bluuebunny/crossref_metadata_2025 huggingface dataset:
Plasma β-Hydroxybutyrate for the Diagnosis of Diabetic Ketoacidosis in the Emergency Department
Authors: Tremblay Elise Schlissel , Millington Kate , Monuteaux Michael C. , Bachur Richard G. , Wolfsdorf Joseph I.
Published: February 2020

Objective

Diabetic ketoacidosis (DKA) is a common emergency department presentation of both new-onset and established diabetes mellitus (DM). β-Hydroxybutyrate (BOHB) provides a direct measure of the pathophysiologic derangement in DKA as compared with the nonspecific measurements of blood pH and bicarbonate. Our objective was to characterize the relationship between BOHB and DKA.

Methods

This is a cross-sectional retrospective study of pediatric patients with DM presenting to an urban pediatric emergency department between January 1, 2016, and September 30, 2018. Analyses were performed on each patient's initial, simultaneous BOHB and pH. Diagnostic test characteristics of BOHB were calculated, and logistic regression was performed to investigate the effects of age and other key clinical factors.

Results

Among 594 patients with DM, with median age of 12.3 years (interquartile range, 8.7–15.9 years), 176 (29.6%) presented with DKA. The inclusion of age, transfer status, and new-onset in the statistical model did not improve the prediction of DKA beyond BOHB alone. β-Hydroxybutyrate demonstrated strong discrimination for DKA, with an area under the curve of 0.95 (95% confidence interval, 0.93–0.97). A BOHB value of 5.3 mmol/L predicted DKA with optimal accuracy (90.6% of patients were correctly classified). The sensitivity, specificity, and positive and negative predictive values of this cut point were 76.7% (95% confidence interval, 69.8%–82.7%), 96.4% (94.2%–98.0%), 90.0% (84.0%–94.3%), and 90.8% (87.7%–93.3%), respectively.

Conclusions

β-Hydroxybutyrate accurately predicts DKA in children and adolescents. More importantly, because plasma BOHB is the ideal biochemical marker of DKA, BOHB may provide a more optimal definition of DKA for management decisions and treatment targets.
Ultrasound-Guided Needle Aspiration of an Iliac Crest Abscess in a Pediatric Emergency Department
Authors: Surdhar Ian , Kirschner David
Published: February 2020

Point-of-care ultrasound (POCUS) is an integral part of pediatric emergency medicine. One evolving use of POCUS is in the diagnosis and management of skin and soft tissue infections. Point-of-care ultrasound can be used to identify clinically occult infections and can be used to guide percutaneous drainage of both superficial and deep abscesses. Here, we present a case where POCUS- and US-guided needle aspiration had a significant impact on patient care by providing rapid diagnosis, as well as expediting microbiological speciation in a young male presenting with left-sided back and buttock pain.
A Replicable Approach to Promoting Best Practices: Translating Cardiovascular Disease Prevention Research
Authors: Hawkins Nikki A. , Bhuiya Aunima R. , Shantharam Sharada , Chapel John M. , Taylor Lauren N. , Thigpen Sally , Decker Amara , Moeti Refilwe , Bernard Stephanie , Jones Christopher D. , Schooley Michael
Published: February 2020

Objective:

Significant delays in translating health care–related research into public health programs and medical practice mean that people may not get the best care when they need it. Regarding cardiovascular disease, translation delays can mean lives may be unnecessarily lost each year. To facilitate the translation of knowledge to action, we created a Best Practices Guide for Cardiovascular Disease Prevention Programs.

Design:

Using the Rapid Synthesis Translation Process and the Best Practices Framework as guiding frameworks, we collected and rated research evidence for hypertension control and cholesterol management strategies. After identifying best practices, we gathered information about programs that were implementing the practices and about resources useful for implementation. Research evidence and supplementary information were consolidated in an informational resource and published online. Web metrics were collected and analyzed to measure use and reach of the guide.

Results:

The Best Practices Guide was released in January 2018 and included background information and resources on 8 best practice strategies. It was published as an online resource, publicly accessible from the Centers for Disease Control and Prevention Web site in 2 different formats. Web metrics show that in the first year after publication, there were 25 589 Web page views and 2467 downloads. A query of partner use of the guide indicated that it was often shared in partners' own resources, newsletters, and online material.

Conclusion:

In following a systematic approach to creating the Best Practices Guide and documenting the steps taken in its development, we offer a replicable approach for translating research on health care practices into a resource to facilitate implementation. The success of this approach is attributed to 3 key factors: using a prescribed and documented approach to evidence translation, working closely with stakeholders throughout the process, and prioritizing the content design and accessibility of the final product.
Deaths, Hospitalizations, and Emergency Department Visits From Food-Related Anaphylaxis, New York City, 2000-2014: Implications for Fatality Prevention
Authors: Poirot Eugenie , He Fangtao , Gould L. Hannah , Hadler James L.
Published: February 2020

Context:

Food-induced anaphylaxis is potentially fatal but preventable by allergen avoidance and manageable through immediate treatment. Considerable effort has been invested in preventing fatalities from nut exposure among school-aged children, but few population-based studies exist to guide additional prevention efforts.

Objectives:

To describe the epidemiology and trends of food-related anaphylaxis requiring emergency treatment during a 15-year span in New York City when public health initiatives to prevent deaths were implemented and to understand the situational circumstances of food-related deaths.

