bluuebunny/crossref_metadata_2025 huggingface dataset:
Semen quality and cigarette smoking in a cohort of healthy fertile men
Authors: Tang Qiuqin , Pan Feng , Wu Xian , Nichols Cody E. , Wang Xinru , Xia Yankai , London Stephanie J. , Wu Wei
Published: July 2019

Background:

Numerous health effects of smoking are well-known; associations with semen quality are uncertain. Most previous studies did not adjust for potential confounders and had limited information on age at smoking initiation or smoking cessation.

Methods:

We investigated 1,631 healthy fertile men in the Nanjing Medical University Longitudinal Investigation of Fertility and the Environment (NMU-LIFE) study. Relationships were examined using multivariable linear regression controlling for potential covariates.

Results:

We found a significant decrease in semen volume (β= −0.10,P= 0.001) and total sperm count (β= −0.42,P= 0.037), and significant increase in total motility (β= 6.02,P= 0.037) and progressive motility (β= 5.52,P= 0.037) in ever smokers of pack-years ≥10 compared with never smokers. We observed an inverse dose-dependent relation between smoking pack-years and semen volume (P< 0.001) and total sperm count (P= 0.010) and a positive dose-dependent relation between smoking pack-years and both total motility and progressive motility (P= 0.042 and 0.048, respectively). No significant differences in semen quality were detected among ever smokers with different ages at smoking initiation nor in former smokers compared with never smokers.

Conclusions:

Cigarette smoking was associated with lower semen volume and total sperm count and higher sperm motility. Smoking cessation might have a restorative effect on semen quality. This finding has important implications for public health research and for understanding the development of abnormal semen quality.
Environmental noise and sleep and mental health outcomes in a nationally representative sample of urban US adolescents
Authors: Rudolph Kara E. , Shev Aaron , Paksarian Diana , Merikangas Kathleen R. , Mennitt Daniel J. , James Peter , Casey Joan A.
Published: July 2019

Background:

Environmental noise has been linked to negative health outcomes, like poor sleep, poor mental health, and cardiovascular disease, and likely accounts for more than 1 million disability-adjusted life years annually in Western Europe. Adolescence may be a particularly sensitive period for noise exposure due to an increased need for sleep, failure to meet sleep guidelines, and increased risk for first onset of some mental health disorders. However, the potential health effects of living in high-noise environments have not been studied in US adolescents, rarely in European adolescents, and mental health outcomes studied have not corresponded to diagnoses from the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Methods:

Using a US-based nationally representative survey of urban adolescents (N = 4,508), we estimated associations of day-night average sound levels exceeding the US Environmental Protection Agency’s 55 decibel limit with sleep outcomes and lifetime mental health DSM diagnoses. We implemented doubly robust targeted minimum loss-based estimation coupled with propensity score matching to account for numerous potential adolescent, household, and environmental confounders.

Results:

Living in a high- versus low-noise Census block group was associated with later bedtimes on weeknights (0.48 hours, 95% confidence interval [CI] = –0.15, 1.12) and weekend nights (0.65 hours, 95% CI = 0.37, 0.93), but not with total hours slept. Associations between living in a high- versus low-noise Census block group and mental disorders were mixed, with wide CIs, and not robust to sensitivity analyses.

Conclusions:

We find evidence for an association between residence in a high-noise area and later bedtimes among urban adolescents but no consistent evidence of such an association with mental health disorders.
Obturator Nerve Split for Gracilis Free-flap Double Reinnervation in Facial Paralysis
Authors: Baccarani Alessio , Starnoni Marta , Zaccaria Giovanna , Anesi Alexandre , Benanti Elisa , Spaggiari Antonio , De Santis Giorgio
Published: July 2019

The use of a double-powered free muscle transfer for facial reanimation has been reported by several authors with different types of nerve coaptation. A new nerve coaptation strategy is presented herein. We performed a 1-stage double-powered free gracilis muscle flap transfer in a patient with long-standing facial paralysis by splitting the obturator nerve and anastomosing the 2 free ends to the contralateral facial nerve (through a sural graft) and to the masseteric nerve. Voluntary movement of the transferred muscle with teeth clenching was observed at 6 months after the operation and a symmetric smile with bilateral elevation of the mouth angle at 10 months. Our limited experience suggests that in case of a large cross-section of the obturator nerve, the latter can be split and sutured to the ipsilateral masseteric nerve and to the contralateral facial nerve with a sural graft by double end-to-end anastomosis.
Unique Uses of SPY: Revision Rhinoplasty
Authors: Amirlak Bardia , Dehdashtian Amir , Sanneic Kyle , Lu Karen B. , Cheng Jonathan
Published: July 2019

