bluuebunny/crossref_metadata_2025_split huggingface dataset:
Nurses’ Participation in Clinical and Administrative Decisions in Different Types of Hospital Units
Authors: Bacon Cynthia Thornton , Shrestha Smriti , Jenkins Marjorie 
Published: February 2019

OBJECTIVE
This study explored the types of decisions and differences in decision making that nurses made in different types of hospital units.

BACKGROUND
The relationship between nurses’ participation in decision making and the different types of hospital units where they work is not well understood.

METHODS
Nurses’ participation in decision making was explored using the Participation in Decision Activities Questionnaire. The final sample included 307 nurses in 24 nursing units in 6 hospitals.

RESULTS
Nurses overall participated more in clinical than administrative decisions, and there were significant differences based on unit type. Critical care nurses had the highest and general care units the lowest levels of participation in decision making.

CONCLUSIONS
Nurses in critical care units participated in higher amounts and at higher levels of clinical decisions overall than either intermediate or general care units. Nurse leaders should determine barriers to decision making in general care units and explore mechanisms to increase participation by clinical nurses.
Transient Pigmentary Lines of the Newborn in a Postmortem Examination
Authors: Terry Merryl , Marlowe Stewart Donna 
Published: February 2019

Abstract
Sudden unexplained death in infancy is a leading cause of death among infants between 1 month and 1 year of age in the United States. The medical examiner is frequently given the difficult task of attempting to rule out other causes of death such as infantile trauma or child abuse. A thorough postmortem examination of the skin is a crucial component of the autopsy, as is sufficient knowledge of both benign and traumatic skin pathologies. In addition to lifesaving interventions performed by medical personnel, traditional remedies may also be performed that could be confused with trauma. Eastern medicinal therapies such as coining, cupping, or spooning may leave unusual markings on the patient. Transient pigmentary lines of the newborn are a rare but benign dermatologic finding of unknown etiology that should also be kept in the differential diagnoses. The authors present a case of this unique skin condition seen on a 1-month-old African American male infant who was found unresponsive, in addition to a current literature review.
Correctly Identifying Deaths Due to Drug Toxicity Without a Forensic Autopsy
Authors: Dye Daniel W. , McGwin Gerald , Atherton Daniel S. , McCleskey Brandi , Davis Gregory G. 
Published: February 2019

Abstract
In 2005, the National Association of Medical Examiners approved the Forensic Autopsy Performance Standards. Standard B3.7 indicates that a forensic pathologist shall perform a forensic autopsy when the death is by apparent intoxication by alcohol, drugs, or poison.
The Jefferson County Coroner/Medical Examiner Office has observed an increase in our caseload by 10% per year since 2012. We designed a study to determine if a pathologist could correctly classify the cause of death (COD) and manner of death (MOD) of suspected drug-related deaths without information from the internal examination. The determination of the COD and MOD was then compared with the case file, which includes information from the internal examination and microscopy, to determine agreement between the case file and the reclassification. The percent correct for COD and MOD was calculated, and kappa values were calculated for MOD.
The pathologists were able to correctly classify the COD in 73% of cases. For MOD, 2 pathologists achieved substantial agreement between the test cases and the actual case file. The third pathologist had moderate agreement. These findings indicate that a full postmortem examination is necessary to correctly classify the COD/MOD in cases of suspected drug toxicity.
Our null hypothesis is that a full autopsy is not necessary to correctly classify the COD and MOD in cases of drug toxicity.
Frequent CTNNB1 or PIK3CA Mutations Occurred in Endometrial Endometrioid Adenocarcinoma With High Levels of Microsatellite Instability and Loss of MSH2/MSH6 Expression
Authors: Huang Hsien-Neng , Kuo Chun-Wei , Lin Ming-Chieh , Mao Tsui-Lien , Kuo Kuan-Ting 
Published: February 2019

Background:
DNA mismatch repair (MMR) proteins form 2 heterodimers—MutSα formed by MSH2 and MSH6, and MutLα by MLH1 and PMS2. In endometrial endometrioid adenocarcinomas, cases with MMR protein defect also usually harbor other recurrent genetic mutations of the neoplasm. However, it remains unknown whether defects of the 2 functionally different heterodimers are linked to mutations in different genes. We aimed to study the MMR protein expression, microsatellite instability (MSI), and other common genetic mutations of endometrial endometrioid adenocarcinoma.

