bluuebunny/crossref_metadata_2025_split huggingface dataset:
Mild Sedation Exacerbates or Unmasks Focal Neurologic Dysfunction in Neurosurgical Patients with Supratentorial Brain Mass Lesions in a Drug-specific Manner
Authors: Lin Nan , Han Ruquan , Zhou Jianxin , Gelb Adrian W. 
Published: January 2016

AbstractAbstract
Mild sedation with propofol and midazolam exacerbated neurologic deficits to a greater extent than fentanyl or dexmedetomidine; the latter had the least effect on neurologic function. The change in neurologic function in patients with preexisting brain lesions is produced in a drug-specific effect and is not due to nonspecific sedation.

Background
Sedation is commonly used in neurosurgical patients but has been reported to produce transient focal neurologic dysfunction. The authors hypothesized that in patients with frontal–parietal–temporal brain tumors, focal neurologic deficits are unmasked or exacerbated by nonspecific sedation independent of the drug used.

Methods
This was a prospective, randomized, single-blind, self-controlled design with parallel arms. With institutional approval, patients were randomly assigned to one of the four groups: “propofol,” “midazolam,” “fentanyl,” and “dexmedetomidine.” The sedatives were titrated by ladder administration to mild sedation but fully cooperative, equivalent to Observer’s Assessment of Alertness and Sedation score = 4. National Institutes of Health Stroke Scale (NIHSS) was used to evaluate the neurologic function before and after sedation. The study’s primary outcome was the proportion of NIHSS-positive change in patients after sedation to Observer’s Assessment of Alertness and Sedation = 4.

Results
One hundred twenty-four patients were included. Ninety had no neurologic deficits at baseline. The proportion of NIHSS-positive change was midazolam 72%, propofol 52%, fentanyl 27%, and dexmedetomidine 23% (P less than 0.001 among groups). No statistical difference existed between propofol and midazolam groups (P = 0.108) or between fentanyl and dexmedetomidine groups (P = 0.542). Midazolam and propofol produced more sedative-induced focal neurologic deficits compared with fentanyl and dexmedetomidine. The neurologic function deficits were mainly limb motor weakness and ataxia. Patients with high-grade gliomas were more susceptible to the induced neurologic dysfunction regardless of the sedative.

Conclusions
Midazolam and propofol augmented or revealed neurologic dysfunction more frequently than fentanyl and dexmedetomidine at equivalent sedation levels. Patients with high-grade gliomas were more susceptible than those with low-grade gliomas.
Common Anesthetic-binding Site for Inhibition of Pentameric Ligand-gated Ion Channels
Authors: Kinde Monica N. , Bu Weiming , Chen Qiang , Xu Yan , Eckenhoff Roderic G. , Tang Pei 
Published: January 2016

AbstractAbstract
Using ELIC, a prokaryotic pentameric ligand-gated ion channel (pLGIC) Erwinia chrysanthemi, as a model, propofol is shown to bind in a transmembrane intrasubunit pocket that overlaps anesthetic-binding sites previously identified in other pLGICs. The functional relevance of this binding site is demonstrated by analysis of chimeric receptors, which suggests that the transmembrane intrasubunit site is a common binding site for anesthetic inhibition of cationic pLGICs.
Supplemental Digital Content is available in the text.

Background
Identifying functionally relevant anesthetic-binding sites in pentameric ligand-gated ion channels (pLGICs) is an important step toward understanding the molecular mechanisms underlying anesthetic action. The anesthetic propofol is known to inhibit cation-conducting pLGICs, including a prokaryotic pLGIC from Erwinia chrysanthemi (ELIC), but the sites responsible for functional inhibition remain undetermined.

Methods
We photolabeled ELIC with a light-activated derivative of propofol (AziPm) and performed fluorine-19 nuclear magnetic resonance experiments to support propofol binding to a transmembrane domain (TMD) intrasubunit pocket. To differentiate sites responsible for propofol inhibition from those that are functionally irrelevant, we made an ELIC-γ-aminobutyric acid receptor (GABAAR) chimera that replaced the ELIC-TMD with the α1β3GABAAR-TMD and compared functional responses of ELIC-GABAAR and ELIC with propofol modulations.

