bluuebunny/crossref_metadata_2025 huggingface dataset:
The impact of race on hysterectomy for benign indications
Authors: McClurg Asha , Wong Jacqueline , Louie Michelle
Published: April 2020

Purpose of review

To review current literature evaluating racial disparities in benign hysterectomy care in the United States.

Recent findings

Evidence shows that black women are half as likely to undergo minimally invasive hysterectomy and have an increased risk of surgical complications compared with white women. Patient level differences including fibroids, prior surgical history, medical comorbidities, and obesity have been implied to account for the increased rate of abdominal hysterectomy in black patients; however, inequalities remain even after controlling for clinical differences. Societal factors including insurance status fail to fully account for disparities, though healthcare system factors, such as geographical region and access to a minimally invasive trained surgeon, continue to have a profound impact on the equity of care that patients receive.

Disparities in hysterectomy route and outcomes by race and socioeconomic status exist and have persisted in the literature for over a decade despite a nationwide trend toward minimally invasive hysterectomy and improving surgical outcomes. These disparities are not fully accounted for by patient or health system factors. Successfully addressing these disparities will require a multipronged approach, which may include improved surgical training for residents, fellows, and practicing gynecologists, increasing referrals to high-volume minimally invasive gynecologic surgeons, and provider and patient education.
A Single Incision Anterior Approach for Transhumeral Amputation Targeted Muscle Reinnervation
Authors: Daly Michael C. , He Janice J. , Ponton Ryan P. , Ko Jason H. , Valerio Ian L. , Eberlin Kyle R.
Published: April 2020

Targeted muscle reinnervation (TMR) is an evolving technique with promising results for prevention and treatment of neuropathic pain, as well as modulation of control for myoelectric prostheses. The previously described and most commonly used technique for transhumeral TMR combines both an anterior and posterior approach to access the major peripheral nerves of the upper extremity. In this article, we review the literature for transhumeral TMR and describe a more expeditious and efficient anterior-only approach that offers safe access through a single incision.
Intraoperative Three-Dimensional Fluorescein Angiography-Guided Pars Plana Vitrectomy for the Treatment of Proliferative Diabetic Retinopathy: The Maximized Utility of the Digital Assisted Vitrectomy
Authors: Imai Hisanori , Tetsumoto Akira , Inoue Saki , Takano Fumio , Yamada Hiroko , Hayashida Mayuka , Otsuka Keiko , Miki Akiko , Kusuhara Sentaro , Nakamura Makoto
Published: April 2020

Purpose:

To show the usefulness of the intraoperative three-dimensional fluorescein angiography (3D-FA)-guided pars plana vitrectomy.

Methods:

The NGENUITY 3D visualization system was used for the digital assisted vitrectomy. Three-dimensional fluorescein angiography-guided pars plana vitrectomy was performed in three patients with vitreous hemorrhage secondary to proliferative diabetic retinopathy. We investigated both whether several angiographic findings can be successfully displayed on the screen during 3D-FA and whether pars plana vitrectomy can be performed simultaneously on the same screen while implementing 3D-FA.

Results:

In all cases, the abnormal FA findings including hypofluorescence due to non-perfusion areas, and the hyperfluorescence due to macular edema and fibrovascular proliferative membrane were successfully displayed on the screen. The segmentation and delamination of fibrovascular proliferative membrane and panretinal photocoagulation for detected non-perfusion areas were able to be performed on the same screen while implementing 3D-FA.

Conclusion:

Three-dimensional fluorescein angiography-guided pars plana vitrectomy is a novel approach that fully utilizes the advantages of digital assisted vitrectomy and a promising option for the treatment of proliferative diabetic retinopathy.
Loteprednol etabonate gel 0.5% vs prednisolone acetate suspension 1% for the treatment of inflammation after cataract surgery in children
Authors: Vittitow Jason L. , Williams Jon I.
Published: April 2020

Purpose:

To compare loteprednol etabonate (LE) gel 0.5% with prednisolone acetate suspension (PA) 1% for the treatment of inflammation after cataract surgery in children.

Setting:

Eleven sites in the United States.

Design:

Randomized, double-masked, parallel-group, noninferiority study.

Methods:

Eligible patients were aged 11 years or younger and candidates for routine, uncomplicated cataract surgery. Patients were randomized to a 4-week postsurgical regimen with LE gel 0.5% or PA 1%, twice on the day of surgery, 4 times daily for 2 weeks, twice daily for 1 week, and once daily for 1 week. Assessments included anterior chamber (AC) cells/flare, anterior chamber inflammation (ACI), synechiae, precipitates on the intraocular lens/cornea, visual acuity, and intraocular pressure.

