialties.
Critical Care Ultrasound: A Systematic Review of International Training Competencies and Program
Authors: Wong Adrian , Galarza Laura , Duska Frantisek
Published: January 2019

Objectives:

Critical care ultrasonography has become established within ICUs as a diagnostic tool and to guide management strategies and practical procedures. Following an international consensus statement in 2011, various national professional societies and organizations have sought to develop and deliver training program. The aim of this review was to assess the similarities and differences among these postgraduate intensive care/critical care training program.

Data Sources:

A systematic review was performed in two steps. First, we searched medical databases and national societies’ websites for documents meeting predefined inclusion criteria. If not found, professionals related to critical care ultrasonography were contacted.

Data Extraction:

Data were extracted independently by two authors. Analyses were conducted on general training requirements as well as specific competencies defined in the documents.

Data Synthesis:

Eight national program from seven countries were identified from a total of 25 countries; all identified program have defined competencies for core critical care ultrasonography. Although there were common themes across these program, significant variations in training requirements and assessments existed, for example, number of scans required for echocardiography training ranged from 10 to 100. Furthermore, the specifics of each ultrasound module varied between program.

Conclusions:

Despite widespread and increasing use of ultrasound in ICUs, the majority of countries lacked a formal training program and clearly defined competencies. Even among the countries where these are available, there remains variability. There is a need to better define the competencies required in core critical care ultrasonography and standardize the assessment process.
Cardioprotection by Humoral Factors Released After Remote Ischemic Preconditioning Depends on Anesthetic Regimen
Authors: Bunte Sebastian , Behmenburg Friederike , Eckelskemper Franziska , Mohr Felix , Stroethoff Martin , Raupach Annika , Heinen André , Hollmann Markus W. , Huhn Ragnar
Published: January 2019

Objectives:

Remote ischemic preconditioning (RIPC) is a practicable and noninvasive method to protect the heart against ischemia reperfusion injury. Unfortunately results from clinical studies are not convincing. Propofol is suggested to be an inhibiting factor of cardioprotection by RIPC, but the underlying mechanism is still unknown. We investigated whether after RIPC the release of humoral factors and/or the direct cardioprotective effect at the myocardium is inhibited by propofol.

Design:

Randomized, prospective, blinded laboratory investigation.

Setting:

Experimental laboratory.

Patients/Subjects:

Male Wistar rats.

Interventions:

Repetitive hind limb ischemia in rats—blood plasma transfers to isolated rat heart.

Measurements and Main Results:

In male Wistar rats (six groups, each n = 6/group), RIPC was induced by four cycles of 5 minutes bilateral hind limb ischemia alternately with 5 minutes of reperfusion. Blood samples were taken with (RIPC) and without RIPC (Con). Rats received continuous anesthesia with pentobarbital (Pento, 40 mg/kg body weight/hr) or propofol (Prop, 12 mg/kg body weight/hr), respectively. Cardioprotective properties of the blood plasma was investigated in the rat heart in vitro (six groups, each n = 6/group) perfused with Krebs-Henseleit buffer alone or with propofol (10 µM). Plasma was administered over 10 minutes before myocardial ischemia. All hearts underwent 33 minutes of global ischemia followed by 1 hour of reperfusion. At the end of the experiments, infarct size was determined by triphenyl-tetrazolium-chloride staining. RIPC plasma from pentobarbital anesthetized rats (Pento-RIPC) reduced infarct size from 64% (62–71%) (Pento-Con) to 34% (30–39%) (p < 0.0001). Infarct size with control plasma from propofol anesthetized rats was 59% (58–64%) (Prop-Con). RIPC plasma could not induce cardioprotection (Prop-RIPC: 63% [56–70%] ns vs Prop-Con). In contrast, RIPC plasma from pentobarbital anesthetized rats induced a significant infarct size reduction under propofol perfusion (Pento-RIPC: 34% [30–42%] vs Pento-Con: 54% [53–63%]; p < 0.0001).

