bluuebunny/crossref_metadata_2025_split huggingface dataset:
Tree-ring δ15N as an indicator of nitrogen dynamics in stands with N2-fixing Alnus rubra
Authors: Nehring L , Kranabetter J M , Harper G J , Hawkins B J 
Published: September 2023

Abstract
Tree-ring δ15N may depict site-specific, long-term patterns in nitrogen (N) dynamics under N2-fixing species, but field trials with N2-fixing tree species are lacking and the relationship of temporal patterns in tree-ring δ15N to soil N dynamics is controversial. We examined whether the tree-ring δ15N of N2-fixing red alder (Alnus rubra Bong.) would mirror N accretion rates and δ15N of soils and whether the influence of alder-fixed N could be observed in the wood of a neighboring conifer. We sampled a 27-year-old replacement series trial on south-eastern Vancouver Island, with red alder and coastal Douglas-fir (Pseudotsuga menziesii [Mirb.] Franco) planted in five proportions (0/100, 11/89, 25/75, 50/50 and 100/0) at a uniform stem density. An escalation in forest floor N content was evident with an increasing proportion of red alder, equivalent to a difference of ~750 kg N ha−1 between 100% Douglas-fir versus 100% alder. The forest floor horizon also had high δ15N values in treatments with more red alder. Red alder had a consistent quadratic fit in tree-ring δ15N over time, with a net increase of $\sim$1.5‰, on average, from initial values, followed by a plateau or slight decline. Douglas-fir tree-ring δ15N, in contrast, was largely unchanged over time (in three of four plots) but was significantly higher in the 50/50 mix. The minor differences in current leaf litter N content and δ15N between alder and Douglas-fir, coupled with declining growth in red alder, suggests the plateau or declining trend in alder tree-ring δ15N could coincide with lower N2-fixation rates, potentially by loss in alder vigor at canopy closure, or down-regulation via nitrate availability.
Identification of Clinically Significant Cytokine Signature Clusters in Patients With Septic Shock
Authors: Zhao Jack O. , Patel Bhakti K. , Krishack Paulette , Stutz Matthew R. , Pearson Steven D. , Lin Julie , Lecompte-Osorio Paola A. , Dugan Karen C. , Kim Seoyoen , Gras Nicole , Pohlman Anne , Kress John P. , Hall Jesse B. , Sperling Anne I. , Adegunsoye Ayodeji , Verhoef Philip A. , Wolfe Krysta S. 
Published: September 2023

OBJECTIVES:
To identify cytokine signature clusters in patients with septic shock.

DESIGN:
Prospective observational cohort study.

SETTING:
Single academic center in the United States.

PATIENTS:
Adult (≥ 18 yr old) patients admitted to the medical ICU with septic shock requiring vasoactive medication support.

INTERVENTIONS:
None.

MEASUREMENTS AND MAIN RESULTS:
One hundred fourteen patients with septic shock completed cytokine measurement at time of enrollment (t1) and 24 hours later (t2). Unsupervised random forest analysis of the change in cytokines over time, defined as delta (t2–t1), identified three clusters with distinct cytokine profiles. Patients in cluster 1 had the lowest initial levels of circulating cytokines that decreased over time. Patients in cluster 2 and cluster 3 had higher initial levels that decreased over time in cluster 2 and increased in cluster 3. Patients in clusters 2 and 3 had higher mortality compared with cluster 1 (clusters 1–3: 11% vs 31%; odds ratio [OR], 3.56 [1.10–14.23] vs 54% OR, 9.23 [2.89–37.22]). Cluster 3 was independently associated with in-hospital mortality (hazard ratio, 5.24; p = 0.005) in multivariable analysis. There were no significant differences in initial clinical severity scoring or steroid use between the clusters. Analysis of either t1 or t2 cytokine measurements alone or in combination did not reveal clusters with clear clinical significance.

