bluuebunny/crossref_metadata_2025_split huggingface dataset:
Short-Term Clinical and Quality Outcomes Have Inconsistent Changes From a Quality Improvement Initiative to Increase Access to Physical Therapy in the Cardiovascular and Surgical ICU
Authors: Tonna Joseph E. , Johnson Joshua , Presson Angela , Zhang Chong , Noren Chris , Lohse Bryan , Bento Haley , Barton Richard G. , Nirula Raminder , Mone Mary , Marcus Robin 
Published: October 2019

Objectives:
Studies of mobility during critical illness have mostly examined transitions from immobility (passive activities) or limited mobility to active “early mobility.”

Design:
Observational analysis of a quality improvement initiative.

Setting:
Two ICUs (surgical ICU, cardiovascular ICU) at a tertiary academic medical center.

Patients:
Critically ill surgical and cardiovascular patients.

Interventions:
Doubling available physical therapy.

Measurements and Main Results:
We examined the outcomes of therapy time/patient/day, ICU and hospital length of stay, disposition location, and change in functional status. We adjusted for age, sex, illness severity, and number of surgeries. Among 1,515 patients (703 baseline, 812 quality improvement), total therapy time increased from 71,994 to 115,389 minutes and from 42,985 to 93,015 minutes, respectively, in each ICU. In the cardiovascular ICU per patient therapy increased 17% (95% CI, –4.9 to 43.9; p = 0.13), and in the surgical ICU, 26% (95% CI, –1 to 59.4; p = 0.06). In the cardiovascular ICU, there was a 27.4% decrease (95% CI, –52.5 to 10.3; p = 0.13) in ICU length of stay, and a 12.4% decrease (95% CI, –37.9 to 23.3; p = 0.45) in total length of stay, whereas in the surgical ICU, the adjusted ICU length of stay increased 19.9% (95% CI, –31.6 to 108.6; p = 0.52) and total length of stay increased 52.8% (95% CI, 1.0–130.2; p = 0.04). The odds of a lower level of care discharge did not change in either ICU (cardiovascular ICU: 2.6 [95% CI, 0.6–12.2; p = 0.22]); surgical ICU: 3.6 [95% CI, 0.9–15.4; p = 0.08]).

Conclusions:
Among diverse cardiothoracic and surgical patients, a quality improvement initiative doubling physical therapy shifts is associated with increased total administered therapy time, but when distributed among a greater number of patients during the quality improvement period, the increase is tempered. This was not associated with consistent changes in ICU length of stay or changes in disposition location.
Increasing Cardiovascular Data Sampling Frequency and Referencing It to Baseline Improve Hemorrhage Detection
Authors: Wertz Anthony , Holder Andre L. , Guillame-Bert Mathieu , Clermont Gilles , Dubrawski Artur , Pinsky Michael R. 
Published: October 2019

Objectives:
We hypothesize that knowledge of a stable personalized baseline state and increased data sampling frequency would markedly improve the ability to detect progressive hypovolemia during hemorrhage earlier and with a lower false positive rate than when using less granular data.

Design:
Prospective temporal challenge.

Setting:
Large animal research laboratory, University Medical Center.

Subjects:
Fifty-one anesthetized Yorkshire pigs.

Interventions:
Pigs were instrumented with arterial, pulmonary arterial, and central venous catheters and allowed to stabilize for 30 minutes then bled at a constant rate of either 5 mL·min–1 (n = 13) or 20 (n = 38) until mean arterial pressure decreased to 40 or 30 mm Hg in the 5 and 20 mL·min–1 pigs, respectively.

Measurements and Main Results:
Data during the stabilization period served as baseline. Hemodynamic variables collected at 250 Hz were used to create predictive models of “bleeding” using featurized beat-to-beat and waveform data and compared with models using mean unfeaturized hemodynamic variables averaged over 1-minute as simple hemodynamic metrics using random forest classifiers to identify bleeding with or without baseline data. The robustness of the prediction was evaluated in a leave-one-pig-out cross-validation. Predictive performance of models was compared by their activity monitoring operating characteristic and receiver operating characteristic profiles. Primary hemodynamic threshold data poorly identified bleed onset unless very stable initial baseline reference data were available. When referenced to baseline, bleed detection at a false positive rates of 10–2 with time to detect 80% of pigs bleeding was similar for simple hemodynamic metrics, beat-to-beat, and waveform at about 3–4 minutes. Whereas when universally baselined, increasing sampling frequency reduced latency of bleed detection from 10 to 8 to 6 minutes, for simple hemodynamic metrics, beat-to-beat, and waveform, respectively. Some informative features differed between simple hemodynamic metrics, beat-to-beat, and waveform models.