Conclusions:

Loss of cardioprotection by RIPC during propofol anesthesia depends on inhibition of release of humoral factors.
Evaluation of Medication Errors at the Transition of Care From an ICU to Non-ICU Location
Authors: Tully Andrea P. , Hammond Drayton A. , Li Chenghui , Jarrell Andrew S. , Kruer Rachel M.
Published: January 2019

Objectives:

To determine the point prevalence of medication errors at the time of transition of care from an ICU to non-ICU location and assess error types and risk factors for medication errors during transition of care.

Design:

This was a multicenter, retrospective, 7-day point prevalence study.

Setting:

Fifty-eight ICUs within 34 institutions in the United States and two in the Netherlands.

Patients:

Nine-hundred eighty-five patients transferred from an ICU to non-ICU location.

Interventions:

None.

Measurements and Main Results:

Of 985 patients transferred, 450 (45.7%) had a medication error occur during transition of care. Among patients with a medication error, an average of 1.88 errors per patient (sd, 1.30; range, 1–9) occurred. The most common types of errors were continuation of medication with ICU-only indication (28.4%), untreated condition (19.4%), and pharmacotherapy without indication (11.9%). Seventy-five percent of errors reached the patient but did not cause harm. The occurrence of errors varied by type and size of institution and ICU. Renal replacement therapy during ICU stay and number of medications ordered following transfer were identified as factors associated with occurrence of error (odds ratio, 2.93; 95% CI, 1.42–6.05; odds ratio 1.08, 95% CI, 1.02–1.14, respectively). Orders for anti-infective (odds ratio, 1.66; 95% CI, 1.19–2.32), hematologic agents (1.75; 95% CI, 1.17–2.62), and IV fluids, electrolytes, or diuretics (odds ratio, 1.73; 95% CI, 1.21–2.48) at transition of care were associated with an increased odds of error. Factors associated with decreased odds of error included daily patient care rounds in the ICU (odds ratio, 0.15; 95% CI, 0.07–0.34) and orders discontinued and rewritten at the time of transfer from the ICU (odds ratio, 0.36; 95% CI, 0.17–0.73).

Conclusions:

Nearly half of patients experienced medication errors at the time of transition of care from an ICU to non-ICU location. Most errors reached the patient but did not cause harm. This study identified risk factors upon which risk mitigation strategies should be focused.
Lipidomics Detection of Brain Cardiolipins in Plasma Is Associated With Outcome After Cardiac Arrest
Authors: Anthonymuthu Tamil S. , Kenny Elizabeth M. , Lamade Andrew M. , Gidwani Hitesh , Krehel Nicholas M. , Misse Amalea , Gao Xiaotian , Amoscato Andrew A. , Straub Adam C. , Kagan Valerian E. , Dezfulian Cameron , Bayır Hülya
Published: January 2019

Objectives:

Brain mitochondrial dysfunction limits neurologic recovery after cardiac arrest. Brain polyunsaturated cardiolipins, mitochondria-unique and functionally essential phospholipids, have unprecedented diversification. Since brain cardiolipins are not present in plasma normally, we hypothesized their appearance would correlate with brain injury severity early after cardiac arrest and return of spontaneous circulation.

Design:

Observational case-control study.

Setting:

Two medical centers within one city.

Participants (Subjects):

We enrolled 41 adult cardiac arrest patients in whom blood could be obtained within 6 hours of resuscitation. Two subjects were excluded following outlier analysis. Ten healthy subjects were controls. Sprague-Dawley rats were used in asphyxial cardiac arrest studies.

Interventions:

None.