Inadequate tissue perfusion is a serious complication following reconstructive surgeries. Skin flap necrosis, especially in the head and neck area, may have significant cosmetic consequences. Although clinical exam is the mainstay in evaluating perfusion, it may not always predict ischemic problems. The SPY Elite laser angiographic system, which has been widely used to analyze tissue perfusion in postmastectomy skin flaps, has been shown to be able to evaluate tissue perfusion objectively. We describe a revision rhinoplasty case where hypoperfusion of the nasal tip was seen following placement of structural grafts to the nasal tip, and before the grafts being removed SPY, angiography was used to evaluate if topical nitroglycerin alone could correct hypoperfusion of the nasal tip rather than removal of structural grafts. A SPY angiography was performed to evaluate the hypoperfusion to the nasal tip. Repeat imaging was then performed following treatment with topical nitroglycerin alone. Perfusion of the nasal tip was restored and confirmed by SPY angiography system. The objective findings from the SPY angiography allowed the grafts to remain in place and lead to optimal cosmetic result. Due to the critical information SPY angiography provided in this case, we recommend the use of technology when evaluating reconstructive cases in which the viability of the tissue may be difficult to deduce from clinical exam.
Three-dimensional Camera Imaging in Postoperative Evaluation of Distraction Osteogenesis
Authors: Hirota Yuka , Ueda Koichi , Otsuki Yuki , Fuse Asuka , Mitsuno Daisuke
Published: July 2019

Distraction osteogenesis needs to be regularly assessed in some way to monitor the degree of advancement. X-ray is used for the general evaluation of osteotomy. However, radiation exposure should be avoided. The purpose of this study is to evaluate 3-dimensional (3D) camera imaging for postoperative evaluation. Three patients who underwent Le Fort I or III advancement osteotomy using rigid external distraction and internal distraction were observed in this study. The degrees of the distractions were evaluated using VECTRA H1 3D imaging in addition to computed tomographic (CT) scans. In the VECTRA 3D imaging, the tilt and size of the faces were corrected using the dedicated software for imaging. The preoperative and postoperative images were superimposed, and the distances of motion between the landmarks were measured. In CT scans, the bone distances between osteotomy points of the pterygomaxillary junction were analyzed. As the VECTRA 3D imaging can be compared by overlaying previous photographs, it served as a good tool to evaluate the distractions. However, both the soft-tissue movement measured by VECTRA and CT bony measurements did not match the total amount of movement for the internal distraction devices. The bony advancements were less than the amount of distraction. The soft tissues shrank after the distraction was completed in all cases. Three-dimensional camera imaging is considered to be a useful tool for the evaluation of distraction osteogenesis.
Nonsurgical Rhinoplasty: A Graft-based Technique
Authors: Segreto Francesco , Marangi Giovanni Francesco , Cerbone Vincenzo , Alessandri-Bonetti Mario , Caldaria Erika , Persichetti Paolo
Published: July 2019

Background:

Nonsurgical rhinoplasty with hyaluronic acid (HA) has gained popularity due to its efficacy and minimal downtime. From a structural standpoint, it is like performing a tridimensional reshaping where only enhancement by grafts is allowed. To date, indications, technique, and products are still debated. The aim of this study is to describe the author’s experience with nonsurgical nasal reshaping, focusing on the indications and maneuvers to safely achieve, by mean of HA, the grafts previously described for surgical rhinoplasty.

Materials and Methods:

A total of 70 consecutive patients underwent nonsurgical rhinoplasty using the same type of HA. The rhinoplasty module of FACE-Q was administered to all patients before treatment and 15 days posttreatment. Statistical analysis was performed.

Results:

No complication was experienced. Two (2.8%) patients required a retouch after 15 days for further dorsal correction. There was a statistically significant difference between preoperative and postoperative values in all domains and overall scores of the rhinoplasty module of FACE-Q.

Conclusions:

The graft-based technique proved to be safe, effective, and reliable. It may allow correction of selected nasal defects with reduced cost and minimal downtime.
A Cross-sectional Study of the Association between Homelessness and Facial Fractures
Authors: Nguyen Audrey B. , Grimes Barbara , Neuhaus John , Pomerantz Jason H.
Published: July 2019

Background:

Little is known about the risk factors for facial fractures among homeless patients. We investigated the association between homelessness, mechanism of injury, and type of facial fracture in patients treated at an urban trauma center.

Methods:

Data for 2,221 adults with facial fractures were obtained retrospectively from a standardized registry of trauma patients at Zuckerberg San Francisco General Hospital from 2011 to 2016. Associations between homelessness and mechanism of injury, facial fracture type, and surgical repair type were evaluated with multivariate multinomial logistic regression analysis.

Results:

Among 2,221 patients with facial fractures, 12% were homeless and, compared with housed patients, more likely to be male, black, and test positive for drug and alcohol use (all P < 0.0001). They had lower injury severity scores but longer hospital stays and were more likely to be discharged to the community than to a rehabilitation facility (all P < 0.0001). After adjusting for confounding variables, homeless patients with facial fractures were nearly 3-fold more likely to have been assaulted than housed patients (OR = 2.8, 95% CI = 1.9–4.1, P < 0.0001) and twice as likely to have mandible fractures (OR = 2.0, 95% CI = 1.3–3.0, P = 0.0030) and to have surgery for these fractures (OR = 2.1, 95% CI = 1.2–3.7, P = 0.0110).