Conclusions:
Knowledge of personal stable baseline data allows for early detection of new-onset bleeding, whereas if no personal baseline exists increasing sampling frequency of hemodynamic monitoring data improves bleeding detection earlier and with lower false positive rate.
Validation of Image Quality and Diagnostic Accuracy Using a Mobile Phone Camera Microscope Adaptor Compared With Glass Slide Review in Teledermatopathology
Authors: Laggis Caroline W. , Bailey Elizabeth E. , Novoa Roberto , Stewart Campbell L. , Stoff Benjamin , Wanat Karolyn A. , Barbieri John , Kovarik Carrie 
Published: October 2019

Abstract:
New modalities of evaluating histopathology, such as whole-slide imaging, have been validated in the field of dermatopathology but are often unfeasible and unavailable in developing countries. Widely available across the globe, mobile phone camera technology represents a potential simple and inexpensive method of imaging histologic slides through the use of a mobile phone camera microscope adaptor. This study aims to validate the use of a commercially available adaptor in the diagnosis of inflammatory and infectious conditions in dermatopathology. Representative images were taken of slides for fifty-four cases using the adaptor and shared through a cloud-based platform with five dermatopathologists who rendered diagnoses and judged the quality of the images. After a washout period of 8 weeks, the same cases were assessed by the same dermatopathologists using the original glass slides. The intraobserver concordance rate was 93.3%, and the quality of the mobile phone images was rated as “excellent” or “diagnostic” in 94.4% of the cases. This study validates the use of this low-tech and low-cost adaptor as a reliable tool in teledermatopathology. Limitations of the study include those inherent to use of the adaptor and the limited panel of diagnoses. The primary value of this device may be in developing countries, but its practicality and ease of use lend itself to use in academic and consultative settings in the developed world as well.
Direct Oral Anticoagulant Use After Transcatheter Aortic Valve Replacement: A Case Series
Authors: Hendricks Abby K. , Nei Scott D. , Greason Kevin L. , Scott Rachael A. 
Published: October 2019

Background:
Use of an anticoagulant after transcatheter aortic valve replacement (TAVR) has been increasing in practice after noted leaflet thrombosis on dual antiplatelet therapy. As the use of anticoagulation increases so does the number of poor warfarin candidates or warfarin intolerant patients. While direct oral anticoagulant (DOAC) use is increasing for other indications, there is a paucity of data for use after TAVR. The objective of this case series is to add to the available evidence for patients who may require a DOAC after TAVR.

Methods:
A single-center, retrospective observational case series was conducted including adults 18 years of age and older who received a DOAC after TAVR between November 2008 and June 2018 at Mayo Clinic Hospital—Rochester. All patients were identified as part of the Society of Thoracic Surgeons database.

Results:
Twenty-one patients were identified as having received a DOAC after TAVR. Median age was 83.5 years (interquartile range 77–87), with 71% males. Within this cohort, 20 patients (95.2%) had an alternative indication for anticoagulation of either atrial fibrillation or atrial flutter. Apixaban was prescribed in 66.7% of patients, followed by rivaroxaban (14.3%), dabigatran (9.5%), and edoxaban (4.8%). No thromboembolic events were reported. Three patients experienced a bleeding event, of which only 2 occurred in the 3 months immediately after TAVR.

Conclusions:
DOAC therapy after TAVR was generally safe and well tolerated. Taken in context of other retrospective studies, these data suggest that the presence of valvular heart disease, specifically TAVR in this case, should not preclude the use of DOACs.
Wise Pattern Direct Implant Breast Reconstruction: A Review and Improved Outcomes Using Dermal Matrix
Authors: Friedman Harold I. , Talebagha Sarah , Gilstrap Jarom , Mujadzic Mirsad , Chen Elliott 
Published: October 2019

Background:
The inverted T (Wise pattern) mastectomy for patients with macromastia or significant breast ptosis has evolved along with generalized techniques for breast reconstruction. We present a review of Wise pattern breast reconstruction along with our technique for direct to implant reconstruction using dermal matrix.

Methods:
The literature was reviewed and an analysis of techniques and complications was performed. We present our series of patients incorporating dermal matrix and relatively large implants in direct to implant reconstruction.

