Rebecca Sealy Hospital

BACKGROUND: Antiphospholipid antibody syndrome (APAS) is characterized by the presence of anticardiolipin antibodies (ACA) in association with thrombotic disorders of arterial and/or venus systems, spontaneous abortion(s) or thrombocytopenia. METHODS: In this multicenter study, 502 end-stage renal disease (ESRD) patients awaiting renal transplants were screened to determine the frequency of APAS, the potential risk associated with APAS, and strategies for therapeutic intervention. Ninety-three patients (19%) had high titers of ACA. Twenty-three patients had documented evidence of one or more of the thrombotic disorders such as lupus, frequent abortions, frequent thrombosis of arteriovenous shunts, biopsy-proven microrenal angiopathy, or thrombocytopenia and thus were diagnosed with APAS. Of these 23 patients, 11 received kidney transplants either with (4 patients) or without (7 patients), concomitant anticoagulation therapy. RESULTS: All seven of the patients with APAS not treated with anticoagulation therapy lost their allografts within 1 week as a result of renal thrombosis. In contrast, three out of four transplant patients with APAS treated with anticoagulation therapy maintained their allografts for over 2 years. The fourth patient lost his graft within a week because of thrombosis. Of the remaining 70 patients with high titers of ACA but no evidence of thrombotic disorders, 37 received kidney transplants. None lost their allografts as a result of thrombosis. Our data suggest that, although 19% of our ESRD patients exhibit high titer of ACA, only 5% of the patients have APAS. CONCLUSION: In conclusion, our data suggest that the patients with APAS are at high risk of posttransplant renal thrombosis. Anticoagulation therapy could prevent patients from posttransplant thrombosis in patients with APAS.

BACKGROUND: Flow cytomeric crossmatch (FCXM) has grown in popularity and has become the "standard of practice" in many programs. Although FCXM is the most sensitive method for detecting alloantibody, the B cell FCXM has been problematic. Difficulties with the B cell FCXMs have been centered around high nonspecific fluorescence background owing to Fc-receptors present on the B cells and autoantibodies. To improve the specificity and sensitivity of the B cell FCXM, we utilized the proteolytic enzyme pronase to remove Fc receptors from lymphocytes before their use in FCXM. METHODS: Lymphocytes isolated from peripheral blood, spleen, or lymph nodes were treated with pronase and then used in a three-color FCXM. A total of 167 T- and B cell FCXMs using pronase-treated and untreated cells were performed. Testing used serial dilutions of HLA allosera (22 class I and 6 class II), with the titer of each antibody at one dilution past the titer at which the complement-mediated cytotoxicity anti-human globulin crossmatch became negative. RESULTS: After pronase treatment, the actual channel values of the negative control in both T cell and B cell FCXMs declined from 78+/-10 to 57+/-4 (P<0.05) and 107+/-11 to 49+/-3 (P<0.00001), respectively. Pronase treatment resulted in improved sensitivity of the T and B cell FCXM in detecting class I antibody by 20% and 80%, respectively. In no instance was a false-positive reaction observed. In this study, pronase treatment improved the specificity of B cell FCXM for detecting class II antibodies from 75% to 100% (P=0.03). In no instance was a false-negative reaction recorded. Lastly, on the basis of these observations we re-evaluated three primary transplant recipients who lost their allografts because of accelerated rejection. One of the patients was transplanted across negative T and B cell FCXM, whereas the other two patients were transplanted across a positive T cell, but negative B cell, FCXM. After pronase treatment, T and B cell FCXMs of each patient became strongly positive, and donor-specific anti-HLA class I antibody was identi. fied in each case. CONCLUSION: Utilization of pronase-treated lymphocytes improves both the sensitivity and specificity of the FCXM.

