bluuebunny/crossref_metadata_2025_split huggingface dataset:
A Quality Improvement Approach to Violence Reduction
Authors: DeSouza Fabio , Bleich Michael 
Published: April 2023

Background:
The impact of aggressive and violent behaviors directed toward staff in psychiatric facilities has layers of implications tied to recruitment and retention, cost, quality and safety.

Local Problem:
Increased patient aggressive behaviors contributed to staff dissatisfaction and high turnover rates, triggering an analysis of current aggression management approaches.

Methods:
The Plan-Do-Study-Act quality improvement method was used for this project.

Interventions:
The Dynamic Appraisal of Situational Aggression (DASA) risk assessment tool was implemented.

Results:
Daily aggression risk identification increased by 69%, and aggressive incidents toward staff and patients decreased by 64% and 28%, respectively, when the tool was completed more consistently. Surveys revealed acceptance of the tool by nurses.

Conclusions:
Quality improvement statistical tools supported evidence-based strategies. A risk for aggression assessment laid the foundations for implementing strategies for reducing aggression and violence.
Using Video to Describe the Patient-Controlled Analgesia Pump Programming Process
Authors: Manojlovich Milisa , Barwig Katie , Bekele Jember , Bradshaw Kimberly , Ali Charania Nadia Ali Muhammad , Lundy Francene , Streelman Marisa , Leech Christine 
Published: April 2023

Background:
Patient-controlled analgesia (PCA) pumps are complex medical devices frequently used for postoperative pain control. Differences in how nurses program PCA pumps can lead to preventable medication errors.

Purpose:
To describe similarities and differences in how surgical nurses program PCA pumps.

Methods:
We conducted a qualitative study using video reflexive ethnography (VRE) to film nurses as they programmed a PCA pump. We spliced and collated videos into separate clips and showed to nursing leaders for their deliberation and action.

Results:
We found nurses ignored or immediately silenced alarms, were uncertain about the correct programming sequence, and interpreted how to load a syringe in the pump in multiple ways; in addition, the PCA pump design did not align with nurses' workflow.

Conclusions:
VRE was effective in visualizing common challenges nurses experienced during PCA pump programming. Nursing leaders are planning several nursing process changes due to these findings.
Contribution of Comorbid Conditions to the Diagnosis of Insomnia
Authors: Liu Xinyue , Dibello Julia , Mott Katrina , Wang Yuanxin , Chekani Farid , Bortnichak Edward A. , Liaw Kai-Li , Zhong Wenjun 
Published: April 2023

Abstract
Insomnia is a common sleep disorder characterized as dissatisfaction with sleep quantity or quality resulting in distress or impairment of social, occupational, or other daily functioning. It is unknown if there are medical conditions that have strong associations with insomnia but are unrecognized in previous literature. In this cross-sectional study based on IBM Marketscan Research Databases, we measured insomnia and 78 medical conditions in patients with 2-year continuous enrollment during 2018–2019. We selected important comorbidities associated with insomnia for eight age-sex groups and built logistic regression models to measure the associations. The prevalence of diagnosed insomnia increased with age, from <0.4% in the age group 0–17 to 4%–5% in the age group ≥65. Females had a higher prevalence of insomnia than males. Anxiety and depression were two important comorbidities across all age-sex subgroups. Most odds ratios of comorbidities remained significant after adjusting for other comorbidities in regression models. We did not find any new medical conditions that had strong associations with insomnia but were unrecognized in previous literature. The findings can help physicians use comorbidities to identify patients with high risk of insomnia.
Wischnewski Spots in a Case of Hyperosmolar Hyperglycemic State
Authors: Lai Jonathan K. , Hickey Tyler B. M. 
Published: April 2023

Abstract
Wischnewski spots were first described as a common finding in gastric mucosa of decedents exposed to hypothermic environmental conditions. In recent literature, they were also reported in cases of diabetic ketoacidosis, pancreatitis, and fatal burns. Although Wischnewski spots are not specific to cases of hypothermia, we present a case that further supports this contention. We report a case of a middle-aged woman with type 2 diabetes who died of complications of hyperosmolar hyperglycemic state. Although there were no features of hypothermia, she presented with Wischnewski spots in the gastric mucosa. On histology, the gastric mucosa contained brown-black pigmentations with no neutrophilic infiltration. Biochemical analysis from vitreous humor and femoral blood showed marked elevation of glucose levels, low concentration of ketone bodies, pseudohyponatremia, and prerenal azotemia. The autopsy findings in this case discussion shed light to the possible genesis and pathophysiology of Wischnewski spots and highlight an additional differential diagnosis for these lesions.
Exertional-Related Sudden Cardiac Death in a Young, Presumed Healthy, and Medically Screened Population
Authors: McLeod Elizabeth V. , Walsh John C. , Haigney Mark C. , Franzos Marc Alaric , Hellwig Lydia D. 
Published: April 2023

