bluuebunny/crossref_metadata_2025 huggingface dataset:
Do toddler’s fractures of the tibia require evaluation and management by an orthopaedic surgeon routinely?
Authors: Adamich John S. , Camp Mark W.
Published: June 2017

Objective

The majority of uncomplicated toddler fractures of the tibia (toddler’s fractures) do not need an orthopaedic surgeon’s intervention or follow-up. However, inexperienced emergency room physicians, general practitioners and orthopaedic trainees and surgeons understandably defer to a cautious approach of referral and subsequent frequent clinical and radiographic follow-up. An evidence-based pathway can help prevent this overtreatment, reduce unnecessary radiation exposure and decrease the financial burden on families and the healthcare system.

Patients and methods

A retrospective analysis of patients who presented for management of toddler’s fractures to The Hospital for Sick Children (SickKids) was performed.

Results

A total of 184 (113 boys, 72 girls) patients, of a mean age of 1.99 (range: 0.2–3.9) years, were included for review. The included patients had attended 2.00±1.0 clinic visits and had had 5.86±2.7 radiographs taken on average. No complications such as cast injuries, nonunion, refracture or subsequent deformity needing assessment or intervention were identified.

Conclusion

Toddler’s fractures do not require routine orthopaedic surgeon assessment, intervention or follow-up. If diagnosed and managed correctly at initial presentation, patients with toddler’s fractures may be discharged safely without the need for further clinician contact. We developed a toddler’s fracture clinical care pathway to reduce unnecessary orthopaedic surgeon referral and clinical and radiographic follow-up, thereby decreasing radiation exposure and costs to families and the healthcare system without risking patient outcomes.
Movement System Diagnosis
Authors: Van Sant Ann F.
Published: June 2017

Background and Purpose:

This article presents the concept of movement system diagnoses (MSDxs), including an examination of the evolution of the ideas that are shaping the development of MSDxs.

Summary of Key Points:

Ideas leading to development of the need for MSDxs are traced, and an overview of Diagnosis Dialog and points of consensus are provided. Four examples from areas of neurologic and pediatric practice where additional work is needed on movement system diagnosis are highlighted.

Clinical Practice:

The development and use of MSDxs are deemed critical to the future development of practice in pediatric and neurologic physical therapy. The prediction of treatment outcomes through research is dependent on homogeneous groups of patients with similar signs and symptoms of movement system disorders. Only by investigating homogeneous groups with refined MSDxs will it be possible to carefully examine and identify interventions that are appropriate to a specific diagnosis. Further, our ability to identify disordered movements, including inactivity and over-activity that could lead across time to disabling conditions presents a strong argument for establishing movement system diagnoses that forewarn of the risk of disordered movement poses to health. Such movement system diagnoses would guide interventions that deter the development of disabling conditions rooted in disordered movement.
From Disease to Health: Physical Therapy Health Promotion Practices for Secondary Prevention in Adult and Pediatric Neurologic Populations
Authors: Quinn Lori , Morgan Don
Published: June 2017

Background and Purpose:

Over the last decade there has been a substantial increase in efforts to better understand how targeted physical activity and exercise interventions can be used to minimize secondary consequences arising from neurological damage in both adult and pediatric populations. This article offers an overview of contemporary research that addresses mediators of functional and neuroplastic adaptations associated with physical activity and exercise. We emphasize the important role that physical therapists can play to increase participation and improve well-being in adults and children with neurological disorders. We further highlight potential strategies to foster translation of evidence-based findings for use by clinicians and consumers.

Summary of Key Points:

Engagement in physical activity can serve as a powerful promoter of health and well-being in adults and youth with neurologic disease, and has the potential to alter the course of disease processes. Physical therapists can play a key role in promoting fitness and wellness by encouraging active living, providing early diagnosis of disease and prescribing targeted activity interventions to improve fitness and participation, and helping individuals overcome personal and environmental barriers to an active lifestyle.

Recommendations for Clinical Practice:

Physical therapists must adopt a model of rehabilitation that emphasizes secondary prevention in adults and youth with neurologic diseases. Physical therapists have a unique role in developing forward-thinking approaches in using innovative health and wellness strategies to promote positive changes in activity and exercise behaviors.
Genetic Variation and Neuroplasticity: Role in Rehabilitation After Stroke
Authors: Stewart Jill Campbell , Cramer Steven C.
Published: June 2017

Background and Purpose:

In many neurologic diagnoses, significant interindividual variability exists in the outcomes of rehabilitation. One factor that may impact response to rehabilitation interventions is genetic variation. Genetic variation refers to the presence of differences in the DNA sequence among individuals in a population. Genetic polymorphisms are variations that occur relatively commonly and, while not disease-causing, can impact the function of biological systems. The purpose of this article is to describe genetic polymorphisms that may impact neuroplasticity, motor learning, and recovery after stroke.

Summary of Key Points:

Genetic polymorphisms for brain-derived neurotrophic factor (BDNF), dopamine, and apolipoprotein E have been shown to impact neuroplasticity and motor learning. Rehabilitation interventions that rely on the molecular and cellular pathways of these factors may be impacted by the presence of the polymorphism. For example, it has been hypothesized that individuals with the BDNF polymorphism may show a decreased response to neuroplasticity-based interventions, decreased rate of learning, and overall less recovery after stroke. However, research to date has been limited and additional work is needed to fully understand the role of genetic variation in learning and recovery.

