bluuebunny/crossref_metadata_2025_split huggingface dataset:
Nondepolarizing Neuromuscular Blocking Agents, Reversal, and Risk of Postoperative Pneumonia
Authors: Bulka Catherine M. , Terekhov Maxim A. , Martin Barbara J. , Dmochowski Roger R. , Hayes Rachel M. , Ehrenfeld Jesse M. 
Published: August 2016

AbstractBackgroundResidual postoperative paralysis from nondepolarizing neuromuscular blocking agents (NMBAs) is a known problem. This paralysis has been associated with impaired respiratory function, but the clinical significance remains unclear. The aims of this analysis were two-fold: (1) to investigate if intermediate-acting NMBA use during surgery is associated with postoperative pneumonia and (2) to investigate if nonreversal of NMBAs is associated with postoperative pneumonia.MethodsSurgical cases (n = 13,100) from the Vanderbilt University Medical Center National Surgical Quality Improvement Program database who received general anesthesia were included. The authors compared 1,455 surgical cases who received an intermediate-acting nondepolarizing NMBA to 1,455 propensity score–matched cases who did not and 1,320 surgical cases who received an NMBA and reversal with neostigmine to 1,320 propensity score–matched cases who did not receive reversal. Postoperative pneumonia incidence rate ratios (IRRs) and bootstrapped 95% CIs were calculated.ResultsPatients receiving an NMBA had a higher absolute incidence rate of postoperative pneumonia (9.00 vs. 5.22 per 10,000 person-days at risk), and the IRR was statistically significant (1.79; 95% bootstrapped CI, 1.08 to 3.07). Among surgical cases who received an NMBA, cases who were not reversed were 2.26 times as likely to develop pneumonia after surgery compared to cases who received reversal with neostigmine (IRR, 2.26; 95% bootstrapped CI, 1.65 to 3.03).ConclusionsIntraoperative use of intermediate nondepolarizing NMBAs is associated with developing pneumonia after surgery. Among patients who receive these agents, nonreversal is associated with an increased risk of postoperative pneumonia.
Cytomegalovirus-Induced Hemophagocytic Lymphohistiocytosis in an Extreme Preterm Infant
Authors: Halliday Matthew , Ross Julie , Southgate W. Michael 
Published: August 2016

Background:
Hemophagocytic lymphohistiocytosis (HLH) is a rare disease that can be triggered by cytomegalovirus, a relatively common infectious exposure to neonates. The clinical presentation is common to many acute illnesses seen in extreme premature infants; however, there are key clinical and laboratory findings that can lead to the diagnosis.

Purpose:
We present a case of an extreme premature infant of 25 weeks' gestation who developed cytomegalovirus-induced HLH. Using the current published protocols that are used in pediatric cancer can be adapted for use in a premature infant, which led to remission of HLH and eventual discharge from the neonatal intensive care unit.

Implications for Practice:
There are published treatment protocols used in pediatric oncology that when initiated early can lead to favorable outcomes and remission in even the most fragile neonates.

Implications for Research:
Additional studies are needed on the pharmacokinetics, dosing, and side effects on medications used for treatment of HLH in preterm infants. Additional research is needed to improve the clinician's ability to reach the diagnosis as well as define treatment strategies that provide optimal outcomes.
Elbow Kinematics During Gait Improve With Age in Children With Hemiplegic Cerebral Palsy
Authors: Gordon Benjamin L. , Wolff Aviva L. , Daluiski Aaron 
Published: August 2016

Background:
Children with hemiplegic cerebral palsy (hCP) exhibit a typical posture of elbow flexion during gait. However, the change in elbow kinematics and symmetry during gait across age span in both hCP and typically developing (TD) children is not well described. The aim of this study was to quantify the change in elbow kinematics and symmetry across age span in hCP children compared with TD children.

Methods:
Upper extremity kinematic data were extracted and analyzed from a database for gait studies performed between 2009 and 2015. A total of 35 hCP and 51 TD children between the ages of 4 and 18 (mean age: TD=11.2±0.6, hCP=9.8±0.5) met inclusionary criteria. The groups were further subdivided into 3 age categories: 4 to 7, 8 to 11, 12+ years old. Elbow angles were extracted and peak elbow flexion, overall range of motion during gait, and asymmetry indices were calculated. A 1-way analysis of variance was performed on each group with post hoc Tukey honestly significant difference pairwise comparisons.