Design/Setting/Participants:

Retrospective death record review and analysis of inpatient hospital discharges and emergency department (ED) visits in New York City residents, 2000-2014.

Main Outcome:

Vital statistics data, medical examiner reports, ED, and hospital discharge data were used to examine risk for death and incidence trends in medically attended food-related anaphylaxis. Potentially preventable deaths were those among persons with a known allergy to the implicated food or occurring in public settings.

Results:

There were 24 deaths, (1.6 deaths/year; range: 0-5), 3049 hospitalizations, and 4014 ED visits, including 7 deaths from crustacean, 4 from peanut, and 2 each from tree nut or seeds and fish exposures. Risk for death among those hospitalized or treated in the ED was highest for persons older than 65 years and for those treated for crustacean reactions (relative risk 6.5 compared with those treated for peanuts, 95% confidence interval = 1.9-22.1). Eleven of 16 deaths with medical examiner data were potentially preventable. Hospitalizations (2000-2014) and ED visit rates (2005-2014) were highest for children and those with peanut exposure and increased across periods.

Conclusions:

Deaths from food-related anaphylaxis were rare; however, rates of hospitalization and ED visits increased. Prevention efforts related to peanut allergies among children should continue, and additional attention is needed to prevent and treat anaphylaxis among adults, particularly those with known crustacean allergies where case fatality is highest.
Preliminary Adaptation, Development, and Testing of a Team Sports Model to Improve Briefing and Debriefing in Neonatal Resuscitation
Authors: Jordache Rebecca , Doherty Cora , Kenny Celyn , Bowie Paul
Published: February 2020

Background:

Briefing in team sports has been shown to benefit both performance and confidence among team members. The neonatal resuscitation team shares similarities with sports teams, where task performance includes rapid decision-making skills within dynamic situations, alongside unpredictable circumstances.

Aim:

We aimed to determine the effect of a team sports briefing model on the neonatal resuscitation team. Method: We adapted and redesigned a team sports briefing and debriefing model and related protocol and tested them with a neonatal resuscitation team in a U.K. university teaching hospital.

Results:

The team’s confidence and perceptions around these 2 aspects of resuscitation were studied along with frequency of task execution before and after a teaching intervention about the sports teams' approach to briefing and the introduction of a 7-point checklist. In 20 preintervention observations of 13 key tasks, areas for improvement in how neonatal intensive care unit (NICU) staff prepared for deliveries and potential resuscitations were found such as in “discussing potential deliveries that day” (n = 10, 50%), “identifying roles within the resus team that shift” (n = 5, 20%), and announcing when and where a debrief would occur (n = 0, 0%). Postintervention, the NICU team’s mean task completion increased significantly from 9.23 (SD = 6.34) to 18.0 (SD = 1.83), a statistically meaningful difference of 8.77 (95% CI, 4.99−12.55; P < 0.001).

Conclusion:

Together with increased levels of confidence and efficiency reported postintervention, this provides some evidence that a brief–debrief process based on how sports team’s approach pregame situations could be potentially transferable and beneficial to NICU team performance.
The impact of self-selection based on HIV risk on the cost-effectiveness of preexposure prophylaxis in South Africa
Authors: Jamieson Lise , Gomez Gabriela B. , Rebe Kevin , Brown Ben , Subedar Hasina , Jenkins Sarah , Shoko Natsai , Bekker Linda-Gail , Johnson Leigh F. , Meyer-Rath Gesine
Published: February 2020

Objectives:

We explored the impact and cost-effectiveness of preexposure prophylaxis (PrEP) provision to different populations in South Africa, with and without effective self-selection by individuals at highest risk of contracting HIV (through concurrent partnerships and/or commercial sex).

Design and methods:

We used a previously developed HIV transmission model to analyse the epidemiological impact of PrEP provision to adolescents, young adults, pregnant women, female sex workers (FSWs) and (MSM), and data from South African PrEP programmes to estimate the cost and cost-effectiveness of PrEP (cost in 2019 USD per HIV infection averted over 20 years, 2019, 38). PrEP uptake followed data from early implementation sites, scaled-up linearly over 3 years, with target coverage set to 18% for adolescents, young adults and pregnant women, 30% for FSW and 54% for MSM.

Results:

The annual cost of PrEP provision ranges between $75 and $134 per person. PrEP provision adolescents and young adults, regardless of risk behaviour, will each avert 3.2--4.8% of HIV infections over 20 years; provision to high-risk individuals only has similar impact at lower total cost. The incremental cost per HIV infection averted is lower in high-risk vs. all-risk sub-populations within female adolescents ($507 vs. $4537), male adolescents ($2108 vs. $5637), young women ($1592 vs. $10 323) and young men ($2605 vs. $7715), becoming cost saving within 20 years for high-risk adolescents, young women, MSM and FSWs.

Conclusion:

PrEP is an expensive prevention intervention but uptake by those at the highest risk of HIV infection will make it more cost-effective, and cost-saving after 14–18 years.
TIGIT is upregulated by HIV-1 infection and marks a highly functional adaptive and mature subset of natural killer cells
Authors: Vendrame Elena , Seiler Christof , Ranganath Thanmayi , Zhao Nancy Q. , Vergara Rosemary , Alary Michel , Labbé Annie-Claude , Guédou Fernand , Poudrier Johanne , Holmes Susan , Roger Michel , Blish Catherine A.
Published: February 2020

Objective:

Our objective was to investigate the mechanisms that govern natural killer (NK)-cell responses to HIV, with a focus on specific receptor--ligand interactions involved in HIV recognition by NK cells.