Measurements and Main Results:

We developed a high-resolution liquid chromatography/mass spectrometry method and determined cardiolipins speciation in human brain, heart, and plasma within 6 hours of (return of spontaneous circulation) from 39 patients with cardiac arrest, 5 with myocardial infarction, and 10 healthy controls. Cerebral score was derived from brain-specific cardiolipins identified in plasma of patients with varying neurologic injury and outcome. Using a rat model of cardiac arrest, cardiolipins were quantified in plasma, brain, and heart. Human brain exhibited a highly diverse cardiolipinome compared with heart that allowed the identification of brain-specific cardiolipins. Nine of 26 brain-specific cardiolipins were detected in plasma and correlated with brain injury. The cerebral score correlated with early neurologic injury and predicted discharge neurologic/functional outcome. Cardiolipin (70:5) emerged as a potential point-of-care marker predicting injury severity and outcome. In rat cardiac arrest, a significant reduction in hippocampal cardiolipins corresponded to their release from the brain into systemic circulation. Cerebral score was significantly increased in 10 minutes versus 5 minutes no-flow cardiac arrest and naïve controls.

Conclusions:

Brain-specific cardiolipins accumulate in plasma early after return of spontaneous circulation and proportional to neurologic injury representing a promising novel biomarker.
How and Whom to Monitor for Seizures in an ICU: A Systematic Review and Meta-Analysis
Authors: Limotai Chusak , Ingsathit Atiporn , Thadanipon Kunlawat , McEvoy Mark , Attia John , Thakkinstian Ammarin
Published: January 2019

Objectives:

To pool prevalence of nonconvulsive seizure, nonconvulsive status epilepticus, and epileptiform activity detected by different electroencephalography types in critically ills and to compare detection rates among them.

Data Sources:

MEDLINE (via PubMed) and SCOPUS (via Scopus)

Study Selection:

Any type of study was eligible if studies were done in adult critically ill, applied any type of electroencephalography, and reported seizure rates. Case reports and case series were excluded.

Data Extraction:

Data were extracted independently by two investigators. Separated pooling of prevalence of nonconvulsive seizure/nonconvulsive status epilepticus/epileptiform activity and odds ratio of detecting outcomes among different types of electroencephalography was performed using random-effect models. This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and also adhered to the Meta-analyses Of Observational Studies in Epidemiology guidelines. Quality of evidence was assessed with the Newcastle-Ottawa Quality Assessment Scale for observational studies and Cochrane methods for randomized controlled trial studies.

Data Synthesis:

A total of 78 (16,707 patients) and eight studies (4,894 patients) were eligible for pooling prevalence and odds ratios. For patients with mixed cause of admission, the pooled prevalence of nonconvulsive seizure, nonconvulsive status epilepticus, either nonconvulsive seizure or nonconvulsive status epilepticus detected by routine electroencephalography was 3.1%, 6.2%, and 6.3%, respectively. The corresponding prevalence detected by continuous electroencephalography monitoring was 17.9%, 9.1%, and 15.6%, respectively. In addition, the corresponding prevalence was high in post convulsive status epilepticus (33.5%, 20.2%, and 32.9%), CNS infection (23.9%, 18.1%, and 23.9%), and post cardiac arrest (20.0%, 17.3%, and 22.6%). The pooled conditional log odds ratios of nonconvulsive seizure/nonconvulsive status epilepticus detected by continuous electroencephalography versus routine electroencephalography from studies with paired data 2.57 (95% CI, 1.11–5.96) and pooled odds ratios from studies with independent data was 1.57 (95% CI, 1.00–2.47).

Conclusions:

Prevalence of seizures detected by continuous electroencephalography was significantly higher than with routine electroencephalography. Prevalence was particularly high in post convulsive status epilepticus, CNS infection, and post cardiac arrest.
Validation and Critical Evaluation of the Effective Arterial Elastance in Critically Ill Patients
Authors: Jozwiak Mathieu , Millasseau Sandrine , Richard Christian , Monnet Xavier , Mercado Pablo , Dépret François , Alphonsine Jean-Emmanuel , Teboul Jean-Louis , Chemla Denis
Published: January 2019

Objectives:

First, to validate bedside estimates of effective arterial elastance = end-systolic pressure/stroke volume in critically ill patients. Second, to document the added value of effective arterial elastance, which is increasingly used as an index of left ventricular afterload.

Design:

Prospective study.

Setting:

Medical ICU.

