bluuebunny/crossref_metadata_2025_split huggingface dataset:
PANRETINAL DEGENERATION ASSOCIATED WITH LONG-TERM HYDROXYCHLOROQUINE USE AND HETEROZYGOUS USH2A MUTATION
Authors: Katsman Diana , Sanfilippo Christian , Sarraf David 
Published: September 2016

Purpose:
To report a case of bilateral panretinal degeneration in a patient with long-term hydroxychloroquine exposure and positive for a heterozygous mutation in the USH2A gene.

Methods:
Retrospective case report. Multimodal imaging including spectral-domain optical coherence tomography, fundus autofluorescence, and fluorescein angiography was performed and the results are presented. Electroretinography findings are also described.

Results:
The authors report a 39-year-old patient with a history of hydroxychloroquine therapy for 20 years (cumulative dose of 2,774 g). Multimodal retinal imaging demonstrated bilateral paracentral outer retinal atrophy with spectral-domain optical coherence tomography and characteristic of hydroxychloroquine toxicity. Full-field electroretinography showed bilateral panretinal depression of the rod and cone responses. Mutational analysis revealed that the patient was a carrier for an autosomal recessive mutation in the USH2A gene.

Conclusion:
We report a case of panretinal degeneration but with features characteristic of hydroxychloroquine retinopathy in a patient who was found to be a heterozygous carrier of the USH2A gene, a cause of recessive retinitis pigmentosa without hearing loss. Carrier status for a retinal degenerative mutation may have rendered this patient more susceptible to the retinotoxic effects of long-term hydroxychloroquine therapy.
Identifying Subgroups of Adult Superutilizers in an Urban Safety-Net System Using Latent Class Analysis
Authors: Rinehart Deborah J. , Oronce Carlos , Durfee Michael J. , Ranby Krista W. , Batal Holly A. , Hanratty Rebecca , Vogel Jody , Johnson Tracy L. 
Published: September 2016

Background:
Patients with repeated hospitalizations represent a group with potentially avoidable utilization. Recent publications have begun to highlight the heterogeneity of this group. Latent class analysis provides a novel methodological approach to utilizing administrative data to identify clinically meaningful subgroups of patients to inform tailored intervention efforts.

Objective:
The objective of the study was to identify clinically distinct subgroups of adult superutilizers.

Research Design:
Retrospective cohort analysis.

Subjects:
Adult patients who had an admission at an urban safety-net hospital in 2014 and 2 or more admissions within the preceding 12 months.

Measures:
Patient-level medical, mental health (MH) and substance use diagnoses, social characteristics, demographics, utilization and charges were obtained from administrative data. Latent class analyses were used to determine the number and characteristics of latent subgroups that best represented these data.

Results:
In this cohort (N=1515), a 5-class model was preferred based on model fit indices, clinical interpretability and class size: class 1 (16%) characterized by alcohol use disorder and homelessness; class 2 (14%) characterized by medical conditions, MH/substance use disorders and homelessness; class 3 (25%) characterized primarily by medical conditions; class 4 (13%) characterized by more serious MH disorders, drug use disorder and homelessness; and class 5 (32%) characterized by medical conditions with some MH and substance use. Patient demographics, utilization, charges and mortality also varied by class.

Conclusions:
The overall cohort had high rates of multiple chronic medical conditions, MH, substance use disorders, and homelessness. However, the patterns of these conditions were different between subgroups, providing important information for tailoring interventions.
Is the Road to Mental Health Paved With Good Incentives? Estimating the Population Impact of Physician Incentives on Mental Health Care Using Linked Administrative Data
Authors: Puyat Joseph H. , Kazanjian Arminee , Wong Hubert , Goldner Elliot M. 
Published: September 2016

Objectives:
The use of physician incentives to improve health care, in general, has been extensively studied but its value in mental health care has rarely been demonstrated. In this study the population-level impact of physician incentives on mental health care was estimated using indicators for receipt of counseling/psychotherapy (CP); antidepressant therapy (AT); minimally adequate counseling/psychotherapy; and minimally adequate antidepressant therapy. The incentives’ impacts on overall continuity of care and of mental health care were also examined.

