bluuebunny/crossref_metadata_2025 huggingface dataset:
Randomized Noninferiority Trial of Telephone vs In-Person Genetic Counseling for Hereditary Breast and Ovarian Cancer: A 12-Month Follow-Up
Authors: Interrante Mary K. , Segal Hannah , Peshkin Beth N. , Valdimarsdottir Heiddis B. , Nusbaum Rachel , Similuk Morgan , DeMarco Tiffani , Hooker Gillian , Graves Kristi , Isaacs Claudine , Wood Marie , McKinnon Wendy , Garber Judy , McCormick Shelley , Heinzmann Jessica , Kinney Anita Y. , Schwartz Marc D.
Published: September 2017

Background

Telephone delivery of genetic counseling is an alternative to in-person genetic counseling because it may extend the reach of genetic counseling. Previous reports have established the noninferiority of telephone counseling on short-term psychosocial and decision-making outcomes. Here we examine the long-term impact of telephone counseling (TC) vs in-person counseling (usual care [UC]).

Methods

We recruited high-risk women for a noninferiority trial comparing TC with UC. Of 1057 potentially eligible women, 669 were randomly assigned to TC (n = 335) or UC (n = 334), and 512 completed the 12-month follow-up. Primary outcomes were patient-reported satisfaction with genetic testing decision, distress, and quality of life. Secondary outcomes were uptake of cancer risk management strategies.

Results

TC was noninferior to UC on all primary outcomes. Satisfaction with decision (d = 0.13, lower bound of 97.5% confidence interval [CI] = –0.34) did not cross its one-point noninferiority limit, cancer-specific distress (d = –2.10, upper bound of 97.5% CI = –0.07) did not cross its four-point noninferiority limit, and genetic testing distress (d = –0.27, upper bound of 97.5% CI = 1.46), physical function (d = 0.44, lower bound of 97.5% CI = –0.91) and mental function (d = –0.04, lower bound of 97.5% CI = –1.44) did not cross their 2.5-point noninferiority limit. Bivariate analyses showed no differences in risk-reducing mastectomy or oophorectomy across groups; however, when combined, TC had significantly more risk-reducing surgeries than UC (17.8% vs 10.5%; χ2= 4.43, P = .04).

Conclusions

Findings support telephone delivery of genetic counseling to extend the accessibility of this service without long-term adverse outcomes.
First star formation in ultralight particle dark matter cosmology
Authors: Hirano Shingo , Sullivan James M , Bromm Volker
Published: September 2017

The formation of the first stars in the high-redshift Universe is a sensitive probe of the small-scale, particle physics nature of dark matter (DM). We carry out cosmological simulations of primordial star formation in ultralight, axion-like particle DM cosmology, with masses of 10−22 and 10−21 eV, with de Broglie wavelengths approaching galactic scales (∼ kpc). The onset of star formation is delayed, and shifted to more massive host structures. For the lightest DM particle mass explored here, first stars form at z ∼ 7 in structures with ∼109 M⊙, compared to the standard minihalo environment within the Λ cold dark matter (ΛCDM) cosmology, where z ∼ 20–30 and ∼105–106 M⊙. Despite this greatly altered DM host environment, the thermodynamic behaviour of the metal-free gas as it collapses into the DM potential well asymptotically approaches a very similar evolutionary track. Thus, the fragmentation properties are predicted to remain the same as in ΛCDM cosmology, implying a similar mass scale for the first stars. These results predict intense starbursts in the axion cosmologies, which may be amenable to observations with the James Webb Space Telescope.
Resident Wellness Initiative to Reduce Burnout and Mitigate Stress
Authors: Wagner Brian , Nentin Farida , Ferrara Lauren
Published: September 2017

BACKGROUND:

Burnout during residency training has gained significant attention over the past several years. High-rates of burnout, depression and anxiety have been documented in residents throughout their training and a call has been made to develop programs to help mitigate the stress of residency training. We undertook a comprehensive resident wellness initiative to assess burnout and offer residents potential interventions and coping strategies to decrease burnout and reduce stress.

METHODS:

An interventional trial was developed where we incrementally introduced multiple wellness initiatives from September 2012 through June 2016 in an OB/GYN residency program in a large urban university medical center. The wellness initiatives included increased access to program and department leadership for ongoing program improvements, formalized mindful practice training with an emphasis on stress-reduction techniques, confidential, free access to psychotherapy, group conflict mediation and peer and faculty engagement in a mentorship program. Prior to the start of the program and annually, the residents were assessed with the Maslach Burnout Inventory (MBI) and the Perceived Stress Scale. Additionally, we tracked resident satisfaction with the program through an annual online survey review of the training program.

RESULTS:

Forty-nine residents participated in the program over 3 years. At the beginning of the wellness initiative, 64% of the residents exhibited signs of burn-out as defined by two or more high-risk scores in the MBI subcategories. Perceived stress was above normative values in 61% of the residents. Within the first year the number with burn-out signs began to stabilize (62%) and improve in year 2 (51%; P<.05). This trend has been maintained through year 3 (49%). Additionally, there was a decrease in the number of residents with perceived stress scores above the norm (49%; P<.05), suggesting an improvement in coping mechanisms with additional exposure to the wellness curriculum. We saw no difference in overall number of residents reporting a “very positive” residency experience (72%, range 65%–79%) over the course of the wellness initiative.

