bluuebunny/crossref_metadata_2025_split huggingface dataset:
Acute Implant-related Complications in Pediatric Cervical Spine Fusion
Authors: O’Neill Nora P. , Hresko Michael T. , Emans John B. , Glotzbecker Michael P. , Verhofste Bram P. , Karlin Lawrence I. , Proctor Mark R. , Hedequist Daniel J. 
Published: November 2019

Background:
The use of modern rigid instrumentation in pediatric cervical fusions decreases the risk of implant-related complications, both acute and long term. However, previous studies have indicated that acute implant-related issues still occur in the adult population. Reports of pediatric acute implant complications, occurring within 3 months of surgery, are under-represented in the literature. The purpose of this study is to document the prevalence of acute implant-related complications in a pediatric cervical fusion population.

Methods:
A retrospective review of instrumented cervical fusions from August 2002 to December 2018 was conducted. Acute implant-related complications were defined as malposition, fracture, or disengagement of cervical instrumentation, including screws, rods, and plates, within 90 days of surgery.

Results:
A total of 166 cases were included (55% male individuals) with an average age at surgery of 12.5 years (SD, ±5.28). Acute implant-related complications occurred in 5 patients (3%). All 5 patients had a syndromic diagnosis: Loeys-Dietz (n=1), osteopetrosis (n=1), neurofibromatosis (n=1), trisomy 20 (n=1), and achondroplasia (n=1). One case involved asymptomatic screw protrusion, 1 case lateral mass screw pull-out, 2 more had screw-rod disengagement, and the last experienced dislodgement of the anterior plate. The median time until the presentation was 25 days (range, 1 to 79 d). All patients (n=5) required surgical revision.

Conclusions:
This case series suggests that the overall incidence of acute cervical implant failure is low. However, failure is more likely to occur in patients with underlying syndromes compared with patients with different etiologies. Intraoperative use of 3-dimensional computed tomography imaging is recommended to evaluate the screw position and potentially avoid later surgery.
Evaluation of Risk Factors for Cerebrospinal Leakage in Pediatric Patients With Cerebral Palsy Treated With Intrathecal Baclofen
Authors: Imerci Ahmet , Rogers Kenneth J. , Miller Freeman , Sees Julieanne P. 
Published: November 2019

Background:
Insertion of an intrathecal baclofen (ITB) pump can provide significant benefits in patients with cerebral palsy (CP). However, there are little data describing the risk of complications. Specifically, there is a lack of data describing the incidence of cerebrospinal fluid (CSF) leakage and risk factors following ITB placement. The purpose of our study was to describe risk factors for developing CSF leak in pediatric patients with CP treated with ITB and to report the treatment and outcome of CSF leaks.

Methods:
Following institutional review board approval, 720 ITB procedures in 341 children with CP were identified retrospectively over a 15-year study period. Patients’ demographic characteristics, medical comorbidities, muscle tone patterns, feeding tube status, seizure history, inpatient events, ITB-related CSF leak and headache complaints and their management, and other complications were evaluated.

Results:
Eighty-five (24.9%) patients experienced 90 CSF leak episodes over a follow-up time of 6.3±3.9 years. There were 72 episodes of headache as a result of CSF leakage in 61 (71.7%) of these 85 patients. There was a positive correlation between the risk of CSF leak and preoperative comorbidities such as epilepsy/seizure history, feeding tube, mixed type CP, and dystonic type CP. The risk of CSF leak after primary ITB administration was 5.8% (20/341), and the risk after secondary ITB procedures due to complications was 24.2% (32/132). There was no significant relationship between CSF leak and primary ITB (P=0.21), but the risk of CSF leak was positively correlated to the secondary ITB due to complications (P<0.05).

Conclusions:
CSF leak was fairly common (25% incidence), and it correlated with epilepsy/seizure history, feeding tube, mixed type CP, and dystonic type CP. Recurrent ITB procedures were a risk factor for CSF leak. Half of these patients had self-limited symptoms that improved with conservative medical treatment, and the epidural blood patch was successful in resistant cases. Successful treatment of CSF leakage complications allows patients to continue ITB.