Materials and Methods:
Monthly cohorts of individuals diagnosed with major depression were identified between January 2005 and December 2012 and their use of mental health services tracked for 12 months following initial diagnosis. Linked health administrative data were used to ascertain cases and measure health service use. Pre-post changes associated with the introduction of physician incentives were estimated using segmented regression analyses, after adjusting for seasonal variation.

Results:
Physician incentives reversed the downward and upward trends in CP and AT. Five years postintervention, the estimated impacts in percentage points for CP, AT, minimally adequate counseling/psychotherapy, and minimally adequate antidepressant therapy were +3.28 [95% confidence interval (CI), 2.05–4.52], −4.47 (95% CI, −6.06 to −2.87), +1.77 (95% CI, 0.94–2.59), and −2.24 (95% CI, −4.04 to −0.45). Postintervention, the downward trends in continuity of care failed to reverse, but were disrupted, netting estimated impacts of +7.53 (95% CI, 4.54–10.53) and +4.37 (95% CI, 2.64–6.09) for continuity of care and of mental health care.

Conclusions:
The impact of physician incentives on mental health care was modest at best. Other policy interventions are needed to close existing gaps in mental health care.
Caregiver Activation and Home Hospice Nurse Communication in Advanced Cancer Care
Authors: Dingley Catherine E. , Clayton Margaret , Lai Djin , Doyon Katherine , Reblin Maija , Ellington Lee 
Published: September 2016

Background:
Activated patients have the skills, knowledge, and confidence to manage their care, resulting in positive outcomes such as lower hospital readmission and fewer adverse consequences due to poor communication with providers. Despite extensive evidence on patient activation, little is known about activation in the home hospice setting, when family caregivers assume more responsibility in care management.

Objective:
We examined caregiver and nurse communication behaviors associated with caregiver activation during home hospice visits of patients with advanced cancer using a prospective observational design.

Methods:
We adapted Street’s Activation Verbal Coding tool to caregiver communication and used qualitative thematic analysis to develop codes for nurse communications that preceded and followed each activation statement in 60 audio-recorded home hospice visits.

Results:
Caregiver communication that reflected activation included demonstrating knowledge regarding the patient/care, describing care strategies, expressing opinions regarding care, requesting explanations of care, expressing concern about the patient, and redirecting the conversation toward the patient. Nurses responded by providing education, reassessing the patient/care environment, validating communications, clarifying care issues, updating/revising care, and making recommendations for future care. Nurses prompted caregiver activation through focused care-specific questions, open-ended questions/statements, and personal questions.

Conclusions:
Few studies have investigated nurse/caregiver communication in home hospice, and, to our knowledge, no other studies focused on caregiver activation. The current study provides a foundation to develop a framework of caregiver activation through enhanced communication with nurses.

Implications for Practice:
Activated caregivers may facilitate patient-centered care through communication with nurses in home hospice, thus resulting in enhanced outcomes for patients with advanced cancer.
Trajectories of Symptom Clusters, Performance Status, and Quality of Life During Concurrent Chemoradiotherapy in Patients With High-Grade Brain Cancers
Authors: Kim Sang-hee , Byun Youngsoon 
Published: September 2016