Results
Photolabeling showed multiple AziPm-binding sites in the extracellular domain (ECD) but only one site in the TMD with labeled residues M265 and F308 in the resting state of ELIC. Notably, this TMD site is an intrasubunit pocket that overlaps with binding sites for anesthetics, including propofol, found previously in other pLGICs. Fluorine-19 nuclear magnetic resonance experiments supported propofol binding to this TMD intrasubunit pocket only in the absence of agonist. Functional measurements of ELIC-GABAAR showed propofol potentiation of the agonist-elicited current instead of inhibition observed on ELIC.

Conclusions
The distinctly different responses of ELIC and ELIC-GABAAR to propofol support the functional relevance of propofol binding to the TMD. Combining the newly identified TMD intrasubunit pocket in ELIC with equivalent TMD anesthetic sites found previously in other cationic pLGICs, we propose this TMD pocket as a common site for anesthetic inhibition of pLGICs.
Internet-administered Health-related Quality of Life Questionnaires Compared With Pen and Paper in an Adolescent Scoliosis Population: A Randomized Crossover Study
Authors: Nitikman Michael , Mulpuri Kishore , Reilly Christopher W. 
Published: January 2016

Background:
Modern technology puts into question the effectiveness of using pen and paper as a means of collecting information from web-enabled patients. This study aimed to validate and test the reliability of using the Internet as a method of administering health-related quality of life questionnaires in a pediatric spine population.

Methods:
A prospective randomized crossover study was conducted. Patients aged 11 to 18 with idiopathic scoliosis were invited to participate, and informed consent was obtained from a scoliosis outpatient clinic setting. Participants were randomized to one of 4 groups determining the method of questionnaire administration [Scoliosis Research Society 30 (SRS-30) and Pediatric Outcomes Data Collection Instrument (PODCI)]. Both questionnaires were completed at 2 separate timepoints and 2 weeks apart to prevent recall bias. Groups included: Paper/Paper, Paper/Internet, Internet/Paper, and Internet/Internet. Paired-samples t tests were used to determine the test-retest reliability of each group. Analysis was stratified for surveys returned within or outside of the allotted 4-week timeframe following enrollment.

Results:
Of the 96 participants who completed and returned both sets of questionnaires, 26 were allocated to the Paper/Paper group (27%), 20 to the Paper/Internet group (21%), 26 to the Internet/Paper group (27%), and 24 to the Internet/Internet group (25%). The second iteration of questionnaires was returned on time by 69 of the participants (71.2%). Of the late questionnaires, 18 (67%) were paper forms. Overall, no differences were observed between Internet-administered compared with pen and paper–administered questionnaires (P=0.206). No differences were observed within any group individually for either the SRS-30 or PODCI questionnaire. In addition, no significant differences were observed within groups for surveys returned within or outside of the 4-week timeframe. Eighty-four percent of the participants who completed both paper and Internet versions of the questionnaires reported a preference of the Internet.

Conclusion:
Internet administration of both the SRS-30 and PODCI questionnaires is a valid and reliable method of acquiring health-related quality of life information in this population

Level of Evidence:
Level II—therapeutic study.
The Impact of Child Safety Restraint Status and Age in Motor Vehicle Collisions in Predicting Type and Severity of Bone Fractures and Traumatic Injuries
Authors: Loftis Christopher M. , Sawyer Jeffrey R. , Eubanks James W. , Kelly Derek M. 
Published: January 2016

Background:
Although morbidity and mortality in children increases in motor vehicle collisions (MVC) if child restraints are not used, no data exist correlating specific injuries with proper or improper use of safety restraints or age. The purpose of this study was to evaluate correlations between childhood MVC injuries, age, and restraint status.

Methods:
A medical record search for pediatric patients involved in a MVC was conducted at a pediatric hospital (level 1 trauma). Charts were reviewed for demographics and injury-specific information. Patients were grouped by age, restraint use, and injuries.

