bluuebunny/crossref_metadata_2025_split huggingface dataset:
Use of Rare Anatomical Variant of the Free Fibula Flap to Reconstruct the Nasal Septum
Authors: Yeap Isobel , Ch’ng Sydney 
Published: November 2023

Summary:
The osteocutaneous fibula free flap (FFF)’s skin paddle is commonly vascularized by the septocutaneous (SC) perforators of the peroneal artery that course through the posterior intercrural septum. However, a rare anatomical variant exists in which the skin paddle is vascularized via a separate arterial system to the fibula. We report the case of a 31-year-old man who was planned for osteocutaneous FFF reconstruction of his anterior maxilla and hard palate following resection of nasal septal chondrosarcoma. Intraoperatively, he was found to have a rare anatomical variant: the perforator to the skin paddle arose proximal to the peroneal artery, off the tibioperoneal trunk. This was a fortuitous, rare anatomical variant, as it enabled a double free flap reconstruction from a single donor site—an intraoral fasciocutaneous free flap oriented with its long axis perpendicular to that of an osseous FFF. This particular defect enabled reconstructive freedom beyond that of the standard osteocutaneous free flap, in which the skin paddle orientation is limited by the risk of kinking the septal perforator. This case report summarizes the flap raising technique and the learning points relevant to the osteocutaneous FFF with no SC perforators. The extant literature on this anatomical variant is then summarized. The average estimated rate of FFF with no SC perforators is between 3% and 25%, based on four published studies.
A cost-analysis of managing secondary and apparent treatment-resistant hypertension in a specialist multidisciplinary hypertension clinic
Authors: Rabbitt Louise , Curneen James , Hobbins Anna , Browne Darragh , Joyce Mary , Lappin David , McEvoy John William , Gillespie Paddy , Dennedy Michael Conall 
Published: November 2023

Objectives:
A knowledge gap exists around the costs and budget impact of specialist hypertension clinics. This study reports on the cost of providing care in a multidisciplinary hypertension clinic staffed by nephrologist, endocrinologist and cardiologist, which manages patients with suspected secondary hypertension and/or apparent treatment-resistant hypertension. The aim of this study is to provide the evidence required to inform policy and planning care pathways for this patient group.

Methods:
A cost analysis from a healthcare provider perspective using micro-costing techniques was conducted to estimate the direct implementation costs of existing standard practice for the care pathway of patients attending the multidisciplinary hypertension clinic. Sixty-five patients originally recruited for a study of medication adherence in hypertension were included in the sample.

Results:
The total care-pathway cost per patient, taking into account clinic visits, clinical reviews, investigations and MDT discussion, was estimated to be €3277, on average. For the patient subgroups, the average cost was €5644 for patients diagnosed with primary aldosteronism and €1446 for patients diagnosed with essential hypertension.

Conclusion:
There is significant cost associated with providing specialized hypertension care for patients with apparent treatment-resistant hypertension. Given the high rates of nonadherence in this population, it is likely that some of this cost could be avoided with better detection and management of medication adherence in this challenging population. Future studies should consider the cost-effectiveness of this or similar models of care by exploring the benefit to patients and the wider healthcare context of providing care of this type.
Long-term blood pressure variability and frailty risk in older adults
Authors: Fravel Michelle A. , Ernst Michael E. , Woods Robyn L. , Beilin Lawrence , Zhou Zhen , Orchard Suzanne G. , Chowdhury Enayet , Reid Christopher M. , Saifuddin Ekram ARM , Espinoza Sara E. , Nelson Mark R. , Stocks Nigel , Polkinghorne Kevan R. , Wolfe Rory , Ryan Joanne 
Published: November 2023

Introduction:
In healthy older adults, the relationship between long-term, visit-to-visit variability in blood pressure (BP) and frailty is uncertain.

Methods:
Secondary analysis of blood pressure variability (BPV) and incident frailty in >13 000 participants ≥65–70 years enrolled in the ASPirin in Reducing Events in the Elderly (ASPREE) trial and its observational follow-up (ASPREE-XT). Participants were without dementia, physical disability, or cardiovascular disease at baseline. BPV was estimated using standard deviation of mean BP from three annual visits (baseline through the second annual follow-up). Frailty was defined using Fried phenotype and a frailty deficit accumulation index (FDAI). Participants with frailty during the BPV estimation period were excluded from the main analysis. Adjusted Cox proportional hazards regression evaluated the association between BPV and incident frailty, and linear mixed models for change in frailty scores, through a maximum of 9 years of follow-up.