Abstract
Sudden cardiac death (SCD) is defined as death from cardiac causes with loss of consciousness occurring within 1 hour of a change in cardiovascular status. As subset, SCD associated with physical exertion (SCD/E) can be defined as a cardiac event whose symptoms start during or within 1 hour of physical exertion. The US military represents a unique opportunity for studying SCD/E because of medical screening at recruitment, mandatory physical training, an active surveillance system, and centralized autopsy services. Because of medical screening, recruits are presumed healthy, but significant conditions can go undetected. We present 4 diverse cases of SCD/E in the military setting. Sudden cardiac death associated with physical exertion is often the first indication of a serious occult cardiac pathology. Postmortem genetic testing revealed a causative pathogenic mutation in 1 of 4 cases, enabling genetic testing of family members to prevent similar catastrophic loss of life, underscoring the importance of postmortem evaluation including genetic testing. Further investigations will help direct screening and prevention to capture those at risk for SCD. The cases presented in this series are a sample of the diverse etiologies and contexts surrounding SCD/E in the military setting that have been captured by Armed Forces Medical Examiner System.
Prevalence and Incidence of Pediatric Acute Respiratory Distress Syndrome in a Tertiary Academic PICU in South Africa
Authors: Lozano Ray Eleonora I. , Argent Andrew C. , Lupton-Smith Alison , Salie Shamiel , Morrow Brenda M. 
Published: April 2023

Objectives:
To determine the prevalence and incidence of pediatric acute respiratory distress syndrome (pARDS) among infants and children admitted to the PICU.

Design:
A single-center descriptive point prevalence study with twice weekly data collection over a 6 months (August 2020 to February 12, 2021).

Setting:
Red Cross War Memorial Children’s Hospital, Cape Town, South Africa.

Patients:
All infants and children admitted to the PICU on study days were included.

Interventions:
Data were captured electronically on a standardized case record form using a Research Electronic Data Capture electronic database.

Measurements and Main Results:
The Pediatric Acute Lung Injury Consensus Conference criteria were used to define pARDS cases. Prevalence was calculated as the total number of pARDS cases/1,000 PICU bed days. The study included 354 patients (median [interquartile range]) 10.1 months old (1.5–61.3 mo old), with 204 males (57.6%), who occupied 879 bed days. Of these 879 bed days, 266 (30.3%; 95% CI, 27.2–33.3%) were occupied by pARDS cases, with a calculated prevalence and incidence of 302.6 of 1,000 bed days (30.3%) and 29.7% (95% CI, 26.7–32.7%), respectively. Three cases from the cohort were defined using the oxygen saturation index calculation. In cases receiving invasive ventilation (n = 494; 56.2%), pARDS severity was classified as mild (n = 143; 16.3%), moderate (n = 44; 5.0%), and severe (n = 29, 3.3%). A further 205 beds (23.3%) were occupied by patients classified as being at risk of pARDS.

Conclusions:
The prevalence and incidence of pARDS in a South African PICU appears substantially higher than findings described in international reports. Further investigation of risk factors and outcomes is warranted.
Admission Pao 2 and Mortality Among PICU Patients and Select Diagnostic Subgroups
Authors: Holton Caroline , Lee Brian R. , Escobar Hugo , Benton Tara , Bauer Paul 
Published: April 2023

OBJECTIVES:
Evaluate the relationship between admission Pao
2 and mortality in a large multicenter dataset and among diagnostic subgroups.

DESIGN:
Retrospective cohort study.

SETTING:
North American PICUs participating in Virtual Pediatric Systems, LLC (VPS), 2015–2019.

PATIENTS:
Noncardiac patients 18 years or younger admitted to a VPS PICU with admission Pao
2.

INTERVENTIONS:
None.