DISCUSSION:

A comprehensive resident wellness initiative can offer a significant improvement in preventing burnout, reducing stress burdens, and potentially improve resiliency in residency through the development of useful coping mechanisms.
Improving Interprofessional Communication Utilizing Obstetric Simulation Training
Authors: Durst Jennifer , Temming Lorene , Gamboa Christine , Tuuli Methodius , Macones George , Young Omar
Published: September 2017

BACKGROUND:

Effective interprofessional communication requires clear, concise, and respectful participation from each provider. Simulation has been shown to improve teamwork and patient safety in nonobstetric fields. Whether the benefit of interdisciplinary participation in simulation extends to the obstetric population is unknown.

METHODS:

We conducted a prospective educational trial involving obstetric residents and L&D nurses. Participants were administered a pretest examining their perception of interprofessional communication and cooperation with responses measured on a Likert scale. Participants then underwent an obstetric simulation, watched their video-taped performance, participated in a structured debrief and educational session, and then repeated the simulation. Following the simulation, they were administered a posttest to assess changes in their perception of communication and cooperation.

RESULTS:

Eighteen L&D nurses and 17 obstetric residents participated in the trial. Following simulation, participants were more likely to report that they feel respect from other providers (P=.0087), use closed-loop communication (P<.001), designate a clear leader (P=.0009), read back verbal orders (P=.0002), conduct a nonaccusatory debrief (P=.0491), and view both their communication and communication from others as clear and effective (P=.0043 and P=.0042, respectively).

DISCUSSION:

Obstetric simulation can be used to improve effective interprofessional communication and cooperation. Continued use of interdisciplinary simulation in obstetrics should be encouraged to promote a commitment to patient safety.
West Virginia University's Department of OB/GYN Resident Resiliency Curriculum: A Focus on Well-Being
Authors: Cohen Elizabeth , Matta Maria , Leonard Cassie , Rowan Shon , Hashmi Mahreen
Published: September 2017

BACKGROUND:

Stress and burnout impact physicians at all stages of training and practice, but resident physicians are particularly at risk. Resiliency skills may protect physicians from the dangers of stress and burnout and may provide improved coping skills.

METHODS:

The Department of Obstetrics and Gynecology conducted monthly meetings with the Residents to discuss resiliency topics in an off-site, private setting without judgment, evaluation consequences, or attending participation.

RESULTS:

During the 2015–2016 academic year, 12 sessions were conducted focusing on Communication Styles, Conflict Resolution, Leadership Skills, Difficult Patient Encounters, Physician Wellness, Resiliency, and Stress/Burnout Management. After completion, residents were anonymously surveyed and sessions were evaluated for effectiveness based on a Likert scale of 1–5. Eleven of 12 sessions returned a 4 or 5 rating, corresponding with a moderately or strongly agree from 100% of the residents. Only one session revealed one resident with a neutral response, or 3.

DISCUSSION:

Sessions explored difficult patient encounters, sentinel events, and interpersonal and professional conflicts. Positive mindfulness-based resilience interventions were discussed. Resident communication about perceived failures and stressors promoted positive discussion and insight. Sessions were almost all uniformly positively scored, with the highest ratings in communication styles, leadership/team-building, and conflict resolution. Resiliency is a key coping skill for physicians to maintain well-being. A residency resiliency curriculum has shown to be well-received in our institution and should be considered as integral in curricula as medical knowledge concepts.
2016 Neonatal Nurse Practitioner Workforce Survey
Authors: Staebler Suzanne , Bissinger Robin
Published: September 2017

The National Association of Neonatal Nurse Practitioners (NANNP) conducted its second workforce survey of certified neonatal nurse practitioners in the fall of 2016. National Association of Neonatal Nurse Practitioners partnered with the National Certification Corporation and the American Association of Nurse Practitioners to conduct this electronic survey, containing 69 questions and focusing on practice sites and total compensation packages (including benefits) and workforce deficits.

Findings indicate a rising neonatal nurse practitioners (NNPs) position vacancy rate across the country. Regional salary data indicated that the southeast had lower compensation rates for NNPs, with regions 4 and 11 (South) having the lowest rates. A promising trend indicated that new graduate NNPs with a doctorate are earning more. The study findings indicate that tailoring benefit packages to the age and years of experience for the individual NNP may aid in recruiting and retaining NNPs in practice. For experienced NNPs, altered shift lengths (shorter), higher employer matching rates in retirement plans, and less employee cost sharing for health insurance benefits are more appealing strategies.

It is critical for NNPs to continually evaluate the profession's workforce data. There are more than 205,000 nurse practitioners practicing in the United States, with neonatal NPs making up approximately 3% of the larger whole. Increased participation in future surveys will assist in creating sustainable solutions to the workforce crisis facing the profession.
Effects of a Short Video–Based Resident-as-Teacher Training Toolkit on Resident Teaching
Authors: Ricciotti Hope A. , Freret Taylor S. , Aluko Ashley , McKeon Bri Anne , Haviland Miriam J. , Newman Lori R.
Published: September 2017

OBJECTIVE:

To pilot a short video–based resident-as-teacher training toolkit and assess its effect on resident teaching skills in clinical settings.