Conclusions:

Our novel results demonstrate that homeless patients with facial fractures are at much higher risk than the general population for being assaulted, suffering mandible fractures, and requiring surgery for these fractures. Further investigations could guide identification, treatment, and prevention efforts.
Medial Upper Lip Vermillion Reconstruction with a Labial Artery-based Cross-lip Vermillion Flap
Authors: Sowa Yoshihiro , Inafuku Naoki , Kodama Takuya , Morita Daiki , Numajiri Toshiaki
Published: July 2019

A defect of the central upper lip vermillion generally requires “like for like” reconstruction because this part of the upper lip can attract attention and has a unique structure and color. In this article, we report use of a labial artery-based horizontal long cross-lip flap for central upper lip vermillion reconstruction. In the first stage of surgery, a horizontal long vermillion flap from the lower lip starting at the left commissure with a vascular pedicle containing an inferior labial artery was raised and transposed to the upper vermillion defect. In the second stage, 12 days later, the pedicle was divided to complete the reconstruction. There were no postoperative complications in articulation or eating, and the patient was satisfied with the esthetic outcome. This surgical technique reduces microstomia and inconvenience in eating and speaking compared with a common horizontal cross-lip flap and provides better color- and texture-matched tissue compared to reconstruction using a tongue flap or mucosal flap. The technique is simple, requires a relatively short surgical time, has minimum donor-site morbidity and permits good esthetic and functional reconstruction of the central upper lip vermillion for a relatively small defect.
Clinical Characteristics of Primary HHV-6B Infection in Children Visiting the Emergency Room
Authors: Hattori Fumihiko , Kawamura Yoshiki , Kozawa Kei , Miura Hiroki , Miyake Misa , Yoshikawa Akiko , Ihira Masaru , Yoshikawa Tetsushi
Published: July 2019

Objective:

This cohort study, based on the design of a prior study in the United States, was conducted to elucidate the clinical features of primary human herpesvirus-6B (HHV-6B) infection.

Methods:

Between June 2014 and May 2016, febrile children younger than 5 years who visited the emergency room (ER) and underwent blood examination were enrolled in this study.

Results:

Fifty-nine (12%) of the 491 patients were diagnosed with primary HHV-6B infection. The rates of both simple and complex febrile seizure were significantly higher in patients with primary HHV-6B infection than in those without (P < 0.001 and P = 0.008, respectively). The median age at primary HHV-6B infection was 15 months. Forty-seven (79.7%) of the 59 patients with primary HHV-6B infection were younger than 2-year-old. Clinical features were compared between HHV-6B–infected patients older and younger than 2 years. The frequency of apparent infection (exanthema subitum) was significantly higher in the younger patients (P = 0.01). The median leukocyte (P = 0.01) and lymphocyte (P < 0.001) counts in the patients older than 2 years were significantly lower than those in the younger patients.

Conclusions:

Primary HHV-6B infection accounted for 12% of ER visits. Secondary febrile seizures, in particular the complex type, were considered to be a major contributor to the disease burden of primary HHV-6B infection. The timing of primary HHV-6B infection occurred at older ages than in past reports, and the frequency of inapparent infection was higher in older patients.
Causes of Pediatric Meningitis in Botswana: Results From a 16-Year National Meningitis Audit
Authors: Mitchell Hannah K. , Mokomane Margaret , Leeme Tshepo , Tlhako Nametso , Tsholo Katlego , Ramodimoosi Chandapiwa , Dube Bonno , Mokobela Kelebeletse O. , Tawanana Ephraim , Chebani Tony , Setlhake Pretty , Pilatwe Tlhagiso , Hurt William J. , Molefi Mooketsi , Mullan Paul C. , Steenhoff Andrew P. , Mine Madisa , Jarvis Joseph N. , Tenforde Mark W.
Published: July 2019

Background:

Central nervous system infections are an important cause of childhood morbidity and mortality in high HIV-prevalence settings of Africa. We evaluated the epidemiology of pediatric meningitis in Botswana during the rollout of antiretroviral therapy, pneumococcal conjugate vaccine and Haemophilus influenzae type B (HiB) vaccine.

Methods:

We performed a cross-sectional study of children (<15 years old) evaluated for meningitis by cerebrospinal fluid (CSF) examination from 2000 to 2015, with complete national records for 2013–2014. Clinical and laboratory characteristics of microbiologically confirmed and culture-negative meningitis were described and incidence of Streptococcus pneumoniae, H. influenzae and cryptococcal meningitis was estimated for 2013–2014.

Results:

A total of 6796 unique cases were identified. Median age was 1 year [interquartile range 0–3]; 10.4% (435/4186) of children with available HIV-related records were known HIV-infected. Overall, 30.4% (2067/6796) had abnormal CSF findings (positive microbiologic testing or CSF pleocytosis). Ten percent (651/6796) had a confirmed microbiologic diagnosis; including 26.9% (175/651) Cryptococcus, 18.9% (123/651) S. pneumoniae, 20.3% (132/651) H. influenzae and 1.1% (7/651) Mycobacterium tuberculosis. During 2013–2014, national cryptococcal meningitis incidence was 1.3 cases per 100,000 person-years (95% confidence interval, 0.8–2.1) and pneumococcal meningitis incidence 0.7 per 100,000 person-years (95% confidence interval, 0.3–1.3), with no HiB meningitis diagnosed.