Results:
Nine hundred sixty-seven patients ≤12 years (average age 6.39 y) were identified. Being properly restrained was most common in all age groups except the 4- to 8-year age group in which being improperly restrained was most common. Unrestrained patients were most commonly found in the 9- to 12-year age group. A statistically significant difference was not observed for orthopaedic injuries among the restraint groups, but internal thoracic injuries, open head wound, and open upper extremity wounds were significantly more common in improperly or unrestrained patients. Improperly restrained infants had a significantly higher rate of intracranial bleeds and abrasions than those properly restrained. Unrestrained and improperly restrained 9- to 12-year olds had significantly more open head, open upper extremity, and vascular injuries. When comparing injury types with age groups, upper extremity fractures, femoral fractures, dislocations, and spinal fractures were found to be significantly higher in older children.

Conclusions:
Preventing orthopaedic injuries in older children may be accomplished by changes in regulations or automotive safety equipment. Rear-facing child safety seats could possibly be improved to prevent head trauma in the youngest patients. There is a continued need to reinforce the importance of proper use of child safety devices to parents. Knowledge of the patient’s age, along with restraint status, might aid in diagnosis of less obvious MCV injuries.

Level of Evidence:
Level III.
The POSNA-COUR International Scholar Program. Results of the First 7 Years
Authors: Fornari Eric D. , Sabharwal Sanjeev , Schwend Richard M. 
Published: January 2016

Background:
The Pediatric Orthopedic Society of North America (POSNA)-Children’s Orthopedics in Underserved Regions (COUR) International Scholar Program was initiated in 2007 to provide educational opportunities for emerging leaders who treat children with orthopaedic conditions in resource-challenged environments worldwide. Financial support is available each year for 4 to 6 orthopaedic surgeons to attend either the POSNA Annual Meeting or the International Pediatric Orthopedic Symposium. The scholars are also encouraged to visit selected centers for observerships during their trip. Since 2007 there have been 41 international scholars who have participated in the program. We wished to assess the impact of the program and to obtain feedback to improve the experience for future participants.

Methods:
A 23-question web-based survey was created and sent to 38 past scholars from 22 countries who have participated in the program by July 2013. The responses were gathered online and the data were analyzed for the 24 (62%) respondents from 18 countries who completed the survey.

Results:
Of the respondents, 16/24 (66%) reported that their current practice is comprised of at least 75% pediatrics. Twelve of 24 (52%) were fellowship trained in pediatric orthopaedics, typically outside of North America. All scholars found the meeting they attended to be very useful and have subsequently made changes to their clinical practice. Nineteen of 24 (82%) did a premeeting or postmeeting observership. Twenty-two of 24 (92%) participants have remained in contact with POSNA members they met at the meeting, with 86% of respondents stating that they have subsequently consulted POSNA members on management of patients. Sixty-two percent of the scholars had a POSNA member visit them following the scholarship and 29% have since returned to visit POSNA members for further clinical observerships. Twenty-one of 24 (91%) have had the opportunity to share the knowledge they gained with others in their region through lectures, surgical demonstrations, and/or clinical training. A common response from the scholars was that the scholarship program was a truly transformative life experience that provided them with an opportunity to receive the highest quality of professional education. The main challenges that these scholars report are lack of available fellowship/subspecialty training in their region, patients’ inability to pay, and excessive physician workload. All of the respondents expressed interest in arranging a POSNA cosponsored regional meeting.

Conclusions:
Since 2007, the POSNA-COUR international scholar program has been a fruitful resource for orthopaedists practicing in resource-challenged environments worldwide. It has provided unique training for the scholars and has further enabled them to teach others in their region. The program has thus far succeeded in fostering lasting relationships that have led to continued educational exchanges.

Level of Evidence:
Level IV—case series.
Breast Cancer is Common in Women With Ovarian Malignant Mixed Mullerian Tumors
Authors: Whynott Rachel M. , Manahan Kelly J. , Geisler John P. 
Published: January 2016

Background:
Ovarian malignant mixed Mullerian tumors (MMMTs) are uncommon cancers. The purpose of the study was to determine the rate of metachronous or synchronous breast cancer as well as the rate of truncating germline BRCA1 and/or BRCA2 mutations in a series of women with these uncommon tumors.

Materials and Methods:
Records were reviewed to identify all women with MMMTs treated by the gynecologic oncology service. The stage, grade, histology, survival, and rate of coexistent breast cancer were determined. Tumor and/or peripheral blood was tested for BRCA1 and BRCA2 truncating mutations.