Design and Methods:

We first performed a mass cytometry-based screen of NK-cell receptor expression patterns in healthy controls and HIV+ individuals. We then focused mechanistic studies on the expression and function of T cell immunoreceptor with Ig and ITIM domains (TIGIT).

Results:

The mass cytometry screen revealed that TIGIT is upregulated on NK cells of untreated HIV+ women, but not in antiretroviral-treated women. TIGIT is an inhibitory receptor that is thought to mark exhausted NK cells; however, blocking TIGIT did not improve anti-HIV NK-cell responses. In fact, the TIGIT ligands CD112 and CD155 were not upregulated on CD4+ T cells in vitro or in vivo, providing an explanation for the lack of benefit from TIGIT blockade. TIGIT expression marked a unique subset of NK cells that express significantly higher levels of NK-cell-activating receptors (DNAM-1, NTB-A, 2B4, CD2) and exhibit a mature/adaptive phenotype (CD57hi, NKG2Chi, LILRB1hi, FcRγlo, Syklo). Furthermore, TIGIT+ NK cells had increased responses to mock-infected and HIV-infected autologous CD4+ T cells, and to PMA/ionomycin, cytokine stimulation and the K562 cancer cell line.

Conclusion:

TIGIT expression is increased on NK cells from untreated HIV+ individuals. Although TIGIT does not participate directly to the response to HIV-infected cells, it marks a population of mature/adaptive NK cells with increased functional responses.
Aging does not impact drug--drug interaction magnitudes with antiretrovirals
Authors: Stader Felix , Decosterd Laurent , Stoeckle Marcel , Cavassini Matthias , Battegay Manuel , Saldanha Susana Alves , Marzolini Catia , Courlet Perrine
Published: February 2020

The risk of drug–drug interactions (DDIs) is elevated in aging people living with HIV (PLWH) because of highly prevalent age-related comorbidities leading to more comedications. To investigate the impact of aging on DDI magnitudes between comedications (amlodipine, atorvastatin, rosuvastatin) and boosted darunavir, we conducted a clinical trial in aging PLWH aged at least 55 years. DDI magnitudes were comparable with those reported in young individuals supporting that the clinical management of DDIs in aging PLWH can be similar.
Elevated cardiac risk score by Atherosclerotic Cardiovascular Disease calculation is associated with albuminuria in older people living with HIV
Authors: Johnston Carrie D. , Ifeagwu Kene-Chukwu C. , Siegler Eugenia L. , Derry Heather , Burchett Chelsie O. , Rice Michelle C. , Gupta Samir K. , Choi Mary E. , Glesby Marshall J.
Published: February 2020

Globally, the proportion of older people living with HIV (PLWH) is growing and the burden of noncommunicable diseases, including cardiac and renal disease, is increasing. There are few studies of renal disease and cardiac risk in older PLWH. This study investigates the relationship between albuminuria and cardiac risk as estimated by the Atherosclerotic Cardiovascular Disease 10-year risk calculator. We report that albuminuria is associated with a higher Atherosclerotic Cardiovascular Disease risk score in both diabetic and nondiabetic older PLWH.
Pilot study assessing the Rotterdam Healthy Aging Score in a cohort of HIV-positive adults in Toronto, Canada
Authors: Walmsley Sharon L. , Ren Melody , Simon Ceylon , Clarke Rosemarie , Szadkowski Leah
Published: February 2020

Objective:

The Rotterdam Healthy Aging Score (HAS) is a validated multidimensional index constructed from five health domains. We describe the HAS distribution in a cohort of HIV-positive adults and correlate it with health outcomes.

Design:

A cross-sectional pilot study of 101 adults aged at least 40 years, on suppressive antiretroviral therapy attending a tertiary HIV clinic in Toronto, Canada.

Methods:

Participants completed questionnaires to calculate their HAS (range 0–14). Demographics, HAS and sub-scores were compared by age and sex. The HAS was compared with results of the Fried Frailty Score, Short Performance Physical Battery score (SPPB) and measures of health utilization. Kruskal--Wallis Rank-Sum and Fisher's exact tests were used for all comparisons.

Results:

Median (IQR) age was 56 (50--62), 81 (80%) men and 50 (50%) born in Canada. Median (IQR) CD4+ cell count was 574 (417--794) cells/μl. Median (IQR) HAS was 12 (10--13) with 39 (39%) achieving a score more than 12 (considered healthy aging). Younger participants experienced more depression, whereas women had greater pain. The HAS score correlated with the Fried Frailty Score (P = 0.008) and trended with the SPPB Score (P = 0.077). Those with the poorest HAS scores were more likely to have been hospitalized in the preceding 6 months (P = 0.034).

Conclusion:

The HAS ranged from 5 to 14 in this cohort of older HIV adults with 39% attaining scores in the ‘healthy’ range. The HAS correlated with measures of physical performance and health utilization. Further validation of an objective outcome in HIV-positive patients will facilitate evaluation of interventional studies to improve healthy aging.
Advances in the diagnosis and treatment of latent tuberculosis infection
Authors: Jung Ye Eun (Grace) , Schluger Neil W.
Published: February 2020

Purpose of review

This review describes the major developments in the rationale for treating latent tuberculosis infection; new approaches to identifying persons with latent infection who are most likely to progress to active disease; and the development of novel short-course regimens for treatment of latent tuberculosis.