Results:
Of 18 breasts reconstructed only 2 failed. One caused by flap necrosis secondary to smoking and one as a result of preoperative radiation.

Conclusion:
Wise pattern breast reconstruction using relatively large implants and dermal matrix in direct to implant reconstruction is a safe technique in selected patients with macromastia.
Addressing the Surgical Deficit: A Global Imperative for Plastic and Reconstructive Surgeons
Authors: Davis Rachel W. , Johnson Walter D. , Hollier Larry H. 
Published: October 2019

Summary:
Despite poor access to quality surgical and anesthesia care for the majority of the world’s people, with greatest impact on low- and middle-income countries, surgery has only recently begun to gain acceptance as a necessary component of global health. As a leader in global surgical funding, the field of Plastic and Reconstructive Surgery is uniquely positioned to influence change in global policy and financial support. For improvements in surgical access and outcomes worldwide, investment in surgical systems, commitment to national surgery, obstetric, and anesthesia planning, and continued evaluation and improvement of care delivery should be pursued.
Metabolic imaging patterns in posterior cortical atrophy and Lewy body dementia
Authors: Gupta Vanshika , Verma Ritu , Ranjan Rajeev , Belho Ethel S. , Seniaray Nikhil , Dinand Veronique , Malik Dharmender , Mahajan Harsh 
Published: October 2019

Purpose
To study the imaging patterns of Posterior cortical atrophy (PCA) and Dementia with Lewy bodies (DLB) on fluoro-deoxyglucose positron emission tomography computed tomography ([18F]FDG PET/CT), identify areas of overlap and differences and to develop a prediction model to assist in diagnosis using univariate and multivariate analysis.

Methods
A retrospective analysis of 72 patients clinically suspected of having posterior dementia was done. All patients underwent [18FF]FDG PET/CT of the brain and dopamine transporter imaging with [[99mTc]TRODAT-1 SPECT scan on separate days. The patients were divided into PCA with normal TRODAT uptake (n=34) and DLB with abnormal TRODAT uptake (n=38). The FDG PET/CT uptake patterns were recorded and areas of significant hypometabolism by z score analysis were considered as abnormal. Receiver operator characteristics (ROC) curve analysis was used to determine cutoff z scores and binary logistic regression analysis was used to determine the Odds ratio of being in the predicted groups.

Results
Significantly hypometabolism was found in parieto-temporo-occipital association cortices and cingulate cortices in PCA patients. DLB patients showed significantly reduced uptake in the visual cortex. No significant difference was found between z score of occipital association cortex which showed hypometabolism in both groups. The cut-off z-score values derived from the ROC curve analysis were as follows- parietal association (cut-off-3, sensitivity-65.6%, specificity - 68.7%), temporal association (cut-off-2, sensitivity-78%, specificity-75%) and posterior cingulate (cut-off-0.5, sensitivity-93.7%, specificity-40.6%), their respective Odds ratio (with 95% confidence interval) for being in the PCA group as derived from univariate logistic regression were 3.66 (1.30–10.32), 10.71 (3.36–34.13) and 7.85 (1.57–39.17). The cut-off z score of primary visual cortex as derived from ROC curve was zero with sensitivity of 87.5%, specificity of 71.9%, and the Odds ratio for being the in the DLB group was 24.7 with 95% confidence interval of 5.99–101.85.

Conclusion
[18F]FDG PET may be useful as a non-invasive diagnostic modality in differentiating the two posterior cortical dementias, despite significant overlap. Primary visual cortical hypometabolism can serve as an independent diagnostic marker for DLB, even in the absence of TRODAT imaging.
Pediatric ossiculoplasty: optimizing outcomes
Authors: Kaffenberger Thomas M. , Eichar Bradley , Chi David H. 
Published: October 2019

Purpose of review
Despite years of research, pediatric ossiculoplasty remains a challenging surgery with numerous variables factoring into successful outcomes. The aim of this review is to summarize recent publications on surgical technique, timing, and reconstruction materials.

Recent findings
The cause behind ossicular discontinuity does not seem to play a role in hearing results after ossiculoplasty; however, revision surgery is associated with worsening outcomes. The status of the ossicles remains an active area of interest, but the data remain mixed in terms of them playing a role in predicting outcomes in adults and pediatric patients. There remains debate regarding the utility of staging the reconstruction and is often undertaken on a case-by-case basis. Other recent publications highlight positive outcomes associated with canal wall-up procedures, titanium prostheses, and partial ossicular reconstruction prostheses. Endoscopic middle ear surgery in ossiculoplasty has been shown to be successful in monitoring and removal of disease and helpful in reconstruction.