CONCLUSIONS:
Longitudinal measurement of cytokine profiles at initiation of vasoactive medications and 24 hours later revealed three distinct cytokine signature clusters that correlated with clinical outcomes.
Use of National Institute for Health and Care Excellence head injury guidelines among patients with delayed presentation after head trauma can lead to missed traumatic brain injury: a 5-year institutional review
Authors: Khan Muhammad Salman , Alam Muhammad Sami , Ismail Sameeha , Ghafoor Bushra , Sajjad Nida , Khan Noman , Memon Wasim Ahmed , Ameen Abdullah Muhammad , Khan Faheemullah , Mumtaz Hassan , Iqbal Javed , Ashraf Ahmer 
Published: September 2023

Introduction:
In 2014, traumatic brain injury (TBI) caused 3 million ER visits, hospitalizations, and deaths in the US. The National Institute for Health and Care Excellence (NICE) guidelines, initially generated using data from patients presenting within 24 h of head trauma, are used to determine the need for head computed tomography (CT) scan in patients after 24 h. The authors wanted to determine the proportion of CT scans for head trauma performed at our center in late presenters (>24 h after head trauma), the incidence of intracranial pathology in early (24 h) versus late (>24 h) presenters, and the sensitivity of the NICE guidelines for TBI in these two subpopulations.

Methods:
A retrospective chart review was conducted at a tertiary care center in Karachi. All people (>16) who had a head CT for head trauma from 2010 to 2015 were included. Age, sex, primary diagnosis, comorbid disorders, mechanism-of-injury, duration (in hours) from head trauma to presentation, site, and extent of injury (injury severity scale), hospital stay, number and details of surgical procedures, CT scan findings, other injuries, and mortality were recorded. Means were compared using the Independent Sample t-test, while categorical variables were compared using χ
2. Multivariate logistic regression analyses were used to identify TBI predictors.

Results:
The authors found 2009 eligible patients; seven were excluded due to incomplete medical records. The final statistical analysis comprised 2002 head trauma patients. Overall, 52% of early and late presenters had severe injuries, and 2.3% died. 32.2% of patients with head trauma had CT after 24 h. Early presenters were 46.7% traumatized, while late presenters were 63%. The NICE guidelines were 93% sensitive for early presenters and 83% for late presenters with traumatic intracranial injury.

Conclusion:
Patients coming to the emergency department after 24 h of head trauma are a large proportion of the overall head trauma population. The NICE guidelines for late-presenting head injuries are less sensitive and may overlook intracranial injuries if imaging is not performed.
Successful removal of an aspirated broken metal tracheostomy tube from the right main bronchus: a case report
Authors: Vakili Ojarood Mohammad , Samady Khanghah Ali 
Published: September 2023

Introduction and importance:
Tracheostomy has been done since ancient Greece, but in today’s modern format, it has been accepted for over one and a half centuries. Improvements in medical care and treatments have survived disabled patients who died in the past decades. Among these, tracheostomy tube (TT) segment aspiration was as rare as less than 100 cases have already been documented. We reported a case of aspirated metal TT to the right main bronchus from a 12-year-old teenage girl and then reviewed the available literature.

Case presentation:
The patient suffered from subglottic stenosis affected after adenotonsillectomy remained for 6 years. She was referred to the emergency department for acute respiratory distress and cyanosis. Immediately underwent rigid bronchoscopy, and on the way to the operating room, she was oxygenated from the tracheal orifice. The detached part was successfully removed.

Clinical discussion:
The common tracheostomy indications in children involve congenital or acquired airway stenosis, some conditions needing long-term ventilation, bilateral vocal fold insufficiency, and infectious compromise of the upper airway. Metal TTs for long-lasting are preferred to synthetic ones. Nevertheless, it has some potential complications.

Conclusion:
Careful inspecting, especially metallic TTs, after every disinfection and regular follow-up by the surgeon, is highly recommended to prevent potential casualties.
Immune-enhancing activity of Astragalus maximus extract for inhibiting the Toxoplasma gondii infection: experimental research
Authors: Behnam Salar , Kharazmkia Ali , Khalaf Amal Khudair , Adineh Ahmad , Ghasemian Yadegari Javad , Mahmoudvand Hossein 
Published: September 2023

Background:
This study aimed to evaluate the in-vitro anti-Toxoplasma effects and cytotoxicity effects of Astragalus maximus chloroformic extract (AMCE) on the T. gondii Rh strain.

Methods:
In-vitro effects of AMCE (2–64 µg/ml) on tachyzoites were measured by MTT assay for 48 h. The effects of AMCE on infectivity rate and intracellular parasites into macrophage cells (J774-A1) were evaluated. The Griess reaction assay and quantitative real-time PCR were used to determine the nitric oxide (NO) and the mRNA expression levels of IFN-γ and iNOS in infected J774-A1 macrophage cells.

