Carbon fiber lumbopelvic reconstruction following sacral giant cell tumor resection: illustrative case.

BACKGROUND: The use of carbon fiber or polyetheretherketone spine constructs has proven to be a safe and effective alternative to standard metal alloy. The mechanical properties of carbon fiber while unique provide a construct that is comparable in strength to previous titanium-based constructs and have additionally shown greater fatigue resistance. These constructs have been especially useful for the mechanical stabilization of the spine following tumor resection. The subsequent interference seen when imaging a patient with a traditional metallic construct is reduced and allows for improved tumor surveillance after the procedure, and a more accurate delivery of radiotherapy when indicated. OBSERVATIONS: This case report details the treatment of a 25-year-old female diagnosed with a sacral giant cell tumor. The authors discuss the use of a carbon fiber-reinforced polyetheretherketone for lumbopelvic reconstruction. LESSONS: Carbon fiber-reinforced polyetheretherketone with its radiolucency and rigidity is a reliable option for complex spinal reconstruction after tumor resection.

Peripheral Ulcerative Keratitis: A Review.

Peripheral ulcerative keratitis (PUK) is a rare but serious ocular condition that is an important clinical entity due to its ophthalmological and systemic implications. It is characterized by progressive peripheral corneal stromal thinning with an associated epithelial defect and can be associated with an underlying local or systemic pro-inflammatory condition, or present in an idiopathic form (Mooren ulcer). Associated conditions include autoimmune diseases, systemic and ocular infections, dermatologic diseases, and ocular surgery. Cell-mediated and auto-antibody-mediated immune responses have been implicated in the pathogenesis of PUK, destroying peripheral corneal tissue via matrix metalloproteinases. Clinically, patients with PUK present with painful vision loss, a peripheral corneal ulcer, and often adjacent scleritis, episcleritis, iritis, or conjunctivitis. Diagnostic evaluation should be focused on identifying the underlying etiology and ruling out conditions that may mimic PUK, including marginal keratitis and Terrien marginal degeneration. Treatment should be focused on reducing local disease burden with topical lubrication, while simultaneously addressing the underlying cause with antimicrobials or anti-inflammatory when appropriate. Existing and emerging biologic immunomodulatory therapies have proven useful in PUK due to autoimmune conditions. Surgical treatment is generally reserved for cases of severe thinning or corneal perforation.

Current and Emerging Therapies for Limbal Stem Cell Deficiency.

The corneal epithelium serves to protect the underlying cornea from the external environment and is essential for corneal transparency and optimal visual function. Regeneration of this epithelium is dependent on a population of stem cells residing in the basal layer of the limbus, the junction between the cornea and the sclera. The limbus provides the limbal epithelial stem cells (LESCs) with an optimal microenvironment, the limbal niche, which strictly regulates their proliferation and differentiation. Disturbances to the LESCs and/or their niche can lead to the pathologic condition known as limbal stem cell deficiency (LSCD) whereby the corneal epithelium is not generated effectively. This has deleterious effects on the corneal and visual function, due to impaired healing and secondary corneal opacification. In this concise review, we summarize the characteristics of LESCs and their niche, and present the current and future perspectives in the management of LSCD with an emphasis on restoring the function of the limbal niche.

Sepsis Among Medicare Beneficiaries: 4. Precoronavirus Disease 2019 Update January 2012-February 2020.

OBJECTIVES: To provide updated information on the burdens of sepsis during acute inpatient admissions for Medicare beneficiaries. DESIGN: Analysis of paid Medicare claims via the Centers for Medicare and Medicaid Services DataLink Project. SETTING: All U.S. acute-care hospitals, excluding federally operated hospitals (Veterans Administration and Defense Health Agency). PATIENTS: All Medicare beneficiaries, January 2012-February 2020, with an explicit sepsis diagnostic code assigned during an inpatient admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The count of Medicare Part A/B (fee-for-service) plus Medicare Advantage inpatient sepsis admissions rose from 981,027 (CY2012) to 1,700,433 (CY 2019). The proportion of total admissions with sepsis in the Medicare Advantage population rose from 21.43% to 35.39%, reflecting the increasing beneficiary proportion enrolled in Medicare Advantage. In CY2019, 6-month mortality rates in Medicare fee-for-service beneficiaries for sepsis continued to decline, but remained high: 59.9% for septic shock, 35.5% for severe sepsis, 30.8% for sepsis attributed to a specific organism, and 26.5% for unspecified sepsis. Total fee-for-service-only inpatient hospital costs rose from $17.79B (CY2012) to $22.98B (CY2019). We estimated that the aggregate cost of sepsis hospital care for the entire U.S. population was at least $57.47B in 2019. Inclusion of 14 months' (January 2019-February 2020) newer data exposed new trends: the cost per patient, number of admissions, and fraction of patients with sepsis labeled as present on admission inflected around November 2015, coincident with the change to International Classification of Diseases, 10th Edition, and introduction of the Severe Sepsis and Septic Shock Management Bundle (SEP-1) metric. CONCLUSIONS: Sepsis among Medicare beneficiaries precoronavirus disease 2019 imposed immense burdens upon patients, their families, and the taxpayers.