Conclusions:

Following HiB vaccination, a marked decline in microbiologically confirmed cases of H. influenzae meningitis occurred. Cryptococcal meningitis remains the most common confirmed etiology, demonstrating gaps in prevention-of-mother-to-child transmission and early HIV diagnosis. The high proportion of abnormal CSF samples with no microbiologic diagnosis highlights limitation in available diagnostics.
False Vaccine Contraindications Among Healthcare Providers in Europe: A Short Survey Among Members of The European Society of Pediatric Infectious Diseases
Authors: Rivero Irene , Raguindin Peter Francis , Buttler Robb , Martinon-Torres Federico
Published: July 2019

Some healthcare providers hold or delay vaccination because of false vaccine contraindications. This study suggests that in 21.4% of scenarios (877/4096) physicians would postpone or contraindicate the vaccination, and 24.2% (237/978) of scenarios would be vaccinated despite the existence of a true contraindication or reason for delay. Addressing false contraindications may result in increasing vaccination uptake in Europe.
General pediatric care for a patient after heart transplant: what the practitioner needs to know
Authors: Chatfield Kathryn , Nakano Stephanie J. , Everitt Melanie D.
Published: July 2019

Purpose of review

The scope of this review is to discuss aspects of general pediatric care which significantly impact the outcome of children after heart transplant. The general practitioner (GP) often serves as the frontline for prevention and early detection of common problems after heart transplant.

Recent findings

Multiple studies in the literature show the negative impact of preventable illness in immune compromised patients, including the appropriateness of vaccine administration. Except for live vaccines, pediatric heart transplant recipients generally follow standard childhood vaccine schedules. In addition, diagnosis of cardiac and noncardiac conditions by the practitioner can lead to earlier treatment by subspecialists. While rejection and infection are such conditions the practitioner may identify, psychological and neurocognitive conditions are common and impact both adherence to medications and quality of life.

These issues are addressed in this review of the recent literature. Through knowledge, detection, and collaboration of care, the practitioner can greatly improve the well being of pediatric heart transplant recipients.
Delay in the Diagnosis of Breast and Colorectal Cancer in People With Severe Mental Disorders
Authors: Céspedes Pedro , Sánchez-Martínez Vanessa , Lera-Calatayud Guillem , Vila-Candel Rafael , Cauli Omar , Buigues Cristina
Published: July 2019

Background

People with severe mental disorders have a worse cancer prognosis, with higher mortality rates than the general population, and this could be partially attributed to a later detection. Breast cancer and colorectal cancer have mass population screenings in Spain, but the influence in early diagnosis is unknown in persons with severe mental disorders.

Objective

To compare the severity of breast and colorectal cancers at diagnosis in people with and without mental disorders.

Methods

This was an observational, retrospective, case-control study with 1:2 matching performed in Eastern Spain. Data were retrieved for analysis from electronic medical records.

Results

The study included 111 oncology patients (75 with breast cancer and 36 with colorectal cancer). Individuals with mental disorders had a significantly higher (P = .002) relative risk (odds ratio [OR], 3.93; 95% confidence interval [CI], 1.60–9.65) to be diagnosed with an advanced tumor stage (clinical stages IIIA, IIIB, IIIC, and IV), for both breast and colorectal cancers when analyzed separately. The variables associated with advanced cancer at the time of diagnosis were the presence of a previous mental disorder (OR, 4.67; 95% CI, 1.73–12.61) and older age (OR, 1.08; 95% CI, 1.02–1.14).

Conclusions

Individuals with severe mental disorders showed a higher risk of being diagnosed with breast and colorectal cancers at advanced stages.

Implications for Practice:

Cancer screening for earlier detection and intervention in people with severe mental disorders needs improvement. Mental health nurses, screening nurses, and oncology nurses could serve an essential role in increasing the screening adherence of this group of individuals.
Simulation to assess intelligent video camera system's actual production performance during chemotherapy preparation
Authors: Laplace Marie , Lefranc Benoit , Dalifard Benoit
Published: July 2019

Introduction:

DRUGCAM is a new approach to control the chemotherapy preparations with an intelligent video system to assist the pharmacy technician during compounding process. This tool is able to control all of our production (except for colored and dark anticancer drugs) with an in-process control and a posteriori inspection. We first aimed to estimate DRUGCAM's performance in real-life production by simulation and to compare it with the double human control. Furthermore, factors influencing the performance of both controls were observed and preventive solutions will be envisaged to optimize our activity.

Equipment and methods:

Each day during 30 days, between 11:30 am and 12:30 am, we controlled 20 different volumes contained in syringes, in real production conditions (clean room) both by human visual inspection then by automated video control. Working conditions have been observed and tasks disturbances and interruptions have been noted. A set of information has been collected: the syringe's model, the volume of product and the disturbances. A statistical analysis has been conducted to interpret results.

Results:

With 24 errors throughout the 600 volume controls, the error rate for the visual human control is 4%. Seven checked volumes were superior to the expected volume (overdosing) and 17 were inferior (underdosing). The error rate for DRUGCAM is 0.17%. Among the disturbance factors, the type of syringe used is responsible for errors: 13 errors have been noticed with the 1 mL syringe and 8 errors with the 10 mL syringe which represent higher error rates than with the other syringes.

The “permanent” staff members of the unit present an error rate of 5.3%, more important than the “non-permanent” ones (1.8%). More mistakes are done in the presence of a pharmacist than in its absence (13% against 4%).