MEASUREMENTS AND MAIN RESULTS:
Thirteen thousand seventy-one patient encounters were included with an overall mortality of 13.52%. Age categories were equally distributed among survivors and nonsurvivors with the exception of small differences among neonates and adolescents. Importantly, there was a tightly fitting quadratic relationship between admission Pao
2 and mortality, with the highest mortality rates seen among hypoxemic and hyperoxemic patients (likelihood-ratio test p < 0.001). This relationship persisted after adjustment for illness severity using modified Pediatric Index of Mortality 3 scores. A similar U-shaped relationship was demonstrated among patients with diagnoses of trauma, head trauma, sepsis, renal failure, hemorrhagic shock, and drowning. However, among the 1,500 patients admitted following cardiac arrest, there was no clear relationship between admission Pao
2 and mortality.

CONCLUSIONS:
In a large multicenter pediatric cohort, admission Pao
2 demonstrates a tightly fitting quadratic relationship with mortality. The persistence of this relationship among some but not all diagnostic subgroups suggests the pathophysiology of certain disease states may modify the hyperoxemia association.
The Relationship Between Esophageal Pressure and Diaphragm Thickening Fraction in Spontaneously Breathing Sedated Children: A Feasibility Study
Authors: De Meyer Gregory R. , Flamey Loïc , Adriaensens Ine , Van der Aerschot Marjan , Van de Walle Hanne , Vanmarsenille Ignace , Jorens Philippe G. , Goligher Ewan C. , Saldien Vera , Schepens Tom 
Published: April 2023

OBJECTIVES:
Diaphragm ultrasound is a novel alternative to esophageal pressure measurements in the evaluation of diaphragm function and activity, but data about its reliability in a pediatric setting are lacking. We aimed to compare the esophageal pressure swing (∆Pes, gold standard) with the diaphragmatic thickening fraction (DTF) as a measure of inspiratory effort in sedated children. Additionally, we studied the effect of positive end-expiratory pressure (PEEP) on the end-expiratory thickness of the diaphragm (DTee).

DESIGN:
Prospective open-label non-randomized interventional physiological cohort study.

SETTING:
Operating room in tertiary academic hospital.

PATIENTS:
Children 28 days to 13 years old scheduled for elective surgery with general anesthesia, spontaneously breathing through a laryngeal mask airway, were eligible for inclusion. Exclusion criteria were disorders or previous surgery of the diaphragm, anticipated difficult airway or acute cardiopulmonary disease. All measurements were performed prior to surgery.

INTERVENTIONS:
Patients were subjected to different levels of respiratory load, PEEP and anesthetic depth in a total of seven respiratory conditions.

MEASUREMENTS AND MAIN RESULTS:
The esophageal pressure and diaphragm thickening fraction were simultaneously recorded for five breaths at each respiratory condition. The relation between ∆Pes and DTF was studied in a mixed model. We analyzed 407 breaths in 13 patients. Both DTF (p = 0.03) and ∆Pes (p = 0.002) could detect respiratory activity, and ∆Pes and DTF were associated across respiratory conditions (p < 0.001; R
2 = 31%). With increasing inspiratory load, ∆Pes increased significantly, while DTF did not (p = 0.08). Additionally, DTee did not differ significantly between 10, 5, and 0 cm H2O PEEP (p = 0.08).

CONCLUSIONS:
In spontaneously breathing sedated children and across different respiratory conditions, DTF could differentiate minimal or no inspiratory effort from substantial inspiratory effort and was associated with ∆Pes. Increased efforts resulted in higher ∆Pes but not larger DTF.
GRAFT AND FLAP. A NOVEL ORTHOPLASTIC APPROACH TO ACHILLES TENDON SECONDARY RUPTURE
Authors: Maruccia Michele , Tedeschi Pasquale , Caizzi Gianni , Palmiotto Florianna , Di Summa Pietro G , Vicenti Giovanni , Moretti Biagio , Giudice Giuseppe , Elia Rossella 
Published: April 2023