Patients:

Fifty hemodynamically stable and spontaneously breathing patients equipped with a femoral (n = 21) or radial (n = 29) catheter were entered in a “comparison” study. Thirty ventilated patients with invasive hemodynamic monitoring (PiCCO-2; Pulsion Medical Systems, Feldkirchen, Germany), in whom fluid administration was planned were entered in a “ dynamic” study.

Interventions:

In the “dynamic” study, data were obtained before/after a 500 mL saline administration.

Measurements and Main Results:

According to the “cardiocentric” view, end-systolic pressure was considered the classic index of left ventricular afterload. End-systolic pressure was calculated as 0.9 × systolic arterial pressure at the carotid, femoral, and radial artery level. In the “comparison” study, carotid tonometry allowed the calculation of the reference effective arterial elastance value (1.73 ± 0.62 mm Hg/mL). The femoral estimate of effective arterial elastance was more accurate and precise than the radial estimate. In the “dynamic” study, fluid administration increased stroke volume and end-systolic pressure, whereas effective arterial elastance (femoral estimate) and systemic vascular resistance did not change. Effective arterial elastance was related to systemic vascular resistance at baseline (r = 0.89) and fluid-induced changes in effective arterial elastance and systemic vascular resistance were correlated (r = 0.88). In the 15 fluid responders (cardiac index increases ≥ 15%), fluid administration increased end-systolic pressure and decreased effective arterial elastance and systemic vascular resistance (each p < 0.05). In the 15 fluid nonresponders, end-systolic pressure increased (p < 0.05), whereas effective arterial elastance and systemic vascular resistance remained unchanged.

Conclusions:

In critically ill patients, effective arterial elastance may be reliably estimated at bedside (0.9 × systolic femoral pressure/stroke volume). We support the use of this validated estimate of effective arterial elastance when coupled with an index of left ventricular contractility for studying the ventricular-arterial coupling. Conversely, effective arterial elastance should not be used in isolation as an index of left ventricular afterload.
Challenges in a Technology-Based Cancer Pain Management Program Among Asian American Breast Cancer Survivors
Authors: Im Eun-Ok , Ji Xiaopeng , Kim Sangmi , Chee Eunice , Bao Ting , Mao Jun J. , Chee Wonshik
Published: January 2019

This paper aims to discuss the challenges faced during a pilot study that tested a technology-based cancer pain management program among Asian American survivors of breast cancer and provide directions for future technology-based interventions for racial and ethnic minorities. Data consisting of research diaries and meeting minutes underwent content analysis to extract themes that reflected the challenges. The challenges included those related to (1) diversities within the population of Asian American survivors of breast cancer; (2) survivors' treatment and healing process; (3) Internet resources from the participants' countries of origin; (4) building trust between researchers and participants/gatekeepers; (5) fidelity of the intervention; and (6) cultural sensitivity. Future design and implementation of technology-based programs for racial and ethnic minorities must consider these challenges.
Usability of and Satisfaction With Vocera Wireless Communication
Authors: West Gordon F. , Lustik Michael B. , Hopkinson Susan G.
Published: January 2019

Qualitative reports of hands-free communication devices highlight numerous improvements in communication. The purpose of this study was to assess both usability and satisfaction scores at approximately 1 year after the implementation of a hands-free communication device at two different large military facilities. To do this, a survey that included the System Usability Scale and questions to assess satisfaction with regard to use, quality, and user satisfaction was provided to staff at both of these facilities. System usability scores indicated moderate satisfaction (61.7 at facility A, 63.8 at facility B). User satisfaction rated highest levels of agreement with the hands-free devices as an important system and being useful (35%–37% at facility A, 46% at facility B). Scores regarding improving the quality of work (A = 12%, B = 16%); safety of patients (A = 23%, B = 29%); and ability to do their job in a timely manner (A = 23%, B = 29%) were the lowest. The results highlight the potential benefits of Vocera for improving communication within the healthcare team. Given the large percentage of staff turnover at both of these facilities, the sustained benefit of hands-free devices will require ongoing training and continued evaluation of workflow processes.
Effect of Neutropenic Diet on Infection Rates in Cancer Patients With Neutropenia
Authors: Ball Somedeb , Brown Timothy J. , Das Avash , Khera Rohan , Khanna Sahil , Gupta Arjun
Published: January 2019

Introduction:

Neutropenic diets are commonly prescribed to cancer patients with neutropenia with the intention of reducing rates of infection. These diets are restrictive and are associated with lower patient satisfaction and possibly malnutrition. Further, it is unclear if these restrictive diets are effective in reducing infection. We performed a meta-analysis on the rates of infection reported in trials comparing the neutropenic diet to unrestricted diets in cancer patients with neutropenia.