Results:

The intent-to-treat population comprised 105 patients (LE gel, n = 53; PA 1%, n = 52) including 52 patients aged 3 years or younger. Patients achieved a similar mean ACI grade on postoperative day 14 (primary efficacy endpoint) whether treated with LE gel 0.5% or PA 1% (difference = 0.006, 2-sided 95% CI, −0.281 to 0.292). Similar ACI outcomes additionally were observed in patients aged 3 years or younger. LE gel 0.5% and PA 1% also appeared equally effective in resolving inflammation at all visits (days 7, 14, and 28 postsurgery), based on categorical distributions of ACI, AC cells, and AC flare scores/grades (P ≥ .06). Synechiae and corneal/IOL precipitates occurred infrequently with no significant differences between groups. No safety or tolerability concerns were identified, including no treatment-related IOP increases.

Conclusions:

LE gel 0.5% was safe and effective in treating pediatric postcataract surgical inflammation, with similar outcomes as PA 1%.
Paid Sick Leave and Sleep
Authors: Collins Cyleste , DeRigne LeaAnne , Bai Rong , Stoddard Dare Patricia
Published: April 2020

Objective:

This study examines links between paid sick leave benefits and sleep as an indicator of well-being.

Methods:

Using data from 12,780 employed adult US workers in the 2018 National Health Interview Survey, the relationship between paid sick leave and sleep was explored while controlling for demographic and health status variables.

Results:

Logistic multiple regression analyses revealed that compared with workers without paid sick leave, workers with paid sick leave had significantly higher odds of staying asleep, lower odds of feeling rested, and marginally significantly higher odds of having little trouble falling asleep. The groups did not differ regarding the odds of taking sleep medication or getting the ideal amount of sleep.

Conclusion:

The findings suggest a link between sleep quality and access to paid sick leave, adding to a growing list of health and well-being variables associated with paid sick leave benefits.
The role of radiation for pancreatic adenocarcinoma
Authors: Gamboa Adriana C. , Lee Rachel M. , Maithel Shishir K.
Published: April 2020

Pancreatic cancer is an aggressive malignancy with a high recurrence rate even after curative-intent resection. Improvements in survival have not been achieved in the last 25 years thus highlighting the need for effective multimodal treatment strategies. The role of radiation therapy for pancreatic cancer remains ill-defined due to historical lack of a standard definition of resectability, and the use of antiquated radiation delivery techniques and chemotherapy regimens. Current level I data regarding neoadjuvant chemoradiotherapy for resectable and borderline resectable pancreatic adenocarcinoma (PDAC) are limited to 2 randomized controlled trials and several retrospective studies and suggest that it may lead to an increased likelihood of a margin-negative resection and certainly allows for improved patient selection for pancreaticoduodenectomy when compared to upfront surgery. In the adjuvant setting, data are similarly lacking but suggest that chemoradiotherapy may be beneficial for patients at high risk of locoregional recurrence. Here we review existing data regarding the role of radiation in PDAC.
Outcomes Following Revision Stapes Surgery in Children: A Single-Surgeon, Single-Center 15-Year Experience
Authors: Jervis-Bardy Joshua , Gau Victoria L. , Allsopp Tristan , King Deanne , Page Joshua Cody , Dornhoffer John L.
Published: April 2020

Objective:

To review a single surgeon experience with revision pediatric stapes surgery for congenital stapes fixation (CSF) and tympanosclerosis (TS). Secondly, to determine whether hearing outcomes following revision surgery may be predicted by a thorough work-up aimed at assessing whether an extruded or malpositioned prosthesis is likely to be encountered intraoperatively.

Setting:

Tertiary referral center.

Study Design:

Retrospective chart review.

Patients:

Fifteen patients having revision surgery for fixation of the stapes footplate over a 15-year period.

Main Outcome Measures:

Hearing results based on pre- and post-revision pure-tone average air-bone gap (PTA-ABG) and speech recognition threshold testing (SRT).

Results:

Overall, the mean improvement of PTA-ABG following revision surgery was 11.9 dB (standard deviation [SD] 15.2) while SRTs improved by a mean of 12.3 (SD 19.9). Outcomes were significantly better in patients who reported a history of trauma following their initial surgery, when there was otoscopic evidence of an extruding or extruded prosthesis and/or a pre-revision CT (where performed) suggested an extruded or malpositioned prosthesis. No patients had a significant postoperative sensorineural hearing loss.