Results:
Participants in the highest systolic BPV tertile were at higher risk of frailty compared to those in the lowest (referent) tertile of systolic BPV [Fried hazard ratio (HR) 1.17, 95% confidence interval (CI) 1.04–1.31; FDAI HR 1.18, 95% CI 1.07–1.30]. Findings were consistent when adjusted for multiple covariates and when stratified by antihypertensive use. Linear mixed models showed that higher systolic BPV was associated with increasing frailty score over time. Diastolic BPV was not consistently associated.

Conclusions:
High systolic BPV, independent of mean BP, is associated with increased risk of frailty in healthy older adults. Variability of BP across visits, even in healthy older adults, can convey important risk information beyond mean BP.

Trial Registration:
ClinicalTrials.gov NCT01038583 and ISRCTN83772183
Role of the Electrocardiographic MVP Risk Score (Morphology-Voltage-P Wave Duration) in Predicting the Development of Atrial Fibrillation in Patients With Systemic Arterial Hypertension
Authors: del Pilar Falcón Rocío , Centurión Osmar Antonio , Meza Alfredo J. , Scavenius Karina E. , Chávez Christian O. , Montiel Carmen R. , García Laura B. , Cáceres Cristina , Martínez Jorge E. , Galeano Erdulfo J. 
Published: November 2023

Background:
There is a global tendency to emphasize the prevention and early diagnosis of diseases that have a great impact on public health. Atrial fibrillation (AF) has a prevalence affecting 1.5–2% of the general population. Certain variables of the P wave allow us to identify and stratify patients at risk of developing AF.

Materials and methods:
This is an observational, descriptive, and longitudinal study to determine the applicability of the electrocardiographic (ECG) morphology, voltage, and P wave duration (MVP) risk score to predict the development of AF in consecutive patients with systemic hypertension (SH) in an initial follow-up of 12 months.

Results:
Initially, 104 patients were included, of whom 12 died during follow-up and 17 did not attend subsequent checkups during the COVID-19 pandemic; therefore, they were excluded. The study patients were 75, of whom AF was detected in 25 patients (33%). The average duration of the P wave was 120 ± 26 ms, the average voltage was 0.1 ± 0.5 Mv. The high-risk MVP ECG score had an [area under the curve, 0.69; 95% confidence intervals (CI), 0.59–0.79] and demonstrated a specificity and a positive predictive value of 100%, a negative predictive value of 76%, and a sensitivity of 40% for predicting the development of AF.

Conclusions:
The present study establishes for the first time that SH patients who possess a high-risk MVP ECG score have a significantly higher incidence of developing AF. The high-risk MVP Score has a specificity and a positive predictive value of 100% and a high negative predictive value with a moderate sensitivity for the prediction of the development of AF in SH patients.
Overweight (BMI of 25–30) Is Independently Associated With Significantly Higher Prevalence of Systolic and Diastolic Hypertension in Adults
Authors: Movahed Mohammad Reza , Motieian Mahsa , Bates Sharon 
Published: November 2023

Objective:
Hypertension (HTN) is a major risk factor for cardiovascular disease. Obesity has been found to be associated with HTN. However, there are not many studies available to evaluate any association between overweight alone and HTN.

Methods:
A database from the Anthony Bates Foundation that performs preventive cardiovascular examinations including measurement of body mass index (BMI) and blood pressure across the United States was used for our study. Using recorded measurements, we evaluated any association between being overweight defined as a BMI of 25 to 30 and the occurrence of systolic and diastolic HTN in adults over the age of 18 years.

Results:
A total of 1558 participants with documented BMI and blood pressure over the age of 18 years were studied. Among them, 758 participants had a normal BMI, and 800 had a BMI in overweight category. The prevalence of systolic and diastolic HTN was significantly higher in participants in the overweight versus normal weight cohort. Systolic HTN was present in 36% of participants in the overweight versus 14% of the normal weight group (P < 0.00.1). Diastolic HTN was present in 43% of participants with overweight versus 21% of normal weight cohort (P < 0.001). After adjusting for age and gender, high systolic blood pressure (SBP) and diastolic blood pressure (DBP) remained independently associated with overweight (SBP prevalence OR, 2.8; CI, 2.1-3.6; P < 0.001; DBP prevalence OR, 2.1; CI, 1.7-2.7; P < 0.001)