METHODS:

A video-based resident-as-teacher training toolkit was previously developed by educational experts at Beth Israel Deaconess Medical Center, Harvard Medical School. Residents were recruited from two academic hospitals, watched two videos from the toolkit (“Clinical Teaching Skills” and “Effective Clinical Supervision”), and completed an accompanying self-study guide. A novel assessment instrument for evaluating the effect of the toolkit on teaching was created through a modified Delphi process. Before and after the intervention, residents were observed leading a clinical teaching encounter and scored using the 15-item assessment instrument. The primary outcome of interest was the change in number of skills exhibited, which was assessed using the Wilcoxon signed-rank test.

RESULTS:

Twenty-eight residents from two academic hospitals were enrolled, and 20 (71%) completed all phases of the study. More than one third of residents who volunteered to participate reported no prior formal teacher training. After completing two training modules, residents demonstrated a significant increase in the median number of teaching skills exhibited in a clinical teaching encounter, from 7.5 (interquartile range 6.5–9.5) to 10.0 (interquartile range 9.0–11.5; P<.001). Of the 15 teaching skills assessed, there were significant improvements in asking for the learner's perspective (P=.01), providing feedback (P=.005), and encouraging questions (P=.046).

CONCLUSION:

Using a resident-as-teacher video-based toolkit was associated with improvements in teaching skills in residents from multiple specialties.
Laparoscopic Major Vascular Injury Simulation Using a Synthetic Compared With Porcine Model
Authors: Milad Magdy P. , Alvi Farah A. , Breen Michael T. , Brincat Cynthia , Frederick Peter J. , Lewicky-Gaupp Christina , Lewis Mark , Rone Bryan , Swan Kimberly , Wollschlaeger Karin
Published: September 2017

BACKGROUND:

Major vascular injury training may improve clinical skills and reduce patient morbidity during gynecologic laparoscopy; thus, reliable models for simulation should be identified.

METHOD:

Two laparoscopic major vascular injury simulations using synthetic or live porcine models were constructed. The primary surgeon was given the opportunity to complete both simulations. After obtaining peritoneal access, the surgeon quickly encountered a major vascular injury. Degrading vital signs and estimated blood loss coupled with the replay of a human heartbeat that increased in volume and intensity were provided to heighten tension during the synthetic simulation.

EXPERIENCE:

Twenty-two gynecologic surgery educators evaluated the simulations. Educators considered the porcine model superior to the synthetic model with regard to tissue handling. The synthetic model simulation was found to be equivalent to the porcine model on how likely the simulation would be able to improve performance in a clinical setting. Educators were more likely to implement the synthetic simulation over the porcine simulation.

CONCLUSION:

The synthetic model was found to be more feasible and as effective as the porcine model to simulate and teach the initial management steps of major vascular injury at laparoscopy by gynecologic educators.
Use of Electrically Evoked Compound Action Potentials for Cochlear Implant Fitting: A Systematic Review
Authors: de Vos Johan J. , Biesheuvel Jan Dirk , Briaire Jeroen J. , Boot Pieter S. , van Gendt Margriet J. , Dekkers Olaf M. , Fiocco Marta , Frijns Johan H. M.
Published: September 2017

Objectives:

The electrically evoked compound action potential (eCAP) is widely used in the clinic as an objective measure to assess cochlear implant functionality. During the past decade, there has been increasing interest in applying eCAPs for fitting of cochlear implants. Several studies have shown that eCAP-based fitting can potentially replace time-consuming behavioral fitting procedures, especially in young children. However, a closer look to all available literature revealed that there is no clear consensus on the validity of this fitting procedure. This study evaluated the validity of eCAP-based fitting of cochlear implant recipients based on a systematic review of the recent literature.

Design:

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used to search the PubMed, Web of Science, and Cochrane Library databases. The term “eCAP” was combined with “cochlear implants,” “thresholds,” and “levels,” in addition to a range of related terms. Finally, 32 studies met the inclusion criteria. These studies were evaluated on the risk of bias and, when possible, compared by meta-analysis.

Results:

Almost all assessed studies suffered from some form of risk of bias. Twenty-nine of the studies based their conclusion on a group correlation instead of individual subject correlations (analytical bias); 14 studies were unclear about randomization or blinding (outcome assessment bias); 9 studies provided no clear description of the populations used, for example, prelingually or postlingually implanted subjects (selection bias); and 4 studies had a high rate of loss (>10%) for patients or electrodes (attrition bias). Meta-analysis of these studies revealed a weak pooled correlation between eCAP thresholds and both behavioral T- and C-levels (r = 0.58 and r = 0.61, respectively).