The association between vision impairment and social participation in community-dwelling adults: a systematic review.

Vision impairment (VI) is an important contributor to the global burden of disability and is associated with decreased well-being. Recent research has attempted to devise a conceptual framework to explain the health consequences of VI. One proposed mechanism by which VI leads to declines in well-being and other adverse health and disability outcomes is through limitations in social participation (SP). SP is an integral component of overall functioning, optimal aging, and well-being, and reductions in SP are associated with lower health-related quality of life. The purpose of this systematic review was to appraise the existing literature on the relationship between VI and SP. The protocol for this review was registered on PROSPERO (CRD42018102767) and adhered to PRISMA guidelines. A comprehensive search of five databases (MEDLINE, EMBASE, PsycINFO, Scopus, Sociology Database) yielded 881 unique studies, of which 19 met inclusion criteria. Among the 19 included studies, 18 concluded that VI was associated with reduced SP and one reported mixed results. Bias was assessed using the Effective Public Health Practice Project Quality Assessment. In the quality assessment, four studies were rated "moderate" and fifteen were rated "weak." There was wide variation in study populations and measurement of VI and SP. In conclusion, there is consensus that VI is associated with reduced SP. However, more rigorous study design and better standardization in the assessment of VI and SP could facilitate valid comparisons across populations, diseases, and levels of VI. Attempts to provide vision rehabilitation and mitigate the effects of VI on overall health and well-being might consider strategies to improve SP.

Traction load, tong position, and head support significantly influence cervical spine loading during traction.

Some cervical dislocation injuries may be acutely treated with traction via Gardner-Wells tongs, which are attached to the skull via two pins. While a variety of techniques have been proposed and utilized in the literature and clinical practice to use the tongs, these techniques have not been methodically studied to confirm how they transmit loads to the cervical spine. The current study investigated the mechanical effect of different traction techniques in a laboratory setting. A 50th male Hybrid anthropomorphic test device was used as a human surrogate to represent an average male in height and weight was modified to represent a patient with a unilateral facet dislocation injury. Electronic sensors at the atlanto-occipital joint recorded the loading delivered to the superior cervical spine by traction loading. Combinations of the following variables were evaluated as traction loads were progressively increased to one-third of body weight: tong pin position in the skull (anterior-posterior and superior-inferior to the recommended neutral position), traction cable angle in the sagittal plane (elevated, horizontal, declined), and presence or absence of an occipital support. Analysis of the cervical axial traction loads showed that the only significant predictor of cervical tension was the magnitude of the traction load. Anterior-posterior changes in the pin positions in the skull significantly influenced the cervical flexion-extension moment and anterior-posterior (AP) shear. The data show that a combined cervical tension, flexion moment, and anterior shear force can be achieved with posteriorly biased pins and a bolster behind the head. Increasing the angle of traction cable increased the cervical flexion moment and anterior shear force. The following variables should be carefully considered when applying cervical traction since they significantly affect cervical loading: magnitude of the hanging traction load, anterior-posterior pin position, use of an occipital bolster, and traction load angle.

Longitudinal Associations of Self-reported Vision Impairment With Symptoms of Anxiety and Depression Among Older Adults in the United States.