Conclusions:
Our study found that increased BMI in the overweight category alone is independently associated with SBP and DBP in adults undergoing screening warranting further investigation.
The Use of Global Longitudinal Strain to Detect Subclinical Reduction in Left Ventricular Pump Function
Authors: EL-Dosouky Ibtesam I. , Seddik Eman H. , Wageeh Shaimaa 
Published: November 2023

Background:
Left ventricular (LV) ejection fraction (LVEF) is not a sensitive marker of LV systolic function in a subset of patients with preserved EF. The relation between LV pump function and global longitudinal strain (GLS) has not been elucidated well in patients with objectively preserved EF and no apparent heart failure (HF). We aimed to detect whether LV GLS can discover impaired LV pump function [presented as low stroke volume index (SVI) and low cardiac output (COP)] in patients with objectively preserved EF and no apparent clinical HF and its practice utility.

Methods:
In total, 100 participants with LVEF of ≥50% were studied for demographic and echocardiographic data, including LVEF, stroke volume, SVI, COP, LV longitudinal strain assessments, apical 4-, 3-, and 2-chamber views averaged for GLS, and were classified into 2 groups: group 1: normal GLS (more negative than −18%) and group 2: low GLS (less negative than −18%).

Results:
Reduced LV GLS was associated with lower SVI (35.6 ± 13.6 vs. 43.8 ± 12.7 mL/m2; P = 0.01), lesser COP (5.4 ± 1.9 vs. 6.5 ± 2.1 l/min; P = 0.02), GLS had strong positive correlations with SVI (r = 0.75; P < 0.001), and COP (r = 0.66; P < 0.001). LV GLS at a cutoff value less negative than −15% is a strong predictor of SVI ≤35 mL/m2 (76% sensitivity and 79% specificity) and at a cutoff value less negative than −13.5% it is a strong predictor of COP ≤4 L/min (76% sensitivity and 73% specificity). LV GLS was the best independent predictor of low SVI (<35 mL/m2) and low COP (<4 L/min).

Conclusion:
Impaired LV strain is associated with lower LV pump function, presented as lower COP and lower SVI in patients with preserved EF even in the absence of clinical HF. It is of great importance to incorporate GLS in the routine evaluation of LV function hand-by-hand with the noninvasive assessment of LV stroke volume and COP that can replace GLS on evaluation of LV pump function in old machines with no GLS modalities, for early pick-up of patients with impaired LV pump function before apparent HF.
Adherence to Clinical Practice Guidelines for Non-ST Elevation Acute Coronary Syndrome in the Emergency Department: Exploring the Role of Social, Healthcare-system, and Clinical Determinants
Authors: Işik Abdullah Kürşat , Özturan İbrahim Ulaş , Pekdemir Murat , Doğan Nurettin Özgür , Yaka Elif , Yilmaz Serkan 
Published: November 2023

Objectives:
The aim of this study was to assess adherence to the European Society of Cardiology 2020 non-ST elevation acute coronary syndrome (NST-ACS) guidelines, identify factors affecting this compliance, and explore the link between adherence and adverse cardiac outcomes.

Methods:
This prospective cohort study was conducted in a tertiary-level academic hospital between January 2022 and January 2023. Patients diagnosed with NST-ACS in the emergency department (ED) were included. The primary outcome measured was the rate of adherence to the guidelines, and secondary outcomes were factors affecting this adherence in the ED and its association with 28-day adverse cardiac outcomes.

Results:
Of the 298 patients included, guideline adherence was achieved in 32.2% in the ED. The highest compliance was observed in performing a 12-lead electrocardiogram (ECG) within 10 minutes (99.7%), while the lowest was found for obtaining additional right and posterior ECG leads when ongoing ischemia was suspected (42.3%). Factors associated with better adherence included the experience level of the treating physician, the presence of cardiac-quality chest pain, initial ischemic ECG findings, higher initial troponin levels, and advanced history, electrocardiogram, age, risk factors, and troponin score and Charlson comorbidity index. Complete guideline adherence over 28 days was achieved in 19.1% of patients and was found to be significantly associated with lower rates of adverse cardiac outcomes.