Recent findings

As many as one-third of the world's population has latent infection with Mycobacterium tuberculosis. Models demonstrate that tuberculosis will not be eliminated without large-scale treatment of persons with latent TB. Current tools for identifying persons at risk for active tuberculosis disease include TST and IGRA, which have poor positive predictive values. Newer approaches using gene expression profiling show promise and are being studied in the ongoing trials. Development of short-course regimens are a major advance in treatment of latent TB. Three months of rifapentine with isoniazid, 4 months of rifampin, and 1 month of rifapentine with isoniazid have been found to be noninferior to the standard 9 months of isoniazid.

Progress towards TB elimination can be accelerated by instituting public health measures that take into account new developments in identifying and treating persons with latent tuberculosis infection who are most likely to progress to active disease.
The skin and soft tissue infections in hematological patients
Authors: Ungaro Riccardo , Mikulska Malgorzata
Published: February 2020

Purpose of review

Skin and soft tissue infections (SSTIs) in patients with hematological malignancies are frequent, but dedicated epidemiological studies are limited. The aim of this review is to provide updated description of the main etiological agents, differential diagnosis, and treatment.

Recent findings

In addition to common causes of bacterial skin infections in any kind of patients, such as streptococci and staphylococci (the letter frequently resistant to methicillin), Pseudomonas aeruginosa is a frequent agent in patients with hematological malignancies, with high virulence and typical infection presenting as ecthyma gangrenosum. Among fungi, fusariosis is the mold infection most frequently associated with skin lesions, although other molds and yeasts (including Candida tropicalis) should be also considered. External infections associated with central venous catheters are frequent in the hematological setting, and in addition to staphylococci, Gram-negative bacteria, fungi, and even rapid growing nontuberculous mycobacteria should be considered. Immunodeficiency might either blunt the typical inflammatory response and make sign or symptoms less evident, or predispose the patients to rapid progression of skin infection to subcutaneous tissues or dissemination.

SSTIs in hematology patients can be caused by various infectious agents resulting in similar clinical presentation. Rapid and accurate diagnosis is fundamental in order to reduce morbidity and mortality.
Treatment of multidrug-resistant Gram-negative skin and soft tissue infections
Authors: Jabbour Jean-Francois , Sharara Sima L. , Kanj Souha S.
Published: February 2020

Purpose of review

The increase in skin and soft tissue infections (SSTI) because of multidrug-resistant (MDR) pathogens is a global concern. Although MDR Gram-negative bacteria (GNB) are often overlooked as a cause of SSTIs, their burden on the morbidity of many subgroups of patients is high. There is a paucity in the available treatment options and guidelines on how to treat these pathogens. This manuscript reviews the management of SSTIs caused by carbapenem-resistant Enterobacteriaceae (CRE), Pseudomonas aeruginosa (CRPA), Acinetobacter baumannii (CRAB), and Stenotrophomonas maltophilia. We also highlight a few novel antibiotics that show promise in the future management of MDR-GNB SSTIs.

Recent findings

Studies on treatment options of MDR-GNB SSTIs are scarce. Most clinical trials investigating new antibiotics have addressed conditions such as complicated intraabdominal infections, complicated urinary infections, and respiratory infections. CREs are a heterogenous group of pathogens with various mechanisms of resistance dictating susceptibility to different antimicrobial agents. Ceftazidime--avibactam, and meropenem--vaborbactam have potent activity against some of the CREs, especially Klebsiella pneumoniae carbapenemase (KPC) producers. Several novel antibiotics have potent activity against CRPA SSTIs, such as ceftazidime--avibactam, ceftolozane--tazobactam, cefiderocol, delafloxacin, finafloxacin, and murepavadin. Cefiderocol may also play an important role in the management of CRAB SSTIs, along with plazomicin and eravacycline.

MDR-GNB play a major role in SSTIs in patients with underlying immunodeficiency, as well as burn or trauma-related injuries. With the alarming global rise in MDR-GNB resistance, antibiotic therapy for SSTIs is challenging and must be guided by in-vitro susceptibility results. Currently, data extrapolated from other indications and combination therapy can be used empirically pending microbiological data and susceptibilities. Novel antibiotics are currently under development. It is hoped that future clinical trials will be designed to address MDR-GNB SSTIs.
Community-acquired pneumonia in chronic obstructive pulmonary disease
Authors: Cavallazzi Rodrigo , Ramirez Julio
Published: February 2020

Purpose of review

The aim of this study was to discuss the literature on community-acquired pneumonia (CAP) in patients with chronic obstructive pulmonary disease (COPD).

Recent findings

Well designed studies show that COPD is the strongest risk factor for development of CAP. Lung microbiome, abnormal lung immunity and pathogen virulence are important components of the pathogenesis of CAP in COPD. The cause of CAP in patients with COPD is similar to that of non-COPD patients. However, patients with COPD are at an increased risk of infection by Gram-negative bacilli, including Pseudomonas aeruginosa. Empiric treatment regimens for CAP in COPD should contemplate the most common pathogens, and consideration should be given for the coverage of Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus depending on the severity of CAP, severity of COPD or prior isolation of these pathogens. COPD has not been consistently shown to be an independent risk factor for worse short-term outcomes in patients with CAP. In a long-term study, COPD is associated with worse outcomes in these patients.