Materials and Methods:
We investigated the MSI status of 107 endometrial endometrioid adenocarcinoma patients. MMR protein expression, and mutation of KRAS, CTNNB1, and PIK3CA were also evaluated by immunohistochemistry and sequencing.

Results:
An overall 34.6% (37/107) of endometrial endometrioid adenocarcinomas were MSI-H. All MSI-H tumors exhibited loss of MMR protein expression (loss of MLH1, PMS2, MSH6, and MSH2 was noted in 22, 25, 12, and 7 cases, respectively). CTNNB1, PIK3CA, and KRAS mutation were present in 9, 7, and 7 MSI-H tumors. Compared with patients with loss of PMS2 and/or MLH1 expression, patients with loss of MSH6 and/or MSH2 expression were associated with higher frequencies of CTNNB1 mutation (P=0.036) and PIK3CA mutation (P=0.025).

Conclusions:
In MSI-H endometrial endometrioid adenocarcinomas, different types of MMR protein deficiency indicate different molecular genetic alterations.
Intraductal Oncocytic Papillary Neoplasms
Authors: Wang Tao , Askan Gokce , Adsay Volkan , Allen Peter , Jarnagin William R. , Memis Bahar , Sigel Carlie , Seven Ipek E. , Klimstra David S. , Basturk Olca 
Published: February 2019

Background:
Intraductal oncocytic papillary neoplasm (IOPN) of the pancreas is a rare tumor. Recent molecular data indicate that it is distinct from other intraductal neoplasms; however, its clinicopathologic characteristics, especially the frequency/significance of an invasive carcinoma component, and biologic behavior remain to be fully defined.

Design:
Clinicopathologic characteristics and survival of 24 IOPNs were analyzed. By definition, all tumors exhibited intraductal growth and oncocytic morphology.

Results:
The female:male ratio was 1.7, and mean age was 59. In 44% of the patients, the IOPN was discovered incidentally; however, the working diagnosis was “ductal adenocarcinoma” in 42%. Fourteen IOPNs occurred in the head of the pancreas. The median tumor size was 4.5 cm. The tumors often grew along adjacent benign ducts, mimicking invasion, but only 29% exhibited unequivocal invasive carcinoma, mostly in the form of microscopic foci (pT1a=4, pT1b=1, pT2=2), and only 6% had lymph node metastasis. Invasive carcinoma was predominantly composed of small tubular units lined by oncocytic cells, or individual oncocytic cells infiltrating the periductal stroma. Follow-up information was available for 18 patients (median=6.8 y). No patients died from the disease, and the overall 10-year survival was 94%. Patients with invasive carcinoma trended toward a lower 5-year recurrence-free survival than those with noninvasive IOPNs (66% vs. 93%, P=0.066), but overall survival was not impacted by the presence of invasion (P=0.38).

Conclusions:
IOPN is a distinct tumor type in the pancreas. Despite its morphologic complexity and often extensive pagetoid spread to adjacent ducts, conventional invasive carcinoma is seen in only 29% and usually as microscopic foci. Thus, it is not surprising that IOPN exhibits indolent behavior even when invasion is present.
A Case of Unintentional Opioid (U-47700) Overdose in a Young Adult After Counterfeit Xanax Use
Authors: Chapman Brittany P. , Lai Jeffrey T. , Krotulski Alex J. , Fogarty Melissa F. , Griswold Matthew K. , Logan Barry K. , Babu Kavita M. 
Published: February 2019