The glutathione system plays a major role in the protection of cells against oxidative stress in humans. The aim of the present study was to find out the relationship between the glutathione system and plasma lipid peroxidation in six renal transplant recipients (who are under oxidative stress and thus at high risk for atherosclerosis), by using dietary selenium to activate the glutathione system. 2,2'-Azobis-2-amidinopropane hydrochloride (AAPH)-induced plasma lipid peroxidation was increased (by 60%) in all six patients in comparison to normal subjects. A similar pattern of increased plasma lipid peroxidation was found even in the basal state (in the absence of added AAPH). CuSO4-induced low-density lipoprotein (LDL) oxidation measured by peroxide formation was also significantly increased by 2.3-fold in the patients' LDL in comparison to normal LDL. Even in the absence of CuSO4, the LDL oxidation state was also increased in the patients' LDL in comparison to normal LDL. We thus analyzed the effect of dietary selenium (0.2 mg/day for a period of 3 months, followed by an additional 3 months on placebo) on plasma and on LDL lipid peroxidation. Selenium treatment resulted in a 50% reduction in AAPH-induced plasma lipid peroxidation. The susceptibility of the patients' plasma to lipid peroxidation returned toward baseline values 3 months after termination of the selenium treatment. Similar results, although less pronounced (only 15% reduction), were obtained for CuSO4-induced LDL oxidation. Analyses of the patients' red blood cell (RBC) glutathione system revealed low levels of reduced glutathione and decreased activities of RBC glutathione peroxidase and glutathione reductase by 23%, 18%, and 20%, respectively, in comparison to normal RBC. Selenium treatment resulted in a significant elevation of RBC glutathione peroxidase and glutathione reductase activities and in reduced glutathione content by 64%, 57%, and 11%, respectively; this effect was also paralleled by a 39% reduction in the RBC oxidized glutathione content. On termination of the selenium treatment, and after 3 months on placebo, all of these values of the glutathione system elements returned toward baseline levels. We thus conclude that dietary selenium, which activates the glutathione system, is a potent antioxidant against plasma and LDL lipid peroxidation in renal transplant recipients, and may thus be considered antiatherogenic.

Having multiple reliable methods of estimating sex and ancestry from various skeletal features increases the likelihood of identifying skeletal remains. Femoral neck axis length (FNAL), as measured in living individuals, has been shown to vary by sex and ancestry. FNAL has not, however, been previously measured directly from skeletonized remains and investigated for its potential use in forensic anthropological applications. This research proposes a method for measuring FNAL from skeletal remains, determines the reliability and repeatability of the measurement, and assesses the validity of FNAL in sex and ancestry estimation. Results showed low interobserver error in the measurement of FNAL (TEM=0.33 mm, R=0.99). Significant differences in FNAL were found between sexes as well as between American Black, American White, and Native American groups. FNAL can correctly classify sex in ~86% of all cases and is considered valuable to sex estimation. The value of FNAL to ancestry estimation, however, is considered limited.

BACKGROUND: Sphingomonas paucimobilis is an emerging opportunistic bacterium with a particular tropism toward bones and soft tissues. It is a gram-negative rod that can infect immunosuppressed or immunocompetent individuals in the community or hospital settings. Prognosis of infected patients is generally good, but morbidity and mortality cases have both been documented. OBJECTIVES: To present and discuss all reported Sphingomonas paucimobilis-mediated bone and soft-tissue infections, and shed light upon the relevance of this organism in orthopaedic surgery. DATA SOURCES: Pubmed and Cochrane Library. STUDY ELIGIBILITY CRITERIA: Studies reporting at least one human bone or soft-tissue infection due to Sphingomonas paucimobilis. RESULTS: Ten articles describing 19 patients met the inclusion criteria. Common infections included osteomyelitis, cellulitis, and septic arthritis. Fifteen patients (78.9%) had community-acquired diseases. All patients were successfully treated with antibiotic therapy and only one (5.3%) had a residual complication. LIMITATIONS: The study included a small sample size presenting with bone or soft-tissue infections. Some cases had lacking data. CONCLUSION: Despite being associated with a good prognosis in most cases, Sphingomonas paucimobilis-related orthopaedic infections may exhibit some complications.

