bluuebunny/crossref_metadata_2025_split huggingface dataset:
Acquired Obliteration of the Proximal Lacrimal Drainage System
Authors: Starks Victoria S. , Yoon Michael K. 
Published: October 2018

Purpose:
We present a series of patients with acquired obliteration of one or more components of the proximal lacrimal drainage system, including puncta and canaliculi. This finding was noted with and without other obstructions or stenoses of the lacrimal drainage system. Review of these patients in search of possible risk factors for this condition and histopathology of two patients are presented.

Methods:
Medical records of patients treated at the Massachusetts Eye and Ear Infirmary between 2010 and 2016 with diagnosis codes of lacrimal punctum stenosis, stenosis of unspecified lacrimal punctum, epiphora due to insufficient drainage, and epiphora not otherwise specified were retrospectively reviewed. Patients were excluded if there was a history of congenital punctal agenesis, trauma, or any other identifiable etiology of lacrimal system obstruction.

Results:
Twelve patients were identified with obliterated puncta. Most patients were female (n = 11, 91.7%) and Caucasian (n = 9, 75%). The mean age was 61 years (median 62, range 22–90 years). Clinical findings ranged from one involved punctum to all four puncta, and associated ipsilateral canalicular obstruction was noted in 4 patients (33.3%). The inferior puncta were the more frequently affected structures (61.5%) compared to the superior puncta (38.5%). Nine patients (75%) reported use of topical ophthalmic medications prior to onset of symptoms. The most frequent class of medication implicated was topical antibiotics; however, patients often used a combination of medications. In 2 cases, pathological specimens of the canaliculi revealed absence of a canalicular lumen.

Conclusions:
Although various combinations of lacrimal system stenoses and obstructions have been described, acquired punctal obliteration is an under-recognized entity. These cases differ from typical punctal stenosis in that the puncta are completely obliterated, and no indication of a punctal opening is clinically detectable. In this study, 3 patients had previously documented normal lacrimal irrigation. The ipsilateral canaliculi were also found to be obstructed in a third of patients. Two patients had complete absence of a canalicular lumen on histopathology. The predominance of inferior punctum involvement, patient history of symptom onset after ipsilateral medication use, and known prior patent irrigation in several cases support the hypothesis that these cases represent a severe yet insidious idiosyncratic reaction to topical medication.
Acute Parotitis Due to Candida glabrata Presenting as Syncope
Authors: Turin Christie G. , McCormick David W. , Mahesh Cynthia , Taylor Addison A. , Hamill Richard J. , Constantine Gregory 
Published: October 2018

AbstractAcute suppurative parotitis is commonly caused by bacterial pathogens, with rare cases reported to be secondary to fungal infections. We present a case ofCandidaparotitis with disseminated infection resulting in carotid sinus hypersensitivity and subsequent syncope. We also present a brief review of literature surrounding this disease and a description of previously reported cases ofCandidaparotitis. To our knowledge, this is the first case ofCandidaparotitis presenting with syncope triggered by mechanical compression of the carotid sinus.
Pain assessment in advanced dementia. Validity of the German PAINAD—a prospective double-blind randomised placebo-controlled trial
Authors: Lukas Albert , Hagg-Grün Ulrich , Mayer Benjamin , Fischer Thomas , Schuler Matthias 
Published: October 2018

AbstractPain in combination with dementia is a common condition that makes pain recognition significantly more difficult. This results in undertreatment of pain in those suffering from dementia. The Pain Assessment in Advanced Dementia (PAINAD) scale currently represents one of the best approaches to pain detection in dementia. In a pilot study, strong inter-rater and retest reliability of the German version (PAINAD-G) was proven. However, the available data concerning the validity of this instrument were insufficient. The aim of the study was to validate the PAINAD-G scale by a double-blind randomised placebo-controlled trial in people with advanced dementia expected to be in pain. A second aim was to examine whether other observational tools (BISAD = Observation Instrument for Assessing Pain in the Elderly with Dementia) (German:Beobachtungsintrument für das Schmerzassessment bei alten Menschen mit Demenz, Checklist of Nonverbal Pain Indicators, Algoplus) were also able to demonstrate a significant difference between the study groups. Surprisingly, the study revealed no difference in “pain reduction” between those treated by oxycodone compared with those treated by placebo. Equally, none of the other 3 observational tools were able to demonstrate a significant difference between the study groups. However, correlations among the 4 observational tools were mostly moderate to high. A number of possible reasons for this observation, such as difficulties regarding sensitivity to change/responsiveness, consistence of the fundamental construct, influence of the early onset study, and efficacy of the analgesic in advanced dementia are discussed.
Narcotic Pain Control for Ureterolithiasis Is Associated With Unnecessary Repeat Imaging in the Emergency Department
Authors: Garcia Kyle , Pham Hannah , Sharma Pranav 
Published: October 2018