Recommendations for Clinical Practice:

Genetic polymorphisms should be considered as possible predictors or covariates in studies that investigate neuroplasticity, motor learning, or motor recovery after stroke. Future predictive models of stroke recovery will likely include a combination of genetic factors and other traditional factors (eg, age, lesion type, corticospinal tract integrity) to determine an individual's expected response to a specific rehabilitation intervention.
Integrating Health Promotion Into Physical Therapy Practice to Improve Brain Health and Prevent Alzheimer Disease
Authors: McGough Ellen , Kirk-Sanchez Neva , Liu-Ambrose Teresa
Published: June 2017

Background and Purpose:

Alzheimer disease is the most common cause of dementia, and brain pathology appears years before symptoms are evident. Primary prevention through health promotion can incorporate lifestyle improvement across the lifespan. Risk factor assessment and identifying markers of disease might also trigger preventive measures needed for high-risk individuals and groups.

Summary of Key Points:

Many potential risk factors are modifiable through exercise, and may be responsive to early intervention strategies to reduce the downward slope toward disability. Through the use of common clinical tests to identify cognitive and noncognitive functional markers of disease, detection and intervention can occur at earlier stages, including preclinical stages of disease. Physical activity and exercise interventions to address modifiable risk factors and impairments can play a pivotal role in the prevention and delay of functional decline, ultimately reducing the incidence of dementia. This article discusses prevention, prediction, plasticity, and participation in the context of preserving brain health and preventing Alzheimer disease and related dementias in aging adults.

Recommendations for Clinical Practice:

Rehabilitation professionals have opportunities to slow disease progression through research, practice, and education initiatives. From a clinical perspective, interventions that target brain health through lifestyle changes and exercise interventions show promise for preventing stroke and associated neurovascular diseases in addition to dementia. Physical therapists are well positioned to integrate primary health promotion into practice for the prevention of dementia and other neurological conditions in older adults.
Telehealth, Wearable Sensors, and the Internet: Will They Improve Stroke Outcomes Through Increased Intensity of Therapy, Motivation, and Adherence to Rehabilitation Programs?
Authors: Burridge Jane H. , Lee Alan Chong W. , Turk Ruth , Stokes Maria , Whitall Jill , Vaidyanathan Ravi , Clatworthy Phil , Hughes Ann-Marie , Meagher Claire , Franco Enrico , Yardley Lucy
Published: June 2017

Background and Purpose:

Stroke, predominantly a condition of older age, is a major cause of acquired disability in the global population and puts an increasing burden on health care resources. Clear evidence for the importance of intensity of therapy in optimizing functional outcomes is found in animal models, supported by neuroimaging and behavioral research, and strengthened by recent meta-analyses from multiple clinical trials. However, providing intensive therapy using conventional treatment paradigms is expensive and sometimes not feasible because of social and environmental factors. This article addresses the need for cost-effective increased intensity of practice and suggests potential benefits of telehealth (TH) as an innovative model of care in physical therapy.

Summary of Key Points:

We provide an overview of TH and present evidence that a web-supported program, used in conjunction with constraint-induced therapy (CIT), can increase intensity and adherence to a rehabilitation regimen. The design and feasibility testing of this web-based program, “LifeCIT,” is presented. We describe how wearable sensors can monitor activity and provide feedback to patients and therapists. The methodology for the development of a wearable device with embedded inertial and mechanomyographic sensors, algorithms to classify functional movement, and a graphical user interface to present meaningful data to patients to support a home exercise program is explained.

Recommendations for Clinical Practice:

We propose that wearable sensor technologies and TH programs have the potential to provide most-effective, intensive, home-based stroke rehabilitation.
Activity-Based Therapy: From Basic Science to Clinical Application for Recovery After Spinal Cord Injury
Authors: Behrman Andrea L. , Ardolino Elizabeth M. , Harkema Susan J.
Published: June 2017

Background and Purpose:

Collaboration between scientists and clinicians effectively accelerated translation of scientific evidence for activity-based therapies (ABTs) into rehabilitation. This article addresses the basic scientific findings of activity-dependent plasticity that led to locomotor training, an ABT, and its principles to advance recovery in adult and pediatric populations with spinal cord injury (SCI). Expansion to new therapies based on these common principles is highlighted, for example, epidural stimulation. The article also describes a recently developed measure, the Neuromuscular Recovery Scale (NRS), and its psychometric properties.

Summary of Key Points:

Locomotor training has led to recovery of walking in some individuals with motor-incomplete SCI even years after injury. Recent studies resulted in individuals with motor-complete SCI regaining some voluntary movements and standing in the presence of epidural stimulation. The level of success for locomotor training and epidural stimulation appears dependent on spinal networks maintaining the appropriate central state of excitability for the desired task. As these new advances in restorative therapies required an outcome measure that measured performance without compensation, the NRS was developed. The NRS has strong psychometric properties in adults, and a pediatric version is under development. Application of locomotor training in children is still novel. Preliminary evidence suggests that locomotor training can improve trunk control and also foster participation in children with chronic SCI.