Conclusion:

Our studies justify the superiority of the DRUGCAM system toward double human control. Moreover, the double human control could possibly be disturbed by external factors whereas DRUGCAM is not. Using DRUGCAM is to be considered to establish preventive measures and reduce tasks interruptions or disturbance factors thanks to video analysis.
Factors Impacting Physician Recommendation for Tracheostomy Placement in Pediatric Prolonged Mechanical Ventilation: A Cross-Sectional Survey on Stated Practice*
Authors: Meyer-Macaulay Colin Blair , Dayre McNally James , O’Hearn Katie , Lynne Katz Sherri , Thébaud Bernard , Vaccani Jean-Philippe , Barrowman Nick , Harrison Mary-Ann , Jouvet Philippe
Published: July 2019

Objectives:

To characterize the stated practices of qualified Canadian physicians toward tracheostomy for pediatric prolonged mechanical ventilation and whether subspecialty and comorbid conditions impact attitudes toward tracheostomy.

Design:

Cross sectional web-based survey.

Subjects:

Pediatric intensivists, neonatologists, respirologists, and otolaryngology-head and neck surgeons practicing at 16 tertiary academic Canadian pediatric hospitals.

Interventions:

Respondents answered a survey based on three cases (Case 1: neonate with bronchopulmonary dysplasia; Cases 2 and 3: children 1 and 10 years old with pediatric acute respiratory distress syndrome, respectively) including a series of alterations in relevant clinical variables.

Measurements and Main Results:

We compared respondents’ likelihood of recommending tracheostomy at 3 weeks of mechanical ventilation and evaluated the effects of various clinical changes on physician willingness to recommend tracheostomy and their impact on preferred timing (≤ 3 wk or > 3 wk of mechanical ventilation). Response rate was 165 of 396 (42%). Of those respondents who indicated they had the expertise, 47 of 121 (38.8%), 23 of 93 (24.7%), and 40 of 87 (46.0%) would recommend tracheostomy at less than or equal to 3 weeks of mechanical ventilation for cases 1, 2, and 3, respectively (p < 0.05 Case 2 vs 3). Upper airway obstruction was associated with increased willingness to recommend earlier tracheostomy. Life-limiting condition, severe neurologic injury, unrepaired congenital heart disease, multiple organ system failure, and noninvasive ventilation were associated with a decreased willingness to recommend tracheostomy.

Conclusion:

This survey provides insight in to the stated practice patterns of Canadian physicians who care for children requiring prolonged mechanical ventilation. Physicians remain reluctant to recommend tracheostomy for children requiring prolonged mechanical ventilation due to lung disease alone at 3 weeks of mechanical ventilation. Prospective studies characterizing actual physician practice toward tracheostomy for pediatric prolonged mechanical ventilation and evaluating the impact of tracheostomy timing on clinically important outcomes are needed as the next step toward harmonizing care delivery for such patients.
Epidemiologic Trends of Adoption of Do-Not-Resuscitate Status After Pediatric In-Hospital Cardiac Arrest*
Authors: Gupta Punkaj , Rettiganti Mallikarjuna , Gossett Jeffrey M. , Nadkarni Vinay M. , Berg Robert A. , Raymond Tia T. , Parshuram Christopher S.
Published: July 2019

Objectives:

To evaluate the prevalence of do-not-resuscitate status, assess the epidemiologic trends of do-not-resuscitate status, and assess the factors associated with do-not-resuscitate status in children after in-hospital cardiac arrest using large, multi-institutional data.

Design:

Generalized estimating equations logistic regression model was used to evaluate the trends of do-not-resuscitate status and evaluate the factors associated with do-not-resuscitate status after cardiac arrest.

Setting:

American Heart Association’s Get With the Guidelines-Resuscitation Registry.

Patients:

Children (< 18 yr old) with an index in-hospital cardiac arrest and greater than or equal to 1 minute of documented chest compressions were included (2006–2015). Patients with no return of spontaneous circulation after cardiac arrest were excluded.

Interventions:

None.

Measurements and Main Results:

In total, 8,062 patients qualified for inclusion. Of these, 1,160 patients (14.4%) adopted do-not-resuscitate status after cardiac arrest. We found low rates of survival to hospital discharge among children with do-not-resuscitate status (do-not-resuscitate vs no do-not-resuscitate: 6.0% vs 69.7%). Our study found that rates of do-not-resuscitate status after cardiac arrest are highest in children with Hispanic ethnicity (16.4%), white race (15.0%), and treatment at institutions with larger PICUs (> 50 PICU beds: 17.8%) and at institutions located in North Central (17.6%) and South Atlantic/Puerto Rico (17.1%) regions of the United States. Do-not-resuscitate status was more common among patients with more preexisting conditions, longer duration of cardiac arrest, greater than 1 cardiac arrest, and among patients requiring extracorporeal cardiopulmonary resuscitation. We also found that trends of do-not-resuscitate status after cardiac arrest in children are decreasing in recent years (2013–2015: 13.8%), compared with previous years (2006–2009: 16.0%).

Conclusions:

Patient-, hospital-, and regional-level factors are associated with do-not-resuscitate status after pediatric cardiac arrest. As cardiac arrest might be a signal of terminal chronic illness, a timely discussion of do-not-resuscitate status after cardiac arrest might help families prioritize quality of end-of-life care.
The Base Deficit, International Normalized Ratio, and Glasgow Coma Scale (BIG) Score, and Functional Outcome at Hospital Discharge in Children With Traumatic Brain Injury*
Authors: Davis Adrienne L. , Hochstadter Elana , Daya Tahira , Kulkarni Abhaya V. , Wales Paul , Stephens Derek , Schuh Suzanne
Published: July 2019

Objectives:

To examine the association of the base deficit, international normalized ratio, and Glasgow Coma Scale (BIG) score on emergency department arrival with functional dependence at hospital discharge (Pediatric Cerebral Performance Category ≥ 4) in pediatric multiple trauma patients with traumatic brain injury.