ABSTRACT
A subset of patients with ureteral stones who present to the emergency department (ED) will return with recurring symptoms and will receive unnecessary repeat imaging. We retrospectively identified 112 patients from 2012 to 2016 diagnosed with at least one ureteral stone on computerized tomography (CT) at our institution who returned to the ED within 30 days. Patients were stratified based on the presence or absence of repeat CT scan imaging. Mean values were compared with independent t-test and proportions with chi-square analysis. Multivariate logistic regression was performed to determine independent predictors of repeat imaging. Sixty-eight patients (60.7%) underwent repeat CT scan imaging upon representation to the ED within 30 days of being diagnosed with ureterolithiasis. Ureteral stone position changed in 34 patients (30.4%) who underwent repeat imaging. On univariate analysis, younger age, nondiabetics, narcotics prescribed on discharge from first ED visit, and longer mean time between ED visits were associated with repeat CT scan imaging being performed (p < .05). Only prescription of narcotic pain medications was an independent predictor of repeat CT scan imaging (odds ratio: 3.18, 95% confidence interval: 1.22–8.28; p = .018). Nonsteroidal anti-inflammatory drugs or nonnarcotic pain medications, therefore, should primarily be used for pain control in these patients to avoid unnecessary testing.
United States Air Force Physician Assistant Postgraduate Specialty Training Factors: A Brief Survey
Authors: Rabener Michael J. , Bonjour Timothy J. 
Published: October 2018

Purpose
The purpose of this study was to determine USAF physician assistants' (PAs') concerns regarding postgraduate education and training.

Methods
This was a single-mode, observational, cross-sectional study using an anonymous-structured survey involving a population of 420 active duty USAF PAs. Potential participants were contacted by email and asked to take a one-time survey via a secure survey site link.

Results
One hundred ten USAF PAs participated in the survey seeking their opinions on factors affecting applying for military postgraduate specialty training. The prime factors identified fell into 3 major groups of concern: types of degrees offered, current job satisfaction, and types of specialty training available. The most desired degree and specialty options were the doctorate of science and emergency medicine. Only a small number of respondents (6%) expressed current job satisfaction and the desire to remain in family medicine.

Conclusions
This study revealed important information to senior leaders who fund, recruit, train, and maintain force-readiness requirements. The 3 identified main priorities of respondents were the types of degrees, current level of job satisfaction, and the types of specialty training. The vast majority of those surveyed preferred the doctorate, which is what all of the specialty degrees in the Air Force are, except for ENT.
Wilms Tumor Associated With the 9q22.3 Microdeletion Syndrome: 2 New Case Reports and a Review of The Literature
Authors: Cayrol Julie , Nightingale Michael , Challis Jacqueline , Campbell Martin , Sullivan Michael , Heloury Yves 
Published: October 2018

Background:
The 9q22.3 syndrome is an autosomal dominant microdeletion syndrome with similarities to Gorlin syndrome (GS). It encompasses the PTCH1 gene locus that harbors mutations for GS. Although the 9q22.3 syndrome is associated with Wilms tumor (WT), WT is not a GS-associated tumor, implying a different mechanism involving PTCH1, or a different locus in the 9q22.3 region. The goal of this study is to report the association between WT and 9q22.3 syndrome and review the outcome of treatment.

Observations:
We report 2 new cases of WT with 9q22.3 deletion and review the literature. Among the 44 described patients with 9q22.3 deletion, 7 developed WT (16%) at a mean age of 45 months (range, 4 to 84 mo). All patients had dysmorphic features, macrocephaly, and developmental delay, and there was an association with overgrowth (4/7). One patient had bilateral WT, another had a synchronous rhabdomyosarcoma. The outcome was excellent with all cases reported to be in complete remission.

