Mortality Risk Factors Among Patients With Cirrhosis and a Low Model for End-Stage Liver Disease Sodium Score (≤15): An Analysis of Liver Transplant Allocation Policy Using Aggregated Electronic Health Record Data

Although the Model for End-Stage Liver Disease sodium (MELD Na) score is now used for liver transplant allocation in the United States, mortality prediction may be underestimated by the score. Using aggregated electronic health record data from 7834 adult patients with cirrhosis, we determined whether the cause of cirrhosis or cirrhosis complications was associated with an increased risk of death among patients with a MELD Na score ≤15 and whether patients with the greatest risk of death could benefit from liver transplantation (LT). Over median follow-up of 2.3 years, 3715 patients had a maximum MELD Na score ≤15. Overall, 3.4% were waitlisted for LT. Severe hypoalbuminemia, hepatorenal syndrome, and hepatic hydrothorax conferred the greatest risk of death independent of MELD Na score with 1-year predicted mortality >14%. Approximately 10% possessed these risk factors. Of these high-risk patients, only 4% were waitlisted for LT, despite no difference in nonliver comorbidities between waitlisted patients and those not listed. In addition, risk factors for death among waitlisted patients were the same as those for patients not waitlisted, although the effect of malnutrition was significantly greater for waitlisted patients (hazard ratio 8.65 [95% CI 2.57-29.11] vs. 1.47 [95% CI 1.08-1.98]). Using the MELD Na score for allocation may continue to limit access to LT.

Changes in pediatric tracheostomy tubes exposed to home dishwashing

OBJECTIVE

Determine the effects of household dishwashing on Tracheostomy Tube safety.

INTRODUCTION

Tracheostomy tubes accumulate biofilms, which may limit their lifespan. Frequent cleaning of the tubes is a method for biofilm prevention. Cleaning practices vary widely. Some families prefer dishwashing of tubes, but its effects are currently unknown. We hypothesize that dishwashing has no significant effect on the physical properties of tracheostomy tubes and can be recommended as a safe way to clean tracheostomy tubes.

METHODS

Twenty 4.0 Shiley™ pediatric tracheostomy tubes were randomly assigned into dishwashed (DW) and non-dishwashed (NDW) groups, 10/group. DW tubes were subjected to 12 wash cycles. Each tube's hardness along with the surface spectra were analyzed to assess for chemical composition changes. Three cannula samples from each group were also randomly assessed with scanning-electron microscopy and scored by blinded examiners to assess for changes in surface heterogeneity.

RESULTS

Hardness testing revealed a statistically significant difference (p = 0.0009) between the NDW and the DW group indicating increased fragility in the dishwashed tubes. Spectral analysis revealed loss of plasticizers, indicating decreased flexibility. Blinded electron microscopy scoring revealed increased surface heterogeneity in the DW group (p = 0.00007).

CONCLUSION

A significant decrease in tube hardness and increased surface heterogeneity were found with dishwashing. The spectral analysis demonstrated increasing fragility. We believe these effects could potentially lead to decreased mechanical safety. With increased surface heterogeneity there is a greater potential for biofilm formation. At this time, dishwashing cannot be recommended as a tracheostomy tube cleaning method.

Beyond the Classic VTA: Extended Amygdala Projections to DA-Striatal Paths in the Primate

