Nevin Manimala

PLoS One. 2021 Oct 26;16(10):e0258867. doi: 10.1371/journal.pone.0258867. eCollection 2021.

ABSTRACT

Cyber insurance is a risk management option to cover financial losses caused by cyberattacks. Researchers have focused their attention on cyber insurance during the last decade. One of the primary issues related to cyber insurance is estimating the premium. The effect of network topology has been heavily explored in the previous three years in cyber risk modeling. However, none of the approaches has assessed the influence of clustering structures. Numerous earlier investigations have indicated that internal links within a cluster reduce transmission speed or efficacy. As a result, the clustering coefficient metric becomes crucial in understanding the effectiveness of viral transmission. We provide a modified Markov-based dynamic model in this paper that incorporates the influence of the clustering structure on calculating cyber insurance premiums. The objective is to create less expensive and less homogenous premiums by combining criteria other than degrees. This research proposes a novel method for calculating premiums that gives a competitive market price. We integrated the epidemic inhibition function into the Markov-based model by considering three functions: quadratic, linear, and exponential. Theoretical and numerical evaluations of regular networks suggested that premiums were more realistic than premiums without clustering. Validation on a real network showed a significant improvement in premiums compared to premiums without the clustering structure component despite some variations. Furthermore, the three functions demonstrated very high correlations between the premium, the total inhibition function of neighbors, and the speed of the inhibition function. Thus, the proposed method can provide application flexibility by adapting to specific company requirements and network configurations.

PMID:34699537 | DOI:10.1371/journal.pone.0258867

PLoS One. 2021 Oct 26;16(10):e0258496. doi: 10.1371/journal.pone.0258496. eCollection 2021.

ABSTRACT

Lack of precipitation and groundwater for irrigation limits crop production in semi-arid regions, such as the Southern High Plains (SHP). Advanced technologies, such as variable rate irrigation (VRI), can conserve water and improve water use efficiency for sustainable agriculture. However, the adoption of VRI is hindered by the lack of on-farm research focusing on the feasibility of VRI. The objective of this study was to assess the effect of irrigation rates on cotton yield as affected by soil physical properties and topography in the Southern High Plains. This study was conducted in two fields within a 194-ha commercially managed farm in Hale County, Texas, in 2017. An irrigation treatment with three rates was implemented in a randomized complete block design with two replications as separate blocks in each field. A total of 230 composite soil samples were collected from the farm in spring 2017 and analyzed for texture. Information on apparent soil electrical conductivity (ECa), elevation, and final yield were collected from the fields. A statistical model showed that the effect of irrigation rates on cotton yield depended on its interaction with soil physical properties and topography. For example, areas with slope >2% and sand content >50% had no significant response to higher irrigation rates. This model suggests that applying irrigation amounts based on the yield response can be a basis for VRI. This study provides valuable information for site-specific irrigation to optimize crop production in fields with significant variability in soil physical properties and topography.

PMID:34699534 | DOI:10.1371/journal.pone.0258496

JAAPA. 2021 Nov 1;34(11):1-9. doi: 10.1097/01.JAA.0000800020.12927.8c.

ABSTRACT

This economic analysis of physician assistant/associate (PA) career earnings sought to assess the increasing effect of student debt, its potential effect on job selection, and whether such financial obligations may influence graduates to select higher-paying specialties. The model was a 30-year-old newly graduated PA who begins working in family medicine. A simulation included wages, student debt, national household expenditures, and real estate statistics. The scenario consisted of a high and middle cost of living in two geographic areas, a family of four, and an average life expectancy. Using a validated economic program, a series of calculations produced the financial effect on moderate-income levels and expenditures based on median PA earnings. On the deficit side is education debt, loan repayment, financing a house, college for children, retirement, and discretionary spending. Weighted variables were used to maximize the sensitivity effect of the simulation. A Monte Carlo probabilistic program predicted the likely outcome of income, expenses, inflation, and investments. Furthermore, the lifetime earnings of a PA who retires at age 67 years and lives to age 85 years falls in the 75th percentile of income of all Americans. The conclusion is that a full-time PA career in any clinical role is as economically rewarding as it is satisfying.

PMID:34699456 | DOI:10.1097/01.JAA.0000800020.12927.8c

Ann Plast Surg. 2021 Nov 1;87(5):600-605. doi: 10.1097/SAP.0000000000002735.