Methods and Materials:

A comprehensive database search for all published randomized controlled trials comparing infection rates in cancer patients receiving a neutropenic diet versus an unrestricted diet was performed for all publications in English language from database’s inception until September 12, 2017. The search strategy, study selection, and subsequent analysis adhered to PRISMA guidelines. Random effects modeling was used to obtain pooled relative risks. The primary outcome measure was the rate of infection.

Results:

Five randomized controlled trials with a total of 388 patients were included in the final analysis. Patients mostly had acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), or sarcoma. Infection was noted in 53.7% patients in the neutropenic diet group, as compared with 50% in the unrestricted diet group. No significant difference in infection rate was observed between the neutropenic diet versus unrestricted diet groups, pooled risk ratio (RR) 1.13 (95% CI, 0.98-1.30; P=0.10).

Conclusions:

This meta-analysis of randomized controlled trials suggests that the use of neutropenic diet was not associated with decreased risk of infection in neutropenic cancer patients. The continued use of neutropenic diets should be questioned.
Impact of Primary Care Access on Mortality of Lung Cancer Patients in an Underserved Community
Authors: Su Christopher T. , Chau Vincent , Halmos Balazs , Shah Chirag D. , Gucalp Rasim A. , Packer Stuart H. , Wilson Kevin , Rapkin Bruce D. , Perez-Soler Roman , Cheng Haiying
Published: January 2019

Background:

Lack of access to primary care physicians (PCPs) may be an important contributor to mortality differences attributed to race/ethnicity. This study examined the effects of primary care access on mortality of lung cancer patients in an underserved community.

Methods:

Medical records of all newly diagnosed patients with primary lung cancer from 2012 to 2016 at a National Cancer Institute (NCI)-designated center in Bronx, New York were reviewed. Demographic data, PCP status, and residence in primary care shortage areas (PCSAs) were collected. Survival data from time of first imaging to death or the end of follow-up on January 1, 2018 were recorded. Survival analysis was performed using Kaplan-Meier and Cox hazards modeling.

Results:

Among 1062 patients, 874 (82%) were PCSA residents, 314 (30%) were Hispanic, and 445 (42%) were African American. PCSA residents were likely Hispanics (P<0.001), African Americans (P<0.001), of lower income (P<0.001), and had advanced disease at diagnosis (P=0.01). Patients without established PCPs had more comorbidities (P=0.04), more advanced disease (P<0.001), and less in-network cancer treatment (P<0.001). PCSA residence (P=0.03, hazard ratio [HR]=1.27) and no established PCP (P<0.001, HR=1.50) were associated with increased mortality. In multivariable modeling, lack of established PCP remained a predictor of increased mortality (P=0.02, HR=1.25).

Discussion:

Among newly diagnosed lung cancer patients, lack of established PCP is associated with increased mortality. Hispanics and African Americans increasingly resided in PCSAs, suggesting race/ethnicity mortality differences may be mediated by primary care shortage. Patients without PCPs had worse health outcomes. Effective health policy efforts to reduce mortality in lung cancer patients must include approaches to improve primary care access.
Factors Associated With Patient-Initiated Communication After Mohs Micrographic Surgery
Authors: Chitgopeker Pooja , Sidey Kirk , Aronson Adam , Hammel Josh , Noe Megan H. , Auh Sogyong , Lehrer Michael , Hopp Shelby , Johnson-Jahangir Hillary , VanBeek Marta , Ferguson Nkanyezi
Published: January 2019

BACKGROUND

Despite extensive counseling, patients commonly call with postoperative concerns after Mohs micrographic surgery (MMS).