The central extended amygdala (CEA) has been conceptualized as a 'macrosystem' that regulates various stress-induced behaviors. Consistent with this, the CEA highly expresses corticotropin-releasing factor (CRF), an important modulator of stress responses. Stress alters goal-directed responses associated with striatal paths, including maladaptive responses such as drug seeking, social withdrawal, and compulsive behavior. CEA inputs to the midbrain dopamine (DA) system are positioned to influence striatal functions through mesolimbic DA-striatal pathways. However, the structure of this amygdala-CEA-DA neuron path to the striatum has been poorly characterized in primates. In primates, we combined neuronal tracer injections into various arms of the circuit through specific DA subpopulations to assess: (1) whether the circuit connecting amygdala, CEA, and DA cells follows CEA intrinsic organization, or a more direct topography involving bed nucleus vs central nucleus divisions; (2) CRF content of the CEA-DA path; and (3) striatal subregions specifically involved in CEA-DA-striatal loops. We found that the amygdala-CEA-DA path follows macrostructural subdivisions, with the majority of input/outputs converging in the medial central nucleus, the sublenticular extended amygdala, and the posterior lateral bed nucleus of the stria terminalis. The proportion of CRF+ outputs is >50%, and mainly targets the A10 parabrachial pigmented nucleus (PBP) and A8 (retrorubal field, RRF) neuronal subpopulations, with additional inputs to the dorsal A9 neurons. CRF-enriched CEA-DA projections are positioned to influence outputs to the 'limbic-associative' striatum, which is distinct from striatal regions targeted by DA cells lacking CEA input. We conclude that the concept of the CEA is supported on connectional grounds, and that CEA termination over the PBP and RRF neuronal populations can influence striatal circuits involved in associative learning.

Insights into targeting young male drivers with anti-speeding advertising: An application of the Step approach to Message Design and Testing (SatMDT)

In Australia, young drivers aged 17-25 years comprise 13% of the population yet account for 22% of all road deaths with young males over-represented in such trauma. Speeding represents a major contributing factor and advertising campaigns have long focused on promoting anti-speeding messages in the effort to reduce drivers' speeds. Positioned within a larger program of research aimed at developing, piloting, and evaluating a range of theoretically-informed anti-speeding messages, the current study reports results relating to the final phase of the research, the evaluation. Six messages were devised in accordance with the guiding framework, the Step approach to Message Design and Testing ([SatMDT]; Lewis et al., 2016) and based on the findings emerging from earlier qualitative and quantitative studies within the program of research. N=938 licensed drivers (n=455 males, 48%) aged 17-62 years completed an online survey. To ensure a controlled test of the persuasiveness of the message content, the messages were presented in an audio-based format and thus were devoid of potential confounds, such as images. The messages sought to address a particular belief (i.e., behavioural, normative, control) and to focus either on emphasising the positive aspects which make speeding less likely or challenging the negative aspects which make speeding more likely. Thus, key to this evaluation was to test the persuasiveness of the message content in terms of the particular belief and focus it was addressing. Participants were randomly assigned to either the Control condition (i.e., no exposure to a message) or the Intervention condition (i.e., exposed to one of the six messages presented as an audio-recorded message within the survey). Persuasiveness was assessed via a range of outcome measures including both direct (i.e., third-person perceptions, message rejection) as well as indirect measures (i.e., intentions, willingness to speed). Age, gender, and message type were independent variables (IVs), together with issue involvement as a covariate (or IV) in the study's analyses. Overall, positive persuasive effects, and a relative absence of any negative, dissuasive effects, were found for two messages, Glass Cars and The Lift. These messages addressed the same salient belief, control beliefs, with the former emphasising the factors which discourage speeding and the latter message challenging those factors which encourage speeding. The implications of the findings are discussed in terms of the insights they offer for the key content of future anti-speeding messages.

Does Allograft Augmentation of Small-Diameter Hamstring Autograft ACL Grafts Reduce the Incidence of Graft Retear?

BACKGROUND

Small-diameter hamstring tendons are frequently encountered during anterior cruciate ligament (ACL) reconstructions in patients with short stature or those who are skeletally immature. The role of augmenting these small-diameter autografts with allograft is unclear.

PURPOSE

To assess clinical outcomes and failure rates in adolescent patients with small hamstring tendon autografts (<7 mm) that were either augmented with soft tissue allograft or accepted "as is" and not augmented.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective chart review of all primary ACL reconstructions performed with hamstring autografts identified 385 patients, of whom 50 (13%) had a quadrupled (semitendinosus-gracilis) graft size less than 7 mm. Patients were grouped based on the surgeon's preference either to augment these grafts with allograft (augmented group; n = 26) or to accept the smaller autograft (nonaugmented group; n = 24). Preoperative demographic, injury, and intraoperative data were documented. All patients were contacted to obtain information about outcome scores, subsequent procedures, and complications. Forty patients (20 in each group) were available for 2-year follow-up.