ABSTRACT

INTRODUCTION: Panniculectomy is a common procedure in plastic surgery, often performed after massive weight loss and in morbidly obese patients. It is also performed in combination with various gynecologic procedures based on the rational that it will reduce complication rates and benefit the patient (Am J Obstet Gynecol, 2000. 182, 1502-1505; J Gynecol Technol, 1997;3:9-16; J Am Coll Surg, 1995). These and other studies fail to provide proof of these claims for a number of reasons, including study design, lack of a control group and the inclusion of nonmorbidly obese patients (J Am Coll Surg, 1995; Gynecol Oncol, 1998, 70, 80-86; Int J Gynecol Cancer, 2015;25(8):1503-1512). Recent medical practice has focused increasingly on minimizing patient morbidity and trends in reimbursement are moving toward penalizing practices, which increase complications. The aim of this study was to evaluate the premise that the addition of panniculectomy to gynecologic surgery in the obese and morbidly obese patient population results in a statistically significant improvement in measureable outcomes.

METHODS/RESULTS: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was reviewed to assess the association of complications with panniculectomy combined with gynecologic surgery in the morbidly obese patient population. The query identified 296 patients with a body mass index greater than 30 who had panniculectomy concomitant with gynecologic surgery. The results demonstrated a statistically significant relationship (P < 0.05) of these concomitant procedures with superficial infection, wound infection, pulmonary embolism, systemic sepsis, return to operating room, length of operation and length of stay. A systematic review of the literature was then performed which identified only 5 studies that included comparative cohorts of those with gynecologic surgery, with and without panniculectomy. There was no significant benefit across the studies in measured paramters.

CONCLUSIONS: This NSQIP study and systematic review of the existing literature does not support the premise that there is a statistically significant benefit associated with performing panniculectomy in conjunction with gynecologic surgery in the morbidly obese patient population. The NSQIP data demonstrate significant elevation of negative outcomes in morbidly obese patients undergoing combined procedures. In the light of the risks to patients and current direction of medical practice the addition of elective panniculectomy to gynecologic surgery should be reevaluated in the a patient population with a body mass index greater than 30.

PMID:34699436 | DOI:10.1097/SAP.0000000000002735

Ann Plast Surg. 2021 Nov 1;87(5):533-536. doi: 10.1097/SAP.0000000000002887.

ABSTRACT

BACKGROUND: Linear scleroderma is a rare connective tissue disease characterized by thickening of the skin due to excess collagen deposit. It is the most frequent type of localized scleroderma in the pediatric population (40%-70%), and it usually affects the extremities and head. Linear scleroderma can cause growth disturbances, extremity length discrepancy, and debilitating joint contractures. The aim of this study was to describe the surgical outcomes of microsurgical flap reconstruction of linear scleroderma in the pediatric population.

METHODS: A retrospective review of all children with linear scleroderma was performed at our institution. Patients less than 18 years of age with clinical diagnosis of linear scleroderma and who underwent microsurgical flap reconstruction for correction of their scleroderma were included. Fat grafting procedures were excluded. Patient demographics and surgical outcomes were collected.

RESULTS: A total 7 patients underwent microsurgical flap reconstruction for treatment of their linear scleroderma producing debilitating soft tissue contractures and preventing ambulation or elbow extension. Six patients had scleroderma involving the lower extremity and 1 involving the upper extremity. Three anterolateral thigh and 4 latissimus dorsi flaps were performed. The median age at surgery was 7 years (Q1-Q3, 5-11), and the median body mass index was 21.3 kg/m2 (Q1-Q3, 16.5-22.1). The median follow-up was 121.1 months (Q1-Q3, 43.2-187.4). All flaps survived, and no donor site complications were reported. Perioperative complications included wound infection that required debridement (n = 1), immediate postoperative bleeding requiring surgical intervention (n = 1), intraoperative venous congestion (n = 1), and scleroderma recurrence outside the flap (n = 2). When comparing anterolateral thigh and latissimus dorsi flaps, there was no statistically significant difference in the development of surgical complications, number of surgical revisions per patient [median, 4 (Q1-Q3, 4-7) vs 2.5 (Q1-Q3, 1.3, 3), P = 0.0916], or unplanned surgical interventions [median, 0 (Q1-Q3, 0-1) vs 1 (Q1-Q3, 0-1), P = 0.7228]. The reconstruction was successful in improving range of motion in 6 patients, 5 of which reached full weight-bearing. However, all patients had residual limb deformity, and 4 had remaining extremity length discrepancy.