Conclusions:

This review shows that the majority of the assessed studies suffered from substantial shortcomings in study design and statistical analysis. Meta-analysis showed that there is only weak evidence to support the use of eCAP data for cochlear implant fitting purposes; eCAP thresholds are an equally weak predictor for both T- and C-levels. Based on this review, it can be concluded that research on eCAP-based fitting needs a profound reflection on study design and analysis to draw well-grounded conclusions about the validity of eCAP-based fitting of cochlear implant recipients.
Complications After Pediatric ACL Reconstruction: A Meta-analysis
Authors: Wong Stephanie E. , Feeley Brian T. , Pandya Nirav K.
Published: September 2017

Background:

The purpose of this meta-analysis is to review clinical outcomes and complications following pediatric anterior cruciate ligament (ACL) reconstruction.

Methods:

The PubMed and EMBASE databases were searched for studies on ACL ruptures in the skeletally immature from 1985 to 2016. Full-text studies in English and performed on humans were included (n=5718). Titles included discussed operative intervention on skeletally immature patients with ACL tears (n=160). Studies that reported rerupture and/or complications with ACL reconstruction specific to the pediatric population, specifically growth disturbance, were then included in a secondary analysis (n=45). Complications not specific to the pediatric population were excluded. Demographics, graft type, surgical technique, follow-up, growth disturbance, rerupture, and patient-reported outcome scores were collected. Data were analyzed in aggregate.

Results:

In total, 45 studies were included with 1321 patients and 1392 knees. The average age was 13.0 years, 67% were male, and mean follow-up was 49.6 months. There were 115 (8.7%) reruptures in the initial 160 studies reviewed. In total, 94.6% of patients with rerupture required revision ACL surgery. There were 58 total growth disturbances (16 required corrective surgery, or 27.6%). Eighteen knees (3.7%) developed angular deformity, most commonly valgus. There were 37 patients (7.5%) had at least a 1 cm limb-length discrepancy. A total of 23 studies reported International Knee Documentation Committee scores (range, 81 to 100, 88% grade A or B). In total, 20 studies reported excellent Lysholm scores with mean scores of 94.6.

Conclusions:

Growth disturbance can occur with any of the reconstruction techniques. Proper surgical technique is likely more important than the specific reconstruction technique utilized. Patients with rerupture require surgery at much higher rates than those with growth disturbance. Although much attention has been focused on growth disturbance, we suggest that equal attention be given to the prevention of rerupture in this age group.

Level of Evidence:

Level III.
Should Proximal Femoral Implants be Removed Prophylactically or Reactively in Children With Cerebral Palsy?
Authors: Truong Walter H. , Novotny Susan A. , Novacheck Tom F. , Shin Eyun-Jung , Howard Andrew , Narayanan Unni G.
Published: September 2017

Background:

Implants are commonly used to stabilize proximal femoral osteotomies in children with cerebral palsy (CP). Removal of implants is common practice and believed to avoid infection, fracture, or pain that might be associated with retained hardware. There is little evidence to support a prophylactic strategy over a reactive approach based on symptoms. The aim of this study was to compare the outcomes of prophylactic and reactive approaches to removal of proximal femoral implants in children with CP.

Methods:

An intention-to-treat model was used to compare 2 institutions that followed a prophylactic (within ∼1 y) and reactive (following complication/symptoms) approach to hardware removal, respectively. Patients with CP who had femoral implants placed at or before age 16, and had ≥2-year postsurgical follow-up were included. Demographics, surgical details, reasons for removal, and complications were recorded. χ2 and t tests were used.

Results:

Six hundred twenty-one patients (prophylactic=302, reactive=319) were followed for an average of 6 years (range, 2 to 17 y). Two hundred eighty-seven (95%) implants were removed in the prophylactic group at 1.2 years. In the reactive group, 64 (20%) implants were removed at an average of 4.2 years. Reasons for removal included pain; infection; fracture; or for repeat reconstruction. The rate of unplanned removals due to fracture or infection was higher in the reactive group (4.7% vs. 0.7%, P=0.002), but there was no difference in the rate of complications during/after removal between the 2 groups (1.7% vs. 3.1%; P=0.616). No specific risk factor associated with unplanned removal could be identified; but children under 8 years old seemed more likely to undergo later removal (odds ratio 1.98; 95% confidence interval, 0.99-3.99).

Conclusions:

Eighty percent of patients in the reactive removal strategy avoided surgery. This group did have a 4% higher rate of fracture or infection necessitating unplanned removal but these were successfully treated at time of removal with no difference in complication rates associated with removal between both groups. One would need to remove implants from 25 patients to avoid 1 additional complication, providing some support for a reactive approach to removal of proximal femoral implants in this population.

Level of Evidence:

Level III—therapeutic.
Quantitative Analysis of Face and Neck Skin Tightening by Microfocused Ultrasound With Visualization in Asians
Authors: Lu Pei-Hsuan , Yang Chih-Hsun , Chang Ya-Ching
Published: September 2017

BACKGROUND

Previous studies of microfocused ultrasound with visualization (MFU-V) on facial and neck laxity were largely based on masked physician assessments, histological analysis, and safety profile. More quantitative studies are needed.

OBJECTIVE

To evaluate the 800 treatment lines of MFU-V on skin tightening effect of face and neck in Asians using 2 quantitative analysis systems at 0, 90, and 180 days after treatment.