Background:Symptom clusters must be identified in patients with high-grade brain cancers for effective symptom management during cancer-related therapy.Objectives:The aims of this study were to identify symptom clusters in patients with high-grade brain cancers and to determine the relationship of each cluster with the performance status and quality of life (QOL) during concurrent chemoradiotherapy (CCRT).Methods:Symptoms were assessed using the Memorial Symptom Assessment Scale, and the performance status was evaluated using the Karnofsky Performance Scale. Quality of life was assessed using the Functional Assessment of Cancer Therapy–General. This prospective longitudinal survey was conducted before CCRT and at 2 to 3 weeks and 4 to 6 weeks after the initiation of CCRT.Results:A total of 51 patients with newly diagnosed primary malignant brain cancer were included. Six symptom clusters were identified, and 2 symptom clusters were present at each time point (ie, “negative emotion” and “neurocognitive” clusters before CCRT, “negative emotion and decreased vitality” and “gastrointestinal and decreased sensory” clusters at 2–3 weeks, and “body image and decreased vitality” and “gastrointestinal” clusters at 4–6 weeks). The symptom clusters at each time point demonstrated a significant relationship with the performance status or QOL.Conclusions:Differences were observed in symptom clusters in patients with high-grade brain cancers during CCRT. In addition, the symptom clusters were correlated with the performance status and QOL of patients, and these effects could change during CCRT.Implications for Practice:The results of this study will provide suggestions for interventions to treat or prevent symptom clusters in patients with high-grade brain cancer during CCRT.
Noninvasive Estimation of Arterial Co 2 From End-Tidal Co 2 in Mechanically Ventilated Children: The GRAeDIENT Pilot Study*
Authors: Baudin Florent , Bourgoin Pierre , Brossier David , Essouri Sandrine , Emeriaud Guillaume , Wysocki Marc , Jouvet Philippe 
Published: September 2016

Objectives:
The aim of our pilot study was to develop a model to better predict Paco2 in mechanically ventilated children using noninvasive parameters including volumetric capnography.

Design:
Prospective clinical pilot study.

Setting:
Level III PICU.

Patients:
Sixty-five mechanically ventilated children.

Interventions:
None.

Materials and Methods:
We conducted a prospective clinical pilot study that included all children admitted to the PICU (< 18 yr; weight, > 3 kg; mechanically ventilated, > 6 hr; with an arterial line). A predictive model for Paco
2 was developed using linear multivariable regression. Among the data collected in PICU patients, candidate predictors of Paco
2 were defined by a panel of experts and included end-tidal partial pressure of carbon dioxide, ventilation parameters, and data resulting from the analysis of volumetric capnogram recorded 5 minutes before an arterial blood gas. Children with tidal volume less than 30 mL were excluded because of technical limits.

Results:
A total of 65 children (43 boys, 65%) (65 [21–150] mo old) were analyzed. By linear multivariable regression, the best model included the mean airway pressure, end-tidal partial pressure of carbon dioxide, Fio
2, and the capnographic index with an R
2 equal to 0.90, p value less than 0.001. After correction, 95% (n = 62) of children had an estimated Paco
2 at ± 5 mm Hg.

Conclusion:
Our model developed provides an accurate estimation of the Paco
2 using end-tidal Co
2 and noninvasive variables. Studies are needed to validate the equation in PICUs.
Ultrasound Guidance and Other Determinants of Successful Peripheral Artery Catheterization in Critically Ill Children*
Authors: Kantor David B. , Su Erik , Milliren Carly E. , Conlon Thomas W. 
Published: September 2016

Objective:
Peripheral arterial catheterization is a common invasive procedure performed in critically ill children. However, the benefits of using ultrasound guidance for this procedure in critically ill children, especially when used by inexperienced trainees, are unclear. Our aims were to evaluate whether the use of ultrasound guidance for the placement of radial arterial catheters reduced time and improved success when compared with the palpation method and also to determine patient and trainee variables that influence procedure outcomes. Finally, we evaluated whether adoption of ultrasound guidance among trainees comes at the expense of learning landmark-based methods.

Design:
Prospective observational cohort.

Setting:
University affiliated PICU.

Patients:
A total of 208 procedures performed by 45 trainees in 192 unique patients (1 mo to 20 yr old) were observed.

Intervention:
Implementation of ultrasound curriculum.

Measurements and Main Results:
The main outcome measures were time and number of attempts required for the procedure. Compared with palpation method, ultrasound guidance was associated with reduced procedure time (8.1 ± 5.2 min compared with 16.5 ± 8.8 min; p < 0.001), reduced number of attempts (3.1 ± 2.6 attempts compared with 6.9 ± 4.2 attempts; p < 0.001), and improved first attempt success rate (28% compared with 11%; p = 0.001) even after adjusting for key confounders in multivariate random effects models. The factors most likely to interfere with peripheral arterial catheterization are patient age, patient systolic blood pressure, patient body mass index, degree of fluid overload, and trainee months in fellowship. The use of ultrasound guidance mitigates the influence of each of these factors. We found no evidence that the adoption of ultrasound guidance by trainees is associated with reduced proficiency in landmark-based methods.