Research focused on lung microbiome and abnormal lug immunity in patients with COPD should be prioritized. Further clinical research should try to consolidate the role of additional treatment approaches such as immunomodulating medications in COPD patients with CAP.
Complex Regional Pain Syndrome Evolving to Full-Blown Fibromyalgia
Authors: Martínez-Lavín Manuel , Vargas Angelica , Silveira Luis H. , Amezcua-Guerra Luis M. , Martínez-Martínez Laura-Aline , Pineda Carlos
Published: February 2020

Background

Spread of complex regional pain syndrome (CRPS) outside the affected limb is a well-recognized phenomenon; nevertheless, the actual evolution from CRPS to fibromyalgia is poorly documented. Similar mechanisms have been recently put forward to explain the development of CRPS and fibromyalgia including dorsal root ganglia (DRG) hyperexcitability and small fiber neuropathy.

Objectives

The aims of this study were to describe 3 cases with typical CRPS evolving to full-blown fibromyalgia and to discuss the potential pathogenetic mechanisms linking these debilitating illnesses.

Methods

This was a review of medical records and PubMed search on the relationship between CRPS-fibromyalgia with DRG and small nerve fiber neuropathy.

Results

Our 3 cases displayed over time orderly evolution from CRPS to fibromyalgia. Dorsal root ganglion hyperexcitability and small fiber neuropathy have been recently demonstrated in CRPS and in fibromyalgia. Dorsal root ganglia contain the small nerve fiber cell bodies surrounded by glial cells. After trauma, DRG perineuronal glial cells produce diverse proinflammatory mediators. Macrophages, lymphocytes, and satellite glial cells may drive the immune response to more rostrally and caudally located DRG and other spinal cord sites. Dorsal root ganglion metabolic changes may lead to small nerve fiber degeneration. This mechanism may explain the development of widespread pain and autonomic dysfunction.

Conclusions

Clinicians should be aware that CRPS can evolve to full-blown fibromyalgia. Spreading of neuroinflammation through DRG glial cell activation could theoretically explain the transformation from regional to generalized complex pain syndrome.
Transverse Myelitis in Systemic Lupus Erythematosus
Authors: Chiganer Edson Hernán , Lessa Carmen Flora , Di Pace José Luis , Perassolo Mónica Beatriz , Carnero Contentti Edgar , Alessandro Lucas , Correale Jorge , Farfan María Fernanda , Galiana Graciana Lourdes , Sánchez Benavides Marvin , Pacello Franco , Stagno Mauro , Cardozo Analía , Nacimiento Cantero María Belén , Elizaur López Juan Gabriel , Delgadillo Pedro Daniel , Melgarejo Patricia , Acosta Colman Isabel , Vázquez Báez Marcos Aurelio , Correa Díaz Edgar Patricio , Jácome Sánchez Elisa Carolina , Alva Linares Magaly , Zamora Tehozol Erick Adrian , Fragoso-Loyo Hilda Esther , Quintanilla-González Lauro , Batún-Garrido José Antonio de Jesús , Sato Emilia Inoue , do Reis-Neto Edgard Torres , Carreño Nigro María Angela , Hryb Javier Pablo
Published: February 2020

Background

Acute transverse myelitis (ATM) is an infrequent but severe complication of systemic lupus erythematosus (SLE). The purpose of study was to describe clinical features and prognostic factors of patients with SLE-related ATM.

Methods

In this medical records review study, data were collected from 60 patients from 16 centers seen between 1996 and 2017 who met diagnostic criteria for SLE and myelitis as defined by the American College of Rheumatology/Systemic International Collaborating Clinics and the Working Group of the Transverse Myelitis Consortium, respectively. Objective neurological impairment was measured with American Spinal Injury Association Impairment Scale (AIS) and European Database for Multiple Sclerosis Grade Scale (EGS).

Results

Among patients included, 95% (n = 57) were female, and the average age was 31.6 ± 9.6 years. Myelitis developed after diagnosis of SLE in 60% (n = 36). Symmetrical paraparesis with hypoesthesia, flaccidity, sphincter dysfunction, AIS = A/B, and EGS ≥ 8 was the most common presentation. Intravenous methylprednisolone was used in 95% (n = 57), and 78.3% (n = 47) received intravenous cyclophosphamide. Sensory/motor recovery at 6 months was observed in 75% (42 of 56), but only in 16.1% (9 of 56) was complete. Hypoglycorrhachia and EGS ≥ 7 in the nadir were associated with an unfavorable neurological outcome at 6 months (p < 0.05). A relapse rate during follow-up was observed in 30.4% (17 of 56). Hypoglycorrhachia and hypocomplementemia seem to be protective factors for relapse. Intravenous cyclophosphamide was associated with time delay to relapse.

Conclusions

Systemic lupus erythematosus–related ATM may occur at any time of SLE course, leading to significant disability despite treatment. Relapses are infrequent and intravenous cyclophosphamide seems to delay it. Hypoglycorrhachia, hypocomplementemia, and EGS at nadir are the most important prognostic factors.
Advanced Diffusion-Weighted Abdominal Imaging
Authors: Dreher Constantin , Kuder Tristan Anselm , König Franziska , Paech Daniel , Tavakoli Andrej , Laun Frederik Bernd , Flothow Florian , Gnirs Regula , Benkert Thomas , Strecker Ralph , Schlemmer Heinz-Peter , Bickelhaupt Sebastian
Published: February 2020

Introduction

Magnetic resonance imaging (MRI) of the abdomen increasingly incorporates diffusion-weighted imaging (DWI) sequences. Whereas DWI can substantially aid in detecting and characterizing suspicious findings, it remains unclear to what extent the use of ultra-high b-value DWI might further be of aid for the radiologist especially when using DWI sequences with advanced processing. The target of this study was therefore to compare high and ultra-high b-value DWI in abdominal MRI examinations.