MATERIALS AND METHODS

Total 25 subjects were recruited in this prospective study. Subjects were treated with MFU-V to the face and neck using 2 different transducers: 4 MHz, 4.5-mm focal depth and 7 MHz, 3.0-mm focal depth with total 800 lines. The subjects were evaluated by skin complexion analysis and 3-dimensional imaging system at 0, 90, and 180 days. Mean brow height lift and submental lift were calculated.

RESULTS

All 25 subjects completed treatment and received the follow-up examinations at 90 and 180 days. Two of the 25 subjects were male. Mean patient age was 53.3 years (range: 39.8–61.1 years). Wrinkles, texture, and pores were 3 variables relevant to analysis of skin laxity. Only mean wrinkles score reduction at 90 days was statistically significant (p = .0222). There was a mean 0.47 mm brow lift at 90 days (p = .0165), but there was a 0.12 mm decrease in brow height compared to baseline at 180 days (p = .6494). At 90 days, a mean 26.44 mm2 submental lift was noted (p = .0217). And at 180 days, a mean 13.76 mm2 submental lift was noted (p = .243).

CONCLUSION

This study showed that the most prominent change after the 800-line MFU-V treatments in Asians was the significant submental lift at 90 days. Other noninvasive or minimally invasive treatment modalities can be considered to combine with MFU-V for the optimal treatment response. Additional MFU-V treatments can be considered 3 months after the first treatment.
Clinical Benefits of Preoperative Conventional Fluorescence Diagnosis in Surgical Treatment of Extramammary Paget Disease
Authors: Wan Miaojian , Ma Han , Zhao Yue , Xie Lin , Chen Zhirui
Published: September 2017

BACKGROUND

In extramammary Paget disease (EMPD), initial margins of surgical excision are difficult to determine preoperatively. Fluorescence diagnosis (FD) may have utility as a noninvasive method for delineating tumor boundaries.

OBJECTIVE

The relationship between FD-delineated borders and results of multiple scouting biopsies (MSBs) in EMPD was investigated, evaluating the potential clinical role of FD.

MATERIALS AND METHODS

A cohort of 21 patients was studied, looking for consistencies between FD and MSB results. Initial surgical margins were determined by FD or FD plus MSB. All margins were subjected to frozen section analysis.

RESULTS

Paget cells were identified in 88 of 117 (71.8%) biopsies obtained from FD borders. When used preoperatively with MSB in 9 patients, 96.4% of margins proved negative at initial resection stage. Using a 6-mm margin beyond FD borders in another 9 patients, 86.7% of margins were negative at initial stage. The maximum distance of excision beyond FD border was 12 mm.

CONCLUSION

Fluorescence diagnosis borders (identified visually) correlated well with MSB histopathology. Fluorescence diagnosis is a useful method to delineate initial margins for surgical resection of EMPD.
Successful Second Microsurgical Replantation for Amputated Penis
Authors: Fujiki Masahide , Ozaki Mine , Kai Akiko , Takushima Akihiko , Harii Kiyonori
Published: September 2017

Penile amputation is a rare emergency, but the best method for its repair is required due to the organ’s functional and societal role. Since the first successful microsurgical replantation of the amputated penis, microsurgical techniques have matured and become the standard treatment for the penile replantation. However, the successful second microsurgical replantation for amputated penis has been rarely reported. We present the case of a 40-year-old man with schizophrenia who had a past history of penile self-mutilation and successful replantation at another hospital 2 years ago. After stopping oral medication for schizophrenia, he again cut his penis with a kitchen knife. We successfully replanted the amputated penis by anastomosing both circumflex arteries, the superficial dorsal vein, and the deep dorsal vein using microsurgical techniques. Postoperatively, the foreskin of the replanted penis gradually developed partial necrosis, requiring surgical debridement. The aesthetic and functional results were satisfactory and retrograde urethrography showed no evidence of leakage and stricture of the urethra. Although skin necrosis after penile replantation has been reported as an unavoidable process owing to the nature of injury, the rate would be higher after secondary replantation because of scar formation due to the previous operation. Therefore, our case of successful secondary replantation suggests that skin necrosis would be a predictable postoperative complication and the debridement timing of the devitalized foreskin should be closely monitored, and also secondary amputation is not a contraindication of replantation.
Analysis of Hypokalemia as a Side Effect of Liposomal Amphotericin in Pediatric Patients
Authors: Kobayashi Ryoji , Keino Dai , Hori Daiki , Sano Hirozumi , Suzuki Daisuke , Kishimoto Kenji , Kobayashi Kunihiko
Published: September 2017

Background:

Liposomal amphotericin (L-AMB) is a widely used broad-spectrum antifungal drug. Although L-AMB demonstrates better safety compared with amphotericin, renal dysfunction and hypokalemia are well-known adverse effects of L-AMB.

Method:

We analyzed 56 episodes in 40 children and adolescents who received L-AMB therapy to determine risk factors of hypokalemia.