Importance: Vision impairment (VI) and mental health conditions are highly prevalent among older adults and are major causes of morbidity and health care expenditures. However, there are few nationally representative data from the United States on the longitudinal association between VI and depressive symptoms, and no such data on anxiety symptoms. Objective: To evaluate the longitudinal association and directionality of the association between self-reported VI and clinically significant symptoms of depression and anxiety in older US adults. Design, Setting, and Participants: The National Health and Aging Trends Study, a nationally representative US survey administered annually from 2011 to 2016 to a cohort of Medicare beneficiaries 65 years and older. A total of 7584 participants with complete data on self-reported VI status at baseline were included. Data analysis was performed from February to October 2018. Main Outcomes and Measures: Multivariable Cox proportional hazards regression models were used to evaluate the longitudinal associations between self-reported VI and depression and anxiety symptoms, adjusting for sociodemographics and medical comorbidities and accounting for the complex survey design. Results: There were 7584 participants included in this study. At baseline, the survey-weighted proportion of participants who were women was 56.6%; 53.0% were aged 65 to 74 years, and 8.9% (95% CI, 8.1%-9.8%) had self-reported VI. Symptoms of depression were significantly more common in participants with self-reported VI than those without self-reported VI (31.2%; 95% CI, 27.0%-35.6% vs 12.9%; 95% CI, 11.9%-14.0%; P < .001), as were symptoms of anxiety (27.2%; 95% CI, 23.7%-30.9% vs 11.1%; 95% CI,10.2%-12.0%, P < .001). Baseline self-reported vision status was significantly associated with future report of depression (hazard ratio [HR], 1.33; 95% CI, 1.15-1.55) but not anxiety (HR, 1.06; 95% CI, 0.85-1.31) symptoms. Baseline depression (HR, 1.37; 95% CI, 1.08-1.75) and anxiety (HR, 1.55; 95% CI, 1.19-2.02) symptoms were both significantly associated with future reports of self-reported VI. In a sensitivity analysis excluding data provided by proxy respondents, statistical significance was unchanged and the effect size was similar for all statistical models. Conclusions and Relevance: Older US adults with self-reported VI were more likely to report symptoms of depression in the future, while those who had symptoms of either depression or anxiety were more likely to report VI in the future. This investigation suggests that there is a significant bidirectional and longitudinal association between self-reported VI and mental health symptoms. Furthermore, the study suggests the need for effective strategies to screen for and address depression and anxiety among older US adults with VI.

Role of interferon-γ and inflammatory monocytes in driving colonic inflammation during acute Clostridium difficile infection in mice.

The inflammatory response to the colonic pathogen Clostridium difficile is characterized by the induction of inflammatory cytokines including Interleukin-23 (IL-23) and interferon-γ (IFN-γ) and the recruitment of myeloid cells including Ly6CHigh monocytes. IL-23 knockout mice showed reduced expression of the monocyte chemokines Ccl4 and Ccl7, but not Ccl2, as well as reduced Ly6CHigh Ly6GMid monocyte recruitment to the colon in response to C. difficile colitis. Clostridium difficile-infected CCR2-/- (CCR2 KO) mice showed a significant defect in Ly6CHigh Ly6GMid monocyte recruitment to the colon in response to C. difficile. Although there was no decrease in expression of the inflammatory cytokines Il1b, Il6 or Tnf or reduction in the severity of colonic histopathology associated with ablation of monocyte recruitment, Slpi and Inos expression was significantly reduced in the colons of these animals. Additionally, neutralization of IFN-γ through the administration of anti-IFN-γ monoclonal antibody resulted in a significant reduction in the expression of the IFN-γ-inducible chemokines Cxcl9 and Cxcl10, but not a reduction in the neutrophil chemokines Cxcl1, Cxcl2 and Ccl3 or the monocyte chemokine Ccl2. Consistently, monocyte and neutrophil recruitment were unchanged following anti-IFN-γ treatment. Additionally, Inos and Slpi expression were unchanged following anti-IFN-γ treatment, suggesting that Inos and Slpi regulation is independent of IFN-γ during C. difficile colitis. Taken together, these data strongly suggest that IL-23 and CCR2 signalling are required for monocyte recruitment during C. difficile colitis. Additionally, these studies also suggest that monocytes, but not IFN-γ, are necessary for full expression of Inos and Slpi in the colon.

Return to Play and Prior Performance in Major League Baseball Pitchers After Repair of Superior Labral Anterior-Posterior Tears.