Summary:
The Achilles tendon rupture represents one of the most common tendon ruptures. Although its primary repair remains the treatment of choice, surgical complications, such as secondary rupture and tendon exposure, require salvage procedures. This study aims to present our orthoplastic approach for the functional reconstruction of composite secondary Achilles tendon defects. Seven patients with chronic open wound and large Achilles tendon defects (Kuwada type IV) underwent one-stage reconstruction between October 2018 and October 2020. The average soft tissue defect was 126,2 (range, 86,1–175,9 cm2) with a tendon gap of 8,2 cm (range, 7,1–10,3 cm). A combined team of orthoplastic surgeons performed the reconstructive procedure with a turndown gastrocnemius fascial flap and a fascia lata autograft for the tendon reconstruction and a free fasciocutaneous anterolateral thigh flap for soft tissue coverage (graft and flap). Subjective evaluation and quality-of-life measures were obtained preoperatively and 12 months postoperatively using AOFAS and SF-36 questionnaire. Mean follow-up was 18,3 months (range, 12–24 months). Flap survival was 100%. Overall range of motion of the reconstructed side was 87% of the unaffected side (54 degrees vs. 62 degrees). The SF-36 and AOFAS scores of all patients improved significantly (p < 0.005) at 12 months of follow-up. Microsurgical approach combined with orthopedic techniques can solve complex cases of Achilles tendon secondary rupture providing a reconstructed tendon that achieves satisfactory anatomical shape and function.
Parents’ Perceptions of Social Media Use by Pediatric Plastic Surgeons
Authors: Huffman Samuel S. , Hetzler Peter T. , Baker Stephen B. , Vercler Christian J. , Fan Kenneth L. 
Published: April 2023

Background:
Pediatric craniofacial surgeons face specific ethical and professional concerns regarding the growth of social media use in plastic surgery. We sought to elucidate parents’ views on social media use by pediatric craniofacial surgeons. In addition, the study examines issues of consent, assent, and exploitation.

Methods:
An anonymous 51-question, multiple-choice survey investigating parents’ views of pediatric plastic surgeons’ social media use was crowdsourced through Prolific.Co.

Results:
Six hundred eighty-one parents responded to the survey. Of the 656 included respondents, 88% to 93% believe that surgeons need to obtain consent from the parents to post pictures of the pediatric patient on social media, regardless of age. Respectively, 84.5% and 75% of respondents believe the surgeon needs to document assent from the 12- and 10-year-old patient. Parents who follow plastic surgeons on social media are more likely to agree that assent needs to be documented from all pediatric patients, regardless of age, before posting pictures on social media. The mean age at which respondents believe physicians should be required to elicit assent from the pediatric patient to post pictures was 9.65-years-old. Approximately 40% of respondents felt that patients portrayed in pictures on social media were being exploited, irrespective of the child’s stated age.

Conclusion:
Plastic surgeons need to recognize parents’ perceptions regarding social media use when considering posting pictures of pediatric patients on social media. The data suggest that surgeons should elicit assent from patients as young as 9-years-old prior to posting pictures on social media.
“A Road Map to Creating a High-Quality Clinical Database in Plastic Surgery”
Authors: Irgebay Zhazira , Bruce Madeleine K. , Fantuzzo Jennifer A. , Beiriger Justin W. , Anstadt Erin E. , Dvoracek Lucas A. , Smetona John , Losee Joseph E. , Goldstein Jesse A. 
Published: April 2023

Background:
Detailed in-house databases are a staple of surgical research and a crucial source of data for many studies from which clinical guidelines are built. Despite the importance of generating a clear and thorough developmental design, the literature on database creation and management is limited. Here we present our stepwise single institution process of developing a clinical facial fracture database.

Methods:
We outline the process of development of a large single-institution clinical pediatric facial fracture database. We highlight critical steps from conception, regulatory approval, data safety/integrity, human resource allocation, data collection, quality assurance, and error remediation. We recorded patient characteristics, comorbidities, details of the sustained fracture, associated injuries, hospitalization information, treatments, outcomes, and follow-up information on REDCap (Research Electronic Data Capture). Protocols were created to ensure data quality assurance and control. Error identification analysis was subsequently performed on the database to evaluate the completeness and accuracy of the data.

Results:
A total of 4451 records from 3334 patients between 2006 and 2021 were identified and evaluated to generate a clinical database. Overall, there were 259 incorrect entries out of 120,177 total entries, yielding a 99.8% completion rate and a 0.216% error rate.