Results:
Peak elbow flexion during gait increased with age in TD children (P<0.05) and decreased with age in hCP children on the affected side (P<0.05). There was no change on the less affected side of hCP children. TD children demonstrated significantly less elbow flexion (mean=51.9±2.1 deg.) compared with the affected side in hCP (mean=82.1±3.8 deg.) across all age categories (P<0.05). There was no change in elbow asymmetry index (0=perfect symmetry) across age in either controls or hCP children; however, there were differences between hCP and TD groups in younger age groups (TD=28, hCP=62, P<0.05) that resolved by adolescence (TD=32, hCP=40).

Conclusions:
During gait, hCP children have greater peak elbow flexion on the affected side than do TD children. Peak elbow flexion angle converged between the 2 groups with age, decreasing in hCP children and increasing in TD children. Furthermore, elbow symmetry during gait improves with age in hCP children, approximating symmetry of TD children by adolescence. These findings have implications for both consideration and optimal timing of surgical intervention to improve elbow flexion in children with hCP.

Level of Evidence:
Level III—retrospective case-control study.
Comparison of Motor-Evoked Potentials Versus Somatosensory-Evoked Potentials as Early Indicators of Neural Compromise in Rat Model of Spinal Cord Compression
Authors: Morris Susan H. , Howard Jason J. , El-Hawary Ron 
Published: August 2016

Study Design.
Randomized controlled study comparing the efficacy of intraoperative somatosensory-evoked potentials (SSEPs) versus transcranial motor–evoked potentials (TcMEPs) as early indicators of neural compromise and predictors of postoperative function in a rat model of spinal cord compression.

Objective.
To compare the relative efficacy of SSEPs and TcMEPs to detect spinal cord compromise and predict postoperative functional deficit after spinal cord compression.

Summary of Background Data.
There is controversy regarding the efficacy of SSEPs versus TcMEPs to detect intraoperative spinal cord compromise and predict functional outcomes. Previous trials provide some guidance as to the role of each modality in spinal cord monitoring but randomized controlled trials, which are not feasible in humans, are lacking.

Methods.
Twenty-four adult male Wistar rats were evenly divided into three experimental groups and one control group. The experimental groups were determined according to the length of time that 100% TcMEP signal loss was maintained: 0, 5, or 15 minutes. All animals had standardized preoperative functional testing. Spinal cord compromise was initiated utilizing a validated protocol, which involved compression via a balloon catheter introduced into the thoracic sublaminar space. Both SSEPs and TcMEPs were recorded during cord compression for each experimental group. Functional behavioral testing using two validated methods (tilt and modified Tarlov) was repeated 24 hours after termination of spinal cord compression. Post hoc, animals were redistributed into two functional subgroups, noncompromised and compromised, for statistical analysis.

Results.
TcMEPs consistently detected spinal cord compromise either in advance of or at the same time as SSEPs; however, the delay in SSEP response was not significant for cases when compromised postoperative function resulted. Both SSEP and TcMEP amplitude recovery correlated well with postoperative functional scores.

Conclusion.
TcMEPs are more sensitive to spinal cord compromise than SSEPs, but the recovery profiles of both SSEP and TcMEP amplitudes are good predictors of postoperative function.

Level of Evidence: 2
The Postcardiac Arrest Consult Team: Impact on Hospital Care Processes for Out-of-Hospital Cardiac Arrest Patients*
Authors: Brooks Steven C. , Scales Damon C. , Pinto Ruxandra , Dainty Katie N. , Racz Elizabeth M. , Gaudio Michelle , Amaral Andre C. K. B. , Gray Sara H. , Friedrich Jan O. , Chapman Martin , Dorian Paul , Fam Neil , Fowler Robert A. , Hayes Chris W. , Baker Andrew , Crystal Eugene , Madan Mina , Rubenfeld Gordon , Smith Orla M. , Morrison Laurie J. 
Published: August 2016

Objective:
To evaluate whether a Post-Arrest Consult Team improved care and outcomes for patients with out-of-hospital cardiac arrest.

Design:
Prospective cohort study of Post-Arrest Consult Team implementation at two hospitals, with concurrent controls from 27 others.

Setting:
Twenty-nine hospitals within the Strategies for Post-Arrest Care Network of Southern Ontario, Canada.

Patients:
We included comatose adult nontraumatic out-of-hospital cardiac arrest patients surviving more than or equal to 6 hours after emergency department arrival who had no contraindications to targeted temperature management.