OBJECTIVE

We sought to determine the incidence, reasons, and patient and surgical characteristics that lead to patient-initiated communication after MMS.

MATERIALS AND METHODS

A retrospective chart review of 1,531 patients who underwent MMS during the observational period was conducted. Demographics and perioperative characteristics of patients who initiated communication were compared with a random sample of matched controls.

RESULTS

Of the 1,531 patients who underwent MMS, 263 patients (17.2%) initiated 412 communication encounters within 90 days of surgery. Top reasons for patient-initiated communication included wound concerns, bleeding, and postoperative pain. Female patients and those with a larger surgical defect size (cm2) were more likely to call postoperatively. Patients who underwent second intention healing, grafts, and interpolation flaps were more likely to initiate communication compared to patients repaired with a linear closure.

CONCLUSION

This study identifies the incidence, reasons, and patient and surgical factors predictive of patient-initiated communication after MMS, which may allow for targeted improvements in postoperative counseling, ameliorating patient anxiety, augmenting patient satisfaction, and improved efficiency for the health care team.
Changes in the Layers of the Temple During Pinch Manipulation: Implications for Thread Lifting
Authors: Oh Seung Min , Kim Bong Cheol , Jung Wonsug
Published: January 2019

BACKGROUND

During minimally invasive aesthetic procedures, the skin is often pinched to facilitate filler injection or thread insertion into the desired layer. However, little is known about changes in the facial layers during pinch manipulation.

OBJECTIVE

To determine which layer of the temple is lifted during pinching and whether the artery and the nerve are affected by pinching.

MATERIALS AND METHODS

At 11 sites on 3 fresh Korean cadavers, the skin of the temple was pinched gently or deeply, and the skin pulled up was cut at the bottom. The exposed areas were grossly and histologically examined.

RESULTS

With gentle pinching, the subcutaneous fat and superficial temporal fascia (STF) layer were separated, and the fat was removed with the skin. The superficial temporal artery and temporal branches of the facial nerve were intact. With deep pinching, the STF was separated from the deep temporal fascia and lifted with the skin.

CONCLUSION

When thread lifting is performed, deep pinching is helpful for anchoring thread to the temporal fascia, whereas gentle pinching helps to insert thread into the safe subcutaneous fat layer, where no significant blood vessels or nerves are present.
Assessment of Provider Utilization Through Skin Biopsy Rates
Authors: Hamid Ramiz N. , McGregor Sean P. , Siegel Daniel M. , Feldman Steven R.
Published: January 2019

BACKGROUND

There have been recent claims of overdiagnosis and unnecessary treatment in dermatology. One potential manifestation of overutilization would be providers who perform numerous biopsies per patient.

OBJECTIVE

To identify the frequency of skin biopsy rate outliers.

MATERIALS AND METHODS

Data on biopsy rates at the individual provider level were obtained from Medicare Provider Utilization and Payment Data Public Use Files. The total number of biopsies for each provider was obtained by summing the number of claimed biopsy services for each unique National Provider Identifier. The visit count for each provider was obtained by summing all evaluation and management services claimed. Provider biopsy rates were calculated by dividing the total number of biopsies associated with each National Provider Identifier by the corresponding visit count.

RESULTS

The mean provider biopsy rate was 0.31 services per visit, or approximately 1 biopsy every 3 visits. Defining outliers as providers who averaged 3 or more biopsies per visit, there were 38 outliers out of 18,260 providers. Physicians had a lower mean biopsy rate than nonphysician clinicians (p = 1.70E–28).

CONCLUSION

Contrary to claims, the authors' results do not indicate widespread overutilization of skin biopsy services.
Stratification of Poor Outcomes for Cutaneous Squamous Cell Carcinoma in Immunosuppressed Patients Using the American Joint Committee on Cancer Eighth Edition and Brigham and Women's Hospital Staging Systems
Authors: Blechman Adam B. , Carucci John A. , Stevenson Mary L.
Published: January 2019

BACKGROUND

Staging systems for cutaneous squamous cell carcinoma (CSCC) include Brigham and Women's Hospital (BWH) and American Joint Committee on Cancer staging system, eighth edition (AJCC-8).