Conclusion:
The quality of clinical research is intrinsically linked to the quality and accuracy of the data collection. Close attention must be paid to quality control at every stage of a database setup. More studies outlining the process of database design are needed to promote transparent, accurate, and replicable research practices.
Understanding Factors Associated with Paid Malpractice Claims in Plastic Surgery
Authors: Remington Austin C. , Schaffer Adam , Hespe Geoffrey E. , Yugar Carlos J. , Sherif Rami , Vercler Christian J. 
Published: April 2023

Background:
Few studies have investigated malpractice broadly in the field of plastic surgery. The purpose of this analysis was to characterize plastic surgery malpractice cases and examine factors influencing malpractice case outcomes, thereby identifying areas of patient safety concern.

Methods:
The Candello database, which catalogs approximately 30% of all paid and unpaid malpractice claims in the United States, was utilized to obtain cases involving plastic surgery closed between 2009 and 2018. A total of 2674 cases were identified. A multivariable regression model was developed to analyze factors associated with a malpractice case closing with indemnity payment.

Results:
A total of 716 (26.8%) of claims resulted in an indemnity payment. The clinical severity was determined to be high in 229 cases (8.6%). Emotional trauma (n=558, 20.9%) was the most frequently cited injury category. Major differences between procedure groups were not observed, with consistent severity of injury across categories. Poor surgical technique, problems with communication among providers, inadequate informed consent, and deficient documentation were significant factors predictive of malpractice cases closing with payment. Issues with technical performance resulting in a known complication and patient factors were protective against paid claims.

Conclusions:
Overall, both the financial and clinical severity of malpractice claims in plastic surgery were relatively low. Multiple factors were found to be associated with a case closing with an indemnity payment. Taken together, these data highlight the importance of the informed consent process and managing expectations in the clinical care of surgical patients.
Tick-borne encephalitis
Authors: Johnson Nicholas , Migné Camille V. , Gonzalez Gaëlle 
Published: April 2023

Purpose of review
Tick-borne encephalitis continues to be one of the most significant causes of viral encephalitis in Europe and Asia. This review will focus on recent developments in the epidemiology, pathogenesis and therapeutic approaches related to infection with tick-borne encephalitis virus.

Recent findings
There is a growing consensus that tick-borne encephalitis viruses are increasing in geographical range, with countries previously free of disease reporting detection of both human cases and presence of virus within indigenous tick populations. The drivers for this are multifactorial but underpinned by human-mediated climate change. Recent developments in pathogenesis have focussed on the intracellular response to infection, particularly in different cell types within the central nervous system (CNS) that are revealing the array of cellular networks triggered by infection. This in turn highlights the need for small molecule therapeutics, such as nucleoside analogues, that can enter the CNS, and the intracellular environment, to inhibit virus replication following neuroinvasion.

Summary
Based on continued epidemiological surveillance, tick-borne encephalitis viruses will increasingly affect human populations in Europe and Asia. Much of the research highlighted in this review demonstrates incremental advances in our understanding of these viruses. However, more is required if effective prevention and treatment of this devastating encephalitic viruses are to be realized.
Creation of a Novel Child Simulator and Curriculum to Optimize Administration of Seizure Rescue Medication
Authors: Stredny Coral M. , Sheehan Theodore , Clark Justice , Tishel Catherine , Gagnon Colleen , Kelly Tara , Cahill Cheryl , O'Connell Brianna , Graber Kelsey , Loan Gregory , Wilson Stephen , Forbes Peter W. , Loddenkemper Tobias , Weinstock Peter H. 
Published: April 2023

Introduction
Although most cases of pediatric convulsive status epilepticus start in the prehospital setting, many patients do not receive treatment. The use of prehospital seizure rescue medications by caregivers is crucial, but studies suggest a lack of proper training on medication use.

Methods
We created a novel proof of principle mannequin and simulation for training proper administration of rectal diazepam, with a scoring paradigm to standardize and assess the educational process.

Results
Twenty-three health care providers (nurses and nurse practitioners, residents/fellows, and attending physicians) and 5 patient guardians/parents were included in the study. The rectal diazepam simulator displayed a high degree of physical and emotional realism (mean ≥ 4/5 on Likert scale survey) that effectively decreased time to treatment (−12.3 seconds; SD, 16.3) and improved the accuracy of medication delivery in a simulation setting (−4.2 points; SD, 3.1). The scoring technique had appropriate interrater reliability (≥86% on all but 2 prompts) and was a feasible instrument to assess the effectiveness of the educational intervention.

Conclusions
A unique procedure-focused child simulator and rescue medication score offer an innovative and effective means to train caregivers on the use of lifesaving seizure rescue medications.