Conclusions:
The use of ultrasound guidance by trainees for radial artery catheterization in critically ill children is associated with improved outcomes compared with the palpation method.
Is Administration of Nitric Oxide During Extracorporeal Membrane Oxygenation Associated With Improved Patient Survival?
Authors: Tadphale Sachin D. , Rettiganti Mallikarjuna , Gossett Jeffrey M. , Beam Brandon W. , Padiyath Asif , Schmitz Michael L. , Gupta Punkaj 
Published: September 2016

Objective:
To evaluate the outcomes associated with the use of inhaled nitric oxide during extracorporeal membrane oxygenation.

Design:
Post hoc analysis of data from an existing administrative national database, Pediatric Health Information system (2004–2014). Multivariable logistic regression models were fitted to study the effect of inhaled nitric oxide during extracorporeal membrane oxygenation on study outcomes.

Setting:
Forty-two children’s hospitals across the United States.

Patients:
Patients in the age group from 1 day through 18 years admitted to an ICU who received extracorporeal membrane oxygenation during their hospital stay were included.

Interventions:
None.

Measurements and Main Results:
In total, 6,419 patients qualified for inclusion. Of these, inhaled nitric oxide was used among 3,629 patients during extracorporeal membrane oxygenation run. Approximately one half of the study patients received inhaled nitric oxide at extracorporeal membrane oxygenation initiation. The proportion of patients receiving inhaled nitric oxide during extracorporeal membrane oxygenation decreased with increasing duration of extracorporeal membrane oxygenation. After adjusting for patient characteristics and center variables, use of inhaled nitric oxide was not associated with any survival benefit. However, higher proportion of patients receiving inhaled nitric oxide were associated with prolonged hospital length of stay and prolonged duration of extracorporeal membrane oxygenation. In adjusted models, the hospital charges were higher in the inhaled nitric oxide group. The median hospital costs among patients receiving inhaled nitric oxide were higher by $39,732 (95% CI, $31,074–48,390) as compared to the patients who did not receive inhaled nitric oxide, after adjusting for patient (including hospital length of stay) and center level variables. As the duration of inhaled nitric oxide therapy increased, proportion of patients with prolonged duration of extracorporeal membrane oxygenation and prolonged hospital length of stay increased.

Conclusions:
This large observational analysis of use of nitric oxide during extracorporeal membrane oxygenation calls into question the benefits of inhaled nitric oxide among patients receiving extracorporeal membrane oxygenation for pulmonary or cardiac failure. Given our inability to determine type of extracorporeal membrane oxygenation and control for severity of illness, these findings should be interpreted as exploratory.
Preoperative Platelet Count Predicts Lower Extremity Free Flap Thrombosis: A Multi-Institutional Experience
Authors: Cho Eugenia H. , Bauder Andrew R. , Centkowski Sierra , Shammas Ronnie L. , Mundy Lily , Kovach Stephen J. , Levin L. Scott , Hollenbeck Scott T. 
Published: September 2016

Background:
Thrombocytosis in patients undergoing lower extremity free tissue transfer may be associated with increased risk of microvascular complications. This study assessed whether preoperative platelet counts predict lower extremity free flap thrombosis.

Methods:
All patients undergoing lower extremity free tissue transfer at Duke University from 1997 to 2013 and at the University of Pennsylvania from 2002 to 2013 were retrospectively identified. Logistic regression was used to assess whether preoperative platelet counts independently predict flap thrombosis, controlling for baseline and operative factors.

Results:
A total of 565 patients underwent lower extremity free tissue transfer, with an overall flap thrombosis rate of 16 percent (n = 91). Elevated preoperative platelet counts were independently associated with both intraoperative thrombosis (500 ± 120 versus 316 ± 144 × 109/liter; p < 0.001) and postoperative thrombosis (410 ± 183 versus 320 ± 143 × 109/liter; p = 0.040) in 215 patients who sustained acute lower extremity trauma within 30 days before reconstruction. In acute trauma patients, preoperative platelet counts predicted a four-fold increased risk of intraoperative thrombosis (cutoff value, 403 × 109/liter; OR, 4.08; p < 0.001) and a two-fold increased risk of postoperative thrombosis (cutoff value, 361 × 109/liter; OR, 2.16; p = 0.005). In patients who did not sustain acute trauma, preoperative platelet counts predicted a four-fold increased risk of intraoperative thrombosis (cutoff value, 352 × 109/liter; OR, 3.82; p = 0.002).