OBJECTIVE

To evaluate and compare AJCC-8 and BWH staging systems for CSCC in immunosuppressed patients.

MATERIALS AND METHODS

A retrospective cohort study of immunosuppressed patients diagnosed with primary CSCC from 2012 to 2016. The main end point was any poor outcome (PO), which included local recurrence, nodal metastasis, and disease-specific death.

RESULTS

Fifty-eight immunosuppressed patients had 263 CSCCs. Fifty percent of tumors were AJCC-8 T1, 44.7% T2, and 4.8% T3. Fifty percent of tumors were BWH T1, 48.5% T2a, 1.3% T2b, and 0.4% T3. Risk of PO for AJCC-8 was 1.7%, 8.8%, and 36.4% for T1, T2, and T3, respectively (p < .01). Risk of PO for BWH was 1.8%, 9.9%, 33.3%, and 100.0% for T1, T2a, T2b, and T3, respectively (p < .01). Thirty-six percent of AJCC-8 T3/T4 tumors had POs compared with 5.1% in low T1/T2 stages (p = .002). Fifty percent of BWH T2b/T3 tumors had POs compared with 5.3% in low T1/T2a stages (p = .01).

CONCLUSION

AJCC-8 and BWH staging systems stratify CSCC with similar distinctiveness, homogeneity, and monotonicity for immunosuppressed patients.
OnabotulinumtoxinA for Treatment of Forehead and Glabellar Lines: Subject-Reported Satisfaction and Impact From a Phase 3 Double-Blind Study
Authors: Ogilvie Patricia , Rivkin Alexander Z. , Dayan Steven , Yoelin Steven G. , Weichman Barry M. , Garcia Julie K.
Published: January 2019

BACKGROUND

Patient-reported outcomes are important measures of treatment benefit in facial aesthetic medicine.

OBJECTIVE

Evaluate prespecified subject-reported satisfaction and impact outcomes with onabotulinumtoxinA treatment of forehead lines (FHL) and glabellar lines (GL).

METHODS

The study randomized (3:1) 391 adults with moderate to severe FHL and GL to onabotulinumtoxinA (FHL, 20 U; GL, 20 U) or placebo in double-blind period 1 (days 0–180); subjects could receive up to 2 additional onabotulinumtoxinA treatments in open-label period 2. Patient-reported outcomes were assessed using the validated Facial Line Satisfaction Questionnaire (FLSQ) and the 11-item Facial Line Outcomes (FLO-11) Questionnaire.

RESULTS

The proportion of subjects mostly or very satisfied with treatment was significantly greater with onabotulinumtoxinA than with placebo (90.3% vs 1.0%; p < .0001). Responder rates on FLSQ Impact Domain (73.9% vs 18.9%), FLO-11 Item 1 (85.4% vs 3.6%), Item 4 (77.2% vs 11.2%), Item 5 (83.5% vs 7.8%), and total score (86.0% vs 6.9%) were significantly greater with onabotulinumtoxinA than with placebo on Day 30 (p < .0001). Responder rates favoring onabotulinumtoxinA in Period 1 were generally maintained with repeated treatment during Period 2.

CONCLUSION

Subjects were highly satisfied with onabotulinumtoxinA treatment and reported significant improvements in appearance-related psychological and emotional impacts of their facial lines.
Prognostic Impact of Blood MN1 Copy Numbers Before Allogeneic Stem Cell Transplantation in Patients With Acute Myeloid Leukemia
Authors: Jentzsch Madlen , Bill Marius , Grimm Juliane , Schulz Julia , Beinicke Stefanie , Häntschel Janine , Goldmann Karoline , Pönisch Wolfram , Franke Georg‐Nikolaus , Vucinic Vladan , Cross Michael , Behre Gerhard , Lange Thoralf , Niederwieser Dietger , Schwind Sebastian
Published: January 2019

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