Recommendations for Clinical Practice:

ABTs may effectively promote neuromuscular recovery and improve function and participation in adults and children post-SCI. Evaluation of outcomes with valid measures, such as the NRS, is necessary to document the ability to perform functional tasks and to assess progress as function improves.
Menstrual Hygiene Management in Resource-Poor Countries
Authors: Kuhlmann Anne Sebert , Henry Kaysha , Wall L. Lewis
Published: June 2017

Importance

Adequate management of menstrual hygiene is taken for granted in affluent countries; however, inadequate menstrual hygiene is a major problem for girls and women in resource-poor countries, which adversely affects the health and development of adolescent girls.

Objective

The aim of this article is to review the current evidence concerning menstrual hygiene management in these settings.

Evidence Acquisition

A PubMed search using MeSH terms was conducted in English, supplemented by hand searching for additional references. Retrieved articles were reviewed, synthesized, and summarized.

Results

Most research to date has described menstrual hygiene knowledge, attitudes, and practices, mainly in sub-Saharan Africa and South Asia. Many school-based studies indicate poorer menstrual hygiene among girls in rural areas and those attending public schools. The few studies that have tried to improve or change menstrual hygiene practices provide moderate to strong evidence that targeted interventions do improve menstrual hygiene knowledge and awareness.

Conclusion and Relevance

Challenges to improving menstrual hygiene management include lack of support from teachers (who are frequently male); teasing by peers when accidental menstrual soiling of clothes occurs; poor familial support; lack of cultural acceptance of alternative menstrual products; limited economic resources to purchase supplies; inadequate water and sanitation facilities at school; menstrual cramps, pain, and discomfort; and lengthy travel to and from school, which increases the likelihood of leaks/stains. Areas for future research include the relationship between menarche and school dropout, the relationship between menstrual hygiene management and other health outcomes, and how to increase awareness of menstrual hygiene management among household decision makers including husbands/fathers and in-laws.

Target Audience

Obstetricians and gynecologists, family physicians.

Learning Objectives

After completion of this educational activity, the obstetrician/gynecologist should be able to define what is meant by “adequate menstrual hygiene management,” identify the challenges to adequate menstrual hygiene management that exist in resource-poor countries, and describe some of the intervention strategies that have been proposed to improve menstrual hygiene management for girls and women in those countries.
Uterine Malformations: An Update of Diagnosis, Management, and Outcomes
Authors: Bhagavath Bala , Greiner Ellie , Griffiths Kara M. , Winter Tom , Alur-Gupta Snigdha , Richardson Carter , Lindheim Steven R.
Published: June 2017

Importance

The prevalence of uterine malformations has been reported in up to 7% of the general population and 18% of those with recurrent pregnancy loss. The diagnosis, classification, management, and outcome of the management have been subject to debate for decades.

Objective

The aim of this article is to summarize the current knowledge regarding the genetics of müllerian anomalies, the varied classification schemes, the appropriate diagnostic modalities, the surgical methods, and the obstetric outcomes related to these surgical methods.

Evidence Acquisition

An extensive literature review using the key words uterine anomaly, classification, mullerian, agenesis, unicornuate, didelphys, bicornuate, septate, arcuate, DES, and diethyl stilbestrol was conducted using PubMed. Only English-language publications were reviewed. Relevant references within these publications were also obtained and reviewed in preparing this article.

Results

Only 4 genes have been clearly linked to müllerian anomalies in humans. All these have been described only in syndromic patients. Four different classification schemes have been proposed including the American Society of Reproductive Medicine classification. There is accumulating evidence that 3-dimensional ultrasonography is an effective and less expensive diagnostic tool. Many innovative surgical methods have been developed for the various categories of anomalies, particularly for müllerian agenesis. Although there is accumulating evidence for the improved obstetric outcomes after surgical repairs, robust evidence from randomized trials is lacking.

Conclusions

Current evidence favors continued use of the American Society of Reproductive Medicine classification. Three-dimensional sonography, especially when combined with saline infusion, can be very helpful in accurately classifying müllerian anomalies.

Relevance

Müllerian anomalies are relatively common. Accurate knowledge of the advantages and limitations of various diagnostic modalities, the limitations of the classification systems, the surgical options available where appropriate, and the obstetric outcomes after these surgeries will help in the optimal management of these patients.

Target Audience

Obstetrician and gynecologists.

Learning Objectives

After completion of this educational activity, the obstetrician/gynecologist should be better able to discuss the current controversies and new classifications of müllerian anomalies, describe the prevalence and pathogenesis of each müllerian anomaly, illustrate the various modalities for the diagnosis of müllerian anomalies, and outline the appropriate counseling and clinical practice for surgical management and obstetric outcomes for each anomaly.
Reducing Health Disparities by Removing Cost, Access, and Knowledge Barriers
Authors: Goodman Melody , Onwumere Ojiugo , Milam Laurel , Peipert Jeffrey F.
Published: June 2017

(Abstracted from Am J Obstet Gynecol 2017;216(4):382.e1–382.e5)

In the United States, black women are thrice more likely and Hispanic women twice as likely to have an unintended pregnancy as white women. The high rates of unintended pregnancy among black and Hispanic women are largely due to incorrect, inconsistent, and nonuse of contraception, as well as health care disparities.
Do Patient Characteristics Impact the Relationship Between Anatomic Prolapse and Vaginal Bulge Symptoms?
Authors: Kowalski Joseph T. , Melero Gerardo Heredia , Mahal Amandeep , Genadry Rene , Bradley Catherine S.
Published: June 2017

(Abstracted from Int Urogynecol J 2017; 28:391–396)