Abstract
We report the case of a young adult who became unresponsive after insufflating what he believed to be “crushed Xanax.” Naloxone was administered, reversing his altered mental status and respiratory depression. Clinicians suspected opioid toxicity; however, the patient adamantly denied opioid use. Because of unclear etiology of his symptoms, blood and urine specimens were obtained. A urine specimen was split and then submitted for a clinical comprehensive drug screen using gas chromatography–mass spectrometry. The blood specimen and the remaining urine specimen were sent to a reference laboratory for analysis using liquid chromatography quadrupole time-of-flight mass spectrometry and liquid chromatography tandem mass spectrometry. The standard, clinical gas chromatography–mass spectrometry urine drug testing procedure only detected caffeine; however, analysis by liquid chromatography quadrupole time-of-flight mass spectrometry and liquid chromatography tandem mass spectrometry confirmed the presence of U-47700 (a high-potency clandestine opioid) and its metabolites in the urine and blood. These findings implicate U-47700 as the agent responsible for the patient's signs of opioid toxicity. In this case, a young adult intending to use alprazolam encountered U-47700 with life-threatening effect. Clinicians must remain vigilant for symptoms consistent with opioid overdose, especially with increasing prevalence of counterfeit drugs containing clandestine opioids. Clinicians must also consider obtaining specimens for appropriate analytical testing to improve surveillance and facilitate public health interventions.
Public Health Senior Deputy's Perceptions of State Health Officials' Success Factors: Professional Characteristics, Personal Attributes, and Signs of Derailment
Authors: Boedigheimer Steven F. , Yeager Valerie A. , Chapple-McGruder Theresa , Moffatt Sharon , Halverson Paul K. 
Published: February 2019

Context:
Senior deputies work closely with state health officials (SHOs) in state public health agencies and are a valuable resource for understanding their roles, responsibilities, and characteristics.

Objective:
Examine senior deputies' perceptions of SHO success factors.

Design:
Qualitative study including nominal group technique focus groups, a small expert focus group, and interviews.

Setting:
US state public health agencies.

Participants:
Senior deputies in state public health agencies 2016/2017.

Main Outcome Measures:
Perceptions of SHO success factors.

Results:
The most commonly perceived professional characteristics of a successful SHO included the following: credible trusted voice with internal respect/external credibility; improves public health prominence/visibility with an evidence-based agenda; and grows the agency/leaves it stronger. Perceptions of the most common personal attributes for success included excellent listening skills; credibility/honesty/trustworthiness; and public health experience/knowledge. The most commonly perceived signs of SHO derailment included when SHOs have a visible lack of support of elected officials (eg, governor/legislators) and when the SHO is “bypassed” by elected officials.

Conclusions:
A key finding of this study centers on the relationship between the SHO and the governor; meeting the expectations of the governor was identified as a significant professional characteristic of success. Findings highlight the expectation that SHOs have a clear understanding of the governor's priorities and how to relate to the governor's office early in their tenure. This goal should be a priority for transition teams that aid new SHOs as they begin in their new roles. Study insights can help better prepare for orientation/onboarding of new SHOs. Development of key transition documents and tools for rapid onboarding should be considered. Transition teams should assist new SHOs in establishing an understanding of the governor's priorities and how to best communicate with to the governor's office early in their tenure. Strong senior management teams should be prioritized and fostered.
Kids, Cops, and Community: A Qualitative Assessment of Police, Youth, and Parent Perceptions of Each Other
Authors: Harty Nicole M. , Friedman Brett , Tung Gregory J. 
Published: February 2019

Context:
Police and communities alike have experienced many traumatic incidents over the last 4 years, prompting police departments across the country to rethink their approach to community programs.

Program:
Aurora's Gang Reduction Impact Program (A-GRIP) launched “Kids, Cops, and Community” (KC&C) in Aurora, Colorado, as a community-based quality improvement project designed to improve community relations by better understanding Aurora police and community members' perceptions of each other and current A-GRIP and Aurora for Youth programs by assessing police, youth, and parents' perceptions of each other.

Implementation:
After a review of current scientific literature on police-community relations, a KC&C advisory group oversaw the creation of key informant interview and focus group guides. A-GRIP recruited participants for 37 interviews (20 police, 8 youth, and 9 parents) and 3 youth focus groups. The community advisory group assisted in the development of salient themes and practical recommendations. The final report outlined 5 major themes (pros/cons of types of police interactions, respectful communication, false uniqueness effect, parenting and police as parents, and youth-police programming awareness) and 2 specific recommendations (sustain/increase opportunities for police-youth interactions and increase community awareness of youth programming).

Evaluation:
A-GRIP members had a rich discussion of the implications of these findings in which there was broad support for identifying a strategy to use these results to improve police-community relations. The coalition was challenged by identifying clear next steps because of turnover in administration and coalition leadership, but they have made progress in increasing information and resource sharing.