Results:

Hypokalemia (<3.0 mEq/L continuously for more than 2 episodes) was observed in 31 of 56 episodes (55.4%). The median onset of hypokalemia was at 10 days on L-AMB (range, 3–54 days), and the median cumulative dose of L-AMB at occurrence of hypokalemia was 25 mg/kg (range, 10–167.5 mg/kg). None of the patients with hypokalemia had solid tumors, and they had significantly higher estimated glomerular filtration rates than those with normokalemia (P = 0.013). Seven of 25 (28.0%) patients in the normokalemia group and 1 of 31 (3.2%) patients in the hypokalemia group had eGFRs of <90 mL/min/1.73 m2 (P = 0.017).

Conclusion:

Although the reason for the association between estimated glomerular filtration rates and hypokalemia is unclear, assessing the estimated glomerular filtration rates before L-AMB administration may predict the development of hypokalemia.
Resurgence of Pertussis and Emergence of the Ptxp3 Toxin Promoter Allele in South Italy
Authors: Loconsole Daniela , De Robertis Anna Lisa , Morea Anna , Metallo Angela , Lopalco Pier Luigi , Chironna Maria
Published: September 2017

Background:

Despite universal immunization programs, pertussis remains a major public health concern. This study aimed to describe the pertussis epidemiology in the Puglia region in 2006–2015 and to identify recent polymorphisms in Bordetella pertussis virulence-associated genes.

Methods:

The pertussis cases in 2006–2015 were identified from the National Hospital Discharge Database and the Information System of Infectious Diseases. Samples of pertussis cases in 2014–2016 that were confirmed by the Regional Reference Laboratory were subjected to ptxA, ptxP and prn gene sequencing and, in 10 cases, multiple-locus variable-number tandem repeat analysis.

Results:

In Puglia in 2006–2015, the pertussis incidence rose from an average of 1.39/100,000 inhabitants in 2006–2013 to 2.56–2.54/100,000 in 2014–2015. In infants <1 year of age, the incidence rose from an average of 60.4/100,000 infants in 2006–2013 to 149.9/100,000 in 2015. Of the 661 cases recorded in 2006–2015, 80.3% required hospitalization; of these, 45.4% were <1 year of age. Of the 80 sequenced samples, the allelic profile ptxA1-ptxP3-prn2 was detected in 74. This variant was detected in both vaccinated and unvaccinated people. Six Bordetella pertussis samples were prn deficient. The multiple-locus variable-number tandem repeat analysis cases exhibited multiple-locus variable-number tandem repeat analysis-type 27.

Conclusions:

The pertussis incidence in Puglia has risen. The hypervirulent strain was also found in vaccinated people. This suggests bacterial adaptation to the vaccine and raises questions about acellular vaccine effectiveness. Prevention of infant pertussis cases is best achieved by immunizing the pregnant mother. Enhanced surveillance and systematic laboratory confirmation of pertussis should be improved in Italy.
Correlates of Nonimprovement to Pharmacotherapy for Chronic, Antidepressant-Resistant, Military Service–Related Posttraumatic Stress Disorder
Authors: Byrne Simon P. , Krystal John H. , Rosenheck Robert A. , Vessicchio Jennier , Pietrzak Robert H.
Published: September 2017

Background

Posttraumatic stress disorder (PTSD) is a chronic and often difficult-to-treat condition that is prevalent among military veterans. First-line pharmacotherapy for this population typically involves antidepressants; however, veterans who do not improve are sometimes prescribed antipsychotics such as risperidone. A 2011 randomized controlled trial of adjunctive risperidone versus placebo for veterans with chronic, antidepressant-resistant, military service–related PTSD revealed no difference between groups. Hence, there is a need to examine predictors of nonimprovement for chronic, treatment-resistant PTSD.

Methods

We examined correlates of nonimprovement and delayed improvement (ie, ≥12 weeks) using data from 267 veterans with chronic, antidepressant-resistant PTSD who were prescribed adjunctive risperidone or a placebo. Veterans received 1 to 4 mg adjunctive risperidone (n = 133; mean dose, 2.74 mg) or a placebo daily (n = 134) in addition to their original treatment regimen over the 24-week trial.

Results

Greater severity of PTSD symptoms at baseline, specifically reexperiencing (ie, nightmares) and emotional numbing (ie, sense of foreshortened future), was independently associated with nonimprovement. Of the 194 veterans (72.7%) who did improve, 95 (49.0%) showed delayed improvement, taking 12 weeks or longer to demonstrate a 10-point reduction in Clinician-Administered PTSD Scale scores. Emotional difficulties affecting role functioning, as assessed using the Veterans RAND 36-item Health Survey, independently predicted nonimprovement.

Conclusions

While results are indicative of nonspecific pharmacotherapeutic effects, they suggest that specific PTSD symptom clusters and impairment are associated with variable improvement in veterans with antidepressant-resistant PTSD. They underscore the importance of developing more effective and targeted pharmacotherapies for specific symptom clusters in this population.
Randomized Controlled Trial of Self-directed Versus In-Classroom Education of Narrow Band Imaging in Diagnosing Colorectal Polyps Using the NICE Criteria
Authors: Allen James E. , Vennalaganti Prashanth , Gupta Neil , Hornung Benjamin , Choudhary Abhishek , Titi Mohammad , Alsop Benjamin R. , Lim Diego , Sharma Prateek
Published: September 2017

Background:

The optimal method for teaching NBI International Colorectal Endoscopic (NICE) criteria to medical trainees is unknown.