Conclusions:
The 9q22.3 microdeletion syndrome should be considered at diagnosis of WT in children with dysmorphic features. Conversely, patients with a known 9q22.3 deletion syndrome should be considered for a WT predisposition surveillance program, especially those with overgrowth. The management should be individualized and given the excellent prognosis, and the unknown future risk of metachronous disease or other malignancy, the surgical approach should be carefully considered.
Leveraging Technology to Enhance Doctor of Nursing Practice Student Health Policy Engagement
Authors: Garritano Nicole , Stec Melissa 
Published: October 2018

Background
Doctor of nursing practice (DNP) students need to develop health policy competencies. The American Association of Colleges of Nursing formed the Faculty Policy Think Tank (FPTT) in 2015, which developed recommendations about health policy curriculum at all levels of nursing education including the DNP.

Problem
Prior to the FPTT recommendations, there were no standardized examples of health policy competencies and their evaluation.

Approach
A DNP health policy course was redesigned based on the FPTT recommendations. Technological capabilities were leveraged to provide an active and experiential learning environment integrating the concepts of cultural competence, health equity, and social awareness.

Outcomes
At the conclusion of the course, DNP students are actively engaged in health policy and have increased confidence in their advocacy abilities.

Conclusions
Providing DNP students with an experiential, technologically driven learning platform gives students practical tools and applications they can use beyond the classroom to influence health policy.
Variation in Adjusted Mortality for Medical Admissions to Pediatric Cardiac ICUs*
Authors: Gaies Michael , Ghanayem Nancy S. , Alten Jeffrey A. , Costello John M. , Lasa Javier J. , Chanani Nikhil K. , Shin Andrew Y. , Retzloff Lauren , Zhang Wenying , Pasquali Sara K. , Banerjee Mousumi , Tabbutt Sarah 
Published: October 2018

Objectives:
Pediatric cardiac ICUs should be adept at treating both critical medical and surgical conditions for patients with cardiac disease. There are no case-mix adjusted quality metrics specific to medical cardiac ICU admissions. We aimed to measure case-mix adjusted cardiac ICU medical mortality rates and assess variation across cardiac ICUs in the Pediatric Cardiac Critical Care Consortium.

Design:
Observational analysis.

Setting:
Pediatric Cardiac Critical Care Consortium clinical registry.

Patients:
All cardiac ICU admissions that did not include cardiac surgery.

Interventions:
None.

Measurements and Main Results:
The primary endpoint was cardiac ICU mortality. Based on multivariable logistic regression accounting for clustering, we created a case-mix adjusted model using variables present at cardiac ICU admission. Bootstrap resampling (1,000 samples) was used for model validation. We calculated a standardized mortality ratio for each cardiac ICU based on observed-to-expected mortality from the fitted model. A cardiac ICU was considered a statistically significant outlier if the 95% CI around the standardized mortality ratio did not cross 1. Of 11,042 consecutive medical admissions from 25 cardiac ICUs (August 2014 to May 2017), the observed mortality rate was 4.3% (n = 479). Final model covariates included age, underweight, prior surgery, time of and reason for cardiac ICU admission, high-risk medical diagnosis or comorbidity, mechanical ventilation or extracorporeal membrane oxygenation at admission, and pupillary reflex. The C-statistic for the validated model was 0.87, and it was well calibrated. Expected mortality ranged from 2.6% to 8.3%, reflecting important case-mix variation. Standardized mortality ratios ranged from 0.5 to 1.7 across cardiac ICUs. Three cardiac ICUs were outliers; two had lower-than-expected (standardized mortality ratio <1) and one had higher-than-expected (standardized mortality ratio >1) mortality.

Conclusions:
We measured case-mix adjusted mortality for cardiac ICU patients with critical medical conditions, and provide the first report of variation in this quality metric within this patient population across Pediatric Cardiac Critical Care Consortium cardiac ICUs. This metric will be used by Pediatric Cardiac Critical Care Consortium cardiac ICUs to assess and improve outcomes by identifying high-performing (low-mortality) centers and engaging in collaborative learning.
Acute Kidney Injury in Critically Ill Children Admitted to the PICU for Diabetic Ketoacidosis. A Retrospective Study
Authors: Weissbach Avichai , Zur Noy , Kaplan Eytan , Kadmon Gili , Gendler Yulia , Nahum Elhanan 
Published: October 2018

Objectives:
Acute kidney injury in the critically ill pediatric population is associated with worse outcome. The aim of this study was to assess the prevalence, associated clinical variables, and outcomes of acute kidney injury in children admitted to the PICU with diabetic ketoacidosis.