Intervention:
The Post-Arrest Consult Team was an advisory consult service to improve 1) targeted temperature management, 2) assessment for percutaneous coronary intervention, 3) electrophysiology assessment, and 4) appropriately delayed neuroprognostication.

Measurements and Main Results:
We used generalized linear mixed models to explore the association between Post-Arrest Consult Team implementation and performance of targeted processes. We included 1,006 patients. The Post-Arrest Consult Team was associated with a significant reduction over time in rates of withdrawal of life-sustaining therapy within 72 hours of emergency department arrival on the basis of predictions of poor neurologic prognosis (ratio of odds ratios, 0.13; 95% CI, 0.02–0.98). Post-Arrest Consult Team was not associated with improved successful targeted temperature management (ratio of odds ratios, 0.91; 95% CI, 0.31–2.65), undergoing angiography (ratio of odds ratios, 1.91; 95% CI, 0.17–21.04), receiving electrophysiology consultation (ratio of odds ratios, 0.93; 95% CI, 0.11–8.16), or functional survival (ratio of odds ratios, 0.75; 95% CI, 0.19–2.94).

Conclusions:
Implementation of a Post-Arrest Consult Team reduced premature withdrawal of life-sustaining therapy but did not improve rates of successful targeted temperature management, coronary angiography, formal electrophysiology assessments, or functional survival for comatose patients after out-of-hospital cardiac arrest.
Peripheral IV Insulin Infusion Infiltration Presenting as “Insulin Resistance”
Authors: Kim Tiffany Y. , Woeber Kenneth A. , MacMaster Heidimarie Windham , Rushakoff Robert J. 
Published: August 2016

Objectives:
We present the case of a 66-year-old woman who developed hypoglycemia following the prolonged infiltration of a high dose continuous peripheral IV insulin infusion.

Study Selection:
Case report.

Data Sources and Extraction:
PubMed was searched for relevant literature on exogenous hyperinsulinemic hypoglycemia.

Data Synthesis:
The patient was postlung transplantation and was receiving high doses of glucocorticoids. Despite increasing the peripheral IV insulin rate, hyperglycemia persisted. We discovered that the IV insulin infusion line infiltrated, resulting in a large subcutaneous insulin depot, estimated to be 450 units of regular insulin. She subsequently experienced prolonged hypoglycemia that was managed with concentrated dextrose containing fluids. In our literature search, there were no similar case reports. The literature on insulin overdose, usually from suicide attempts, can help guide the management of iatrogenic hyperinsulinemic hypoglycemia. Important management considerations include anticipated duration of hypoglycemia, supplemental glucose, fluid management, and electrolyte monitoring.

Conclusion:
Peripheral IV insulin infusion infiltration should be considered when patients do not respond to increasing rates of insulin infusion.
Comparing Time-Fixed Mortality Prediction Models and Their Effect on ICU Performance Metrics Using the Simplified Acute Physiology Score 3
Authors: Engerström Lars , Kramer Andrew A. , Nolin Thomas , Sjöberg Folke , Karlström Göran , Fredrikson Mats , Walther Sten M. 
Published: August 2016

Objectives:
To examine ICU performance based on the Simplified Acute Physiology Score 3 using 30-day, 90-day, or 180-day mortality as outcome measures and compare results with 30-day mortality as reference.

Design:
Retrospective cohort study of ICU admissions from 2010 to 2014.

Setting:
Sixty-three Swedish ICUs that submitted data to the Swedish Intensive Care Registry.

Patients:
The development cohort was first admissions to ICU during 2011–2012 (n = 53,546), and the validation cohort was first admissions to ICU during 2013–2014 (n = 57,729).

Interventions:
None.

Measurements and Main Results:
Logistic regression was used to develop predictive models based on a first level recalibration of the original Simplified Acute Physiology Score 3 model but with 30-day, 90-day, or 180-day mortality as measures of outcome. Discrimination and calibration were excellent for the development dataset. Validation in the more recent 2013–2014 database showed good discrimination (C-statistic: 0.85, 0.84, and 0.83 for the 30-, 90-, and 180-d models, respectively), and good calibration (standardized mortality ratio: 0.99, 0.99, and 1.00; Hosmer-Lemeshow goodness of fit H-statistic: 66.4, 63.7, and 81.4 for the 30-, 90-, and 180-d models, respectively). There were modest changes in an ICU’s standardized mortality ratio grouping (< 1.00, not significant, > 1.00) when follow-up was extended from 30 to 90 days and 180 days, respectively; about 11–13% of all ICUs.