Methods:

Trainees (medical students, residents, and gastroenterology fellows) were randomized to 2 groups (in-classroom vs. self-directed training). Teaching phase: A standardized presentation was developed about narrow band imaging (NBI) and NICE criteria. The in-class teaching group attended a single live-teaching session (with NBI expert). The self-directed training group was provided with the same educational tool with recorded audio. Testing phase: All participants provided their predicted histology and their level of confidence. After completing initial 10 clips, the in-class teaching group received live feedback (NBI expert), whereas the self-teaching group received automated audio feedback. All participants then reviewed the next 30 NBI videos. The diagnostic performance of NBI in predicting histology was compared between the 2 groups.

Results:

Twenty medical trainees (8 students, 8 residents, and 4 gastroenterology fellows) participated in the study. The overall accuracy, sensitivity, specificity, and negative predictive value in using NBI to predict histology were: 79.0% [95% confidence interval (CI), 76.2-81.8], 69.5% (95% CI, 65.0-74.0), 88.5% (95% CI, 85.3-91.6), and 74.4% (95% CI, 70.4-78.3). There were no significant differences in the performance characteristics between the in-classroom and self-directed groups for all responses including those answered with high confidence.

Conclusions:

Using a standardized educational tool, the accuracy of distinguishing adenomatous versus hyperplastic colon polyps using NBI between the in-class teaching and self-directed learning were similar. This suggests that both training methods can be utilized for the education of medical trainees in the use of NICE criteria.
Trafficking and Trauma
Authors: Ravi Anita , Pfeiffer Megan R. , Rosner Zachary , Shea Judy A.
Published: September 2017

Background:

Sex-trafficked persons experience significant trauma while exploited, resulting in complex health issues and barriers to health care. Incorporating survivor perspectives is critical in optimizing health care delivery for this population.

Objectives:

We interviewed sex-trafficking survivors regarding their experiences with trauma while being trafficked and elicited advice about health care delivery.

Research Design:

Qualitative interviews were conducted in New York City’s Rikers Island jail from July to September 2015.

Subjects:

In total, 21 English-speaking women who had experienced sex trafficking were the subjects of the study.

Measures:

Interview domains included: interpersonal violence, behavioral health, and health care delivery advice.

Results:

Interviewees described experiencing severe and chronic trauma perpetrated by traffickers and sex buyers. Substance use was the primary method of coping with trauma. With regard to mental health, interviewees noted diagnoses of depression, anxiety and posttraumatic stress disorder, low self-esteem, and challenges in intimate relationships. Health care delivery themes included approaches to discussing trafficking in health care settings, concerns regarding sexual assault examinations, and suggestions for improving direct-services and prevention programming.

Conclusions:

With this perspective into the complex intersection of trauma and behavioral health that sex-trafficked women can experience, health care providers can better understand the context and recommendations regarding trauma-informed care practices for this population. Our results also offer several avenues for future studies with regard to discussing trafficking in clinical settings and an opportunity for stakeholders to incorporate survivor-based input to improve health care for this population.
Does a p53 “Wild-type” Immunophenotype Exclude a Diagnosis of Endometrial Serous Carcinoma?
Authors: Fadare Oluwole , Roma Andres A. , Parkash Vinita , Zheng Wenxin , Walavalkar Vighnesh
Published: September 2017

An aberrant p53 immunophenotype may be identified in several histotypes of endometrial carcinoma, and is accordingly recognized to lack diagnostic specificity in and of itself. However, based on the high frequency with which p53 aberrations have historically been identified in endometrial serous carcinoma, a mutation-type immunophenotype is considered to be highly sensitive for the histotype. Using an illustrative case study and a review of the literature, we explore a relatively routine diagnostic question: whether the negative predictive value of a wild-type p53 immunophenotype for serous carcinoma is absolute, that is, whether a p53-wild type immunophenotype is absolutely incompatible with a diagnosis of serous carcinoma. The case is an advanced stage endometrial carcinoma that was reproducibly classified by pathologists from 3 institutions as serous carcinoma based on its morphologic features. By immunohistochemistry, the tumor was p53-wild type (DO-7 clone), diffusely positive for p16 (block positivity), and showed retained expression of PTEN, MSH2, MSH6, MLH1, and PMS2. Next generation sequencing showed that there indeed was an underlying mutation in TP53 (D393fs*78, R213*). The tumor was microsatellite stable, had a low mutational burden (4 mutations per MB), and displayed no mutations in the exonuclease domain of DNA polymerase epsilon (POLE) gene. Other genomic alterations included RB1 mutation (R46fs*19), amplifications in MYST3 and CRKL, and ARID1A deletion (splice site 5125-94_5138del108). A review of the recent literature identified 5 studies in which a total of 259 cases of serous carcinoma were whole-exome sequenced. The average TP53 mutational rate in endometrial serous carcinoma was only 75% (range, 60 to 88). A total of 12 (33%) of 36 immunohistochemical studies reported a p53-aberrant rate of <80% in endometrial serous carcinoma. We discuss in detail several potential explanations that may underlie the scenario of serous carcinoma-like morphology combined with p53-wild-type immunophenotype, including analytic limitations, a nonserous histotype displaying morphologic mimicry of serous carcinoma, and true biological phenomena (including the possibility of a TP53-independent pathway of endometrial serous carcinogenesis). Ultimately, our central thematic question is provisionally answered in the negative. At present, the available data would not support a categorical conclusion that a p53 alteration is a necessary and obligate component in the genesis and/or diagnosis of endometrial serous carcinoma. On the basis of their collective experience, the authors proffer some recommendations on the use of p53 immunohistochemistry in the histotyping of endometrial carcinomas.
Implant Porosity and the Foreign Body Response
Authors: Jordan Sumanas W. , Fligor Jennifer E. , Janes Lindsay E. , Dumanian Gregory A.
Published: September 2017