RESULTS

The mean age of the entire cohort was 15.7 years (range, 12-18 years), and 38% were male. No between-group differences were found with respect to any of the preoperative or intraoperative variables except extremity side. The mean graft size for the augmented group was 8.9 mm and for the nonaugmented group was 6.4 mm. At a mean follow-up of 3 years, 6 (30%) of the patients in the augmented group had a graft failure, whereas only 1 (5%) in the nonaugmented group had a failure ( P = .04). Five of the 6 augmented failures occurred within 1 year of surgery, whereas the single failure in the nonaugmented group occurred 2.7years postoperatively. No differences were noted in the reported outcomes between patients in the augmented and nonaugmented groups who did not experience graft failure (Lysholm score, 88 vs 92; Tegner score, 6.4 vs 6.3; single-assessment numeric evaluation score, 86 vs 86; satisfaction, 8.4 vs 8.9, respectively).

CONCLUSION

Adolescents undergoing an ACL reconstruction frequently have small hamstring tendon autograft size. The augmentation of these small grafts with allograft does not reduce graft failure rates and may in fact lead to higher retear rates, with earlier graft failure.

GEL THE NEC: a prospective registry evaluating the safety, ease of use, and efficacy of the HydroSoft coil as a finishing device

Background and purpose

The HydroSoft coil was developed as a finishing coil, ideally to be placed along the aneurysm neck to enhance intracranial aneurysm healing. The GEL THE NEC (Gaining Efficacy Long Term: Hydrosoft, an Emerging, New, Embolic Coil) multicenter registry was developed to assess the safety and efficacy of HydroSoft coils in treating intracranial aneurysms. We report angiographic and clinical results of this prospective registry.

Materials and methods

GEL THE NEC was performed at 27 centers in five countries. Patients aged 21–90 years with a ruptured or unruptured aneurysm 3–15 mm in size were eligible for enrollment. The following variables were obtained: demographics/comorbidities, aneurysm geometry, adjunctive devices used, proportion of patients in whom HydroSoft coils were successfully placed, and long-term angiographic outcomes (graded by an independent core laboratory using the Modified Raymond Scale), and procedure-related adverse events. Predictors of good angiographic outcome were studied using χ2 and t-tests.

Results

A total of 599 patients with 599 aneurysms were included in this study. HydroSoft coils were successfully deployed in 577 (96.4%) patients. Procedure-related major morbidity and mortality were 0.5% (3/599) and 1.3% (8/599), respectively. The most common perioperative complications were iatrogenic vasospasm (30/599, 5.0%), thromboemboli (27/599, 4.5%), and aneurysm perforation (16/599, 2.7%). At last angiographic follow-up (mean 9.0±6.3 months), the complete occlusion rate was 63.2% (280/442) and near complete occlusion rate was 25.2% (107/442). The core laboratory read recanalization rate was 10.8% (46/425) and the retreatment rate was 3.4% (20/599).

Conclusions

Endovascular treatment of intracranial aneurysms with HydroSoft coils resulted in complete/near complete occlusion rates of 88% and a major complication rate of 1.8%.

Trial registration number

NCT01000675.

Yeast recombinant Factor C from horseshoe crab binds endotoxin and causes bacteriostasis

Carcinoscorpius rotundicauda Factor C cDNA has been cloned and expressed in Pichia pastoris to produce a recombinant full-length Factor C (rFC) which is both immunoreactive and functional. The presence of a functional endotoxin-binding domain on rFC was ascertained by LPS-binding assays. One involved the relative binding affinity of rFC to electroblotted lipid A moiety of LPS. The second assay showed that rFC competed against native Factor C contained in C. rotundicauda amebocyte lysate (CAL) to bind LPS. Purification of rFC enhanced its binding affinity to LPS. By agglutination, rFC caused bacteriostasis of Gram-negative bacteria within 2 h. In an in vivo system, rFC also decreased the mortality of actinomycin D-sensitized/LPS-challenged mice. The rFCEE, bearing the 5' terminal LPS binding domain displayed a lowered affinity for LPS. This is in contrast to the rFCSN subclone that is devoid of the 5' end of Factor C, and which does not bind LPS. The presence of a fully-functional endotoxin binding domain in rFC probably requires a full-length protein for co-operative interaction of its downstream sequences. Thus, rFC has potential in the detection and removal of contaminating LPS from biological specimens and fluids for injection, since it is capable of binding both free and bound lipid A.