Conclusion:

Revision stapes surgery in children is a safe procedure in experienced hands which nonetheless should only be contemplated in patients in whom preoperative work-up suggests an extruded or malpositioned prosthesis is likely to be encountered intraoperatively.
Rat Model of External Auditory Canal Stenosis
Authors: Lang Dustin M. , Antonelli Patrick J. , Dirain Carolyn O.
Published: April 2020

Hypothesis:

Circumferential electrocautery injury of the rat external auditory canal (EAC) can induce a reproducible animal model of acquired stenosis.

Background:

Acquired EAC stenosis may occur as a result of chronic inflammation or trauma to the EAC skin and is characterized by narrowing of the EAC, retention of debris, and hearing loss. Treatment is surgery but it is often complicated by restenosis. A reliable and inexpensive animal model of EAC stenosis has not been described. There have been no studies correlating the extent of EAC injury with the extent of stenosis.

Methods:

Rats received a 25, 50, or 75% circumferential EAC injury with electrocautery. The extent of resulting stenosis was quantified 21 days following injury. The nature of the injury and healing response was assessed with histology.

Results:

A 25% circumferential injury led to 4 to 34% stenosis (mean, 13%), 50% injury resulted in 43 to 100% stenosis (mean, 73%), and 75% injury resulted in 94 to 100% stenosis (mean=99%, p < 0.0001). The 50% circumferential injury produced 30 to 75% stenosis in five of eight ears, the remainder had >75% stenosis. Wounded ears showed evidence of intact cartilage and epithelium, with increased thickness of the subepithelial layer and localized fibrosis.

Conclusions:

Electrocautery injury in the ventral aspect of the rat EAC resulted in reproducible EAC stenosis. This rat model may be useful in studying therapy to prevent acquired EAC stenosis due to acute injury. The correlation of the extent of injury (circumference) with resulting stenosis may inform clinical management of EAC injuries.
Vitamin D Deficiency, Hypocalcemia, and Hearing Loss in Children
Authors: Mehta Charmee H. , Close Michaela F. , Dornhoffer James R. , Liu Yuan F. , Nguyen Shaun A. , McRackan Theodore R. , Meyer Ted A.
Published: April 2020

Objective:

Characterize relations between vitamin D deficiency (VDD), hypocalcemia, and hearing loss (HL) in children.

Study Design:

Retrospective review.

Setting:

Tertiary referral hospital.

Patients:

Children in the Audiological and Genetic Database with a diagnosis of VDD, rickets, or osteomalacia.

Intervention:

None.

Main Outcome Measures:

Prevalence, type, severity (4-tone pure-tone average, PTA), and progression of HL. HL was defined as greater than 15 dB HL at any threshold by pure tone, greater than 20 dB HL by sound field audiometry, or greater than 25 dB in infants less than 1 year of age.

Results:

Of 888 children with VDD, 474 (53.4%) had HL, with 17% having moderate-profound HL. Compared with an age-matched cohort of 13,320 children drawn from the same database, children with VDD were significantly more likely to have sensorineural HL (SNHL) (adjusted odds ratios [aOR] 1.26 [95% confidence interval [CI] 1.01–1.58]). Among children with VDD, children with femur fracture had a significantly higher rate of HL (81% versus 53%, p = 0.008) and children with hypocalcemia had a significantly higher rate of moderate-profound HL (36% versus 18%, p = 0.016). Additionally, hypocalcemia with and without VDD was associated with SNHL (aOR 2.30 [1.07–4.56]).

Conclusions:

Both vitamin D deficiency and hypocalcemia were found to be independently associated with SNHL, a type of HL that is less likely to improve over time. Recognition of VDD and hypocalcemia as independent risk factors for the development of SNHL could allow for better evaluation and treatment of this patient population. Routine audiological evaluation should be considered in this population.
Bisphosphonate Therapy for Treating Osteonecrosis in Pediatric Leukemia Patients: A Systematic Review
Authors: Daneshdoost Shanaz M. , El Abiad Jad M. , Ruble Kathy J. , Jones Lynne C. , Crane Janet L. , Morris Carol D. , Levin Adam S.
Published: April 2020

Background:

Despite improved outcomes in children with leukemia, complications such as osteonecrosis are common. We conducted a systematic review to investigate the role of bisphosphonates in reducing pain, improving mobility, and stabilizing lesions in pediatric leukemia survivors.

Methods:

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched the PubMed, Embase, Cochrane, Web of Science, Scopus, CINAHL, and ClinicalTrials.gov databases. Five of 221 articles retrieved met our inclusion criteria.