Summary
Pediatric ossiculoplasty remains a challenging yet rewarding procedure. The bulk of publications are retrospective making much of the literature difficult to interpret. There remains a need for prospective and well controlled studies in both adult and pediatric populations.
Death by Wheat-Loaded Cartridge
Authors: Okdemir Erdem , Keten Alper , Avşar Abdullah , Kaya Ömer 
Published: October 2019

Abstract
The materials used to produce shotgun ammunition can have different properties depending on the purpose, and ammunition can be fabricated or loaded manually. In Turkey, wheat-loaded cartridges are manufactured for use as sound cartridges. This ammunition is understood by the public to be harmless. However, we present a case of a 13-year-old adolescent boy who was wounded from a contact shot to the chest. An entrance wound measuring 7 cm and 5 cm in diameter was seen on the skin. Wheat grains could not be detected in the internal organs and were only observed between the chest muscles around the entrance wound. A plastic wad was also found in this area. The cause of death was internal bleeding due to internal organ injury. Wheat-loaded cartridges are not visible on x-ray and are difficult to detect visually in the wound.
The Effect of Astaxanthin on Random Pattern Skin Flaps
Authors: Gürsoy Koray , Teymur Hakan , Koca Gökhan , Tanas Işikçi Özlem , Göktaş Demircan Fethiye Berna , Kankaya Yüksel , Koçer Uğur 
Published: October 2019

Background
Skin flaps are the first-line treatment modality for skin defect reconstruction. With the increased importance and use of flap surgery, a growing number of studies have investigated the ways for the prevention of ischemia-reperfusion injury. The aim of this study was to investigate the effect of astaxanthin, which is an antioxidant molecule from the xanthophyll family, on the survival of random pattern skin flaps.

Methods
Thirty-two Sprague-Dawley rats with a caudally based random pattern skin flap (3 × 9 cm) were divided into 4 groups: group A (astaxanthin orally 1 mg/kg per day), group B (astaxanthin orally 4 mg/kg per day), group C (astaxanthin orally 16 mg/kg per day), and the control group. On postoperative day 7, the flaps were evaluated by photographic, scintigraphic, and histological methods. Photographs were taken to investigate the total flap, necrotic flap, and surviving flap areas. A scintigraphic evaluation was undertaken to analyze the surviving area. The flaps were evaluated histopathologically for vascularization, acute inflammation, and chronic inflammation.

Results
The rate of surviving flap areas was observed to increase in parallel to the increase in the astaxanthin dose. Surviving flap areas and flap perfusion values were higher in group C compared with the control group and group A (P < 0.05). The values were also significantly higher in group B compared with control group (P < 0.05). All study groups were shown to have statistically significantly higher vascular density than the control group (P < 0.05), whereas lymphocyte and neutrophil densities were similar among all groups (P > 0.05). The photographic and scintigraphic evaluations for the viable area percentages of the flaps correlated with each other (r
s = 0.913, P < 0.001).

Conclusions
Orally administered astaxanthin, if given at doses higher than 4 mg/kg, increases flap viability rates and vascularization and can be used as an adjunctive agent.
A Sequential Thoracoacromial Artery Perforator Flap for Reconstructing the Donor Site of Sternocleidomastoid Myocutaneous Flaps
Authors: Song Dajiang , Pafitanis Georgios , Reissis Dimitris , Koshima Isao , Zhang Yixin , Narushima Mitsunaga , Zhou Xiao , Li Zan 
Published: October 2019

BackgroundThe current study introduces and demonstrates our experience of using asequentialthoracoacromial artery perforator (TAAP) flap to repair the sternocleidomastoid (SCM) flap donor site in this context. The aims of this technique are to optimize both esthetic and functional outcomes and to reduce postoperative complications for patients.MethodsBetween September 2013 and March 2017, the SCM flap combined with sequential TAAP flap was used for reconstruction postradical parotidectomy in 12 patients. Flap characteristics, patient outcomes, and postoperative complications were monitored and objectively measured, with 10 to 24 months of follow-up.ResultsThere were no incidences of total flap loss. All TAAP flap donor sites were closed directly, and all healed without any complications. The SCM flap and TAAP flap donor areas were esthetically acceptable, with good esthetic and functional outcomes achieved in all 12 patients.ConclusionsThe sequential TAAP flap has a consistent vascular supply and provides a reliable surgical approach to reconstruct the SCM flap donor site with good esthetic and functional outcomes.
Gliding Tissue Reconstruction Using a Dorsal Digital Adipofascial Flap in Complex Extensor Injury
Authors: Hosomi Kento , Iwasawa Motonao , Mishima Yoshito , Kawamura Tatsuya , Nagai Fumio 
Published: October 2019