Design:

A retrospective cohort study of a pediatric trauma database from 2001 to 2018.

Setting:

Level 1 trauma program at a university-affiliated pediatric institution.

Patients:

Two to 17 years old children sustaining major blunt trauma including a traumatic brain injury and meeting trauma team activation criteria.

Interventions:

None.

Measurements and Main Results:

Two investigators, blinded to the BIG score, determined discharge Pediatric Cerebral Performance Category scores. The BIG score was measured on emergency department arrival. The 609 study patients were 9.7 ± 4.4 years old with a median Injury Severity Score 22 (interquartile range, 12). One-hundred seventy-one of 609 (28%) had Pediatric Cerebral Performance Category greater than or equal to 4 (primary outcome). The BIG constituted a multivariable predictor of Pediatric Cerebral Performance Category greater than or equal to 4 (odds ratio, 2.39; 95% CI, 1.81–3.15) after adjustment for neurosurgery requirement (odds ratio, 2.83; 95% CI, 1.69–4.74), pupils fixed and dilated (odds ratio, 3.1; 95% CI, 1.49–6.38), and intubation at the scene or referral hospital (odds ratio, 2.82; 95% CI, 1.35–5.87) and other postulated predictors of poor outcome. The area under the BIG receiver operating characteristic curve was 0.87 (0.84–0.90). Using an optimal BIG cutoff less than or equal to 8, sensitivity and negative predictive value for functional dependence at discharge were 93% and 96%, respectively, compared with a sensitivity of 79% and negative predictive value of 91% with Glasgow Coma Scale less than or equal to 8. In children with Glasgow Coma Scale 3, the BIG score was associated with brain death (odds ratio, 2.13; 95% CI, 1.58–2.36). The BIG also predicted disposition to inpatient rehabilitation (odds ratio, 2.26; 95% CI, 2.17–2.35).

Conclusions:

The BIG score is a simple, rapidly obtainable severity of illness score that constitutes an independent predictor of functional dependence at hospital discharge in pediatric trauma patients with traumatic brain injury. The BIG score may benefit Trauma and Neurocritical care programs in identifying ideal candidates for traumatic brain injury trials within the therapeutic window of treatment.
Mortality and Factors Associated With Hemorrhage During Pediatric Extracorporeal Membrane Oxygenation
Authors: O’Halloran Conor P. , Andren Kristofer G. , Mecklosky Jessica , Larsen Stephanie , Brediger Steven , Vitali Sally , Zalieckas Jill M. , Fynn-Thompson Francis , Thiagarajan Ravi R. , Alexander Peta M. A.
Published: July 2019

Objectives:

To quantify and identify factors associated with bleeding events during pediatric extracorporeal membrane oxygenation.

Design:

Retrospective cohort study with primary outcome of bleeding days on extracorporeal membrane oxygenation.

Setting:

Single tertiary care children’s hospital.

Subjects:

One-hundred twenty-two children supported with extracorporeal membrane oxygenation for greater than 12 hours during January 2015 through December 2016.

Interventions:

Bleeding days were identified if mediastinal or cannula site exploration, activated factor VII administration, gastrointestinal, pulmonary, or intracranial hemorrhages occurred. Logistic regression was used to assess factors associated with bleeding days.

Measurements and Main Results:

Study population was identified from institutional extracorporeal membrane oxygenation database. Clinical, laboratory, and survival data were obtained from medical records. Only data from patients’ first extracorporeal membrane oxygenation run were used. One-hundred twenty-two patients with median age of 17 weeks (interquartile range, 1–148 wk) were analyzed. Congenital heart disease (n = 56, 46%) was the most common diagnosis. Bleeding days comprised 179 (16%) of the 1,121 observed extracorporeal membrane oxygenation-patient-days. By extracorporeal membrane oxygenation day 4, 50% of users had experienced a bleeding day. Central rather than peripheral cannulation (odds ratio, 2.58; 95% CI, 1.47–4.52; p < 0.001), older age (odds ratio, 1.31 per increased week; 95% CI, 1.14–1.52; p < 0.001), higher lactate (odds ratio, 1.08 per 1 mmol/L increase; 95% CI, 1.05–1.12; p < 0.001), and lower platelets (odds ratio, 0.87 per 25,000 cell/μL increase; 95% CI, 0.77–0.99; p = 0.005) were associated with bleeding days. Patients who experienced more frequent bleeding (> 75th percentile) had fewer ventilator-free and hospital-free days in the 60 days after cannulation (0 vs 31; p = 0.002 and 0 vs 0; p = 0.008) and higher in-hospital mortality (68 vs 34%; p < 0.001).