Expression of full length and deletion homologues of Carcinoscorpius rotundicauda Factor C in Saccharomyces cerevisiae: immunoreactivity and endotoxin binding

Deletion homologues of the cloned Factor C cDNAs from the horseshoe crab Carcinoscorpius rotundicauda were engineered to express in Saccharomyces cerevisiae under the regulation of a galactose-inducible promoter. Expression cassettes were constructed in the vectors: pEMBLyex4 and YEpsec1 to direct, respectively, the intracellular expression, and the secretion of the protein into the culture medium using a heterologous signal sequence. The effect of insert size on the efficiency of expression and the functionality of the resulting recombinant Factor C (rFC) were studied by creating expression constructs bearing various deletion and/or hybrid fragments of Factor C. Removal of the long 5' UTR from the Factor C cDNA improved expression of the rFC. 3' Deletions of up to 84%, or internal deletions of 65% of the Factor C cDNA resulted in either the lack of detectable amounts of Factor C or loss of immunoreactivity. Depending on the construct, full length or partial rFC-related proteins were correspondingly expressed intracellularly, regardless of the vector. The rFC partitioned with the insoluble cell fraction, was solubilised with either SDS or Triton X-100, and found to be immunoreactive. The rFCs were functionally active, being able to bind Gram-negative bacterial endotoxin, provided critical regions of the endotoxin-binding domain were preserved.

Optimizing the collection and reporting of wait time data

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Background: Wait times for critical interventional radiology (IR) procedures have long been reported as barriers to access for cancer patients. Wait times have been difficult to measure in the province of Ontario as no mechanisms exist to capture IR data. Three individual programs at Cancer Care Ontario (CCO) began collection of CT-guided biopsies wait time data, with nuances dependent on program area of focus. The Cancer Imaging Program collects appointment availability for lung biopsies through a monthly email survey. The Diagnostic Assessment Program collects patient-level lung biopsy data at select facilities in the province. The Access to Care program collects patient-level data from facilities that perform CT biopsies, but the data is not specific to lung biopsies. To streamline data collection processes and provide a comprehensive report for the province, the three programs are collaborating to validate current data sets and optimize data collection. Methods: A four phase approach has been developed to prepare for the ongoing comprehensive report: Planning – identify target audience, timelines, and data; Data Validation – three step evaluation to compare data sets; Test Report – consultation of draft report with clinical experts; and Evaluation – lessons learned from steps one to three to prepare for ongoing report. Results: This initiative allows each program to: Critically assess the components of their respective datasets; Cross-validate data for consistency or alignment; and Frame the clinically relevant data components to support and inform decision making and reporting processes. Through this process, efficiencies are gained by streamlining data collection and ensuring alignment between program areas. The collaborative approach ensures the business needs of each program are protected in the final product. Furthermore, this process will allow decision makers at CCO to analyze various methods of wait time data collection and aid in methodology decisions of future collections. Conclusions: The final product of this initiative will provide physicians and decision makers throughout Ontario with robust data to understand what is happening in their hospitals. The report will also facilitate impact analysis of interventions to reduce wait times.

Proposed mechanism of antibacterial action of chemically modified apatite for reduced bone infection

Surface-bound silver ions were demonstrated to be responsible for the antibacterial action of silver, silicon-containing hydroxyapatite (Ag,Si-HA). X-ray photoelectron spectroscopy, transmission electron microscopy, and induced coupled plasma spectroscopy results suggested that silver ions in the crystal structure diffused toward the crystal surface of Ag,Si-HA, and interacted with adherent Staphylococcus aureus bacteria, thus damaging the cell wall and inducing leakage of potassium ions. All these steps constitute the mechanism of antibacterial action for Ag,Si-HA. Consequently, Ag,Si-HA gave rise to a 7-log reduction of the adherent bacteria as compared to HA and Si-HA at 168 h. Silicon in Ag,Si-HA helped to mitigate the reduced effect of bone differentiation in Ag-HA as shown in the alkaline phosphatase, type I collagen and osteocalcin results, promoting enhanced biological response, without compromising the antibacterial property. On the whole, Ag,Si-HA containing an optimized content of 0.5 wt % silver and 0.7 wt % silicon provides antibacterial properties and enhanced biological response.