Morphology reflects ecological pressures, phylogeny, and genetic and biophysical constraints. Disentangling their influence is fundamental to understanding selection and trait evolution. Here, we assess the contributions of function, phylogeny, and habitat to patterns of plastron (ventral shell) shape variation in emydine turtles. We quantify shape variation using geometric morphometrics, and determine the influence of several variables on shape using path analysis. Factors influencing plastron shape variation are similar between emydine turtles and the more inclusive Testudinoidea. We evaluate the fit of various evolutionary models to the shape data to investigate the selective landscape responsible for the observed morphological patterns. The presence of a hinge on the plastron accounts for most morphological variance, but phylogeny and habitat also correlate with shape. The distribution of shape variance across emydine phylogeny is most consistent with an evolutionary model containing two adaptive zones--one for turtles with kinetic plastra, and one for turtles with rigid plastra. Models with more complex adaptive landscapes often fit the data only as well as the null model (purely stochastic evolution). The adaptive landscape of plastron shape in Emydinae may be relatively simple because plastral kinesis imposes overriding mechanical constraints on the evolution of form.

Summary Background and Objectivs: Survivors of pediatric and adolescent cancer are at an increased risk of chronic and debilitating health conditions and require life-long specialized care. Stand-alone electronic personal health records (ePHRs) may aid their self-management. This analysis characterizes young adult survivors and parents who meaningfully use an ePHR, Cancer SurvivorLinkTM, designed for survivors of pediatric and adolescent cancer. Methods: This was a retrospective observational study of patients seen at a pediatric survivor clinic for annual survivor care. Young adult survivors and/or parent proxies for survivors &lt;18 years old who completed ePHR registration prior to their appointment or within 90 days were classified as registrants. Registrants who uploaded or downloaded a document and/or shared their record were classified as meaningful users. Results: Overall, 23.7% (148/624) of survivors/parents registered and 38% of registrants used SurvivorLink meaningfully. Young adult registrants who transferred to adult care during the study period were more likely to be meaningful users (aOR: 2.6 (95% CI: 1.1, 6.1)) and used the ePHR twice as frequently as those who continued to receive care in our institution’s pediatric survivor clinic. Among survivors who continued to receive care at our institution, being a registrant was associated with having an annual follow-up visit (aOR: 2.6 (95% CI: 1.2, 5.8)). Conclusions: While ePHRs may not be utilized by all survivors, SurvivorLink is a resource for a subset and may serve as an important bridge for patients who transfer their care. Using SurvivorLink was also associated with receiving recommended annual survivor care.

Background: Chronic Achilles tendon ruptures are uncommon and increase long-term morbidity when untreated. There is no standard treatment for this condition. Methods: Chronic Achilles tendon rupture was repaired in 10 patients by harvesting the flexor hallucis longus tendon (FHL) using a minimally invasive technique. It was then transferred to the calcaneus and the remnant used to bridge the gap for reconstructing the Achilles tendon itself. The patients were assessed using the American Orthopaedic Foot and Ankle Score (AOFAS) Ankle-Hindfoot Scale. Results: Patients were evaluated postoperatively to assess pain, function, and alignment of the ankle and hindfoot. Average follow-up time was 30.9 months (range = 17-43 months). The average postoperative AOFAS score was 78.5 (range = 54-94). The average postoperative score for pain was 33.5 out of 40; for function, 38.7 out of 50; and for alignment, 6.3 out of 10. A single surgical site infection requiring Incision and Drainage (I&amp;D) was the only operative complication noted. No patient developed a significant deformity of the hallux after transfer. Conclusions: FHL transfer using a minimally invasive harvest for the treatment of chronic Achilles tendon ruptures produces good to excellent outcome measures as judged by an AOFAS score of 75 or greater while minimizing risk to the medial neurovascular bundle. Levels of Evidence: Case series, Level IV: Retrospective