Methods

This institutional review board–approved, prospective study included abdominal MRI examinations of 70 oncologic patients (mean age, 58 years; range, 21-90 years) examined with a clinical 1.5 T MRI scanner (MAGNETOM Aera, Siemens Healthcare, Erlangen, Germany) with an advanced echo planar DWI sequence (b = 0, 50, 900, and 1500 s/mm2) after ex vivo phantom and in vivo volunteer investigations. High b900 and ultra-high b1500 DWIs were compared by a qualitative reading for image quality and lesion conspicuity using a 5-point Likert scale with 2 radiologists as readers. The ratios of apparent signal intensities of suspicious lesions/normal tissue of the same organ (LNTRs) were calculated. Appropriate methods were used for statistical analysis, including Wilcoxon signed-rank test and κ statistic for interreader agreement analysis (P < 0.05/0.0125/0.005 after Bonferroni correction).

Results

Image quality was significantly increased with b900 as compared with b1500 DWI (P < 0.001) despite using an advanced DWI sequence. A total of 153 suspicious lesions were analyzed. Overall reader confidence for characterization/detection of malignant lesions and, correspondingly, the LNTR (mean, 2.7 ± 1.8 vs 2.4 ± 1.6) were significantly higher with b900 than with b1500 DWI (P < 0.001 and P < 0.001). The increased confidence of lesion recognition and LNTR in the b900 DWI remained significant qualitatively in lymphatic and hepatic lesions and quantitatively in lymphatic, pulmonal, and osseous lesions.

Conclusions

Using high b-value DWI (900 s/mm2) provided an improved image quality and also lesion conspicuity as compared with ultra-high b-value DWI (1500 s/mm2) in oncologic abdominal examinations despite using advanced processing. Consequently, the value for additional ultra-high b-value DWI in oncologic examinations should be critically evaluated in future studies.
Assessment of Low-Grade Focal Cartilage Lesions in the Knee With Sodium MRI at 7 T
Authors: Zbýň Štefan , Schreiner Markus , Juras Vladimir , Mlynarik Vladimir , Szomolanyi Pavol , Laurent Didier , Scotti Celeste , Haber Harry , Deligianni Xeni , Bieri Oliver , Nieminen Miika T. , Trattnig Siegfried
Published: February 2020

Objectives

Several articles have investigated potential of sodium (23Na) magnetic resonance imaging (MRI) for the in vivo evaluation of cartilage health, but so far no study tested its feasibility for the evaluation of focal cartilage lesions of grade 1 or 2 as defined by the International Cartilage Repair Society. The aims of this study were to evaluate the ability of 23Na-MRI to differentiate between early focal lesions and normal-appearing cartilage, to evaluate within-subject reproducibility of 23Na-MRI, and to monitor longitudinal changes in participants with low-grade, focal chondral lesions.

Materials and Methods

Thirteen participants (mean age, 50.1 ± 10.9 years; 7 women, 6 men) with low-grade, focal cartilage lesions in the weight-bearing region of femoral cartilage were included in this prospective cohort study. Participants were assessed at baseline, 1 week, 3 months, and 6 months using morphological MRI at 3 T and 7 T, compositional 23Na-MRI at 7 T, and the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire. 23Na signal intensities corrected for coil sensitivity and partial volume effect (23Na-cSI) were calculated in the lesion, and in weight-bearing and non–weight-bearing regions of healthy femoral cartilage. Coefficients of variation, repeated measures analysis of covariance models, and Pearson correlation coefficients were calculated to evaluate within-subject reproducibility as well as cross-sectional and longitudinal changes in 23Na-cSI values.

Results

The mean coefficients of variation of 23Na-cSI values between the baseline and 1-week follow-up were 5.1% or less in all cartilage regions. Significantly lower 23Na-cSI values were observed in lesion than in weight-bearing and non–weight-bearing regions at all time points (all P values ≤ 0.002). Although a significant decrease from baseline 23Na-cSI values in lesion was found at 3-month visit (P = 0.015), no substantial change was observed at 6 months. KOOS scores have improved in all subscales at 3 months and 6 months visit, with a significant increase observed only in the quality of life subscale (P = 0.004).

Conclusions

In vivo 23Na-MRI is a robust and reproducible method that allows to differentiate between low-grade, focal cartilage lesions and normal-appearing articular cartilage, which supports the concept that compositional cartilage changes can be found early, before the development of advanced morphological changes visible at clinical 3-T MRI.
Burn Survivor Artist Changes Artistic Approach by Sharing How Other Survivors of Traumatic Events Can Use Art to Heal Themselves by Helping Others Heal
Authors: Hall Joel Thomas
Published: February 2020