Trauma-Induced Parkinson’s Syndrome

Objectives:

Investigate if facial fractures predispose patients to developing Parkinson’s disease. Facial trauma ranges from lacerations to complex facial fractures. These fractures can result from sports, motor vehicle collisions, or assaults. The long-term neurologic effects of facial fractures have not been studied. Significant force is required to break midface buttresses or the mandible. Such force is transmitted toward the cranial vault contents. The location of the basal ganglia along the skull base predispose this area to higher strain. Chronic traumatic encephalopathy (CTE) shows similar neurologic damage related to repeated head injuries, as seen in the NFL and boxing.

Methods:

A total of 146 Parkinson’s patients were recruited from the neurology clinic. They were given a voluntary survey. This survey consisted of demographic questions: sex, age, age of diagnosis, involvement in sports, and history of facial fractures. The incidences of facial fracture ICD9 820.0 were analyzed with Wolfram Alpha and then chi-square.

Results:

Twenty-two of 146 (15%) had a positive history of facial fractures. Of the 22, 9 (6%) experienced multiple fractures. Twenty-six of 146 (17.8%) patients were involved in contact sports, with 7 out of 26 patients having fractures and participating in sports. Utilizing Wolfram Alpha, the incidence of ICD9 820.0 was calculated to be 1 out of 4100 (0.024%) in the US population. A chi-square test comparing our results showed a P value of .023

Conclusions:

Based on these statistically significant results, patients who experience facial fractures show an increased predilection for developing Parkinson’s disease.

Central spike proteins of contractile ejection systems

Contractile tails of bacteriophages and related systems - R-type pyocins, the Serratia entomophila antifeeding prophage, the Photorhabdus Virulence Cassette, and the Type VI Secretion System (T6SS) - contain a special spike-shaped protein complex, which is involved in breaching the target cell envelope during infection. We have identified the genes and determined crystal structures for several spike proteins from phages, pyocins, and T6SS, and established a paradigm for their organization and function. The architecture of spike proteins is remarkably well conserved at the level of tertiary structure, but the corresponding genes and amino acid sequences have undergone huge rearrangements with domains becoming separate genes that are very far away from each other in the genome. Large bacteriophages and T6SS have the most complex spikes, in which the tip is a small protein that forms a very sharp conical extension on the spike. The membrane-attacking tip is stabilized by a buried Fe or Zn ion. The spike tip proteins belong to the PAAR (Proline-Alanine-Alanine-aRginine) repeat domain superfamily with several thousand members in the GenBank. PAAR repeat proteins from T6SS are often extended by a domain with a putative effector function (nuclease, DNases, peptidases, etc.) or by a transthyretin domain. PAAR knockout mutants of Vibrio cholerae and Acinetobacter baylyi have either reduced or completely abolished T6SS activity, showing that PAAR proteins are essential for T6SS function and can play an important role in building of the T6SS machine and/or target cell membrane piercing. The unique HMM profile of PAAR repeat proteins makes it possible to identify their orthologs in all T6SS and contractile tail phages including T4, phiKZ, P1, etc. Complete structures (including the tip protein) of phage T4 central spike and T6SS spike of Vibrio cholerae will be presented and discussed.

The price of doing pediatric sinus procedures (a look at cost)

OBJECTIVE

Display the cost savings of minimal sterile covers and preparatory time while still maintaining optimal outcomes for sinus procedures. In-office non-sterile endoscopic sinus procedures have not shown a difference in infections and complications. Institutions continue to employ more "traditional" sterile preparation with similar procedures in the operating room. Multiple studies have also shown no significant difference in postoperative course when preoperative antibiotics are administered for sinus procedures.

METHODS

Endoscopic sinus procedures were selected (58 patients) to analyze itemized sterile costs. Drapes, gloves, gowns, and antibiotics were then tallied and compared to the same items for cochlear implants (14 procedures). The "sterile-prep" time was also analyzed and compared between the two procedures. Cost difference was analyzed.