Conclusions:
Adherence to NST-ACS guidelines was generally low but was associated with improved patient outcomes. This study highlighted the importance of various factors associated with guideline adherence. Future research should explore further barriers to guideline adherence and develop targeted interventions.
Comparison of the Efficacy and Safety of Ranibizumab 0.5 mg versus 1.0 mg with PPV for the Treatment of PDR: A Randomized, Controlled Trial
Authors: Su Tong , Lai Dongwei , Wu Yang , Gu Chufeng , He Shuai , Meng Chunren , Cai Chunyang , Zhang Jingfa , Luo Dawei , Chen Jili , Zheng Zhi , Qiu Qinghua 
Published: November 2023

Purpose:
To investigate the effectiveness of two regimens of ranibizumab-assisted pars plana vitrectomy (PPV) in the treatment of patients with proliferative diabetic retinopathy (PDR).

Methods:
This is a prospective, 6-month, randomized, controlled trial. 80 patients with 87 eyes requiring PPV treatment for PDR were included and randomly divided into a 1.0-mg injection group and a 0.5-mg injection group. The ranibizumab was delivered intra-operatively, at the close of surgery. The vitreous hemorrhage (VH) grade, best corrected visual acuity (BCVA), central macular thickness (CMT) and safety data were assessed to Month 6.

Results:
The 1.0-mg injection group had a milder grade and a lower reoccurrence rate of early postoperatively VH than the 0.5-mg injection group (35.0% and 63.4%, respectively, P =0.0195). The mean BCVA of two groups was significantly improved from baseline to 6 months after surgery,1.60 ± 0.72 LogMAR (<20/200) to 0.47 ± 0.49 LogMAR (20/59) for the 1.0-mg injection group, and 1.51 ± 0.69 LogMAR (<20/200) to 0.50 ± 0.31 LogMAR (20/63) for the 0.5-mg injection group, but there was no significant difference between the two groups (P = 0.74). There was no significant difference in the mean decrease in CMT and probability of postoperative adverse events between the two groups.

Conclusion:
Intravitreal injection of 1.0 mg of ranibizumab after PPV compared with the recommended dose of 0.5 mg significantly reduced the recurrence and severity of early postoperative VH in patients with PDR. It also contributed to the early recovery of visual acuity after surgery and did not increase postoperative adverse events.
Ketamine for Traumatic Assault-Induced Depression: A Case Report
Authors: Coffelt Caitlyn B. , Gibson Kyle , VanLandingham Jason 
Published: November 2023

BACKGROUND:
This case report describes the use of ketamine as a rapid, effective treatment of depression in a 68-year-old female patient with no significant medical history of psychiatric disorders. Patients who experience intentional or unintentional traumas are at an increased risk for developing depression or posttraumatic stress disorder, and emerging evidence has supported the use of ketamine as an alternative treatment of depression.

CASE PRESENTATION:
This is the case of a 68-year-old female patient who was assaulted, resulting in multiple stab wounds to both hands and the right upper quadrant. She underwent placement of a chest tube and surgical repair of the liver and was subsequently admitted to the intensive care unit. These events led to the development of severe depression symptoms, as evidenced by a Montgomery–Asberg Depression Rating Scale (MADRS) score of 37. As treatment of her acute depression, the patient received a single intravenous dose of ketamine (0.5 mg/kg) infused over 40 min and was monitored for side effects. The MADRS is a 10-item depression screening tool that assesses symptoms and changes over time. Within 4 hr of receiving ketamine, the patient reported a significant improvement in her mood and her MADRS score decreased to 16, classifying this patient as experiencing mild depression. The patient continued to improve, and 24 hr after receiving ketamine, her MADRS score was 4, indicating remission of her depression symptoms.

CONCLUSION:
This case report aims to provide an account of the potential benefits of ketamine as a rapid treatment of depression in an adult trauma patient.
Improving care practices of the patient with type 2 diabetes in community health centers
Authors: Slade Deloris , Carr Kayla , Karimi Masoumeh , Stewart Mary W. 
Published: November 2023

ABSTRACT

Background:
Diabetes ranks seventh in morbidity and mortality in the United States. In addition, more than 25 million Americans living with diabetes depend on community health centers (CHCs) for primary care.

Local problem:
Preimplementation data in a group of CHCs indicated poor adherence to standards of care practices as recommended by the American Diabetes Association (ADA) with quarterly A1c (33.1%), annual serum laboratory tests (66.6%), and annual urine microalbumin (26.5%).

Methods:
Using a pre- and postimplementation comparison method, a NP-led practice improvement project was conducted in a group of CHCs, which sought to (1) identify adherence to ADA care standards; (2) determine whether an intervention could affect adherence to ADA standards; and (3) compare pre- and postimplementation occurrences of hemoglobin A1c greater than 7.1% and greater than 9%.