Results:
Twenty-four patients with MMMTs were found. Tumor and paired peripheral blood was available on 20 patients and 4 more patients had only peripheral blood available. Family pedigrees were available on all 24 patients. Fifteen of 24 (62.5%) patients were found to have metachronous or synchronous breast cancers with 9 of 15 (60%) having bilateral breast cancer. No BRCA1 or BRCA2 mutations were found (somatic or germline) in this cohort.

Conclusions:
Although an uncommon tumor, MMMTs are often found in women with breast cancer. Despite this finding, BRCA1 or BRCA2 germline mutations are not common in this population.

Precis:
Ovarian MMMTs are frequently found in women with cancer but are not frequently associated with defects in BRCA1 or BRCA2.
ACQUIRED VITELLIFORM DETACHMENT IN MULTIPLE MYELOMA
Authors: El Ameen Alaa , Mrejen-Uretsky Sarah , Abraham Julie , Souied Eric H. , Cohen Salomon Y. 
Published: January 2016

Purpose:
To report a case of subfoveal acquired vitelliform detachment in a patient with multiple myeloma.

Methods:
Case report.

Results:
A 65-year-old man was referred for treatment of a serous macular detachment considered to be caused from chronic central serous chorioretinopathy or adult pseudovitelliform macular dystrophy. His medical history revealed an untreated multiple myeloma. Systemic chemotherapy was undertaken and resulted in a rapid resolution of the detachment.

Conclusion:
Multiple myeloma may be considered as a possible cause of vitelliform macular detachment.
Out-of-Hospital Cardiac Arrest in the Pediatric Population in Hong Kong
Authors: Law Alex Kwok-Keung , Ng Man-Ho , Hon Kam-Lun , Graham Colin A. 
Published: January 2016

Aim
To describe the epidemiology and outcomes of out-of-hospital cardiac arrest (OHCA) in a Hong Kong (HK) pediatric population and to identify factors associated with favorable outcomes.

Methods
Retrospective case note review of patients younger than 18 years who presented to the emergency department of Prince of Wales Hospital, HK with cardiac arrest from 2003 to 2013. Patients were classified as infants (<1 year), children (1–11 years) and adolescents (12–18 years). Patient characteristics, OHCA details, interventions, and outcomes were reported following the Utstein format.

Results
There were 53 patients in the study (77.4% men) and 34.6% of patients had chronic illnesses. In the infant group, 35.7% had complicated pregnancies. The incidence of OHCA in HK was 5.37 per 100,000 person-years. Out-of-hospital cardiac arrest was identified by bystanders in 62.3%, but bystander cardiopulmonary resuscitation was provided in only 28.3%. Shockable rhythms were uncommon (9.4%). Most OHCA in infants had unknown causes. In children, commonest causes were respiratory illness and environmental hazards, and in adolescents, trauma and cardiogenic events. Overall survival to hospital discharge rate was 20.8%; 13.2% had good neurological outcomes. Bystander cardiopulmonary resuscitation (odds ratio [OR], 7.44; 95% confidence interval [95% CI], 1.75–31.7; P = 0.007), prehospital return of spontaneous circulation (OR, 11.4; 95% CI, 1.75–74.7; P = 0.013), and return of spontaneous circulation within 30 minutes (OR, 90.0; 95% CI, 11.1–727; P < 0.0005) were associated with survival to discharge.

Conclusions
The incidence of OHCA in HK is comparable to global data. The outcome of OHCA in the pediatric population has improved over the decades. Better prehospital care could improve outcome.
Lengthening Temporalis Myoplasty for Single-Stage Smile Reconstruction in Children with Facial Paralysis
Authors: Panossian Andre 
Published: January 2016

Background:
Free muscle transfer for dynamic smile reanimation in facial paralysis is not always predictable with regard to cosmesis. Hospital stays range from 5 to 7 days. Prolonged operative times, longer hospital stays, and excessive cheek bulk are associated with free flap options. Lengthening temporalis myoplasty offers single-stage smile reanimation with theoretical advantages over free tissue transfer.