Results:

Bisphosphonates, especially when combined with dietary calcium and vitamin D supplements and physical therapy (supplements/PT) were associated with improved pain and mobility in 54% and 50% of patients, respectively. A significantly greater proportion of patients treated with bisphosphonates (83%) reported mild/moderate pain or no pain compared with those with supplements/PT alone (36%) (P<0.001). Sixty-six percent of patients treated with bisphosphonates achieved improved/full mobility compared with 27% of those treated with supplements/PT alone (P=0.02). However, 46% of patients showed progressive joint destruction despite bisphosphonate therapy. No adverse events were reported, except for acute phase reactions to intravenous therapies.

Conclusions:

Bisphosphonates, when combined with supplements/PT, were associated with less pain and improved mobility, but not prevention of joint destruction in pediatric leukemia patients with osteonecrosis.
Hemophagocytic Lymphohistiocytosis in Patients With Primary Immunodeficiency
Authors: Cetinkaya Pinar G. , Cagdas Deniz , Gumruk Fatma , Tezcan Ilhan
Published: April 2020

Hemophagocytic lymphohistiocytosis (HLH) is characterized by uncontrolled and excessive immune responses with high mortality. We aimed to define mortality-related parameters in HLH secondary to primary immunodeficiency (PID). A total of 28 patients with HLH between the years 2013 and 2017 were enrolled in the study. The patients were evaluated in 2 groups including PID with hypopigmentation (n=7) (Chédiak-Higashi syndrome [CHS] and Griscelli syndrome type 2 [GS2]) and other PIDs (n=21). The median age of the study population was 23 (4.3 to 117.0) months at the time of the diagnosis of HLH. Central nervous system involvement was recorded in 7 (GS2/CHS patients [n=4], other PIDs [n=3], P=0.026), and death was observed in 9 patients (GS2/CHS patients [n=1], other PIDs [n=8], P=0.371). Five patients (3 GS2/CHS and 2 other PID patients) underwent hematopoietic stem cell transplantation. Low serum albumin level was the only variable associated with the mortality and albumin levels less than the cut-off value of 3.07 g/dL increased mortality 5.8 times in patients with HLH secondary to PID. We presented a single-center experience consisting of patients with HLH secondary to PID with a mortality rate of 32.1%. Hypoalbuminemia was the only risk factor to increase the overall mortality rate of HLH.
Highlighting Contributions of Behavioral and Social Sciences in Advancing Public Health: Where We've Come, Where We're Headed
Authors: Alber Julia M. , Green Lawrence W. , Gambescia Stephen F. , McLeroy Kenneth R. , Sofalvi Alan , Auld M. Elaine
Published: April 2020

Context:

Social and behavioral sciences, a cross-disciplinary field that examines the interaction among behavioral, biological, environmental, and social factors, has contributed immensely to some public health achievements over the last century. Through collaboration with community organizations and partners, social and behavioral scientists have conducted numerous program interventions involving community engagement and advocacy efforts at the local, state, federal, and international levels.

Contributions of Social and Behavioral Sciences:

This article traces select historical underpinnings of the applications of social and behavioral sciences theories and evidence to public health and highlights 4 areas in which health education specialists have distinctly contributed to public health achievements by building on theory and evidence. Applied social and behavioral sciences have formed the basis of various health education interventions. These 4 areas include the following: (1) Theory, Model Development, and the Professionalization of Health Education; (2) Participation and Community Engagement; (3) Health Communication; and (4) Advocacy and Policy.

Discussion:

We present contemporary challenges and recommendations for strengthening the theory, research, and practice of health education within the context of social and behavioral sciences in addressing emerging public health issues.
Outbreak Response Capacity Assessments and Improvements Among Public Health Department Health Care–Associated Infection Programs—United States, 2015-2017
Authors: Franklin Steven M. , Crist Matthew B. , Perkins Kiran M. , Perz Joseph F.
Published: April 2020

Context:

The Centers for Disease Control and Prevention awarded $85 million to health care–associated infection and antibiotic resistance (HAI/AR) programs in March 2015 as part of Infection Control Assessment and Response (ICAR) activities in the Epidemiology and Laboratory Capacity cooperative agreement Domestic Ebola Supplement.

Program:

One goal of this funding was to assess and improve program capacity to respond to potential health care outbreaks (eg, HAI clusters). All 55 funded programs (in 49 state and 6 local health departments) participated.