Intervention:
Intervention composed of an educational component, standing orders to facilitate care practice changes, and electronic health record utilization changes.

Results:
Postimplementation data reveal statistically significant improvements in quarterly hemoglobin A1c (93.6%), annual serum laboratory tests (96.5%), and annual urine microalbumin screening (85.5%).

Conclusions:
Improvements in translation to care for standardized guidelines facilitate improvements in health outcomes for patients. This project demonstrated improvements that can decrease the morbidity and mortality experienced by persons living with diabetes and being seen within a CHC. In addition, this project demonstrated that advanced practice nurses have the training and occupy a unique position within health care to spearhead initiatives for translation of evidence into care practices.
Extreme Reticulocytosis After Splenectomy in a Patient With Hemoglobin Mizuho
Authors: Narvestad-Bøttger Helene , Winther-Larsen Anne , Haugbølle Bjerre Jens , Dziegiel Morten Hanefeld , Hansen Anne Todsen , Hasle Henrik 
Published: November 2023

Background:
Patients with Hb Mizuho may be splenectomized at a young age to decrease their need for blood transfusions.

Observations:
Transfusion-dependency decreased dramatically in a 4-year-old white boy with Hb Mizuho after splenectomy. Surprisingly, he developed reticulocytosis (>1000×109/L) with a peak reticulocyte percentage of 49%, and erythrocyte abnormalities, including Heinz bodies, Howell-Jolly bodies, and basophilic stippling. Manual reticulocyte counting and flow cytometric measurement with anti-CD71 antibodies supported a truly elevated reticulocyte count.

Conclusions:
We propose possible explanations for the extreme reticulocytosis that arose postsplenectomy and compare the reticulocyte count in the present case with previously published cases.
Pediatric acute hydrocephalus developing after tubercular meningitis: a case report study
Authors: Kachuei Maryam , Zare Ramin , Sadr Zahra , Eghdami Shayan 
Published: November 2023

Background:
Tuberculosis ranks second as the most common cause of death among infectious diseases, preceded only by COVID-19, which can involve multiple organs. Tuberculous meningitis (TBM) is known to have serious and atypical complications affecting the central nervous system, especially in more vulnerable populations such as children and adolescents.

Case presentation:
The 15-year-old female patient was admitted to the hospital with altered mental status after complaining of nausea, weakness, and cough for 3 weeks. A chest computed tomography (CT) scan showed cavitary lesions, a lumbar puncture sample had a glucose level of 15 mg/dl, and the brain CT scan revealed acute hydrocephalus. While the patient was treated with anti-tubercular medications, an external ventricular drain was placed and the patient was monitored.

Conclusion:
This report presents acute hydrocephalus as a rare and atypical consequence of disseminated tubercular infection resulting in meningitis.
First case of congenital methemoglobinemia in Nepalese population: a case report
Authors: Bista Prashu Ram , Shrestha Anjila , Shrestha Saloni 
Published: November 2023

Introduction and importance:
Congenital methemoglobinemia is a rare hereditary disorder that leads to decreased oxygen delivery to the tissues. The severity of symptoms is directly proportional to the methemoglobin levels in the blood. Furthermore, this is the first case of congenital methemoglobinemia reported in the Nepalese population.

Case presentation:
We herein present a case of a 33-year-old male with congenital methemoglobinemia, the first reported case among the Nepalese population. His peripheral oxygen saturation level did not improve despite increasing the oxygen supplementation, and a saturation gap of more than 5% was present. The dark brown color of the blood was noted on the blood sample. On investigations, the methemoglobin level was 9%.

Clinical discussion:
Congenital methemoglobinemia can occur due to a deficiency of an enzyme known as cytochrome b5 reductase, which primarily converts methemoglobin to hemoglobin. There are two types of congenital methemoglobinemia, type I and type II which can be distinguished clinically by the presence of neurological impairment and mental retardation, which can be seen in type II congenital methemoglobinemia.

Conclusion:
Congenital methemoglobinemia is a rare syndrome and has not been previously reported in the Nepalese population. Although there are various diagnostic clues including relevant medical history, saturation gap of more than 5%, dark brown coloration of blood, and investigations such as methemoglobin level, healthcare services like cytochrome b5 reductase enzymatic activity and molecular genetic testing regarding congenital methemoglobinemia is recommended.