Level of Evidence:
Level III.
Neuroprognostication Practices in Postcardiac Arrest Patients: An International Survey of Critical Care Providers
Authors: Maciel Carolina B. , Barden Mary M. , Youn Teddy S. , Dhakar Monica B. , Greer David M. 
Published: November 2019

Objectives:
To characterize approaches to neurologic outcome prediction by practitioners who assess prognosis in unconscious cardiac arrest individuals, and assess compliance to available guidelines.

Design:
International cross-sectional study.

Setting:
We administered a web-based survey to members of Neurocritical Care Society, Society of Critical Care Medicine, and American Academy of Neurology who manage unconscious cardiac arrest patients to characterize practitioner demographics and current neuroprognostic practice patterns.

Subjects:
Physicians that are members of aforementioned societies who care for successfully resuscitated cardiac arrest individuals.

Interventions:
Not applicable.

Measurements and Main Results:
A total of 762 physicians from 22 countries responses were obtained. A significant proportion of respondents used absent corneal reflexes (33.5%) and absent pupillary reflexes (36.2%) at 24 hours, which is earlier than the recommended 72 hours in the standard guidelines. Certain components of the neurologic examination may be overvalued, such as absent motor response or extensor posturing, which 87% of respondents considered being very or critically important prognostic indicators. Respondents continue to rely on myoclonic status epilepticus and neuroimaging, which were favored over median nerve somatosensory evoked potentials for prognostication, although the latter has been demonstrated to have a higher predictive value. Regarding definitive recommendations based on poor neurologic prognosis, most physicians seem to wait until the postarrest timepoints proposed by current guidelines, but up to 25% use premature time windows.

Conclusions:
Neuroprognostic approaches to hypoxic-ischemic encephalopathy vary among physicians and are often not consistent with current guidelines. The overall inconsistency in approaches and deviation from evidence-based recommendations are concerning in this disease state where mortality is so integrally related to outcome prediction.
Effect of Best Practice Advisories on Sedation Protocol Compliance and Drug-Related Hazardous Condition Mitigation Among Critical Care Patients*
Authors: Greene Rebecca A. , Zullo Andrew R. , Mailloux Craig M. , Berard-Collins Christine , Levy Mitchell M. , Amass Timothy 
Published: November 2019

Objectives:
To determine whether best practice advisories improved sedation protocol compliance and could mitigate potential propofol-related hazardous conditions.

Design:
Retrospective observational cohort study.

Setting:
Two adult ICUs at two academic medical centers that share the same sedation protocol.

Patients:
Adults 18 years old or older admitted to the ICU between January 1, 2016, and January 31, 2018, who received a continuous infusion of propofol.

Interventions:
Two concurrent best practice advisories built in the electronic health record as a clinical decision support tool to enforce protocol compliance with triglyceride and lipase level monitoring and mitigate propofol-related hazardous conditions.

Measurements and Main Results:
The primary outcomes were baseline and day 3 compliance with triglyceride and lipase laboratory monitoring per protocol and time to discontinuation of propofol in the setting of triglyceride and/or lipase levels exceeding protocol cutoffs. A total of 1,394 patients were included in the study cohort (n = 700 in the pre–best practice advisory group; n = 694 in the post–best practice advisory group). In inverse probability weighted regression analyses, implementing the best practice advisory was associated with a 56.6% (95% CI, 52.6–60.9) absolute increase and a 173% relative increase (risk ratio, 2.73; 95% CI, 2.45–3.04) in baseline laboratory monitoring. The best practice advisory was associated with a 34.0% (95% CI, 20.9–47.1) absolute increase and a 74% (95% CI, 1.39–2.19) relative increase in day 3 laboratory monitoring after inverse probability weighted analyses. Among patients with laboratory values exceeding protocol cutoffs, implementation of the best practice advisory resulted in providers discontinuing propofol an average of 16.6 hours (95% CI, 4.8–28.3) sooner than pre–best practice advisory. Findings from alternate analyses using interrupted time series were consistent with the inverse probability weighted analyses.

Conclusions:
Best practice advisories can be effectively used in ICUs to improve sedation protocol compliance and may mitigate potential propofol-related hazardous conditions. Best practice advisories should undergo continuous quality assurance and optimizations to maximize clinical utility and minimize alert fatigue.
Intraepidermal Nerve Fiber Density in Postmortem Skin: A Novel Approach
Authors: Waheed Waqar , Taicher Christopher , Dulaney Eugene , Eckenstein Felix , Hehir Michael , Sprague Julian , Tandan Rup 
Published: November 2019

Abstract

Objective:
To determine the feasibility of examining intraepidermal nerve fiber density (IENFD) in postmortem skin.