Conclusions:

Central cannulation, older age, low platelets, and high lactate are associated with bleeding days during pediatric extracorporeal membrane oxygenation. Patients who bleed more frequently during extracorporeal membrane oxygenation have higher in-hospital mortality, longer technological dependence, and reduced hospital-free days.
Epidemiology of Pediatric Severe Sepsis in Main PICU Centers in Southwest China*
Authors: Xiao Changxue , Wang Sa , Fang Fang , Xu Feng , Xiao Shufang , Li Bin , Zhang Guoying , Luo Xiaoli , Jiang Jianyu , Huang Bo , Chen Yu , Chen Jianli , Wang Huazhu , Yu Jing , Ren Dan , Ren Xiaoling , Tang Chenxi
Published: July 2019

Objectives:

To estimate the prevalence, management, and outcomes of pediatric severe sepsis in the main PICUs in Southwest China.

Design:

A prospective, observational, and multicenter study.

Setting:

Eight PICUs in Southwest China with 19 (13–24) beds and 1,322 (1,066–1,452) annual admissions each.

Patients:

A total of 10,598 patients (29 d to 18 yr old) were consecutively admitted between September 1, 2016, and August 31, 2017. All patients were screened and evaluated for severe sepsis or septic shock. Of them, 10,353 patients were excluded due to incomplete data or not meeting the consensus criteria for severe sepsis or septic shock; 245 patients were included with complete data.

Interventions:

None.

Measurements and Main Results:

Finally, 245 patients who were diagnosed with severe sepsis or septic shock were included in the study, with an incidence rate of 2.3%. Of them, 64.0% of the enrolled patients were male with 80.8% being less than 5 years old and 60.8% being from rural areas. The respiratory system was the most common organ system in which dysfunction was observed (76.7%) as well as the most frequently infected site (37.6%). The primary therapies were antibiotics (99.0%), immunoglobulin (88.3%), mechanical ventilation (78.4%), vasoactive infusions (59.6%), and corticosteroids (46.1%). Among the 188 patients who had respiratory dysfunction, 173(92%) required mechanical ventilation and 39 (20.7%) met the criteria for pediatric acute respiratory distress syndrome. Seven of the patients with pediatric acute respiratory distress syndrome died (7/39, 17.9%). The median durations for mechanical ventilation and vasoactive medications were 123.5 hours (35.25–226.00 hr) and 2 days (1–5 d), respectively. Eighty-six percent of patients had multiple organ dysfunction syndrome at the point at which severe sepsis was recognized, and 31% had underlying conditions. The hospital mortality rate was 18.8%.

Conclusions:

This report is the first to present the prevalence, treatment, and outcomes of pediatric severe sepsis in the main PICU centers in Southwest China. The mortality rate remains high; therefore, improved clinical management and implementation of large-scale clinical trials are necessary to improve early diagnoses and treatment.
Constraint-Induced Movement Therapy for Improving Motor Function of the Paretic Lower Extremity After Stroke
Authors: dos Anjos Sarah M. , Morris David M. , Taub Edward
Published: July 2019

A 56-yr-old woman with chronic stroke and gait dysfunction was recruited for this study. A lower-extremity constraint-induced movement therapy protocol was given consisting of 3.5 hrs/d of supervised intervention activities on 10 consecutive weekdays. Motor training was intensive and involved shaping. In addition, a group of behavior management strategies was used to induce further unsupervised practice and transference of motor skills from the laboratory to real-world situations. Changes in functional mobility, walking speed, balance, level of assistance, perceived quality of movement, and level of confidence while performing daily activities were assessed five times in both the baseline and intervention phases. The outcomes observed after the intervention were determined by calculating the difference between the average scores obtained in both phases. Changes in perceived quality of movement, level of confidence, level of assistance, and balance were observed.
The Mechanism of Hip Dislocation Related to the Use of Abduction Bar and Hip Compression Bandage in Patients With Spastic Cerebral Palsy
Authors: Kim Sangyoung , Lee Dajeong , Ko Jin Young , Park Yulhyun , Yoon Yong Hoon , Suh Jee Hyun , Ryu Ju Seok
Published: July 2019

Objective

The aims of the study were to identify the differences of forces in the hip adductors between with or without the abduction bar and to evaluate the effect of hip compression bandage on the spasticity of the adductor muscles.

Design

Thirty-three patients with cerebral palsy (Gross Motor Functional Classification System IV and V) were prospectively included. Surface electromyography was taken by attaching electromyography on the adductor and abductor muscles. Theraband was used as hip compression bandage. Surface electromyography were taken when spasticity provoked with and without abduction bar, as well as with both abduction bar and hip compression bandage. Root mean square values were measured.

Results

Root mean square values were significantly increased with abduction bar in the adductor longus, adductor magnus, and tensor fascia lata muscles. Adductor Sum and Net Adduction Index showed significant increases after the use of abduction bar. After applying hip compression bandage, the Net Adduction Index was significantly decreased.

Conclusions

Our results showed significant changes in the adductor muscles’ amplitude, Adduction Sum, and Net Adduction Index. These results indicate that forces that worsen hip dislocation may develop, and therefore, abduction bar should either not be used for spastic cerebral palsy patients or should only be used with hip compression wrapping in place as well.
“Brazilian Butt Lift” Performed by Board-Certified Brazilian Plastic Surgeons: Reports of an Expert Opinion Survey
Authors: Cansancao Alvaro Luiz , Condé-Green Alexandra , Gouvea Rosique Rodrigo , Junqueira Rosique Marina , Cervantes André
Published: July 2019

Background:

Gluteal fat augmentation has increased worldwide, and so have major complications. Brazilian plastic surgeons have been performing this procedure for more than 30 years, and more often every year. Therefore, the authors performed a study among board-certified plastic surgeons, members of the Brazilian Society of Plastic Surgery, to evaluate their techniques; identify their preferences, complications, and outcomes with this procedure; and make some recommendations.