Conclusions:
The recalibrated Simplified Acute Physiology Score 3 hospital outcome prediction model performed well on long-term outcomes. Evaluation of ICU performance using standardized mortality ratio was only modestly sensitive to the follow-up time. Our results suggest that 30-day mortality may be a good benchmark of ICU performance. However, the duration of follow-up must balance between what is most relevant for patients, most affected by ICU care, least affected by administrative policies and practically feasible for caregivers.
Double-Stranded RNA Interacts With Toll-Like Receptor 3 in Driving the Acute Inflammatory Response Following Lung Contusion
Authors: Suresh Madathilparambil V. , Thomas Bivin , Machado-Aranda David , Dolgachev Vladislov A. , Kumar Ramakrishnan Sadeesh , Talarico Nicholas , Cavassani Karen , Sherman Matthew A. , Hemmila Mark R. , Kunkel Steven L. , Walter Nils G. , Hogaboam Cory M. , Raghavendran Krishnan 
Published: August 2016

Objectives:
Lung contusion is a major risk factor for the development of acute respiratory distress syndrome. We set to determine the role of toll-like receptor 3 and the binding of double-stranded RNA in the pathogenesis of sterile injury following lung contusion.

Design:
Toll-like receptor 3 expression was analyzed in postmortem lung samples from patients with lung contusion. Unilateral lung contusion was induced in toll-like receptor 3 (–/–), TIR-domain-containing adapter-inducing interferon-β (–/–), and wild-type mice. Subsequently, lung injury and inflammation were evaluated. Apoptotic indices, phagocytic activity, and phenotypic characterization of the macrophages were determined. Double-stranded RNA in bronchoalveolar lavage and serum samples following lung contusion was measured. A toll-like receptor 3/double-stranded RNA ligand inhibitor was injected into wild-type mice prior to lung contusion.

Measurements and Main Results:
Toll-like receptor 3 expression was higher in patients and wild-type mice with lung contusion. The degree of lung injury, inflammation, and macrophage apoptosis was reduced in toll-like receptor 3 (–/–), TIR-domain-containing adapter-inducing interferon-β (–/–), and wild-type mice with toll-like receptor 3 antibody neutralization. Alveolar macrophages from toll-like receptor 3 (–/–) mice had a lower early apoptotic index, a predominant M2 phenotype and increased surface translocation of toll-like receptor 3 from the endosome to the surface. When compared with viral activation pathways, lung injury in lung contusion demonstrated increased p38 mitogen-activated protein kinases, extracellular signal-regulated kinase 1/2 phosphorylation with inflammasome activation without a corresponding increase in nuclear factor-κB or type-1 interferon production. Additionally, pretreatment with toll-like receptor 3/double-stranded RNA ligand inhibitor led to a reduction in injury, inflammation, and macrophage apoptosis.

Conclusions:
We conclude that the interaction of double-stranded RNA from injured cells with toll-like receptor 3 drives the acute inflammatory response following lung contusion.
Plastic Surgery and Suicide: A Clinical Guide for Plastic Surgeons
Authors: Reddy Vikram , Coffey M. Justin 
Published: August 2016

Summary:
Several studies have identified an increased risk of suicide among patient populations which a plastic surgeon may have a high risk of encountering: women undergoing breast augmentation, cosmetic surgery patients, and breast cancer patients. No formal guidelines exist to assist a plastic surgeon when faced with such a patient, and not every plastic surgery team has mental health clinicians that are readily accessible for consultation or referral. The goal of this clinical guide is to offer plastic surgeons a set of practical approaches to manage potentially suicidal patients. In addition, the authors review a screening tool, which can assist surgeons when encountering high-risk patients.
Nipple Reconstruction with the Biodesign Nipple Reconstruction Cylinder: A Prospective Clinical Study
Authors: Collins Brendan , Williams Jeremy Z. , Karu Heather , Hodde Jason P. , Martin Victoria A. , Gurtner Geoffrey C. 
Published: August 2016

Background:
Nipple reconstruction is the last stage in cosmetic reconstruction of the breast after mastectomy, but no method produces reliable and consistent aesthetic results. This study examined the use of the Biodesign Nipple Reconstruction Cylinder (NRC) during reconstruction of the nipple after mastectomy.