Recurrent respiratory papillomatosis is an increasingly common viral infection of children caused by the human papilloma virus [1]. Progressive formation of multiple papillomas in the respiratory tract requires surgical removal to prevent speech difficulties and respiratory compromise. Patients are commonly diagnosed with change in voice or hoarseness prior to the development of severe respiratory compromise [2,3]. We present a case of complete airway obstruction during induction of general anesthesia in which the usual signs of severe respiratory compromise (including difficulty clearing secretions, sleep disturbances, decreased activity, and difficulty eating) were not present preoperatively. Case Report A 1.5-yr-old boy presented as a day surgery admit for CO2 ablation of laryngeal papillomas. He had been seen by his pediatrician for inspiratory airway noise and had been treated (as an outpatient) with antibiotics for "croup" and bronchodilators for "asthma" prior to being diagnosed with laryngeal papillomatosis. The patient had no history of decreased activity or breathing difficulties during sleep. He had an occasional coughing episode during eating that quickly resolved with a sip of water, but he had not required a change in diet. On physical examination, he had mild inspiratory stridor but was otherwise alert with normal activity and no evidence of respiratory difficulty or distress. Preoperative lateral radiographs of the neck revealed a mass in the posterior pharynx that did not obstruct the airway. Indirect laryngoscopy revealed one large papilloma on the epiglottis and arytenoids and several small ones around the laryngeal inlet. On the day of surgery, the patient was sedated preoperatively with 0.3 mg/kg midazolam orally 45 min before the procedure. He was taken to the operating room awake, calm, and cooperative. Routine monitors were applied, and general anesthesia was induced via a face mask with 70% nitrous oxide, 30% oxygen, and incrementally increased halothane concentrations with the patient in the sitting position. The patient remained calm and cooperative during induction of anesthesia, and spontaneous ventilation was maintained. After the patient was positioned supine, partial airway obstruction occurred, which improved with positive pressure support. Spontaneous ventilation was continued with pressure support. Several minutes later, complete obstruction of the airway occurred. Succinylcholine (1 mg/kg) and atropine (0.1 mg) were given intravenously (IV). Visualization of the posterior pharynx by direct laryngoscopy revealed a mass of papillomas completely occluding the airway. Placement of the endotracheal tube was abandoned, and rigid bronchoscopy was attempted by the otolaryngologist. On rigid bronchoscopy, the mass of papillomas precluded advancement of the rigid bronchoscope. An emergency tracheostomy was performed, and a 4.5 uncuffed endotracheal tube placed into the tracheostomy site. Total duration of desaturation (i.e., < 95%) was approximately 8 min, and saturation < 50% was < 5 min. Bradycardia and hypotension did not develop during the period of desaturation. After placement of the tracheostomy and return of oxygen saturation to 100%, rigid bronchoscopy was performed and photographs were taken (Figure 1). The case proceeded uneventfully, and the patient was taken to the recovery room postoperatively awake but sedated. When he was completely awake, a neurologic examination was performed and was completely normal. The patient returned to the operating room for a second look 2 wk later. Both the vocal cords and posterior pharynx were normal at that time (Figure 2).Figure 1: Total obstruction of the vocal cords by papillomas as seen on direct laryngoscopy.Figure 2: Normal airway seen 2 wk postoperatively by direct laryngoscopy.Discussion Recurrent respiratory papillomatosis was first described by MacKenzie in 1880 as a disease of the larynx confined to children [4], but subsequent studies have identified this disease in adults as well [5]. It is caused by infection of the mucous membranes with the human papilloma virus types 6 and 11 [1]. It was originally thought to be transmitted to the child during birth from maternal genital warts; however, there are numerous cases where this history is not present [1,2]. Several studies [6,7] suggest that abnormal immune systems with subnormal killer cell activity and decreased T-lymphocyte counts are necessary for contraction of this disease. The initial presentation of this disease is variable and often mistaken for asthma, bronchitis, croup, or laryngomalacia [3]. The most common symptoms are a change in voice, hoarseness, or stridor, usually prior to the development of significant respiratory difficulty [2,3]. Papillomas are typically located near the vocal cords but may also be found on the palate, tonsils, and epiglottis. Extension of the papillomas into the subglottic region is common (35% of the pediatric cases and 43% of the adult cases), but extension into the trachea or proximal bronchi is rare (2%-5%) [5,8]. Lung involvement, while also rare (<1%), is often fatal [3,9]. The clinical course of this disease includes multiple recurrences after all modes of therapy. In most cases, spontaneous remissions do not occur, and the disease can continue well into adult life [2]. Death from recurrent respiratory papillomatosis, although rare, is most commonly due to surgical complications, airway obstruction with seeding of the distal trachea and lung, or malignant transformation [3]. Until remission of the disease, the mainstay of therapy is surgical excision of the papillomas. Prior to the use of the CO2 laser, electrocautery, suction diathermy, and cryotherapy were used [3,10]. Although effective at removing the papillomas, the extensive use of these techniques lead to marked scar formation and airway stenosis [3,10]. CO2 laser ablation, while not a cure, is the current treatment of choice [3,10,11]. Postoperative complications including airway stenosis, webbing, scarring, and granulation formation can occur, but with less severity than older techniques [11,12]. Less common complications include tracheal perforation, tracheoesophageal fistula, bronchitis, pneumonia, pneumothorax, hemorrhage, respiratory arrest, and death [5,13]. Wegrzynowicz et al. [14] noted an unusual complication. Burning vapors created by ignition of the surgeon's gloves were inhaled around the laryngoscope then exhaled through the nose, causing ignition of the patient's mustache [14]. Numerous medical therapies have been tried to slow the rate of papilloma growth, including interferon [15,16], acyclovir [17,18], riboviron [19], and cabbage juice [3], all with limited success. Abramson et al. [20] combined preoperative IV dihematoporphyrin with argon pump dye laser phototherapy and noted a 50% reduction in the papilloma growth rate. Addition of this mode of therapy to CO2 ablation may decrease the perioperative risks of airway complications due to a decrease in the size of the lesions, but it will probably not reduce long-term complications as the recurrence rate was not affected [20]. A variety of anesthetic techniques have been successfully used with these patients. General anesthesia is often induced by incremental inhalation of halothane, nitrous oxide, and oxygen [21,22]. However, both IV thiopental and intramuscular ketamine inductions have been used without complications [21,22]. Whether to maintain spontaneous ventilation or use muscle relaxants has been a controversial issue for more than a decade. Spontaneous ventilation is advocated to reduce the risk of airway fires and the incidence of postoperative croup. Periods of CO2 laser ablation are alternated with supplemental oxygenation by mask or temporary placement of a small endotracheal tube. Muscle relaxants, while used routinely in the past without complications [21], are often avoided because of the concern that relaxation of the posterior pharyngeal muscles will lead to airway obstruction by pedunculated masses. However, since relaxation of these same muscles occurs with surgical planes of inhaled anesthesia even with spontaneous ventilation, airway obstruction may still occur. Additionally, the use of muscle relaxants after total airway obstruction may relieve superimposed laryngospasm improving ventilation, avoid postobstructive pulmonary edema, and prevent further traction of the mass into the airway by inspiratory efforts. Tracheostomy, while used in up to 61% of patients in the past [1,2,21], is currently reserved for total airway obstruction when ventilation and intubation are not possible [21]. Administration of local anesthetics to lessen the risk of laryngospasm is also common [21]. Topical application is ineffective, because resection of the papillomas leaves areas of denuded tissue that are not anesthetized [22]. Lawson et al. [22] used a continuous infusion of procaine (1 mg [[centered dot]] kg-1 [[centered dot]] min-1), which produced blunting of the cough reflexes without the toxic reactions or delayed emergence seen with lidocaine [22]. Unfortunately, occasional respiratory depression, including apnea, occurred, which makes this technique less than ideal [22]. Perioperative nebulized racemic epinephrine and IV steroids have been used to prevent and treat postoperative croup [23]. While the efficacy of racemic epinephrine is well known, the usefulness of steroids remains controversial. Forestner et al. [21] studied the incidence of croup with and without intraoperative steroid administration. Although there was no statistical difference between the groups, they recommended the use of steroids because they cause few adverse reactions and may potentially be beneficial [21]. In summary, it appears that a variety of anesthetic techniques can be used on these patients successfully. Preoperative planning between the otolaryngologist and the anesthesiologist is essential for optimal care of the patient. It is important to be prepared for an emergency tracheostomy at all times when conducting a general anesthetic on these patients, even when severe preoperative airway compromise is not present, as is illustrated by this case.