Previous studies have shown that seeing or feeling a vaginal bulge is the most specific symptom for identifying pelvic organ prolapse (POP). It has been suggested that the critical point at which bulge symptoms appear in most women is prolapse to or beyond the level of the hymen.
Urinary Microbiome and Cytokine Levels in Women With Interstitial Cystitis
Authors: Abernethy Melinda G. , Rosenfeld Amy , White James R. , Mueller Margaret G. , Lewicky-Gaupp Christina , Kenton Kimberly
Published: June 2017

(Abstracted from Obstet Gynecol 2017;129:500–506)

Evidence for the existence of a biodiverse urinary microbiome that cannot be isolated by conventional culture has significant clinical implications for the diagnosis and treatment of several urinary tract conditions. Interstitial cystitis is a debilitating chronic condition characterized by suprapubic pain and urinary frequency.
Factors Associated With Deciding Between Risk-Reducing Salpingo-oophorectomy and Ovarian Cancer Screening Among High-Risk Women Enrolled in GOG-0199: An NRG Oncology/Gynecologic Oncology Group Study
Authors: Mai Phuong L. , Piedmonte Marion , Han Paul K. , Moser Richard P. , Walker Joan L. , Rodriguez Gustavo , Boggess John , Rutherford Thomas J. , Zivanovic Oliver , Cohn David E. , Thigpen J. Tate , Wenham Robert M. , Friedlander Michael L. , Hamilton Chad A. , Bakkum-Gamez Jamie , Olawaiye Alexander B. , Hensley Martee L. , Greene Mark H. , Huang Helen Q. , Wenzel Lari
Published: June 2017

(Abstracted from Gynecol Oncol 2017;145(1):122–129)

Currently, there is no safe and effective ovarian cancer screening (OCS) test, and novel screening modalities are being investigated. Recently, the Risk of Ovarian Cancer Algorithm (ROCA), a novel screening strategy, has shown promise among average-risk and high-risk women.
Use of MRI in the Diagnosis of Fetal Brain Abnormalities in Utero (MERIDIAN): A Multicentre, Prospective Cohort Study
Authors: Griffiths Paul D. , Bradburn Michael , Campbell Michael J. , Cooper Cindy L. , Graham Ruth , Jarvis Deborah , Kilby Mark D. , Mason Gerald , Mooney Cara , Robson Stephen C. , Wailoo Allan
Published: June 2017

(Abstracted from Lancet 2017;389:538–546)

Ultrasound is routinely used for antenatal screening. One role of antenatal sonography is in the detection of fetal anomalies; among these, fetal brain anomalies occur in almost 3 of every 1000 pregnancies and lead to significant rates of morbidity and mortality.
The Annual Economic Burden of Syphilis: An Estimation of Direct, Productivity, and Intangible Costs for Syphilis in Guangdong Initiative for Comprehensive Control of Syphilis Sites
Authors: Zou Yaming , Liao Yu , Liu Fengying , Chen Lei , Shen Hongcheng , Huang Shujie , Zheng Heping , Yang Bin , Hao Yuantao
Published: June 2017

Background

Syphilis has continuously posed a great challenge to China. However, very little data existed regarding the cost of syphilis. Taking Guangdong Initiative for Comprehensive Control of Syphilis area as the research site, we aimed to comprehensively measure the annual economic burden of syphilis from a societal perspective.

Methods

Newly diagnosed and follow-up outpatient cases were investigated by questionnaire. Reported tertiary syphilis cases and medical institutions cost were both collected. The direct economic burden was measured by the bottom-up approach, the productivity cost by the human capital method, and the intangible burden by the contingency valuation method.

Results

Three hundred five valid early syphilis cases and 13 valid tertiary syphilis cases were collected in the investigation to estimate the personal average cost. The total economic burden of syphilis was US $729,096.85 in Guangdong Initiative for Comprehensive Control of Syphilis sites in the year of 2014, with medical institutions cost accounting for 73.23% of the total. Household average direct cost of early syphilis was US $23.74. Average hospitalization cost of tertiary syphilis was US $2,749.93. Of the cost to medical institutions, screening and testing comprised the largest proportion (26%), followed by intervention and case management (22%) and operational cost (21%). Household average productivity cost of early syphilis was US $61.19. Household intangible cost of syphilis was US $15,810.54.

Conclusions

Syphilis caused a substantial economic burden on patients, their families, and society in Guangdong. Household productivity and intangible costs both shared positive relationships with local economic levels. Strengthening the prevention and effective treatment of early syphilis could greatly help to lower the economic burden of syphilis.
Improving Hypertension Control Population-wide in Minnesota
Authors: Foti Kathryn , Auerbach John , Magnan Sanne
Published: June 2017

Context:

Hypertension is a common and costly risk factor for cardiovascular disease, but just over half of all adults with hypertension have their blood pressure controlled nationally. In Minneapolis–St Paul, Minnesota, the rate of hypertension control is approximately 70% despite a rate of hypertension control similar to the national average as recently as the first half of the 1990s.

Objective:

The purposes of this study were to identify factors in Minneapolis–St Paul and state-level policies and programs in Minnesota that may have contributed to the more rapid increase in blood pressure control there than that in the rest of the nation and to identify factors that can potentially be replicated in other jurisdictions.