Methods:
Patients with a history of breast cancer and mastectomy desiring nipple reconstruction were invited to participate. After obtaining consent, unilateral or bilateral nipple reconstruction was performed. Skin flaps were raised, the NRC was placed beneath the flaps as a stent, and the site was protected for up to 4 weeks with a nipple shield. Nipple projection was measured for 12 months after surgery. Patient satisfaction was measured and adverse events were recorded. Follow-up examinations were performed at 1 week, and then at 1, 3, 6, and 12 months after surgery.

Results:
Eighty-two nipple reconstructions were performed in 50 patients. Related postoperative adverse events were minor, but reported in 8 reconstructions (9.8%) representing 7 patients (14.0%). Average projection at 6 and 12 months was 4.1 ± 1.6 mm and 3.8 ± 1.5 mm, respectively, compared with 10.5 ± 2.2 mm 1 week after surgery. Of patients completing the satisfaction questionnaire at 12 months, 70/75 (93.3%) of reconstructions were rated “pleased” or “very pleased” with the overall outcome. Overall, 45/46 (97.8%) patients would recommend nipple reconstruction to other women.

Conclusions:
The Biodesign NRC offers a safe alternative to nipple reconstruction, resulting in stable projection and a high level of patient satisfaction for 12 months after placement.
Physiological Responses to Arm Activity in Individuals With Chronic Obstructive Pulmonary Disease Compared With Healthy Controls
Authors: Lima Vanessa Pereira , Iamonti Vinicius C. , Velloso Marcelo , Janaudis-Ferreira Tania 
Published: August 2016

PURPOSE:
The mechanisms underlying physiological limitations during arm activity in individuals with chronic obstructive pulmonary disease (COPD) are unknown. The objective of this systematic review was to describe cardiorespiratory responses, symptoms, chest wall kinematics, muscle activity, and lung volumes during arm activity in individuals with COPD relative to the responses of healthy controls.

METHODS:
Original research articles that compared cardiorespiratory responses, symptoms, muscle activity, chest wall kinematics, and lung function during arm activity between individuals with COPD and healthy controls were identified after searches of 5 electronic databases and reference lists of pertinent articles. Two reviewers performed the electronic and manual searches with 1 screening title and abstracts. Two investigators screened the full texts to determine eligibility for inclusion. One reviewer performed the data extraction and tabulation using a standardized form with a second reviewer double-checking the data extracted.

RESULTS:
Of the 54 full-text articles assessed for eligibility, 6 met the inclusion criteria. Reduced cardiorespiratory responses during peak arm exercise in individuals with COPD compared with healthy controls were evident. Compared with healthy controls, individuals with COPD had increased dyspnea and hyperinflation during peak arm exercise. Increased effort of the trapezius muscle during arm activities was also found in persons with COPD compared with healthy controls.

CONCLUSIONS:
There is limited evidence describing physiological responses during arm activity in individuals with COPD. Findings of this systematic review suggest that individuals with COPD have decreased cardiorespiratory responses during peak arm exercise compared with controls but increased dyspnea, hyperinflation, and arm muscle effort.
BRANCH RETINAL ARTERY OCCLUSION ASSOCIATED WITH PARACENTRAL ACUTE MIDDLE MACULOPATHY IN A PATIENT WITH LIVEDO RETICULARIS
Authors: Baciu Paul , Nofar Candice M. , Spaulding Justin , Gao Hua 
Published: August 2016

Purpose:
To report the occurrence of a branch retinal artery occlusion with paracentral acute middle maculopathy in an otherwise healthy young man with a history of livedo reticularis (LR).

Methods:
Retrospective case report.

Patients:
A 21-year-old man with a history of LR being treated with pentoxifylline developed an acute branch retinal artery occlusion with initial best-corrected visual acuity at presentation of 20/80.

Results:
A thorough diagnostic work up was negative for potential causes of branch retinal artery occlusion or LR. The patient was continued on pentoxifylline and started on aspirin 81 mg daily. At five-month follow-up, vision had improved to 20/25. Optical coherence tomography testing showed a hyperreflective band in the inner nuclear layer and outer plexiform layers in the affected eye that ultimately thinned, consistent with paracentral acute middle maculopathy.

Conclusion:
To our knowledge, this is the first case of branch retinal artery occlusion occurring in a patient with a history of LR. This could potentially be an early manifestation of Sneddon syndrome, a rare entity characterized by LR and cerebrovascular disease, which has been previously associated with central retinal artery occlusions.