QUESTIONS UNDER STUDY: Patient characteristics and risk factors for death of Swiss trauma patients in the Trauma Audit and Research Network (TARN). METHODS: Descriptive analysis of trauma patients (≥16 years) admitted to a level I trauma centre in Switzerland (September 1, 2009 to August 31, 2010) and entered into TARN. Multivariable logistic regression analysis was used to identify predictors of 30-day mortality. RESULTS: Of 458 patients 71% were male. The median age was 50.5 years (inter-quartile range [IQR] 32.2-67.7), median Injury Severity Score (ISS) was 14 (IQR 9-20) and median Glasgow Coma Score (GCS) was 15 (IQR 14-15). The ISS was >15 for 47%, and 14% had an ISS >25. A total of 17 patients (3.7%) died within 30 days of trauma. All deaths were in patients with ISS >15. Most injuries were due to falls <2 m (35%) or road traffic accidents (29%). Injuries to the head (39%) were followed by injuries to the lower limbs (33%), spine (28%) and chest (27%). The time of admission peaked between 12:00 and 22:00, with a second peak between 00:00 and 02:00. A total of 64% of patients were admitted directly to our trauma centre. The median time to CT was 30 min (IQR 18-54 min). Using multivariable regression analysis, the predictors of mortality were older age, higher ISS and lower GCS. CONCLUSIONS: Characteristics of Swiss trauma patients derived from TARN were described for the first time, providing a detailed overview of the institutional trauma population. Based on these results, patient management and hospital resources (e.g. triage of patients, time to CT, staffing during night shifts) could be evaluated as a further step.