Design, Setting, Participants:

The study included analysis of trends in hypertension control since 1980 based on the Minnesota Heart Survey and the National Health and Nutrition Examination Survey, as well as interviews with health care and public health leaders in Minnesota.

Main Outcome Measure:

Prevalence of hypertension control.

Results:

Probable contributing factors identified include a focus on collaborative and continuous quality improvement; a forum for setting statewide clinical guidelines and measures; the willing participation from the largest health systems, purchasers, and nonprofit health plans; and the use of widely accepted mechanisms for providing feedback to clinicians and reporting performance. The relatively high rate of insurance coverage and socioeconomic status may have contributed but do not fully explain the difference in hypertension control as compared with the rest of the United States.

Conclusions:

The experience in Minnesota demonstrates that it is possible to dramatically increase hypertension control at the population level, across health systems, and health plans in a relatively short period of time. Lessons learned may be helpful to informing local, state, and national efforts to improve hypertension control.
Revolving Loan Fund: A Novel Approach to Increasing Access to Long-Acting Reversible Contraception Methods in Community Health Centers
Authors: Evans Megan L. , Breeze Janis L. , Paulus Jessica K. , Meadows Audra
Published: June 2017

Objective:

The aim of this study was to assess the impact of a revolving loan fund (RLF) on timing of device insertion and long-acting reversible contraception (LARC) access among a high-risk urban population at 3 Boston community health centers.

Design:

Three health centers were identified to implement a RLF. Each clinic received $5000 from the RLF to purchase LARC devices. Data collected through medical record review retrospectively 1 year prior to start of the RLF and prospectively for 1 year thereafter included patient demographics, type of LARC selected, patient's date of documented interest in a LARC device, and date of insertion. The effect of a RLF on delay to LARC insertion was tested using negative binomial regression, controlling for site and potential confounding variables between the pre- and post-RLF periods.

Setting:

Three urban community health centers.

Participants:

Reproductive-aged women who received family planning services at the 3 participating health centers.

Main Outcome Measures:

Increasing access to LARC and decreasing wait times to LARC insertion after implementation of the RLF.

Results:

Data on 133 patients in the pre-RLF group and 205 in the post-RLF group were collected. There were no statistically significant differences in demographic or clinical characteristics between the 2 time periods. LARC uptake increased significantly from the pre- to post-RLF period, specifically among implant users. There was a statistically significant decrease in the mean number of days in delay from interest to insertion from the pre- to post-RLF period (pre-RLF: 31.3 ± 50.6 days; post-RLF: 13.6 ± 16.7 days, adjusted P < .001). The reasons for the delay did not differ significantly between the 2 time periods.

Conclusion:

The RLF decreased wait time for the devices and increased overall insertion rates. This may serve as a promising solution to improve LARC access in community health centers. This project could be expanded to include more health centers, creating a city wide RLF. This expansion could allow for further data analysis, including unintended pregnancy rates with LARC delay, LARC continuation rates, and sustainability of a RLF.
Distributed Data Networks That Support Public Health Information Needs
Authors: Tabano David C. , Cole Elizabeth , Holve Erin , Davidson Arthur J.
Published: June 2017

Introduction:

Data networks, consisting of pooled electronic health data assets from health care providers serving different patient populations, promote data sharing, population and disease monitoring, and methods to assess interventions. Better understanding of data networks, and their capacity to support public health objectives, will help foster partnerships, expand resources, and grow learning health systems.

Methods:

We conducted semistructured interviews with 16 key informants across the United States, identified as network stakeholders based on their respective experience in advancing health information technology and network functionality. Key informants were asked about their experience with and infrastructure used to develop data networks, including each network's utility to identify and characterize populations, usage, and sustainability.

Results:

Among 11 identified data networks representing hundreds of thousands of patients, key informants described aggregated health care clinical data contributing to population health measures. Key informant interview responses were thematically grouped to illustrate how networks support public health, including (1) infrastructure and information sharing; (2) population health measures; and (3) network sustainability.

Conclusion:

Collaboration between clinical data networks and public health entities presents an opportunity to leverage infrastructure investments to support public health. Data networks can provide resources to enhance population health information and infrastructure.
A Collaborative Approach to Childhood Obesity Surveillance From a Local Health Department
Authors: Alleman Elizabeth , Murphy Elizabeth , Baskerville Kristin , Chugh Rashmi
Published: June 2017

DuPage County Health Department collected de-identified data from health forms submitted by participating schools for academic years 2011-2015 for kindergarten, sixth-, and ninth-grade students to determine the prevalence of obesity and elevated blood pressure among public school students. The prevalence of obesity in students for the 2014-2015 school year was 15.1%, and the prevalence of elevated blood pressure was 22.8%. Students in the “obese” body mass index percentile category had an elevated blood pressure prevalence of 44.2%, which was higher than students in the “nonobese” category (P < .001). Significant differences were also observed both by sex and by grade. The results identify the need to support implementation and evaluation of policies to reduce childhood obesity and improve health outcomes. By partnering with schools to obtain preexisting health data, state or local health departments with limited resources may replicate these methods to develop a childhood obesity surveillance system.
Determinants of HIV-1 CD4-Independent Brain Adaptation
Authors: Shakirzyanova Madina , Kong Xiang-Peng , Cheng-Mayer Cecilia
Published: June 2017

Background:

HIV-1 is known to adapt to the local environment in its usage of receptors, and it can become CD4 independent in the brain where the receptor is scarce. This adaptation is through amino acid variations, but the patterns of such variation are not yet well understood. Given that infection of long-lived CD4-low and CD4-negative cells in anatomical compartments such as the brain expands cell tropism in vivo and may serve as potential viral reservoirs that pose challenge for HIV eradication, understanding the evolution to CD4 independence and envelope conformation associated with infection in the absence of CD4 will not only broaden our insights into HIV pathogenesis but may guide functional cure strategies as well.