The biocompatibility of prosthetic mesh is dependent on a number of physicochemical properties that ultimately incite an optimal foreign body response. The magnitude and character of the foreign body response directly affect the clinical success of the hernia repair, with too little scar resulting in bulge or hernia recurrence and too much scar causing mesh wrinkling and pain. Moreover, it is important to consider the effect of a sustained foreign body response and scar remodeling on the combined strength of the mesh-tissue construct over time. Understanding key elements that determine the foreign body response, such as implant porosity, surface area, and filament size, is critical to the performance of surgery. New absorbable materials introduce the additional variable of durability and persistence of the foreign body response after the foreign body itself has dissolved. In this review, we discuss the experimental and clinical literature relating the quality of the foreign body response to the physical attributes of implants in an effort to demystify prosthetic mesh selection.
Columellar Reconstruction following Nasal Continuous Positive Airway Pressure Injury
Authors: Chang Catherine S. , Swanson Jordan W. , Wilson Anthony , Low David W. , Bartlett Scott P.
Published: September 2017

Nasal continuous positive airway pressure is used increasingly to treat pulmonary immaturity in premature neonates. Nasal injury is common with nasal continuous positive airway pressure use, with full-thickness tissue loss at the columella among the most devastating complications. Columellar necrosis often imparts a full-thickness injury to the overlying columellar skin, the medial crura of the lower lateral nasal cartilages, the anteromedial inner nasal mucosal lining, and potentially the anterior septal cartilage. Consequently, the columella can become scarred and shortened. Although multiple techniques have been described to reconstruct the columella, no known technique has been specifically developed to treat the unique columellar defect common to severe nasal continuous positive airway pressure injury. Donor-site morbidity related to these techniques, and how growth of the reconstructed nose will proceed, are obvious concerns, especially in young children. The authors present a novel reconstruction technique that uses recreation of the defect with posteriorly based book flaps and auricular chondrocutaneous composite graft interposition. This technique has several advantages, including avoiding central facial scars, supplying well-matched skin color and texture, and facilitating robust tip support. The authors retrospectively review the use and outcomes of this technique from 1995 and 2016 on all patients with a history of nasal continuous positive airway pressure columellar necrosis at their center.
The Regulations and Mechanisms of Laparoscopic Sleeve Gastrectomy (LSG) for Obesity and Type 2 Diabetes: A Systematic Review
Authors: Chang Xusheng , Cai Hui , Yin Kai
Published: September 2017

Obesity and diabetes mellitus are becoming 2 of the most leading risk factors that threaten public health worldwide. Obesity is a very strong but preventable risk factor for getting type 2 diabetes. Laparoscopic sleeve gastrectomy (LSG) has been a main approach to the surgical management of morbid obesity and type 2 diabetes but its role remains undefined. Here, we overviewed the clinical outcomes and regulatory mechanisms of LSG, aiming at providing thorough theoretical supports and effective technical guidance to the pathogenesis, prognosis, treatment and prevention of type 2 diabetes with obesity. Futher more, the prospectives and main drawbacks (such as considerable heterogeneity and unicity, little comparability and relevance) of LSG are also discussed.
Internal Hernia After Laparoscopic Total Gastrectomy for Gastric Cancer
Authors: Ojima Toshiyasu , Nakamori Mikihito , Nakamura Masaki , Katsuda Masahiro , Hayata Keiji , Kato Tomoya , Tsuji Toshiaki , Yamaue Hiroki
Published: September 2017

Purpose:

The aim of this study was to clarify internal hernia (IH) characteristics after laparoscopic gastrectomy.

Materials and Methods:

This was a retrospective study of 1943 consecutive gastric cancer patients who underwent surgery at our institute between 2004 and 2015. Since 2013, our technique includes antecolic Roux-en-Y (RY) with closure of all mesenteric defects during laparoscopic total gastrectomy (LTG) as standard.

Results:

Postoperative IH was only detected in patients who underwent total gastrectomy with RY reconstruction. Furthermore, the incidence of IH was significantly higher after LTG than after open total gastrectomy (4.9% vs. 1.0%; P=0.005). IH after LTG occurred in 8.0% of patients before standardization with closure of the mesenteric defects, but no IH was observed after standardization (P=0.047).

Conclusions:

Closure of all mesenteric defects is recommended for gastric cancer patients who undergo LTG with antecolic RY. Registration number: UMIN000009163/000025029 (www.umin.ac.jp/ctr/)