Results:
The mortality rate of the parasites significantly (P<0.001) increased in a dose-dependent manner with an IC50 value of 9.85 μg/ml. The rate of infection and the mean number of intracellular tachyzoites in macrophage cells were significantly reduced (P<0.001) after exposure of the macrophage cells to AMCE. The mRNA expression levels of IFN-γ, iNOS, and NO production in macrophage cells after treatment with the AMCE were increased, especially at the concentration of ½ IC50 and IC50 (P<0.001).

Conclusion:
The findings of the current in vitro investigation revealed favorable anti-Toxoplasma effects of AMCE against tachyzoites and intracellular forms of T. gondii. Despite the fact that the accurate anti-Toxoplasma mechanisms of AMCE are not clear, our results showed that triggering NO production and cellular immunity can be considered as the main mechanisms of action of AMCE for controlling and eliminating T. gondii. However, further surveys are mandatory to assess the efficacy and safety of AMCE in an animal model and its accurate mechanisms of action.
What makes women receptive to breast self-examination, animation, or simulation? – a comparative study
Authors: Idrees Sarrah , Mayilvaganan Sabaretnam , Mishra Shagun , Chand Gyan , Mishra Anjali , Agarwal Gaurav 
Published: September 2023

Background:
Breast self-examination (BSE) plays an important role in the early diagnosis of breast cancer in India owing to the stigma attached to cancer. The authors compared the efficacies of animation video versus simulation techniques in BSE.

Methods:
Women with no previous history of conditions affecting the breasts were included in this prospective observational study and divided into an animation or simulation arm. The latter was further divided into three subgroups as per the simulation models used : the German (Delta Healthcare), British (Health Edco), and Indian (low-cost, validated) models used for teaching BSE. The hybrid animation video had a 9 min runtime with a lecture on BSE and a virtual character performing BSE. In both the arms, participants filled in a validated modified patient satisfaction questionnaire.

Results:
A total of 500 women participated. The mean age of the participants in the animation video arm was 20.21±3.88 years and 19.34±2.27, 22.94±9.6, and 18.97±1.31(20.41±5.99) years in the Indian, German, and British simulation models arm, respectively. The age difference between the two arms was statistically significant (P<0.05). Both animation video and simulation models were found to be useful by the participants. The participants’ response to animation video being a better organized tool for learning BSE was statistically significant (90.48±7.98 vs. 84.02±15.09 P≤0.001) when compared to simulation models. The younger women (≤20 years) found these tools significantly more useful than those aged >20 years.

Conclusions:
All models had good efficiency and utility as learning tools for BSE. However, large studies in BSE set up with combination models are needed.
Erythema nodosum after golimumab treatment in ankylosing spondylitis patients: a case report and literature review
Authors: Kudsi Maysoun , Asaad Wisam , Khalayli Naram , Soud Alkousa Hamzeh , Haidar Ghina 
Published: September 2023

Introduction:
Erythema nodosum (EN) is a self-limited septal panniculitis that presents with fever, arthralgia, and arthritis. Tumor necrosis factor alpha (TNF-α) inhibitor such as golimumab has been found to treat EN in inflammatory bowel diseases (IBD). We herein report the paradoxical occurrence of EN following golimumab for ankylosing spondylitis.

Case presentation:
A 34-year-old female presented in June 2022 with a complaint of ‘sores’ on her feet that intermittently presented for approximately 5 months but that had worsened dramatically in the last 24 h. The patient had an 8-year history of ankylosing spondylitis for 7 years. Subcutaneous golimumab was administered every 4 weeks as she had not responded to other treatments. Twenty-four hours after the fifth subcutaneous injection, painful, erythematous nodules appeared, histologically compatible with EN. Despite this side effect, we continue therapy due to the good response and efficacy.

Discussion:
Skin reactions were associated with the treatment with golimumab, including warm tender skin around the injection site, eruptions, itchiness, and sometimes a full-body rash. Golimumab was successfully used in treating EN in Crohn’s disease. Because our patient continued on golimumab, the temporal association of EN flares with therapeutic injection and the lack of any etiology support a direct causal relationship between EN and golimumab treatment.