BACKGROUND: The published return-to-play (RTP) rates for Major League Baseball (MLB) pitchers who have undergone surgical repair of superior labrum anterior-posterior (SLAP) tears vary widely and are generally accepted to be lower in the subset of competitive throwers. The efficacy of surgical treatment for MLB players is largely unknown. PURPOSE: To examine the RTP rate and performance of MLB pitchers who have undergone SLAP tear repair between 2003 and 2010. STUDY DESIGN: Descriptive epidemiological study. METHODS: A retrospective review of MLB pitchers undergoing SLAP repair was performed using the MLB disabled list. Data collected included the following player statistics: earned run average (ERA), walks plus hits per inning pitched (WHIP), and innings pitched (IP). The mean values for performance variables both before and after surgery were compared. A definition of return to prior performance (RTPP) was established as an ERA within 2.00 and WHIP within 0.500 of preoperative values. RESULTS: Twenty-four MLB players met inclusion criteria, of which 62.5% were able to RTP at the MLB level after SLAP repair surgery. Of those able to RTP, 86.7% were able to RTPP. However, the overall rate of RTPP, including those unable to RTP, was 54.2%. Mean performance analysis of the RTP group revealed a statistically significant decrease in IP for MLB pitchers throwing a mean 101.8 innings before injury and 65.53 innings after injury (P = .004). CONCLUSION: Of those pitchers able to RTP, chances of a full recovery were good (86.7%). Our results indicate the need for future research aimed at proper surgical selection of who will return to play, as they will likely achieve full recovery. We believe this information can help surgeons advise high-level overhead-throwing athletes about expected outcomes for surgical treatment of SLAP tears.

Disinfecting personal protective equipment with pulsed xenon ultraviolet as a risk mitigation strategy for health care workers.

The doffing of personal protective equipment (PPE) after contamination with pathogens such as Ebola poses a risk to health care workers. Pulsed xenon ultraviolet (PX-UV) disinfection has been used to disinfect surfaces in hospital settings. This study examined the impact of PX-UV disinfection on an Ebola surrogate virus on glass carriers and PPE material to examine the potential benefits of using PX-UV to decontaminate PPE while worn, thereby reducing the pathogen load prior to doffing. Ultraviolet (UV) safety and coverage tests were also conducted. PX-UV exposure resulted in a significant reduction in viral load on glass carriers and PPE materials. Occupational Safety and Health Administration-defined UV exposure limits were not exceeded during PPE disinfection. Predoffing disinfection with PX-UV has potential as an additive measure to the doffing practice guidelines. The PX-UV disinfection should not be considered sterilization; all PPE should still be considered contaminated and doffed and disposed of according to established protocols.

Interleukin-22 and CD160 play additive roles in the host mucosal response to Clostridium difficile infection in mice.

Our previous work has shown the significant up-regulation of Il22 and increased phosphorylation of signal transducer and activator of transcription 3 (STAT3) as part of the mucosal inflammatory response to Clostridium difficile infection in mice. Others have shown that phosphorylation of STAT3 at mucosal surfaces includes interleukin-22 (IL-22) and CD160-mediated components. The current study sought to determine the potential role(s) of IL-22 and/or CD160 in the mucosal response to C. difficile infection. Clostridium difficile-infected mice treated with anti-IL-22, anti-CD160 or a combination of the two showed significantly reduced STAT3 phosphorylation in comparison to C. difficile-infected mice that had not received either antibody. In addition, C. difficile-infected mice treated with anti-IL-22/CD160 induced a smaller set of genes, and at significantly lower levels than the untreated C. difficile-infected mice. The affected genes included pro-inflammatory chemokines and cytokines, and anti-microbial peptides. Furthermore, histopathological and flow cytometric assessments both showed a significantly reduced influx of neutrophils in C. difficile-infected mice treated with anti-IL-22/CD160. These data demonstrate that IL-22 and CD160 are together responsible for a significant fraction of the colonic STAT3 phosphorylation in C. difficile infection. They also underscore the additive effects of IL-22 and CD160 in mediating both the pro-inflammatory and pro-survival aspects of the host mucosal response in this infection.

Role of GM-CSF in the inflammatory cytokine network that regulates neutrophil influx into the colonic mucosa during Clostridium difficile infection in mice.

Clostridium difficile infection in antibiotic-treated mice results in acute colitis characterized by severe intestinal histopathology, robust neutrophil influx, and increased expression of numerous inflammatory cytokines, including GM-CSF. We utilized a neutralizing monoclonal antibody (mAb) against GM-CSF in a murine model to study the role of GM-CSF during acute C. difficile colitis. Cefoperazone-treated mice were challenged with C. difficile (strain 630) spores. Expression of GM-CSF was significantly increased in animals challenged with C. difficile. Treatment with an anti-GM-CSF mAb did not alter C. difficile colonization levels, weight loss, or expression of IL-22 and RegIIIγ. However, expression of the inflammatory cytokines TNFα and IL-1ß, as well as iNOS, was significantly reduced following anti-GM-CSF treatment. Expression of the neutrophil chemokines CXCL1 and CXCL2, but not the chemokines CCL2, CCL4, CXCL9, and CXCL10, was significantly reduced by anti-GM-CSF treatment. Consistent with a decrease in neutrophil-attractant chemokine expression, there were fewer neutrophils in histology sections and a reduction in the expression of secretory leukocyte protease inhibitor (SLPI), a tissue anti-protease that protects against damage by secreted neutrophil elastase. These data indicate that GM-CSF plays a role in the inflammatory signaling network that drives neutrophil recruitment in response to C. difficile infection but does not appear to play a role in clearance of the infection.