BACKGROUND: Despite the high prevalence of civilian gunshot injuries (GSIs) in the United States, no universally accepted classification currently exists. Recently, two of us (ZG, RWL) proposed a GSI classification based on energy transferred, vital structure damage, wound characteristics, fracture, and degree of contamination. This classification has not been validated in a clinical setting. QUESTIONS/PURPOSES: We determined the feasibility, internal consistency, and predictive accuracy of this classification. METHODS: We reviewed the medical records of 216 patients with 264 GSIs treated at a Level I trauma center. Feasibility was determined by the investigators' ability to retrospectively complete the classification system based on patient information routinely collected in medical records. Internal consistency was determined using Cronbach's coefficient alpha. Predictive accuracy was constructed and interpreted in a receiver operating characteristic (ROC) curve using all the classification components to predict GSI severity. The clinical management/outcome (deceased, hospitalization versus nonadmission, and surgical versus nonsurgical treatment) was used as a proxy measure of GSI severity. RESULTS: We were able to apply the classification to 82% of charts we reviewed. The classification components appeared to be internally consistent (Cronbach's alpha was 0.69 and was increased to 0.78 after exclusion of contamination). Each component was associated with clinical management. GSI classified as high energy, worse vital structure, and high contamination had higher rates of surgery (84%, 84%, and 100%, respectively). The area under the ROC curve was 0.80, suggesting the classification can accurately describe GSI severity. CONCLUSIONS: Our results suggest this new civilian GSI classification is statistically valid and has clinical merits warranting further investigation in the setting of a prospective trial.