Methods:
From 12 subjects, 3-mm skin punch biopsies were collected 1–4 days postmortem from the proximal leg and distal leg, with a mean (range) interval from the death of 37 (15–91) hours. Causes of death varied broadly, including hepatocellular carcinoma, chronic lymphocytic leukemia, generalized atherosclerosis, progressive supranuclear palsy, Parkinson disease, emphysema, and obesity. The mean (range) number of sections evaluated from each biopsy was 5.08 (2–6) from the proximal leg and 5.92 (5–6) from the distal leg. Sections were stained with PGP 9.5 for blinded counting using bright field microscopy. Qualitative and quantitative assessment of feasibility included a comparison of fiber staining with that in healthy subjects and mean IENFD in postmortem samples. Interobserver reliability was assessed among 3 blinded raters by calculating intraclass correlation coefficients and percentage variability of IENFD in at least 4 sections from biopsies in 5 healthy subjects.

Results:
Intraobserver and interobserver correlation coefficients of blinded IENFD counts undertaken by 4 authors were consistently >0.80, and the coefficient of variation was ≤10%. The quality of staining in postmortem samples was comparable with that in healthy subjects and was not substantially affected by time from death to specimen collection of up to nearly 4 days. Mean (range) IENFD from postmortem samples in the proximal and distal leg was 2.73 (0–7.65) and 1.93 (0–4.91) fibers/mm of skin, respectively. Two of 3 patients who had received chemotherapy during life showed a nearly complete absence of intraepidermal nerve fibers.

Conclusions:
IENFD measurement in postmortem skin is feasible and may be used to study the epidemiology of SFN.
Evaluation of Quality of Life in Patients With Chronic Inflammatory Demyelinating Polyneuropathy in Iran
Authors: Okhovat Ali Asghar , Gholamalizadeh Saba , Nafissi Shahriar , Fatehi Farzad 
Published: November 2019

Abstract

Objectives:
In addition to the physical disability in chronic inflammatory demyelinating polyneuropathy (CIDP), various aspects of quality of life (QoL) are affected by the disease. Our goal was to evaluate the QoL in Iranian patients with CIDP and to study the association of clinical and demographic factors with QoL parameters.

Methods:
Twenty-six Iranian patients with CIDP were asked to complete a standardized Persian version of SF-36, and the association of demographic and functional parameters with QoL parameters was assessed.

Results:
Sex, living place, and income had no significant effect on QoL. Mean physical composite score was 37.7 ± 9.4, and mean mental composite score was 37.2 ± 15.2 that was lower than similar studies. There was a positive correlation between QoL and muscle strength of different muscle groups [hand (r = 0.41, P = 0.04); hip (r = 0.44, P = 0.02); and foot (r = 0.41, P = 0.04); total manual muscle testing (r = 0.46, P = 0.02)] and a significant negative correlation between the duration of illness and mean physical composite score (r = −0.61, P = 0.00).

Conclusions:
Our patients achieved low scores in both the physical and mental aspects of QoL compared with other studies. We found a significant correlation between the physical domain of the SF-36 score and muscle strength of the hand, hip, and foot muscle group and with total manual muscle testing, suggesting that physical disability is the most crucial factor affecting QoL. Also, there was a significant negative association between the duration of the disease and the physical domain.
Drug-Drug Interactions Between Antiretrovirals and Carbamazepine/Oxcarbazepine: A Real-Life Investigation
Authors: Cattaneo Dario , Baldelli Sara , Cozzi Valeria , Fusi Marta , Atzori Chiara , Micheli Valeria , Filice Carlo , Gervasoni Cristina 
Published: November 2019

Background:
Carbamazepine and oxcarbazepine are potent modulators of metabolic enzymes. Hence, potential drug-drug interactions (DDIs) may occur between these 2 drugs and antiretrovirals. Here, we aimed to assess the relevance of these drug-drug interactions in real-life clinical settings.