Discussion:
This project provides the first model we are aware of that incorporates a systematic assessment of police, youth, and parent perspectives from the same community. Other communities may find value in adapting the KC&C process to identify promising approaches and refine programming elements of police-community engagement activities.
A Cost-Minimization Analysis Evaluating the Use of Liposomal Bupivacaine in Reconstructive Plastic Surgery Procedures
Authors: Little Andrea , Brower Kristin , Keller Deborah , Ramshaw Bruce , Janis Jeffrey E. 
Published: February 2019

Background:
Postsurgical pain management is critical to patient satisfaction and value. Several studies have evaluated liposomal bupivacaine in postoperative pain management protocols; however, its economic feasibility remains undefined. This study analyzes the economic impact of liposomal bupivacaine using a national claims database to assess postoperative clinical and financial outcomes in plastic and reconstructive procedures.

Methods:
The Vizient Clinical Data Base/Resource Manager electronic database was reviewed for plastic surgery procedures (i.e., abdominoplasty, abdominal wall reconstruction, mastectomy with immediate tissue expander placement, mastectomy with direct-to-implant reconstruction, autologous breast reconstruction, and augmentation mammaplasty) at participating hospitals from July 1, 2016, to July 1, 2017. The main outcome measures were the length of stay; 7-, 14-, and 30-day readmission rates; and direct and total costs observed.

Results:
During the study period, 958 total cases met inclusion criteria. Liposomal bupivacaine was used in 239 cases (25 percent). Compared with cases that did not use liposomal bupivacaine, liposomal bupivacaine cases had a decreased length of stay (9.2 days versus 5.8 days), decreased cost (total cost, $39,531 versus $28,021; direct cost, $23,960 versus $17,561), and lower 30-day readmission rates (4 percent versus 0 percent). The 14- and 7-day readmission rates were similar between the two groups.

Conclusions:
The use of liposomal bupivacaine may contribute to a reduction in length of stay, hospital costs, and 30-day readmission rates for abdominal and breast reconstructive procedures, which could contribute to a favorable economic profile from a system view. Focusing on the measurement and improvement of value in the context of whole, definable, patient processes will be important as we transition to value-based payments.
Myth-Busting the DIEP Flap and an Introduction to the Abdominal Perforator Exchange (APEX) Breast Reconstruction Technique: A Single-Surgeon Retrospective Review
Authors: DellaCroce Frank J. , DellaCroce Hannah C. , Blum Craig A. , Sullivan Scott K. , Trahan Christopher G. , Wise M. Whitten , Brates Irena G. 
Published: February 2019

Background:Anatomical variations in perforator arrangement may impair the surgeon’s ability to effectively avoid rectus muscle transection without compromising flap perfusion in the deep inferior epigastric artery perforator (DIEP) flap.Methods:A single surgeon’s experience was reviewed with consecutive patients undergoing bilateral abdominal perforator flap breast reconstruction over 6 years, incorporating flap standardization, pedicle disassembly, and algorithmic vascular rerouting when necessary. Unilateral reconstructions were excluded to allow for uniform comparison of operative times and donor-site outcomes. Three hundred sixty-four flaps in 182 patients were analyzed. Operative details and conversion rates from DIEP to abdominal perforator exchange (“APEX”) arms of the algorithm were collected. Patients with standardized DIEP flaps served as the controlling comparison group, and outcomes were compared to those who underwent abdominal perforator exchange conversion.Results:The abdominal perforator exchange conversion rate from planned DIEP flap surgery was 41.5 percent. Mean additional operative time to use abdominal perforator exchange pedicle disassembly was 34 minutes per flap. Early postsurgical complications were of low incidence and similar among the groups. One abdominal perforator exchange flap failed, and there were no DIEP flap failures. One abdominal bulge occurred in the DIEP flap group. There were no abdominal hernias in either group. Fat necrosis rates (abdominal perforator exchange flap, 2.4 percent; DIEP flap, 3.4 percent) were significantly lower than that historically reported for both transverse rectus abdominis musculocutaneous and DIEP flaps.Conclusions:This study revealed no added risk when using pedicle disassembly to spare muscle/nerve structure during abdominal perforator flap harvest. Abdominal bulge/hernia was nearly completely eliminated. Fat necrosis rates were extremely low, suggesting benefit to pedicle disassembly and vascular routing exchange when required.CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, III.
Is There a Preferred Incision Location for Nipple-Sparing Mastectomy? A Systematic Review and Meta-Analysis
Authors: Daar David A. , Abdou Salma A. , Rosario Lauren , Rifkin William J. , Santos Pauline J. , Wirth Garrett A. , Lane Karen T. 
Published: February 2019