RESULTS

Comparing the supplies used for sinus procedures (56) and cochlear implants, our average sinus cost was $10.19, compared to $34.64, with a difference of $24.45. This equated to a savings of $1418.00 in sinus procedure supplies that year. The difference in draping and scrubbing time showed a difference of 20 min between groups, equaling a value of $1760 difference/case. This calculated to a savings of $10,2080 for sinus operating room time. There was no difference in patient outcomes with this surgical preparatory approach.

CONCLUSION

Our analysis showed a large cost savings over a fiscal year in operative time and supplies. This did not compromise any patient outcomes given the already non-sterile nature of endoscopic sinus surgery. This practice can be adopted to greatly enhance efficiency without sacrificing surgical results.

Assembling a Three-Dimensional Computed Tomography Database

Objectives:

It is important for surgery to keep up with new technologies. Current skull-base techniques use stereotactic navigation, assisted by magnetic resonance (MRI) and computed tomography (CT) compilation. Our objective is to assemble a normalized CT database for three-dimensional (3D) endocranial renderings. This database can provide preoperative information for assistive mapping and intraoperative land marking during procedures.

Methods:

222 CT studies were pooled between October 2011and December 2012. These studies were then deidentified and loaded into third party software, Osirix (Pixmeo, Switzerland), and reconstructed into 3D renderings. The Osirix program is a freeware-based Apple-only-program capable of volumetric analysis, metrics, and 3D space manipulation. The database was then encrypted for patient information protection.

Results:

A total of 179 studies(101 males and 78 females) were ultimately used. Two-hundred gigabytes of hard-disk space was used. An Apple (Cuptertino, CA) laptop, running Mac OSX, was used for computation. The Osirix software was downloaded as freeware, requiring no payment. The hard-disk was purchased at a local electronics store for $100.00 USD. The computer was approximately $1300.

Conclusions:

Radiologic imaging drives preoperative surgical planning. This can be augmented by new technology and creative applications of current innovations. There has not been an explanation process on how to assemble this data for departments and individuals. We provide a simple, reproducible, and inexpensive guide to CT head databases. Once the database is assembled, it may be used for such projects as mapping the parapharyngeal carotid, estimating endocranial volumes, and surgical diagrams.

Pediatric oral burns: a ten-year review of patient characteristics, etiologies and treatment outcomes

OBJECTIVE

To summarize etiologies and treatments of pediatric oropharyngeal burns.

DESIGN

Retrospective summary of 75 patients treated from January 1999 to January 2009.

SETTING

Tertiary Children's Hospital.

METHODS

Data collected included demographics, etiology of burn, site of injury, medical and/or surgical treatments, need for endoscopy, duration of hospitalization, and complications.

RESULTS

75 patients were treated with 50 being males (66%). Mean age was 4.3 years (median 2.7 years). The five most common causes were chemical (34.6%), electrical (12.3%), hot liquids (12.3%), food (12.3%) and battery ingestion (9.9%). Ingestion of hair products made up nearly 1/3 of the chemical causes (9/28) and alone made up 12% of the burns in our study. Main sites of injury included buccal mucosa (77.3%), lips (56%), tongue (48%), and palate (22.7%). One-third of the patients' required PICU/Burn unit admissions, 1/3 were admitted to floor, and 1/3 were discharged home from the ED. Average duration of hospitalization was 5 days. Of those admitted, 30% received antibiotics and only 8% received systemic steroids. Patients were made NPO on the first day of admission in 33.3% of patients and allowed to resume normal diet after surgical consultation. Only 9/75 (12%) patients required intubation. Otolaryngology consultation was obtained in 10.7% of cases. Only 18% of all patients required surgical intervention with debridement being most common (>60%). In this group, 20% received esophagogastroduodenoscopies due to ingestion of alkali substance. Complications occurred in less than 6% of all cases.

CONCLUSION

Ingestion of chemicals, including hair dye/relaxer products, as well as overheated liquids and foods, are leading causes of oropharyngeal burns treated at our Children's Hospital Emergency Department over the past decade.