Design:
Retrospective cohort.

Setting:
PICU of a tertiary, university affiliated, pediatric medical center.

Patients:
All children less than age 18 years with a primary diagnosis of diabetic ketoacidosis admitted to the PICU between November 2004 and October 2017.

Interventions:
None.

Measurements and Main Results:
Acute kidney injury was categorized into three stages using the Kidney Disease Improving Global Outcomes scale. Of the 82 children who met the inclusion criteria, 24 (30%) had acute kidney injury: 18 (75%) stage 1, five (21%) stage 2, and one (4%) stage 3. None needed renal replacement therapy. Compared with the patients without acute kidney injury, the acute kidney injury group was characterized by higher mean admission serum levels of sodium (143.25 ± 9 vs 138.6 ± 4.9 mmol/L; p = 0.0035), lactate (29.4 ± 17.1 vs 24.1 ± 10.8 mg/dL; p = 0.005), and glucose (652 ± 223 vs 542 ± 151 mg/dL; p = 0.01). There was no between-group difference in length of PICU stay (1.38 ± 0.7 vs 1.4 ± 0.7 d; p = 0.95) or hospitalization (6.1 ± 2.1 vs 5.8 ± 5.6 d; p = 0.45). Kidney injury was documented at discharge in four patients with acute kidney injury (16.7%), all stage 1; all had normal creatinine levels at the first clinical outpatient follow-up. All 82 patients with diabetic ketoacidosis survived.

Conclusions:
In this study, acute kidney injury was not uncommon in children with diabetic ketoacidosis hospitalized in the PICU. However, it was usually mild and not associated with longer hospitalization or residual kidney injury.
Topical Ketoprofen Versus Placebo in Children Presenting With Ankle Sprain to the Emergency Department
Authors: Serinken Mustafa , Eken Cenker , Tünay Kamil , Gölcük Yalcin 
Published: October 2018

Objective
Despite the favorable data concerning topical agents use in outpatient clinics, they are not commonly in emergency departments (EDs). The present study aimed to compare the effect of 2.5% topical ketoprofen (gel form) to placebo in children presenting with ankle sprain to the ED.

Study Design
Children between 7 and 18 years old presenting with ankle sprain composed the study population. Study patients were randomized into 2 study arms: 2.5% ketoprofen gel and placebo administered in a 5-cm area locally. Pain improvements at 15 and 30 minutes were measured by visual analog scale.

Results
Median pain reductions at 15 minutes for ketoprofen and placebo groups were 27.5 (16–39) and 5 (4–10), respectively. Median changes in pain intensity at 30 minutes for ketoprofen and placebo gel groups were 48 (43–52) and 9 (6–16), respectively. When compared 2 arms for the pain improvement at 15 and 30 minutes, the differences between 2 study drugs were 20 (13–28) and 35 (29–41), respectively. There were 7 (12.7%) rescue drug needs in the placebo group and 1 (1.7%) in the ketoprofen group (difference, 10.9%; 95% confidence interval, −6% to 7%; P = 0.83). There were no adverse effects in either group.

Conclusions
Ketoprofen gel is superior to placebo in ceasing pain in children presenting with ankle sprain to the ED with a high safety profile.
Walking Speed Is Correlated With the Isokinetic Muscular Strength of the Knee in Patients With Charcot-Marie-Tooth Type 1A
Authors: Reynaud Vivien , Morel Claire , Givron Pascal , Clavelou Pierre , Cornut-Chauvinc Catherine , Pereira Bruno , Taithe Frederic , Coudeyre Emmanuel 
Published: October 2018