Methods:

We characterize, by site-directed mutagenesis, neutralization assay, and structural analysis, a pair of CD4-dependent (cl2) and CD4-independent (cl20) envelopes concurrently isolated from the cerebral spinal fluid of an SHIV-infected macaque with neurological AIDS and with minimum sequence differences.

Results:

Residues different between cl2 and cl20 are mapped to the V1V2 and surrounding regions. Mutations of these residues in cl2 increased its CD4 independence in infection, and the effects are cumulative and likely structural.

Conclusions:

Our data suggested that the determinants of CD4 independence in vivo mapped principally to V1V2 of gp120 that can destabilize the apex of the envelope spike, with an additional change in V4 that abrogated a potential N-linked glycan to facilitate movement of the V1V2 domain and further expose the coreceptor-binding site.
Increased Persistence of Initial Treatment for HIV Infection With Modern Antiretroviral Therapy
Authors: Davy-Mendez Thibaut , Eron Joseph J. , Zakharova Oksana , Wohl David A. , Napravnik Sonia
Published: June 2017

Background:

Initiating antiretroviral therapy (ART) early improves clinical outcomes and prevents transmission. Guidelines for first-line therapy have changed with the availability of newer ART agents. In this study, we compared persistence and virologic responses with initial ART according to the class of anchor agent used.

Setting:

An observational clinical cohort study in the Southeastern United States.

Methods:

All HIV-infected patients participating in the UNC Center for AIDS Research Clinical Cohort (UCHCC) and initiating ART between 1996 and 2014 were included. Separate time-to-event analyses with regimen discontinuation and virologic failure as outcomes were used, including Kaplan–Meier survival curves and adjusted Cox proportional hazards models.

Results:

One thousand six hundred twenty-four patients were included (median age of 37 years at baseline, 28% women, 60% African American, and 28% white). Eleven percent initiated integrase strand transfer inhibitor (INSTI), 33% non–nucleoside reverse transcriptase inhibitor (NNRTI), 20% boosted protease inhibitor, 27% other, and 9% NRTI only regimens. Compared with NNRTI-containing regimens, INSTI-containing regimens had an adjusted hazard ratio of 0.49 (95% confidence interval, 0.35 to 0.69) for discontinuation and 0.70 (95% confidence interval, 0.46 to 1.06) for virologic failure. All other regimen types were associated with increased rates of discontinuation and failure compared with NNRTI.

Conclusions:

Initiating ART with an INSTI-containing regimen was associated with lower rates of regimen discontinuation and virologic failure.
Antiretroviral Prescription and Viral Suppression in a Representative Sample of HIV-Infected Persons in Care in 4 Large Metropolitan Areas of the United States, Medical Monitoring Project, 2011–2013
Authors: Wohl Amy Rock , Benbow Nanette , Tejero Judith , Johnson Christopher , Scheer Susan , Brady Kathleen , Gagner Alexandra , Hughes Alison , Eberhart Michael , Mattson Christine , Skarbinski Jacek
Published: June 2017

Background:

Comparisons of antiretroviral therapy (ART) prescription and viral suppression among people in HIV care across US metropolitan areas are limited. Medical Monitoring Project, 2011–2013, data were used to describe and compare associations between sociodemographics and ART prescription and viral suppression for persons receiving HIV care.

Setting:

Chicago, Los Angeles County (LAC), Philadelphia, and San Francisco in the United States.

Methods:

Bivariate and multivariable methods were used.

Results:

The proportion of patients prescribed ART (91%–93%) and virally suppressed (79%–88%) was consistent although more persons were virally suppressed in San Francisco compared with the other areas, and a smaller proportion was virally suppressed in Philadelphia compared with Chicago. In the combined cohort, persons aged 30–49 years were less likely than persons 50+ (adjusted prevalence ratio (aPR) –0.97, confidence interval (CI): 0.94 to 0.99); persons reporting non-injection drug use were less likely than non-users (aPR = 0.94, CI: 0.90 to 0.98); and Hispanics were more likely than whites (aPR – 1.04, CI: 1.01 to 1.08) to be prescribed ART. Blacks (aPR = 0.93; CI: 0.87 to 0.99) and homeless persons (aPR = 0.87; CI: 0.80 to 0.95) were less likely to be virally suppressed in the combined cohort. In LAC, persons aged 30–49 years were less likely than those 50+ to be prescribed ART (aPR = 0.94, CI: 0.90 to 0.98). Younger persons (18–29) (aPR = 0.77; CI: 0.60 to 0.99) and persons with less than a high school education (aPR = 0.80; CI: 0.67 to 0.95) in Philadelphia, blacks (aPR = 0.90; CI: 0.83 to 0.99) and men who have sex with women only (aPR = 0.89; CI: 0.80 to 0.99) in Chicago, and homeless individuals in LAC (aPR = 0.80; CI: 0.67 to 0.94) were less likely to be virally suppressed.