Methods:
From 2012 to 2014, 18 lengthening temporalis myoplasties were performed in 14 children for smile reconstruction. A retrospective chart review was completed for demographics, operative times, length of hospital stay, and perioperative complications.

Results:
Fourteen consecutive patients with complete facial paralysis were included. Four patients underwent single-stage bilateral reconstruction, and 10 underwent unilateral procedures. Diagnoses included Möbius syndrome (n = 5), posterior cranial fossa tumors (n = 4), posttraumatic (n = 2), hemifacial microsomia (n = 1), and idiopathic (n = 2). Average patient age was 10.1 years. Average operative time was 410 minutes (499 minutes for bilateral lengthening temporalis myoplasty and 373 for unilateral lengthening temporalis myoplasty). Average length of stay was 3.3 days (4.75 days for bilateral lengthening temporalis myoplasty and 2.8 for unilateral lengthening temporalis myoplasty). Nine patients required minor revisions.

Conclusions:
Lengthening temporalis myoplasty is a safe alternative to free tissue transfer for dynamic smile reconstruction in children with facial paralysis. Limited donor-site morbidity, shorter operative times, and shorter hospital stays are some benefits over free flap options. However, revisions are required frequently secondary to tendon avulsions and adhesions.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
Sustaining Innovations in Complex Health Care Environments: A Multiple-Case Study of Rapid Response Teams
Authors: Stolldorf Deonni P. , Havens Donna S. , Jones Cheryl B. 
Published: January 2016

Objectives
Rapid response teams (RRTs) are one innovation previously deployed in U.S. hospitals with the goal to improve the quality of care. Sustaining RRTs is important to achieve the desired implementation outcomes, reduce the risk of program investment losses, and prevent employee disillusionment and dissatisfaction. This study sought to examine factors that do and do not support the sustainability of RRTs.

Methods
The study was conceptually guided by an adapted version of the Planning Model of Sustainability. A multiple-case study was conducted using a purposive sample of 2 hospitals with high RRT sustainability scores and 2 hospitals with low RRT sustainability scores. Data collection methods included (a) a hospital questionnaire that was completed by a nurse administrator at each hospital; (b) semistructured interviews with leaders, RRT members, and those activating RRT calls; and (c) a review of internal documents. Quantitative data were analyzed using descriptive statistics; qualitative data were analyzed using content analysis.

Results
Few descriptive differences were found between hospitals. However, there were notable differences in the operationalization of certain factors between high- and low-sustainability hospitals. Additional sustainability factors other than those captured by the Planning Model of Sustainability were also identified.

Conclusions
The sustainability of RRTs is optimized through effective operationalization of organizational and project design and implementation factors. Two additional factors—individual and team characteristics—should be included in the Planning Model of Sustainability and considered as potential facilitators (or inhibitors) of RRT sustainability.
Factors Influencing Time-Dependent Quality Indicators for Patients With Suspected Acute Coronary Syndrome
Authors: France Daniel J. , Levin Scott , Ding Ru , Hemphill Robin , Han Jin , Russ Stephan , Aronsky Dominik , Weinger Matt 
Published: January 2016

Objectives
Rapid risk stratification and timely treatment are critical to favorable outcomes for patients with acute coronary syndrome (ACS). Our objective was to identify patient and system factors that influence time-dependent quality indicators (QIs) for patients with unstable angina/non–ST elevation myocardial infarction (NSTEMI) in the emergency department (ED).

Methods
A retrospective, cohort study was conducted during a 42-month period of all patients 24 years or older suspected of having ACS as defined by receiving an electrocardiogram and at least 1 cardiac biomarker test. Cox regression was used to model the effects of patient characteristics, ancillary service use, staffing provisions, equipment availability, and ED and hospital crowding on ACS QIs.

Results
Emergency department adherence rates to national standards for electrocardiogram readout time and biomarker turnaround time were 42% and 37%, respectively. Cox regression models revealed that chief complaints without chest pain and the timing of stress testing and medication administration were associated with the most significant delays.

Conclusions
Patient and system factors both significantly influenced QI times in this cohort with unstable angina/NSTEMI. These results illustrate both the complexity of diagnosing patients with NSTEMI and the competing effects of clinical and system factors on patient flow through the ED.