Conclusion:
TNF-α inhibitors are useful in treating Crohn’s disease patients with EN, although it may present as an adverse effect of this treatment. Further work is needed.
The comparative study of skin staples and polypropylene sutures for securing the mesh in Lichtenstein’s tension-free inguinal hernia repair in HIV and hepatitis (B and C)-positive patients: a randomized controlled trial
Authors: Pragya  , Kumar Anil , Manish  , Ranjan Rahul , Jha Nawal Kishore 
Published: September 2023

Introduction:
The mesh fixation in the Lichtenstein’s hernioplasty was traditionally performed with polypropylene sutures. A modification of this technique uses skin staples for securing the mesh. Using polypropylene sutures may increase the needle prick injuries (NPIs) in HIV and hepatitis-positive patients. This is the first study in India to compare the efficacy of anchoring the mesh with skin staplers and polypropylene sutures in hepatitis and HIV-positive patients.

Methods:
Fifty-two seropositive patients undergoing sixty repairs were randomized into two groups. In the control group polypropylene mesh was secured with polypropylene sutures and the skin was closed with ethilon. In the study group polypropylene mesh was secured with skin staples and the skin was closed with staples from the same stapler. Duration of surgery, postoperative complications, NPIs, recurrences and costs were compared.

Results:
The operation was significantly shorter when staples were used (median 46 vs. 57 min, P<0.00001). There was no significant difference in the incidence of postoperative complications. The NPIs was statistically significant in the suture group as compared to the stapler group (P<0.05).

Conclusion:
Using skin staples to secure the mesh in Lichtenstein inguinal hernioplasty significantly reduced the duration of surgery. It was as effective as conventional mesh fixation with polypropylene with added advantages to reduce the operating time, duration of exposure to infected blood, and the NPIs significantly in HIV, hepatitis B virus and hepatitis C virus-positive patients.
Esophageal variceal bleeding: portal hypertension and portal vein thrombosis secondary to protein S deficiency – a case report
Authors: Sapkota Prakash , Mainali Sumina , Khadayat Paras , K.C. Narendra , Joshi Arun , Koirala Prashant 
Published: September 2023

Introduction:
Proteins C and S play a key role in the inhibition of the coagulation cascade. Deficiencies of proteins C and S deficiency are rare conditions that lead to abnormal activation of the coagulation cascade, resulting in a prothrombotic state and an increased risk of venous thromboembolism. These deficiencies also pose a risk factor for the development of portal vein thrombosis (PVT). PVT secondary to these deficiencies in the acute phase is usually asymptomatic, but the disease in chronic cases may present with features suggestive of portal hypertension, usually hepatosplenomegaly, variceal bleeding. However, cavernous transformation of the portal vein due to proteins C and S is usually rare.

Introduction and Importance:
Proteins C and S are rare thrombophilic disorders that may present even with PVT, resulting in esophageal bleeding as an uncommon presentation. Hence, protein S and protein C deficiency should also be considered a cause of noncirrhotic portal hypertension with esophageal bleeding.

Case Presentation:
The authors hereby present you with the case of a 22-year-old female who presented with complaints of abdominal pain and black-colored stool in the emergency department.

Clinical Discussion:
Relevant investigations were sent, and she was treated in line with esophageal variceal bleeding with the cavernous transformation of a thrombosed portal vein secondary to noncirrhotic portal hypertension due to protein C and S deficiency. Esophageal varices were managed with rubber band ligation. An oral anticoagulant was started for the thrombophilic disorder. The patient was also advised for splenectomy for splenomegaly and ongoing anemia and thrombocytopenia.

Conclusion:
The main aim of the article is to highlight a rare case of protein S deficiency that has led to upper GI bleeding due to esophageal varices secondary to portal hypertension secondary to PVT. Esophageal variceal bleeding secondary to PVT is an uncommon presentation of protein S deficiency. PVT without liver cirrhosis is also uncommon. Protein S and C deficiency is a rare clotting disorder that may cause clots in vessels and ultimately dislodgement of clots that can result in life-threatening complications. Hence, timely diagnosis, treatment, and prophylaxis can prevent life-threatening complications.
Dying and Death in a Pediatric Cardiac ICU: Mixed Methods Evaluation of Multidisciplinary Staff Responses
Authors: Broden Elizabeth G. , Bailey Valerie K. , Beke Dorothy M. , Snaman Jennifer M. , Moynihan Katie M. 
Published: September 2023

OBJECTIVES:
Understanding factors influencing quality of pediatric end-of-life (EOL) care is necessary to identify interventions to improve family and staff experiences. We characterized pediatric cardiac ICU (PCICU) staff free-text survey responses to contextualize patterns in quality of dying and death (QODD) scoring.