BACKGROUND: fat-soluble vitamin deficiency may be a health problem not recognized in children and adolescents. OBJECTIVE: to estimate the prevalence and factors associated with the deficiency of vitamins A, D and E among adolescent students from Northeastern Brazil. METHODS: transversal study with adolescents aged 12 to 19 of both genders. A questionnaire to collect socioeconomic and lifestyle data and food intake was applied to adolescents. Then, an anthropometric evaluation and a blood sampling were performed to analyze serum concentrations of retinol, β-carotene, α-tocopherol and 25-hydroxy vitamin D (25[OH]D). RESULTS: the intake of vitamins A (50.3%), E (94.0%) and D (99.8%), as well as α-tocopherol (88.1%), β-carotene (74.1%), 25(OH)D (50.9%) and retinol (46.6%) serum levels were mostly deficient/insufficient. An increased risk of α-tocopherol deficiency was observed in girls (PR = 1.11) and an increased risk of 25(OH)D deficiency was observed in boys (PR = 1.41). An increased likelihood of β-carotene (PR = 1.14) and 25(OH) D (PR = 1.38) insufficiency was observed in overweight individuals. CONCLUSIONS: the adolescents had a deficit in the intake and in serum levels of fat-soluble vitamins. The greatest risk of inadequacy was associated with gender and weight excess. However, the behavior of fat-soluble vitamins in adolescents needs further research.

Solitary plasmacytoma (SP) is a rare plasma cell dyscrasia. In this retrospective multicenter study, 68 SP patients were included. Compared to solitary extramedullary plasmacytoma (SEP), patients with solitary bone plasmacytoma (SBP) were younger (57.3 vs. 70.9 years, p = 0.031), had larger plasmacytoma (median: 5.4 vs. 3 cm, p = 0.007) and higher median involved free light chain level (61 vs. 25.8 mg/L, p = 0.056). 92.6% of patients were treated by radiotherapy and 11.8% received systemic anti-myeloma treatment. With a median follow-up of 42 months, 45.6% of patients progressed (8.8% – recurrent SP, 36.8% – active myeloma). The median PFS was 58 months and the median OS has not been reached (10-year OS: 84.8%). Patients who received also anti-myeloma treatment had longer PFS compared to those who did not (median not reached vs. 48 months, p = 0.056). In conclusion, SBP and SEP appear to be different diseases. Radiotherapy is the cornerstone in the SP treatment. A large prospective trial is needed to evaluate the impact of adding systemic anti-myeloma treatment to local radiotherapy.

A new modification of the extensor indicis proprius transfer to the extensor pollicis longus tendon through a fourth dorsal compartment retinacular pulley is described. This new modification has been assessed in cadavers biomechanically via computer simulation and in a limited number of patients with success. It affords the benefit over the standard subcutaneous extensor indicis proprius to the extensor pollicis longus tendon transfer of maintaining the adduction moment arm of the thumb. The moment arm mechanics of the pulley transfer resemble those of the intact extensor pollicis longus. Therefore this new modification offers better thumb function in both adduction and circumduction motions.

This article identifies the various functions and outlines the requirements of the clinical record in home care.

Abstract. The Green Edge initiative was developed to investigate the processes controlling the primary productivity and the fate of organic matter produced during the Arctic phytoplankton spring bloom (PSB) and to determine its role in the ecosystem. Two field campaigns were conducted in 2015 and 2016 at an ice camp located on landfast sea ice southeast of Qikiqtarjuaq Island in Baffin Bay (67.4797N, 63.7895W). During both expeditions, a large suite of physical, chemical and biological variables was measured beneath a consolidated sea ice cover from the surface to the bottom at 360 m depth to better understand the factors driving the PSB. Key variables such as temperature, salinity, radiance, irradiance, nutrient concentrations, chlorophyll-a concentration, bacteria, phytoplankton and zooplankton abundance and taxonomy, carbon stocks and fluxes were routinely measured at the ice camp. Here, we present the results of a joint effort to tidy and standardize the collected data sets that will facilitate their reuse in other Arctic studies. The dataset is available at http://www.seanoe.org/data/00487/59892/ (Massicotte et al., 2019a).