When creating art, the mind becomes free of physical barriers, no longer feeling broken or different. These same results can be sustained long term over large populations of survivors of traumatic events by grouping individuals into teams to create art of all types with the focus being on helping others. Long-term sustainability can occur with the concept of dedicated centers such as art studios and performing art centers with others that believe in art's healing potential. The simple activity of healing yourself while helping others heal, in whatever large or small way, can help us thrive beyond just surviving. No matter how long ago a traumatic event occurred in someone's life, those lessons learned should be shared with new burn survivors as they go through the long and difficult healing process by having a place that they can go and be with others who have been through the same process.
Lipofilled Mini Dorsi Flap
Authors: Piat Jean-Marc , Tomazzoni Gabriela , Giovinazzo Vincenzo , Dubost Valentine , Maiato Anna Paula , Ho Quoc Christophe
Published: February 2020

Introduction

The traditional extended latissimus dorsi flap technique, in addition to lipofilling, has been one of the main procedures used for breast reconstruction after mastectomy. However, to obtain excellent results, this technique requires a large muscle harvest and further lipofilling sessions. The lipofilled mini dorsi flap technique, performed in a single operation, appealed to us as a way to improve the traditional technique.

We present our experience with the lipofilled mini dorsi flap technique in a new scenario.

Materials and Methods

We performed breast reconstruction with a lipofilled mini dorsi flap in female patients with breast cancer who underwent mastectomy and immediate breast reconstruction with a lipofilled mini dorsi flap. The operative technique is detailed in this article. The results were evaluated by the patients and the surgical team.

Results

We performed 72 lipofilled mini dorsi flap procedures during breast reconstruction surgery from May 2017 to January 2019. Fifty-nine (81.9%) cases were immediate reconstructions. Complications, such as infection or necrosis of the flap, were not observed in this study. We noticed seroma and 1 case of infected lymphocele, which was drained.

Body mass index (BMI) was directly related to postoperative dorsal seroma. The authors reported that greater BMI was associated with a higher seroma volume.

Most patients evaluated their reconstruction as satisfactory. The surgical team evaluated most of the results as very satisfactory or satisfactory. There were no cases of unsatisfactory results reported either by the patients or the surgical team.

Conclusions

The lipofilled mini dorsi flap technique is an efficient, elegant, and less invasive solution that is more easily and quickly performed and achieves excellent long-term results in the immediate breast reconstruction scenario. For the first time to our knowledge, lipofilling was used to reduce the extent of latissimus dorsi dissection. The postoperative follow-up was better tolerated by patients. This technique may be offered to patients regardless of oncological treatment. In our experience, the lipofilled mini dorsi flap method has become the primary technique for immediate breast reconstruction.
A Comparative Analysis of Outcomes After Reduction of Zygomatic Fractures Using the Carroll-Girard T-bar Screw
Authors: Choi Bong Gyu , Kang Chan-Su , Kim Yong-Ha , Chung Kyu-Jin
Published: February 2020

Purpose

Several approaches are available for managing zygomatic fractures; however, each approach has its complications. Use of the Carroll-Girard T-bar screw (CGTS) can reduce complications because it reduces the number of approaches needed for reduction. This study aimed to analyze the efficiency of the CGTS compared with the 3-point approach.

Methods

A retrospective study was conducted by reviewing the computed tomography scans of 204 patients who underwent reduction surgery of Knight and North type 3, 4, or 5 zygomatic fractures from March 2009 to August 2017. Facial asymmetry, operative time, and complications were evaluated to compare 2 groups of patients: those who underwent CGTS and those who did not. Bilateral differences in the distance from the reference plane to the malar eminence in 3 dimensions based on computed tomography scans were used to calculate facial asymmetry.

Results

Among 204 patients, 91 were treated with CGTS whereas 113 patients underwent a 3-point approach. Bilateral differences in the position of the malar eminence and facial asymmetry were not statistically different in both groups. Operative time was not different in both groups. However, when patients with type 4 fracture were independently compared, the mean operative time was significantly shorter for the CGTS group. Wound dehiscence occurred in 11 patients (9.7%) in the 3-point approach group, compared with none in the CGTS group. None of the patients in the CGTS group complained of postoperative cheek scars over their incision sites.

Conclusions

This study revealed that CGTS is a useful and feasible instrument that can reduce the number of approaches for zygomatic bone reduction and help clinicians achieve satisfactory outcomes.
Reconstruction of Traumatic Defects of the Tibia With Free Fibula Flap and External Fixation
Authors: Bibbo Christopher , Bauder Andrew R. , Nelson Jonas , Ahn Jaimo , Levin L. Scott , Mehra Samir , Kovach Stephen J.
Published: February 2020

Introduction

Traumatic intercalary defects of the tibia may be effectively managed with the free fibula flap. However, any alteration of limb alignment with residual bony angular deformity of the tibia must be also addressed. We describe the use of the free fibula flap in conjunction with external fixation to allow residual deformity correction and patient mobilization ambulation during healing of the free flap.

Methods

Retrospective medical record review was conducted of patients with segmental tibial defects greater than 7 cm who underwent reconstruction with fibula free flap and simple pin-bar external fixation, followed by conversion to 6-axis computer-assisted multiplanar circular ring external fixation to correct residual bony deformity. Outcomes analyses included free flap complications, return to the operating room, complications associated with the external fixation, bony union, correction of residual deformity, amputation rate, visual analog pain scales, and patient satisfaction.

Results

Eight patients (8 tibiae) underwent reconstruction. Mean tibial bone defect was 10.2 cm; all limbs had soft-tissue defects (mean size, 138 cm2). Free fibula grafts were harvested as osteocutaneous or osteomyocutaneous flaps (average length, 12 cm). Complications included 1 delayed union and 3 (37.5%) patients readmitted for graft fracture. Ultimately, 100% of patients achieved graft union with satisfactory correction of residual limb deformity. Limb salvage rate was 100%.