Methods:
Patients treated concomitantly with carbamazepine or oxcarbazepine and antiretrovirals for at least 3 months were considered. Data on therapeutic drug monitoring (TDM) of both antiepileptic and antiretrovirals as trough concentrations were collected. HIV-infected patients not concomitantly treated with antiepileptic drugs and who underwent TDM for antiretrovirals in the previous 2 years were considered as controls.

Results:
Eleven HIV-positive patients prescribed carbamazepine or oxcarbazepine were identified. All the TDM evaluations for carbamazepine and oxcarbazepine that resulted were within the therapeutic ranges. TDM results of darunavir measured in these patients were comparable with values usually measured in the control group. Conversely, the trough concentrations for atazanavir and dolutegravir demonstrated significantly lower values when compared with values usually measured in HIV-infected patients not treated with antiepileptic drugs (190 ± 91 versus 546 ± 380 ng/mL; −65%, P < 0.001; 191 ± 78 versus 1096 ± 510 ng/mL; −83%, P < 0.001, respectively).

Conclusions:
Co-administration of carbamazepine or oxcarbazepine with atazanavir or dolutegravir should be avoided owing to the potential risk of virological failure; in case of these 2 drugs, the adoption of TDM is strongly advisable, eventually combining with increased antiretroviral doses.
Intravenous Ketorolac Reduces Pain Score and Opioid Requirement in Orbital Surgery
Authors: Wladis Edward J. , Lee Katherine W. , De Arup 
Published: November 2019

Purpose:
Intravenous ketorolac (IVK) is an effective agent to reduce postoperative pain without the risks inherent to opioid analgesics. However, many clinicians avoid using this agent due to concerns regarding hemorrhagic complications. This study was performed to assess the efficacy and safety of IVK in the setting of orbital surgery.

Methods:
In a single dose prospective study, patients either received IVK immediately before orbital surgery (n = 50) or acted as controls (n = 50). Postoperative pain was evaluated via a numerical scale (range = 0–10) immediately after surgery, before discharge to home, and on the first postoperative day (POD1). The requirements for opioid analgesic and anti-emetic medications were determined by the nursing staff and recorded. Statistical analyses were performed via a dedicated software package.

Results:
Fifty patients received IVK (24 males, 26 females, mean age = 54 years, SD = 18 years) and 50 patients acted as controls (26 males, 24 females, mean age = 50 years, SD = 19 years) immediately before orbital surgery. Mean pain scores were lower in patients who received IVK than in controls immediately after surgery (3.08 vs. 5.44, p = 0.0001) and on POD1 (1.04 vs. 2.66, respectively, p = 0.0001). Four patients (8%) who received IVK and 12 patients who did not (24%) required opioid analgesics to control pain (p = 0.03). No patient experienced a hemorrhagic complication or required an emergent return to the operating room.

Conclusions:
In the setting of orbital surgery, IVK safely and effectively reduces pain and the requirement for opioid analgesics. Within the limits of the study size, increased risks of bleeding-related complications were not identified.
Optic Nerve Stretch Is Unlikely to Be a Significant Causative Factor in Dysthyroid Optic Neuropathy
Authors: Rose Geoffrey E. , Vahdani Kaveh 
Published: November 2019

Purpose:
Although it is a commonly held belief that stretching of the optic nerve is important in dysthyroid optic neuropathy (DON), it is probably mainly due to microvascular ischemia arising from high pressure at the orbital apex. If stretch is important in DON, one would expect longer optic nerves and reduced optic nerve compliance in these patients.

Methods:
Retrospective comparative case series for 75 patients with DON, and for age- and sex-matched control patients with thyroid eye disease (but no DON). Masked assessments of medial wall length, lateral wall length, optic nerve limits (ONLs), globe dimension, and globe projection were made from orbital CT images, and, from these measurements, various derivatives were estimated. The optic nerve shape was also judged as “straight,” “mildly curved,” or “markedly curved.” Estimates of optic nerve compliance were compared in the 2 groups and examined particularly to look for evidence of reduced compliance in orbits with DON.

Results:
Paired right–left comparisons suggested a small systematic bias in the estimates of orbital dimensions, possibly due to software performance; this does not complicate the study, as only ipsilateral orbits were compared in the 2 groups. In 115 paired orbits, there was no difference in the proportions with various optic nerve configuration (p = 1.0), but the mean ONL in DON was 32.9 mm, compared with 31.5 mm in thyroid eye disease without DON (p = 0.011). In 5 patients with bilateral thyroid eye disease but unilateral DON, when corrected for side-to-side bias, the ONL on the DON side was greater than the non-DON side (DON, 36.7 mm; non-DON, 34.7 mm; p = 0.066). Compliance estimates for the 115 paired orbits are almost identical (p = 0.99).