DESIGN:
This mixed methods study reports on a cross-sectional survey of PCICU staff involved in patient deaths.

SETTING:
Single, quaternary PCICU from 2019-2021.

PARTICIPANTS:
Multidisciplinary staff (bedside nurses, allied health professionals, and medical practitioners) rated QODD and voluntarily added free-text responses. We derived descriptive categories of free-text responses using content analysis. Response sentiment was classified as positive, negative or both positive and negative. We compared category and sentiment frequency by discipline, EOL medical intensity, years of experience and QODD score quartiles.

INTERVENTIONS:
None.

MEASUREMENTS AND MAIN RESULTS:
Of 60 deaths and 713 completed staff surveys, 269 (38%) contained free-text responses, including 103 of 269 (38%) from nurses. Of six qualitative categories (i.e., relational dynamics, clinical circumstances, family experiences, emotional expressions, temporal conditions, and structural/situational factors), relational dynamics was most frequent (173 responses). When compared by discipline, family experiences were more common in nursing responses than medical practitioners or allied health. High intensity was associated with infrequent discussion of family experience and greater focus on temporal conditions and clinical circumstances. Emotional expressions and temporal conditions were more common in lowest QODD quartile surveys. Although 45% staff responses contained both sentiments, relational dynamics and family experiences were more likely positive. Negative sentiments were more common in the lowest QODD quartile surveys and responses containing temporal conditions or structural/situational factors.

CONCLUSIONS:
Synergistic relationships between the multidisciplinary team and family shaped clinician’s positive responses. Attention to team dynamics may be a crucial ingredient in interventions to improve EOL care. Our data support that team-based education initiatives should consider differential foci between disciplines and EOL characteristics.
Test Characteristics of Cardiac Point-of-Care Ultrasound in Children With Preexisting Cardiac Conditions
Authors: Hoffmann Robert M. , Neal Jeffrey T. , Arichai Piyawat , Gravel Cynthia A. , Neuman Mark I. , Monuteaux Michael C. , Levy Jason A. , Miller Andrew F. 
Published: September 2023

Objective
The aim of the study is to assess diagnostic performance of cardiac point-of-care ultrasound (POCUS) performed by pediatric emergency medicine (PEM) physicians in children with preexisting cardiac disease.

Methods
We evaluated the use of cardiac POCUS performed by PEM physicians among a convenience sample of children with preexisting cardiac disease presenting to a tertiary care pediatric ED. We assessed patient characteristics and the indication for POCUS. The test characteristics of the sonologist interpretation for the assessment of both pericardial effusion as well as left ventricular systolic dysfunction were compared with expert POCUS review by PEM physicians with POCUS fellowship training.

Results
A total of 104 children with preexisting cardiac disease underwent cardiac POCUS examinations between July 2015 and December 2017. Among children with preexisting cardiac disease, structural defects were present in 72%, acquired conditions in 22%, and arrhythmias in 13% of patients. Cardiac POCUS was most frequently obtained because of chest pain (55%), dyspnea (18%), tachycardia (17%), and syncope (10%). Cardiac POCUS interpretation compared with expert review had a sensitivity of 100% (95% confidence interval [CI], 85.7–100) for pericardial effusion and 100% (95% CI, 71.5–100) for left ventricular systolic dysfunction; specificity was 97.5% (95% CI, 91.3.1–99.7) for pericardial effusion and 98.9% (95% CI, 93.8–99.8) for left ventricular systolic dysfunction.

Conclusions
Cardiac POCUS demonstrates good sensitivity and specificity in diagnosing pericardial effusion and left ventricular systolic dysfunction in children with preexisting cardiac conditions when technically adequate studies are obtained. These findings support future studies of cardiac POCUS in children with preexisting cardiac conditions presenting to the ED.