Rebecca Friedman Zuber, MA, BSW, is President, Rebecca Friedman Zuber, Inc., a consulting firm in Chicago, IL. Address for correspondence: 1752 North Mohawk Street, Chicago, IL 60614 (e-mail: [email protected]).

A key limitation shared by both electronic and optogenetic sight recovery technologies is that they cause simultaneous rather than complementary firing within on- and off-center cells. Here, using "virtual patients"-sighted individuals viewing distorted input-we examine whether gamified training improves the ability to compensate for distortions in neuronal population coding. We measured perceptual learning using dichoptic input, filtered so that regions of the image that produced on-center responses in one eye produced off-center responses in the other eye. The Non-Gaming control group carried out an object discrimination task over five sessions using this filtered input. The Gaming group carried out an additional 25 hours of gamified training using a similarly filtered variant of the video game Fruit Ninja. Both groups showed improvements over time in the object discrimination task. However, there was no significant transfer of learning from the "Fruit Ninja" task to the object discrimination task. The lack of transfer of learning from video game training to object recognition suggests that gamification-based rehabilitation for sight recovery technologies may have limited utility and may be most effective when targeted on learning specific visual tasks.

Abstract: Breast cancer related lymphedema (BCRL) is estimated to affect up to 50% of patients after lymph node surgery, with risk factors including axillary lymph node dissection (ALND), radiation therapy, and higher body mass index (BMI). BCRL causes significant morbidity for patients and is currently a chronic, progressive disease with no known medical or surgical cure. Immediate lymphatic reconstruction (ILR) is a promising surgical intervention performed at the time of lymph node dissection to prevent secondary lymphedema. Using axillary reverse mapping (ARM), lymphatic channels draining the upper extremity can be identified and preserved during lymph node surgery. Lymphatic channels that are unable to be preserved are bypassed to a nearby recipient vein, physiologically restoring lymphatic drainage from the extremity into the venous system. This lymphovenous bypass (LVB), also called lymphatic microsurgical preventive healing approach (LYMPHA), is most often performed with microsurgical techniques, though other techniques such as simplified or S-LYMPHA have also been described. Therefore, ILR requires close communication and a learning curve for both the oncologic and reconstructive surgeon. Early clinical outcomes show that ILR reduces the incidence of lymphedema, though short follow up times and heterogeneity between studies make it difficult to draw conclusions. As part of a series on BCRL, the purpose of this review article is to provide an overview of ILR with a focus on the historical background, surgical considerations, current outcomes data, and future directions of ILR.

PURPOSE: Extravasation is an uncommon but high-risk adverse event that occurs when an agent with the potential to cause tissue damage leaks out of the intended administration space into the surrounding area. This guideline presents evidence-based side effect management recommendations to support interprofessional teams in decision-making to minimize severity or progression of extravasation injury from antineoplastic treatment in individuals with cancer. METHODOLOGIC APPROACH: The Oncology Nursing Society and the American Society of Clinical Oncology appointed healthcare professional and patient representative members to a panel for guideline development focused on antineoplastic vesicants and irritants with vesicant properties. The panel applied GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology and followed the National Academies of Sciences, Engineering, and Medicine criteria for trustworthy guidelines. A systematic review of studies examining outcomes of antineoplastic agent extravasation in adults informed the guideline. The panel assessed the certainty of the evidence using the GRADE approach. FINDINGS: The panel agreed on recommendations related to the use of antidotes for antineoplastic vesicants and irritants with vesicant properties, thermal compress application and duration, and early surgical referral or escalation to specialty care for central venous access device extravasation. IMPLICATIONS FOR NURSING: This guideline summarizes evidence-based interventions for the management of extravasation of antineoplastic vesicants or irritants with vesicant properties to guide clinical care.