Conclusion:

Data highlight the need to increase ART prescription to achieve viral suppression among younger persons, noninjection drug users, blacks, and homeless persons in US metropolitan areas and underscores the importance of region-specific strategies for affected subgroups.
Risk of Post-transplant Hepatocellular Carcinoma Recurrence Is Higher in Recipients of Livers From Male Than Female Living Donors
Authors: Han Sangbin , Yang Ju Dong , Sinn Dong Hyun , Kim Jong Man , Choi Gyu Sung , Jung Gangha , Ahn Joong Hyun , Kim Seonwoo , Ko Justin S. , Gwak Mi Sook , Kwon Choon Hyuck D. , Leise Michael D. , Gwak Geum-Youn , Heimbach Julie K. , Kim Gaab Soo
Published: June 2017

Objective:

To evaluate the relationship between donor sex and hepatocellular carcinoma (HCC) recurrence after living donor liver transplantation.

Background:

HCC shows a male predominance in incidence and recurrence after tumor resection due to sex differences in hepatic sex hormone receptors. There have been no studies evaluating the importance of donor sex on post-transplant HCC recurrence.

Methods:

Of 384 recipients of livers, from living donors, for HCC: 104/120 who received grafts from female donors were matched with 246/264 who received grafts from male donors using propensity score matching, with an unfixed matching ratio based on factors like tumor biology. Survival analysis was performed with death as a competing risk event. The primary outcome was overall HCC recurrence.

Results:

The median follow-up time was 39 months. Before matching, recurrence probability at 1/2/5 years after transplantation was 6.1/9.7/12.7% in recipients with female donors and 11.7/19.2/25.3% in recipients with male donors. Recurrence risk was significantly higher with male donors in univariable analysis (hazard ratio [HR] = 2.04 [1.15–3.60], P = 0.014) and multivariable analysis (HR=2.10 [1.20–3.67], P = 0.018). In the matched analysis, recurrence risk was also higher with male donors (HR=1.92 [1.05–3.52], P = 0.034): both in intrahepatic recurrence (HR=1.92 [1.05–3.51], P = 0.034) and extrahepatic recurrence (HR=1.93 [1.05–3.52], P = 0.033). Multivariable analysis confirmed the significance of donor sex (HR=2.08 [1.11–3.91], P = 0.023). Interestingly, the significance was lost when donor age was >40 years. Two external cohorts validated the significance of donor sex.

Conclusions:

Donor sex appears to be an important graft factor modulating HCC recurrence after living donor liver transplantation.
Open versus Laparoscopic Surgery for Advanced Low Rectal Cancer
Authors: Hida Koya , Okamura Ryosuke , Sakai Yoshiharu , Konishi Tsuyoshi , Akagi Tomonori , Yamaguchi Tomohiro , Akiyoshi Takashi , Fukuda Meiki , Yamamoto Seiichiro , Yamamoto Michio , Nishigori Tatsuto , Kawada Kenji , Hasegawa Suguru , Morita Satoshi , Watanabe Masahiko
Published: June 2017

Background:

Laparoscopic surgery for rectal cancer is widely performed all over the world and several randomized controlled trials have been reported. However, the usefulness of laparoscopic surgery compared with open surgery has not been demonstrated sufficiently, especially for the low rectal area.

Objective:

The aim of this study was to investigate the hypothesis that laparoscopic primary tumor resection is safe and effective when compared with the open approach for locally advanced low rectal cancer.

Patients and Methods:

Data from patients with clinical stage II to III low rectal cancer below the peritoneal reflection were collected and analyzed. The operations were performed from 2010 to 2011. Short-term outcomes and long-term prognosis were analyzed with propensity score matching.

Results:

Of 1608 cases collated from 69 institutes, 1500 cases were eligible for analysis. The cases were matched into 482 laparoscopic and 482 open cases. The mean height of the tumor from the anal verge was 4.6 cm. Preoperative treatment was performed in 35% of the patients. The conversion rate from laparoscopic to open surgery was 5.2%. Estimated blood loss during laparoscopic surgery was significantly less than that during open surgery (90 vs 625 mL, P < 0.001). Overall, the occurrence of complications after laparoscopic surgeries was less than that after open surgeries (30.3% vs 39.2%, P = 0.005). Three-year overall survival rates were 89.9% [95% confidence interval (95% CI) 86.7–92.4] and 90.4% (95% CI 87.4–92.8) in the laparoscopic and open groups, respectively, and no significant difference was seen between the 2 groups. No significant difference was observed in recurrence-free survival (RFS) between the 2 groups (3-year RFS: 70.9%, 68.4 to 74.2 vs 71.8%, 67.5 to 75.7).

Conclusion:

Laparoscopic surgery could be considered as a treatment option for advanced, low rectal cancer below the peritoneal reflection, based on the short-term and long-term results of this large cohort study (UMIN-ID: UMIN000013919).
Immediate Impact of Centralization on Abdominal Aortic Aneurysm Repair Outcomes for a Vascular Network in the South West of England
Authors: Leighton Philippa , Doe Matthew , Pathak Samir , AlDuwaisan Abdullah , Brooks Marcus
Published: June 2017

Objective:

Our aim was to assess the short-term impact of centralization on the outcomes of patients undergoing abdominal aortic aneurysm repair in a vascular network in the South West of England.