CONCLUSIONS: Microsurgical flaps are a good option for functional improvement of severe pediatric linear scleroderma affecting the extremities. However, residual limb deformity is common, and patients are often required to undergo additional surgical revisions.

PMID:34699432 | DOI:10.1097/SAP.0000000000002887

Ann Plast Surg. 2021 Nov 1;87(5):493-500. doi: 10.1097/SAP.0000000000003022.

ABSTRACT

INTRODUCTION: The safety of combined augmentation-mastopexy is controversial. This study evaluates a national database to analyze the perioperative safety of combined augmentation-mastopexy to either augmentation or mastopexy alone.

METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients undergoing augmentation mammaplasty and mastopexy from 2005 to 2018. The patients were divided into the following groups: group I, augmentation; group II, mastopexy; group III, combined augmentation-mastopexy. Baseline characteristics and outcomes were compared. Outcomes were 30-day complications, reoperation, and readmission.

RESULTS: We found 5868 (74.2%) augmentation only, 1508 (19.1%) mastopexy only and 534 (6.6%) combined augmentation-mastopexy cases. Mean operative time was highest among the combined group at 129 minutes compared with 127 minutes for mastopexy alone and 66 minutes for augmentation alone (P < 0.01). Rates of any complications and readmission were different among groups (0.8% vs 2.5% vs 1.5% respectively, P < 0.01 and 0.7% vs 1.5% vs 1.5% respectively, P = 0.049), whereas reoperation was not statistically different (1.2% vs 1.4% vs 1.5%, P = 0.75). The incidence of dehiscence (0.6%; P < 0.01) was highest in the combined group. Multivariable logistic regression analysis did not reveal an increased odds of complications, reoperation, or readmission with combined augmentation-mastopexy.

CONCLUSIONS: An evaluation of the nationwide cohort suggests that combined augmentation-mastopexy is a safe procedure in the perioperative period.

PMID:34699429 | DOI:10.1097/SAP.0000000000003022

Blood Press Monit. 2021 Oct 25. doi: 10.1097/MBP.0000000000000572. Online ahead of print.

ABSTRACT

OBJECTIVES: To characterize the blood pressure (BP) profile of the new β3-adrenergic receptor agonist, vibegron, in patients with overactive bladder.

METHODS: Patients were randomized to once-daily vibegron 75 mg or placebo for 28 days and underwent ambulatory BP monitoring. The primary endpoint was change from baseline (CFB) to day 28 in mean daytime ambulatory systolic BP (SBP). Secondary endpoints were CFB in mean 24-h SBP and in mean daytime and mean 24-h ambulatory diastolic BP (DBP) and heart rate (HR). Safety was assessed through adverse event reporting.

RESULTS: Of 214 patients randomized, 96 receiving vibegron and 101 receiving placebo had evaluable baseline and day 28 measurements. Overall, 39.6 and 30.7% of patients receiving vibegron and placebo, respectively, had preexisting hypertension. The least squares mean difference (LSMD; 90% confidence interval) between vibegron and placebo in CFB in mean daytime SBP was 0.8 (-0.9, 2.5) mmHg. LSMD in CFB in mean daytime DBP and HR was 0.0 mmHg and 0.9 bpm, respectively. No significant differences between treatments were seen in CFB in mean 24-h SBP (LSMD, 0.6 mmHg), DBP (-0.2 mmHg) or HR (1.0 bpm). The most common treatment-emergent adverse event was hypertension, with rates comparable between groups [vibegron: n = 5 (4.7%); placebo: n = 4 (3.7%)]. One patient receiving vibegron took a prohibited medication (phentermine) known to increase BP.

CONCLUSIONS: Once-daily vibegron had no statistically significant or clinically relevant effects on BP or HR.

PMID:34699409 | DOI:10.1097/MBP.0000000000000572

Clin J Pain. 2021 Oct 26. doi: 10.1097/AJP.0000000000000998. Online ahead of print.

ABSTRACT

OBJECTIVES: High-quality evidence demonstrates analgesic effects of sweet tasting solutions for infants during painful procedures. However, evidence of the analgesic effects of sucrose beyond 12 months of age is less certain. The aim of this study was to ascertain the efficacy of oral sucrose in hospitalized toddlers (ages 12 to 36▒mo) compared to placebo (water) during venipuncture.