The myth of instant orthodontics: an ethical quandary.

BACKGROUND: There is a clinical trend of using porcelain veneer restorations (PVRs) for the correction of malaligned anterior teeth. Use of PVRs for this purpose raises clinical and ethical dilemmas. TYPES OF STUDIES REVIEWED: A literature review of four different topics (PVR preparation, enamel thickness of anterior teeth, dentinal bonding adhesive effectiveness and PVR long-term success) was conducted to determine the optimal preparation for a successful PVR. The amount of tooth malalignment that may be corrected with a PVR without adversely affecting its success was calculated. RESULTS: The optimal preparation for a successful PVR may have dentin exposed in the body of the preparation. However, most of the preparation must be in enamel, and all the margins must end in enamel. The strength of a dentin bond varies greatly owing to a multistep, technique-sensitive cementation process and is weaker than an enamel bond. It is not possible to correct atypical gingival esthetics (uneven gingival margins, uneven papillae, short papillae and bulbous gingivae) resulting from malaligned teeth through use of PVRs. CONCLUSIONS: and CLINICAL IMPLICATIONS: Aligning a healthy tooth with a PVR is not a conservative procedure and more conservative treatment options (such as orthodontics, bleaching, direct bonding and enamelplasty) should be offered to the patient. In addition, the inability to restoratively improve gingival relationships with PVRs may result in achieving less-than-optimal esthetics. A clinician should present only treatment options that involve predictable, conservative restorations or that preserve healthy tooth structure. Aligning teeth with PVRs may create ethical dilemmas that can be resolved with the help of the American Dental Association Principles of Ethics and Code of Professional Conduct.

Periodontal concerns associated with the orthodontic treatment of impacted teeth.

Impacted teeth are common and are often treated with orthodontic eruption, but periodontal problems associated with the process can evade detection. Profound destruction of the periodontium of an impacted tooth or adjacent teeth can occur. This case report describes the orthodontic eruption of 4 impacted canines in a 19-year-old woman. An open surgical approach was used. Within 6 months of treatment, the maxillary right canine and the lateral incisor experienced severe periodontal destruction, resulting in questionable prognoses for the teeth. Plaque control, periodontal architecture, and subgingival microflora were examined as local etiologic factors of periodontal destruction associated with orthodontic eruption of impacted teeth. Plaque control measures were evaluated, and the consequences of orthodontic tooth movement in the presence of inadequate plaque control were considered. Areas of periodontal architecture made vulnerable by the surgical exposure of the impacted teeth were identified, and the effect of orthodontic force on the periodontium was explored. An increase in putative periopathogens in the subgingival microflora after orthodontic appliance placement was observed. Microbiologic monitoring for pathologic levels of periopathogens and antibiotic therapy were considered. Orthodontic treatment of impacted teeth might require additional professional and personal plaque control measures, 3-dimensional diagnostic imaging, and control of putative periopathogens to preserve the health of the periodontium.

Assessment of Left Atrial Appendage Structure and Function by Transesophageal Echocardiography: A Review.

This article examines the transesophageal echocardiographic assessment of the left atrial appendage anatomy and function in individuals without significant structural heart disease and in those with atrial fibrillation with or without cardioembolism or mitral valve stenosis. We also summarize the available data in the usefulness of transesophageal echocardiographic studies in patients undergoing cardioversion for atrial fibrillation and percutaneous balloon valvuloplasty for mitral stenosis. Also, potential limitations and ongoing developments in the use of transesophageal echocardiography in the assessment of the left atrial appendage are outlined, and recommendations are given for the uniform reporting of quantitative data.

Desarrollo historico de la enfermeria / Historical development of nursing

Aborda a influência da filosofia e da religiäo na formaçäo do enfermeiro. Afirma que o movimento da história da humanidade, de uma maneira geral, tem sido impulsionado por uma filosofia originária das geraçöes anteriores, calcado nos fatos sociais, econômicos, políticos e religiosos. Coloca que o desenvolvimento da enfermagem ao longo do tempo passou gradualmente de um simples estado de ofício ao estado profissional. Destaca, ainda, que a filosofia e a religiäo, com o desenvolvimento intelectual e cultural, deixou suas marcas também no desenvolvimento da enfermagem. (JGC)