Methods:

An anonymous Web-based survey consisting of 16 questions was sent to 5655 members in July of 2017. A supplementary survey was subsequently sent to obtain more information about major complications.

Results:

A total of 853 responses were analyzed. The highest percentage of responses in the different categories were as follows: fat decantation for processing, injection with a 3-mm-diameter cannula, use of superior incisions, subcutaneous fat grafting only, and with a volume of 200 to 399 ml of fat per buttock. The majority of surgeons received training in this procedure during residency. The most common complications were contour irregularities. The estimated mortality rate was one in 20,117 cases, and the rate of nonfatal fat embolism was one in 9530. The risk of death was 16 times greater when fat was injected intramuscularly.

Conclusions:

Based on this survey, the authors recommend injecting fat only subcutaneously, by means of superior incisions, using cannulas 3 mm in diameter or more. They find that by following these recommendations, this procedure can be as safe as any other. More research to establish guidelines and increase its safety is necessary.
Relative Tissue Oxygenation and Temperature Changes for Detecting Early Upper Extremity Skin Ischemia
Authors: Polfer Elizabeth M. , Sabino Jennifer M. , Fleming Isaac C. , Means Kenneth R.
Published: July 2019

The authors’ purpose was to determine whether there are reliable noninvasive methods of assessing upper extremity ischemia regardless of skin pigmentation. The authors conducted a study of healthy subjects classified based on skin pigmentation using the Fitzpatrick scale, the von Luschan color scale, and self-described race (two Hispanics, three Caucasians, and four African Americans). A surface temperature probe and a near-infrared spectroscopy monitor were placed on the posterior interosseous artery skin territory. Temporary upper limb ischemia was induced by tourniquet insufflation. Readings from both devices were taken at baseline and every 15 seconds for a total of 10 minutes of ischemia. During tourniquet insufflation, the authors found a reliable decrease in tissue oxygenation measured by near-infrared spectroscopy in all subjects and no significant change in temperature readings for any subjects. There was an average decrease of 19 percent in tissue oxygenation using near-infrared spectroscopy, with measurements on average starting at 77 percent and ending at 57 percent. There was no significant difference in the change in near-infrared spectroscopy oxygenation between participants with Fitzpatrick skin types 3, 4, and 5 or when participants were grouped into Fitzpatrick skin type less than or equal to 3 versus greater than 3, or when grouped into Fitzpatrick skin type less than or equal to 4 versus greater than 4. There was also no significant difference in participants grouped into von Luschan scores less than or equal to 20 versus greater than 20. In this healthy subjects study, near-infrared spectroscopy rapidly identified ischemia in all cases, whereas skin surface temperature did not. Near-infrared spectroscopy may be a reliable way of noninvasively monitoring for ischemia regardless of skin pigmentation degree.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Diagnostic, IV.
Gadolinium Deposition in the Brain in a Large Animal Model
Authors: Radbruch Alexander , Richter Henning , Fingerhut Stefanie , Martin Louise Francoise , Xia Anna , Henze Niklas , Paulus Werner , Sperling Michael , Karst Uwe , Jeibmann Astrid
Published: July 2019

Objective

Recent studies reported a signal intensity increase in the deep cerebellar nuclei (DCN) on magnetic resonance images caused by gadolinium deposition after the injection of gadolinium-based contrast agents (GBCAs). There is an ongoing debate if the propensity of a GBCA to deposit gadolinium is primarily determined by its class as either linear or macrocyclic. In the current study, we aimed to compare the amount and the distribution of retained gadolinium of linear and macrocyclic GBCAs in the DCN after a single injection at a dose comparable to a human patient's in a large animal model.

Materials and Methods

Eighteen sheep were randomly assigned in 6 groups of 3 animals, which received a single injection of 0.1 mmol/kg body weight of either the macrocyclic GBCAs gadobutrol, gadoteridol, or gadoterate meglumine; the linear GBCAs gadobenate dimeglumine or gadodiamide; or saline. Animals were euthanized 10 weeks after injection. Local distribution and concentration of gadolinium and colocalization to other metals (iron, zinc, copper) in the DCN was assessed by laser ablation-inductively coupled plasma-mass spectrometry.

Results

Average gadolinium concentration for the macrocyclic GBCAs and the saline group was below the limit of quantification (5.7 ng/g tissue). In contrast, 14 (for gadobenate) and 27 (for gadodiamide) times more gadolinium than the limit of quantification was found for the linear GBCAs gadobenate (mean, 83 ng/g) or gadodiamide (mean, 155 ng/g brain tissue). Gadolinium distribution colocalized with other metals for linear GBCAs and a specific accumulation in the DCN was found.

Discussion

The current study supports the hypothesis that the amount of gadolinium deposited in the brain is primarily determined by its class as either macrocyclic or linear. The accumulation of gadolinium in the DCN for linear GBCAs explains the hyperintensities in the DCN found in previous patient studies with linear GBCAs.