METHODS: Blinded, two-armed randomized controlled trial (RCT) including hospitalized toddlers aged 12-36 months. Toddlers were randomized to either 25% sucrose or water prior to venipuncture, stratified by age (12-24▒mo and >24-36▒mo). Standard of care included topical anesthetics for both groups. Pain assessment included cry duration and FLACC (Face, Legs, Activity, Cry, Consolability) scores. Descriptive statistics and linear models were used to report the percentage of time crying and mean differences in FLACC scores. Data analysis was performed using R version 3.6.3.

RESULTS: A total of 95 toddlers were randomized and 85 subsequently studied. The median percentage of time spent crying between insertion of the first needle and 30s after the end of procedure in both groups was 81% (IQR=66). There was no significant difference in crying time and FLACC scores between groups (P>0.05). When examining effects of sucrose for the younger toddlers (less than 24 months of age) there was a reduction in crying time of 10% and a 1.2-point reduction in mean FLACC scores compared to the toddlers older than 24 months.

DISCUSSION: Findings highlight that toddlers become highly distressed during venipuncture, despite the standard care of topical anesthetics. In addition, sucrose does not effectively reduce distress especially in the older group of toddlers.

PMID:34699407 | DOI:10.1097/AJP.0000000000000998

Clin J Pain. 2021 Oct 26. doi: 10.1097/AJP.0000000000000994. Online ahead of print.

ABSTRACT

INTRODUCTION: Opioid-induced hyperalgesia (OIH) remains an issue in patients suffering from chronic pain. Multiple cases of OIH in patients with chronic pain exposed to opioids have been reported worldwide. The objective of this systematic review was to summarize the evidence of OIH from clinical reports.

METHODS: We searched the PubMed, Cochrane, EMBASE, and LILACS databases for case reports and case series of OIH published up to December 2020, with the aim to summarize the evidence for OIH in patients with chronic pain from clinical reports and to discuss issues relevant to the clinical diagnosis and management of OIH.

RESULTS: We retrieved and reviewed 41 articles describing 72 cases. Clinical features of OIH were observed in patients of both sexes, all ages, and suffering from various types of pain treated with different classes of opioids. OIH was reported at all doses, but most published studies reported a pattern of OIH following treatment with very high daily doses of opioids (median oral morphine equivalent dose (oMED) of 850▒mg). OIH was diagnosed clinically in all cases. Three different strategies for OIH management were described: opioid rotation, opioid cessation and the use of adjuvant pharmacotherapies. All had statistically similar success rates for OIH treatment: 72%, 57%, and 79%, respectively. The decrease in pain was achieved rapidly (mean: 8▒d; range: 1 to 28▒d). Adjuvant therapies resulted in the largest decrease in dose. Ketamine and dexmedetomidine were the most widely used adjuvant drugs.

CONCLUSION: The key finding is that clinical symptoms of OIH can be resolved when this condition is diagnosed and managed.

PMID:34699405 | DOI:10.1097/AJP.0000000000000994

Otol Neurotol. 2021 Oct 25. doi: 10.1097/MAO.0000000000003398. Online ahead of print.

ABSTRACT

INTRODUCTION: Superior canal dehiscence syndrome (SCDS) is a rare disorder characterized by an array of audiovestibular symptoms due to a dehiscence of bone overlying the superior semicircular canal (SSC). In the presence of debilitating symptoms, surgical management, to plug or resurface the SCC is performed. Although computed tomography (CT) may overestimate the size or presence of a dehiscence due to a partial volume effect, it remains an invaluable diagnostic tool.

OBJECTIVES: To assess for correlation between the arc and length of dehiscence and clinical symptomology.

METHOD: A single-center, single-operator retrospective analysis of 42 patients who underwent trans mastoid plugging of SCC with confirmed radiological dehiscence of their SSC between January 2008 and July 2019 was undertaken. Patients were assessed based on seven predefined clinical symptoms. Length and arc of dehiscence’s were evaluated by means of high resolution (0.5 mm) CT (HRCT), using multiplanar reconstruction (MPR). Receiver operating characteristics (ROC), and more specifically the area under the ROC curve (AUROC) were used to assess for statistical significance.

RESULTS: Our results demonstrate overall very little correlation between the arc and size of the dehiscence and symptoms. The only statistically significant correlation we found was between length of dehiscence and the presence of aural fullness.

CONCLUSION: SCDS is a debilitating condition with an array of symptoms on presentation. While dehiscence length demonstrated a correlation with aural fullness, no other symptomology in patients with radiologically evident SCDS demonstrated a statistically significant correlation either against the length or arc of dehiscence.

PMID:34699403 | DOI:10.1097/MAO.0000000000003398