Conclusions:
Acute trauma patients with elevated preoperative platelet counts are at increased risk for lower extremity free flap complications. Prospective evaluation is warranted for guiding risk stratification and targeted treatment strategies.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Risk, III.
Facial Nerve Axonal Analysis and Anatomical Localization in Donor Nerve: Optimizing Axonal Load for Cross-Facial Nerve Grafting in Facial Reanimation
Authors: Hembd Austin , Nagarkar Purushottam A. , Saba Salim , Wan Dinah , Kutz J. Walter , Isaacson Brandon , Gupta Sachin , White Charles L. , Rohrich Rod J. , Rozen Shai M. 
Published: September 2016

Background:
Donor nerve axonal count over 900 in two-stage reconstructions using cross-facial nerve grafts is possibly associated with improved outcomes in facial reanimation. Facial nerve axonal analysis was performed to determine the ideal location for optimizing axonal load. Correlation of axonal number, branch diameter, and age was also assessed.

Methods:
Twenty-eight fresh unpreserved cadaveric hemifaces were dissected exposing the extracranial facial nerve branches. Axonal counts at 2-cm intervals from the pes anserinus along branches inserting into the zygomaticus major muscle were taken, noting position relative to the zygomatic arch, posterior ramus border, lateral border of the zygomaticus muscle, and anterior parotid gland border. Nerves were fixed, sectioned, and stained with SMI-31 antineurofilament stain for digital axonal analysis.

Results:
All specimens had one or more intraparotid zygomatic branches with over 900 axons, and 96 percent had an extraparotid branch with over 900 axons. The likelihood that a zygomatic branch would have over 900 axons at its last intraparotid point (mean, 6 mm posterior to the parotid border) was 92 percent (range, 67 to 100 percent) in contrast to 61 percent (range, 25 to 100 percent) when sampled at the first extraparotid point (mean, 14 mm anterior to the parotid border). Nerve cross-sectional area was positively correlated to its axonal count (R° = 78 percent; p < 0.0001), with nerve diameter over 0.6 mm predicting over 900 axons. Age did not correlate with axonal counts.

Conclusions:
Branches with adequate axonal load were found in all specimens. The likelihood of adequate branch selection improved from 61 percent to 92 percent with short retrograde intraparotid dissection. Nerve diameter correlated with axonal load.
Amphibian diversity and abundance in ponds is lower in exotic plantations than native forests
Authors: Iglesias-Carrasco Maider , Artexte Iraide , Cabido Carlos , Larrañaga Aitor 
Published: September 2016

AbstractWhat effect do tree plantations have on the diversity of native organisms? Some studies show that plantations reduce the diversity and abundance of certain taxa, while other studies suggested that plantations help to conserve biodiversity. Pine and eucalyptus plantations are among the most widespread exotic plantations worldwide, and they have negative effects on many taxa. But how do they affect amphibian diversity and abundance? We barely know. We therefore tallied up the number of amphibian taxa and their abundance from 18 ponds in patches of native oak forests, pine or eucalypt plantations. We also quantified water quality by measuring its physicochemistry and identifying the macroinvertebrates present in each pond. There were significantly fewer amphibian species in tree plantations than in native forest. Compared to native forest, the total density of amphibians was also significantly lower in eucalypt, but not pine, plantations. Species varied in the effects of plantations on their presence and abundance. We suggest that the decline in the presence and abundance of amphibians in plantations is linked to the physicochemical of pond water, combined with the relatively low presence of invertebrate. It seems likely that earlier desiccation, greater toxicity, and poor quality detritus in ponds in plantation are key drivers of species decline. The effects of these drivers are expected to worsen as climate change continues.