Background:
The incidence of nipple-sparing mastectomy is rising, but no single incision type has been proven to be superior. This study systematically evaluated the rate and efficacy of various nipple-sparing mastectomy incision locations, focusing on nipple-areola complex necrosis and reconstructive method.

Methods:
A systematic literature review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines identifying studies on nipple-sparing mastectomy where incision type was described. Pooled descriptive statistics meta-analysis of overall (nipple-areola complex) necrosis rate and nipple-areola complex necrosis by incision type was performed.

Results:
Fifty-one studies (9975 nipple-sparing mastectomies) were included. Thirty-two incision variations were identified and categorized into one of six groups: inframammary fold, radial, periareolar, mastopexy/prior scar/reduction, endoscopic, and other. The most common incision types were inframammary fold [3634 nipple-sparing mastectomies (37.8 percent)] and radial [3575 nipple-sparing mastectomies (37.2 percent)]. Meta-analysis revealed an overall partial nipple-areola complex necrosis rate of 4.62 percent (95 percent CI, 3.14 to 6.37 percent) and a total nipple-areola complex necrosis rate of 2.49 percent (95 percent CI, 1.87 to 3.21 percent). Information on overall nipple-areola complex necrosis rate by incision type was available for 30 of 51 studies (4645 nipple-sparing mastectomies). Periareolar incision had the highest nipple-areola complex necrosis rate (18.10 percent). Endoscopic and mastopexy/prior scar/reduction incisions had the lowest rates of necrosis at 4.90 percent and 5.79 percent, respectively, followed by the inframammary fold incision (6.82 percent). The rate of single-stage implant reconstruction increased during this period.

Conclusions:
For nipple-sparing mastectomy, the periareolar incision maintains the highest necrosis rate because of disruption of the nipple-areola complex blood supply. The inframammary fold incision has become the most popular incision, demonstrating an acceptable complication profile.
Body Contouring Surgery after Massive Weight Loss: Excess Skin, Body Satisfaction, and Qualification for Reimbursement in a Dutch Post–Bariatric Surgery Population
Authors: Monpellier Valerie M. , Antoniou Evangelia E. , Mulkens Sandra , Janssen Ignace M. C. , Jansen Anita T. M. , Mink van der Molen Aebele B. 
Published: February 2019

Background:
Body contouring surgery improves quality of life, weight loss, and body image after bariatric surgery. It is unclear why only a minority of the post–bariatric surgery population undergoes body contouring surgery. This study assesses overhanging skin, body satisfaction, and qualification for reimbursement of body contouring surgery in a Dutch post–bariatric surgery population.

Methods:
Post–bariatric patients were selected from a prospective database. Electronic questionnaires evaluated demographics, desire for body contouring surgery, excess skin, and satisfaction with their body.

Results:
A total of 590 patients were included: 368 patients (62.4 percent) desired body contouring surgery, 157 (26.6 percent) did not and 65 (11.0 percent) had undergone body contouring surgery. There were no significant differences between the groups regarding the percentage of patients who met the qualifications for reimbursement. Patients who desired body contouring surgery had more body parts affected by overhanging skin and more often rated the overhanging skin with a Pittsburgh Rating Scale grade 3 compared with patients without a desire to undergo body contouring surgery. The plastic surgeon was never consulted by 39.1 percent of the “desire” population; 44.1 percent of these patients met the weight criteria.

Conclusions:
Post–bariatric patients who desired body contouring surgery had more excess skin than patients without a desire and were less satisfied with their body. Almost half of these patients never consulted a plastic surgeon, partly because of incorrect assumptions regarding reimbursement. Plastic surgeons (together with bariatric teams) should better inform these patients about body contouring surgery possibilities.