Abstract
Charcot-Marie-Tooth disease type 1A is the most common hereditary neuropathy. Affected individuals have a distal motor deficit, initially affecting the lower limbs and impairing walking performance. Isokinetic dynamometry can be used to objectively assess muscle strength of patients with neuromuscular disorders. No studies have evaluated the effect of muscle strength deficits of knee extensors and flexors on walking parameters for patients with Charcot-Marie-Tooth disease type 1A. The purpose of this study was to determine correlations between the isokinetic muscular strength of knee flexors and knee extensors and walk parameters for patients with Charcot-Marie-Tooth disease type 1A. isokinetic muscular strength of the knee was assessed on an isokinetic dynamometer (Cybex) and walking by instrumented walkway analysis (GaitRite). We included 33 patients (23 females, mean ± SD age 46.7 ± 13.3 yrs, mean ± SD body mass index 25.7 ± 4.6 kg/m2). We found a correlation between walking speed and isokinetic muscular strength of knee extensors for the entire population and between walking speed and isokinetic muscular strength of knee extensors and knee flexors for patients younger than 50 yrs. Isokinetic dynamometry can provide objective measures of knee muscle strength, which is correlated with walking speed but not cadence or step/stride length of patients with Charcot-Marie-Tooth disease.
The Timing of Chemoprophylaxis in Autologous Microsurgical Breast Reconstruction
Authors: Bassiri-Tehrani Brian , Karanetz Irena , Bernik Stephanie F. , Dec Wojciech , Lehman Jennifer C. , Lerman Oren Z. 
Published: October 2018

Background:
Patients undergoing autologous breast reconstruction are at high risk of perioperative venous thromboembolic events. The efficacy of chemoprophylaxis in decreasing venous thromboembolic events is well established, but the timing of chemoprophylaxis remains controversial. The authors compare the incidence of bleeding following preoperative versus postoperative initiation of chemoprophylaxis in microvascular breast reconstruction.

Methods:
A retrospective chart review was performed from August of 2010 to July of 2016. Initiation of chemoprophylaxis changed from postoperative to preoperative in 2013, dividing subjects into two groups. Patient demographics, comorbidities, and complications were reviewed.

Results:
A total of 196 patients (311 flaps) were included in the study. A total of 105 patients (166 flaps) received preoperative enoxaparin (40 mg) and 91 patients (145 flaps) received postoperative chemoprophylaxis. A total of five patients required hematoma evacuation (2.6 percent). Of these, one hematoma (1 percent) occurred in the preoperative chemoprophylaxis group. Seven patients received blood transfusions: three in the preoperative group and four in the postoperative group (2.9 percent versus 4.4 percent; p = 0.419). There was a total of one flap failure, and there were no documented venous thromboembolic events in any of the groups.

Conclusions:
This study demonstrates that preoperative chemoprophylaxis can be used safely in patients undergoing microvascular breast reconstruction. The higher rate of bleeding in the postoperative group may be related to the onset of action of enoxaparin of 4 to 6 hours, which allows for intraoperative hemostasis in the preoperative group and possibly potentiating postoperative oozing when administered postoperatively.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, III.
The Relationship between Age and Facial Asymmetry
Authors: Linden Olivia E. , He Jun Kit , Morrison Clinton S. , Sullivan Stephen R. , Taylor Helena O. B. 
Published: October 2018

Background:
Facial symmetry is a fundamental goal of plastic surgery, yet some asymmetry is inherent in any face. Three-dimensional photogrammetry allows for rapid, reproducible, and quantitative facial measurements. With this tool, the authors investigated the relationship between age and facial symmetry.

Methods:
The authors imaged normal subjects using three-dimensional photogrammetry. Facial symmetry was calculated by identifying the plane of maximum symmetry and the root-mean-square deviation. Regression analysis was used to assess the relationship between age and symmetry. Subgroup analyses were performed among facial thirds.

Results:
The authors imaged 191 volunteers with an average age of 26.7 ± 22.2 years (range, 0.3 to 88 years). Root-mean-square deviation of facial symmetry clustered between 0.4 and 1.3 mm (mean, 0.8 ± 0.2 mm). The authors found a significant positive correlation between increasing age and asymmetry (p < 0.001; r = 0.66). The upper, middle, and lower facial third’s average root-mean-square deviations were 0.5 ± 0.2 mm (range, 0.2 to 1.2 mm), 0.6 ± 0.2 mm (range, 0.2 to 1.4 mm), and 0.6 ± 0.2 mm (range, 0.2 to 1.2 mm), respectively. Asymmetry also increased with age across all facial thirds (p < 0.001).

Conclusions:
Facial asymmetry increases with age in each facial third, with a greater asymmetry and increase in asymmetry in the lower two-thirds. Contributing factors may include asymmetric skeletal remodeling along with differential deflation and descent of the soft tissues. The observed correlation between increasing facial asymmetry and age may be a useful guide in plastic surgery to produce age-matched features.