Background
Postoperative scar adhesions between tendons and phalanx bones cause persistent disability in complex injuries involving tendons and bones of the hand. Although gliding tissue reconstruction is effective in preventing peritendinous adhesion formation and a dorsal digital adipofascial flap is a reliable method to prevent scar adhesion between tendon and bone after extensor tendon repair, no comparative clinical reports exist. This study aimed to determine the usefulness of a gliding tissue reconstruction method by comparing postoperative range of motion between patients who underwent gliding tissue reconstruction and those who did not.

Methods
Medical records of patients with complex extensor tendon injury who underwent extensor repair between April 2005 and March 2018 were retrospectively analyzed. Ten patients underwent extensor repair with gliding tissue reconstruction using a dorsal digital adipofascial flap and 13 underwent only extensor repair. A triangular flap was separated after zig-zag incision to expose the injured extensor tendon into dermal and adipofascial flaps. The adipofascial flap, based on a dorsal branch of the digital artery, was placed on the injured bone as the tendon gliding surface. The same extensor tendon suture method and rehabilitation protocol were used in both groups. All patients were followed up for 6 to 12 months.

Results
The mean ± SD % total active movements were 84.1% ± 12.4% and 57.6% ± 13.0% in the groups with and without gliding tissue reconstruction, respectively. Significant differences were found between the 2 groups (P < 0.05).

Conclusions
Patients with gliding tissue reconstruction had better functional recovery. This reconstruction is recommended to restore the extensor function in cases of complex extensor injury involving finger tendons and bones.
Evaluation of Direct Surgical Remodeling of Frontal Bossing in Patients With Sagittal Synostosis
Authors: Yen Debra W. , Nguyen Dennis C. , Skolnick Gary B. , Naidoo Sybill , Smyth Matthew D. , Patel Kamlesh B. , Woo Albert S. 
Published: October 2019

Background:
The need for surgical correction of frontal bossing in patients with sagittal synostosis is currently debated. The authors retrospectively analyzed frontal bossing in patients with isolated, nonsyndromic sagittal synostosis who underwent calvarial remodeling with and without frontal craniotomy and compared with control subjects.

Methods:
The authors analyzed computed tomography (CT) scans of patients with sagittal synostosis <9 months of age (6.2 ± 1.6 months) who underwent modified-pi procedure either with frontal craniotomy (FC, n = 15) or without frontal craniotomy (NFC, n = 10). Only patients treated with both pre-operative and 1-year post-operative CT scans were included. Non-synostotic age-matched control scans were also analyzed. Cephalic index (CI), 3 previously validated measures of frontal bossing (bossing angle, horizontal bossing ratio, and vertical bossing ratio), and pre-nasion volume ratio were obtained. Additionally, three-dimensional photographs of 10 FC patients were evaluated for frontal bossing between 1 and 8 years post-operatively.

Results:
Pre-operatively, no significant differences were found between the 2 groups (.064<P < 0.940). Both groups showed greater scaphocephaly and frontal bossing compared to controls (P < 0.001). One-year post-operatively, all measures improved but remained significantly different than normal values except: CI of NFC patients (P = 0.296); bossing angle (P = 0.068) and horizontal bossing ratio (P = 0.129) of FC patients. Compared to NFC patients, horizontal bossing ratio was significantly improved in FC patients (P = 0.017, mean difference of 0.047). No other statistically significant differences were found between the 2 techniques (0.127<P < 0.637).
In our long-term study of FC patients up to 9 years of age (n = 10), the authors analyzed forehead inclination as our measure of frontal bossing in three-dimensional photographs. A linear regression analysis showed a significant reduction in forehead inclination with age, decreasing 1.3 ± 0.4 degrees per year (P = 0.021). Forehead inclination for controls did not change significantly with age (P = 0.558).

Conclusions:
At 1-year following modified-pi procedure, FC patients approached normalization of their forehead morphology to a greater extent than NFC patients. However, neither group completely normalized during this time period. Frontal bossing in FC patients continued to decrease with age, which reveals the post-operative dynamic nature of frontal bone morphology during childhood for these patients.