Background:

The centralization of vascular services has been implemented nationally across the National Health Service to improve patient outcomes. The full impact of these major changes has not yet been fully analyzed.

Methods:

A retrospective cohort study examining outcomes of patients undergoing abdominal aortic aneurysm repair, based on prospectively entered National Vascular Registry data, pre and post centralization in the South West of England. The primary outcome was mortality at 30 days. Secondary measures included 30-day morbidity, length of hospital stay, and length of intensive care unit stay.

Results:

The 30-day mortality was unchanged pre and post-centralization (11% vs 12%, P = 0.84). The 30-day morbidity rate was also unchanged (24% vs 25%, P = 0.83), as was length of intensive care unit stay (3 vs 3 days, P = 0.74). Overall length of stay was not significantly different (8 vs 6 days, P = 0.76). Subgroup analysis of patients with elective, ruptured, and symptomatic aneurysm repair demonstrated no differences in 30-day mortality. There was a significantly shorter stay post-centralization for patients with symptomatic aneurysms (6 vs 12 days pre-centralization, P = 0.012).

Conclusions:

The process of centralization of abdominal aortic aneurysm repair in a vascular network was safe for patients and had no immediate impact on outcomes. Longer-term outcome measures and financial data will be required to further assess the benefit of centralization.
The Surgeon Volume-outcome Relationship
Authors: Modrall J. Gregory , Minter Rebecca M. , Minhajuddin Abu , Eslava-Schmalbach Javier , Joshi Girish P. , Patel Shivani , Rosero Eric B.
Published: June 2017

Objective:

Increasing surgeon volume may improve outcomes for index operations. We hypothesized that there may be surrogate operative experiences that yield similar outcomes for surgeons with a low-volume experience with a specific index operation, such as esophagectomy.

Background:

The relationship between surgeon volume and outcomes has potential implications for credentialing of surgeons. Restrictions of privileges based on surgeon volume are only reasonable if there is no substitute for direct experience with the index operation. This study was aimed at determining whether there are valid surrogates for direct experience with a sample index operation—open esophagectomy.

Methods:

The Nationwide Inpatient Sample (2003–2009) was utilized. Surgeons were stratified into low and high-volume groups based on annual volume of esophagectomy. Surrogate volume was defined as the aggregate annual volume per surgeon of upper gastrointestinal operations including excision of esophageal diverticulum, gastrectomy, gastroduodenectomy, and repair of diaphragmatic hernia.

Results:

In all, 26,795 esophagectomies were performed nationwide (2003–2009), with a crude inhospital mortality rate of 5.2%. Inhospital mortality decreased with increasing volume of esophagectomies performed annually: 7.7% and 3.8% for low and high-volume surgeons, respectively (P < 0.0001). Among surgeons with a low-volume esophagectomy experience, increasing volume of surrogate operations improved the outcomes observed for esophagectomy: 9.7%, 7.1%, and 4.3% for low, medium, and high-surrogate-volume surgeons, respectively (P = 0.016).

Conclusions:

Both operation-specific volume and surrogate volume are significant predictors of inhospital mortality for esophagectomy. Based on these observations, it would be premature to limit hospital privileges based solely on operation-specific surgeon volume criteria.
Robotic Versus Video-assisted Lobectomy/Segmentectomy for Lung Cancer
Authors: Liang Hengrui , Liang Wenhua , Zhao Lei , Chen Difei , Zhang Jianrong , Zhang Yiyin , Tang Shiyan , He Jianxing
Published: June 2017

Objective: To compare the safety/efficacy of the robotic-assisted lobectomy/segmentectomy (RAL/S) with the video-assisted lobectomy/segmentectomy (VAL/S) for radical lung cancer resection.

Background:

It remains uncertain whether the newly developed RAL/S is comparable with the VAL/S.

Methods:

A comprehensive search of online databases was performed. Perioperative outcomes were synthesized. Cumulative meta-analysis was performed to evaluate the temporal trend of pooled outcomes. Specific subgroups (propensity score matching studies, pure lobectomy studies) were examined.

Results:

Analysis of 14 studies including a total of 7438 patients was performed. RAL/S was performed on 3239 patients, whereas the other 4199 patients underwent VAL/S. The 30-day mortality [0.7% vs 1.1%; odds ratio (OR) 0.53, P = 0.045] and conversion rate to open surgery (10.3% vs 11.9%; OR 0.57, P < 0.001) were significantly lower in patients who underwent RAL/S than VAL/S. Meanwhile, the postoperative complications (27.5% vs 28.2%; OR 0.95, P = 0.431), operation time [176.63 vs 162.74 min; standardized mean difference (SMD) 0.30, P = 0.086], duration of hospitalization (4.90 vs 5.23 days; SMD −0.08, P = 0.292), days to tube removal (4.10 vs 3.53 days; SMD 0.25, P = 0.120), retrieved lymph node (11.96 vs 10.67; SMD 0.46, P = 0.381), and retrieved lymph node station (4.98 vs 4.32; SMD 0.83, P = 0.261) were similar between the 2 groups. The cumulative meta-analyses suggested that the relative effects between 2 groups have already stabilized. All outcomes of subgroup and overall analyses were similar.

Conclusions:

This up-to-date meta-analysis confirms that RAL/S is a feasible and safe alternative to VAL/S for radical resection of lung cancer. Future studies should focus on the long-term benefits and cost effectiveness of RAL/S compared with VAL/S.