Discussion

Management of segmental tibial bone loss utilizing initial simple external fixation and microsurgical reconstruction followed by application of computer-assisted circular external fixator may provide a reliable reconstructive protocol for posttraumatic tibial defects with residual bone malalignment.
Geriatric Patients Carry Increased Risk for Deep Venous Thrombosis and Pulmonary Embolism in Reduction Mammaplasty
Authors: Davé Dattesh R. , Arora Aman , Zeiderman Matthew R. , Wong Michael S.
Published: February 2020

Introduction

Reduction mammaplasty is one of the most common plastic surgery procedures performed. No study has evaluated whether geriatric patients are at greater risk for developing postoperative complications relative to nongeriatric patients.

Methods

The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database was reviewed for reduction mammaplasty procedures from 2005 to 2017. Hypothesis testing for demographics, comorbidities, and postoperative complications between geriatric and nongeriatric patients was performed. Statistically significant differences were then evaluated with multivariate logistic regression analysis.

Results

A total of 25,909 reduction mammaplasties were collected by NSQIP from 2005 to 2017, with 1897 patients older than 64 years (8% of all cases). The average age for geriatric breast reduction patients was 69 years versus 41.5 years for nongeriatric patients. Rates of comorbidities including diabetes, smoking status, dyspnea status, and hypertension medication were statistically different between the groups. Rates of deep venous thrombosis (DVT) and pulmonary embolism (PE) were significantly higher in geriatric versus nongeriatric patients, respectively (0.32 vs 0.06, P < 0.001 and 0.37 vs 0.09, P < 0.001). Multivariate analysis demonstrated geriatric patients had a 4.2 and 3.9 times higher risk of developing a DVT and PE than nongeriatric patients (C.I. 1.5–11.6, P = 0.006 and C.I. 1.6–9.8, P = 0.004).

Discussion

This study represents the largest evaluation of geriatric reduction mammaplasties in the United States. Although rare, geriatric age confers a 4 times increased risk for developing DVT and PE relative to nongeriatric patients all while adjusting for preoperative risk factors in reduction mammaplasty. Plastic surgeons should consider counseling their geriatric patients regarding these increased risks.
Artificial Intelligent Virtual Assistant for Plastic Surgery Patient's Frequently Asked Questions
Authors: Boczar Daniel , Sisti Andrea , Oliver Jeremie D. , Helmi Haytham , Restrepo David J. , Huayllani Maria T. , Spaulding Aaron C. , Carter Rickey , Rinker Brian D. , Forte Antonio Jorge
Published: February 2020

Background

Artificial Intelligent Virtual Assistants (AIVA) is a segment of artificial intelligence that is rapidly developing. However, its utilization to address patients' frequently asked questions remains unexplored.

Methods

We developed an AIVA to answer questions related to 10 frequent topics asked by plastic surgery patients in our institution. Between July 27, 2018, and August 10 of 2018, we recruited subjects with administrative positions at our health care institution to chat with the virtual assistant. They asked, with their own words, 1 question for each topic and filled out a satisfaction questionnaire. Postsurvey analysis of questions and answers allowed assessment of the virtual assistant's accuracy.

Results

Thirty participants completed the survey. The majority was female (70%), and the mean age was 27.76 years (SD, 8.68 [19–51] years). The overall accuracy of the plastic surgery AIVA was 92.3% (277/294 questions), and participants considered the answer correct in 83.3% of the time (250/294 answers). Most of the participants considered the AIVA easy to use, answered adequately, and could be helpful for patients. However, when asked if this technology could replace a human assistant, they stayed neutral.
Platelet-Rich Plasma for Skin Graft Storage
Authors: Gökkaya Ali , Görgü Metin , Kızılkan Jehat , Karanfil Ertuğrul , Doğan Ali , Astarcı Hesna Müzeyyen
Published: February 2020

Background

Storage of surplus grafts for later use is one of the standard procedures used in plastic surgery. For the delayed use of skin grafts, various methods and media have been investigated for short-term storage. This study aimed to investigate the effect of platelet-rich plasma (PRP) skin graft storage on the survival of skin grafts obtained from rabbit ears.

Materials and Methods

Twelve rabbits were used in this study. A total of 12 skin grafts measuring 1 × 1 cm2 were obtained from the inner surfaces of the rabbits' ears. The grafts were stored at +4°C in saline, Hartmann's, and PRP media. On days 3, 7, 10, and 14, the grafts were implanted into the ears in areas measuring 1 × 1 cm2 where the skin, cartilage, and perichondria were excised. After the implantation of the grafts, the survival rates were evaluated by measuring the graft areas on day 0, day 10, and day 30.

Results

The graft survival rate decreased as the storage period increased in all 3 of the media. The decrease in survival rate was higher in the grafts that were stored in the Hartmann's media in comparison with the saline and PRP media, and the difference was statistically significant. The decrease in graft survival was similar between the storage in saline and PRP media; however, the differences were statistically insignificant.

Conclusions

Although in vitro criteria are important for evaluating graft survival, in vivo studies showing the graft take rate in the recipient area are required. When the in vivo criteria are evaluated, the use of PRP is not superior to the use of saline for graft storage. However, additional studies are required to evaluate the effects of PRP media on graft quality.