Conclusions:
The almost identical compliance estimates for DON and non-DON orbits suggest that ONL elongation in DON, albeit significant, is not extending optic nerve to its elastic limits and is, therefore, unlikely to be causing metabolic stress to the optic nerve. The 1.4 mm extra ONL in DON orbits probably just represents more retrobulbar tissues—with more advanced disease—and optic nerve stretch is probably not significant in the pathogenesis of DON.
Clinicopathologic Correlation of Kaposi Sarcoma Involving the Ocular Adnexa: Immunophenotyping of Diagnostic and Therapeutic Targets
Authors: Ulloa-Padilla Jan P. , Ghassibi Mark P. , Dubovy Sander R. , Kerr Darcy A. 
Published: November 2019

Purpose:
To describe the clinicopathologic characteristics and the expression of diagnostic/treatment targets in ocular adnexal Kaposi Sarcoma.

Methods:
We conducted a clinical-pathologic retrospective case series. Immunohistochemical staining for cluster of differentiation 31 (CD31), human herpesvirus-8 (HHV8), platelet-derived growth factor receptor alpha (PDGFR-A), vascular endothelial growth factor receptor-1 (VEGF), tyrosine-protein kinase Kit (c-Kit), and programmed cell death protein 1 (PD-1) were performed. Percentage of positive tumor cells was recorded for PD-1; staining intensity and distribution (H-score) were determined for the remaining stains. A Friedman non-parametric ANOVA analysis evaluated the staining.

Results:
The study cohort included 13 patients (age 25 to 95 years; mean 46): 7 lesions were in the eyelid, 5 in the conjunctiva, and 1 in the cornea. Nine of 11 lesions (82%) were in human immunodeficiency syndrome-positive patients (human immunodeficiency syndrome status was unknown in 2 cases). Staging included 6 plaques and 7 nodules. The mean H-scores of CD31, HHV8, c-Kit, VEGF, and PDGF-A were 8.00, 8.23, 2.77, 11.54, and 10.31, respectively. Mean PD-1 staining was 6.46%. The Friedman non-parametric ANOVA analysis showed VEGF, PDGF-A, CD31, and HHV8 differed significantly, and all differed significantly from c-Kit. Programmed cell death protein 1 staining was not significant with any clinical variable.

Conclusions:
Cluster of differentiation 31 and HHV8 are helpful diagnostic adjuncts for ocular adnexal Kaposi Sarcoma. Platelet-derived growth factor receptor alpha and VEGF are promising treatment targets. Programmed cell death protein 1/PD-L1 and c-Kit are targets that are useful in several tumors; their roles in ocular adnexal Kaposi Sarcoma warrant further studies.
Corneal Laceration Associated With Upper Eyelid Blepharoplasty
Authors: Shoji Marissa K. , Tran Ann Q. , Nikpoor Neda , Lee Wendy W. 
Published: November 2019

A 64-year-old woman underwent bilateral upper eyelid blepharoplasty and subsequently presented with decreased vision at her first postoperative visit 1 week later. She was found to have an 8-mm partial-thickness corneal laceration of her left eye and underwent immediate surgical laceration repair. The laceration etiology was thought to be related to damage from the initial blepharoplasty incision or Bovie cautery tip–induced laceration. After laceration repair, she had residual astigmatism and corneal scarring leading to poor vision. Corneal injuries, including abrasions and perforations, are rare complications of blepharoplasty, and the case in this study is the first report of corneal laceration following blepharoplasty. Corneal perforations and lacerations can lead to significant damage and vision loss, indicating a need for careful attention to surgical technique and instrument placement intraoperatively, routine use of corneal protectors even during superficial aesthetic procedures such as blepharoplasties, and comprehensive postoperative patient instructions.
A 64-year-old woman who underwent an upper eyelid blepharoplasty sustained a partial-thickness corneal laceration of her OS, which required emergent repair and resulted in persistent vision loss secondary to large corneal scar.