Implementation:

The Centers for Disease Control and Prevention developed guidance and tools for HAI/AR programs to document relevant response capacities, assess policies, and measure progress. HAI/AR programs completed an interim assessment in 2016 and a final progress report in 2017.

Evaluation:

During the project period, 78% (n = 43) of the programs developed new investigation tools, 85% (n = 47) trained staff on outbreak response, and 96% (n = 53) of the programs reported hiring staff to assist with outbreak response activities. Staffing and expertise to support HAI outbreak response increased substantially among awardees reporting staffing limitations on the interim assessment, including in domains such as on-site infection control assessment (n = 20; 83%), laboratory capacity (n = 20; 91%), and data management/analytics (n = 14; 67%). By 2017, reporting requirements in 100% of the programs addressed possible HAI/AR outbreaks; 93% (n = 51) also addressed sentinel events such as identification of novel AR threats. More than 90% (n = 50) of programs enhanced capacities for tracking response activities; in 2016, these systems captured 6665 events (range, 3-1379; median = 46). Health departments also reported wide-ranging efforts to engage regulatory, public health, and health care partners to improve HAI/AR outbreak reporting and investigation.

Discussion:

Broad capacity for responding to HAI/AR outbreaks was enhanced using Ebola ICAR supplemental funding. As response activities expand, health department programs will be challenged to continue building expertise, reporting infrastructure, investigation resources, and effective relations with health care partners.
Wildfire Smoke Risk Communication Efficacy: A Content Analysis of Washington State's 2018 Statewide Smoke Event Public Health Messaging
Authors: Van Deventer Darcy , Marecaux Justine , Doubleday Annie , Errett Nicole , Isaksen Tania M. Busch
Published: April 2020

Context:

Wildfire events are increasing in prevalence and intensity in the Pacific Northwest. Effective communication of health risks and actions to reduce exposure to wildfire smoke is imperative.

Objective:

We assessed the content of wildfire smoke risk messages from government organizations and mainstream media during a major wildfire smoke event in August 2018.

Design:

We conducted a content analysis of wildfire smoke risk information communicated by local and state government organizations and the mainstream media.

Setting:

Eight Washington State counties during a statewide wildfire smoke event in August 2018.

Main Outcome Measure:

Leveraging the Extended Parallel Process Model and information in the existing literature on wildfire smoke and health, we assessed messages for the presence of information regarding health risk, personal interventions, administrative interventions, vulnerable populations, and trusted sources of information. Summary statistics were calculated to identify common messages about recommended interventions, vulnerable populations cited, and trusted sources of public health information.

Results:

Of the 273 identified government and media messages on wildfire smoke, the majority (71% and 66%) contained information about health risks. However, only 46% and 33% of government and media messages contained information about personal interventions to reduce risk, and 37% and 14% of government and media messages contained information about administrative interventions to reduce risk. Less than half of government and media messages (28% and 31%) contained information specific to vulnerable populations, and 58% and 46% of government and media messages contained any reference to a trusted source of information.

Conclusions:

While information about wildfire smoke and health risks was communicated during Washington's August 2018 wildfire smoke event, there remains considerable opportunity to include additional information about interventions, vulnerable populations, and trusted sources of information. We recommend several opportunities to improve and evaluate risk communication and risk reduction before, during, and after future wildfire smoke events.
Decreasing Chronic Lung Disease Associated with Bubble CPAP Technology: Experience at Five Years
Authors: Miller Tricia A. , Li Jing , Riddell Stella , Barkley Steven C.
Published: April 2020

Introduction:

Bubble continuous positive airway pressure (bCPAP) is associated with a decreased risk for chronic lung disease (CLD) in preterm neonates. This report examined the effectiveness of adopting bCPAP to reduce respiratory complications and medication usage in a community hospital NICU.

Methods:

The efficacy of bCPAP was assessed by retrospective examination and comparison of 45 neonates who received bCPAP and 87 neonates who received conventional ventilation only. Data on medication usage were also collected and analyzed.

Results:

After introduction of the bCPAP protocol, the median number of days on oxygen decreased in the bCPAP group compared with the conventional ventilation only group (median = 33 days, IQR = 7.5–66 vs median = 0, IQR = 0–0; P < 0.001). The exposure to conventional ventilation decreased in the bCPAP group compared with the conventional ventilation only group (median = 18 days, IQR = 5–42.5 vs median = 0, IQR = 0–7; P < 0.001). Postimplementation of bCPAP revealed decreases in CLD from 26 (30%) in the conventional ventilation only group to 2 (4%) in the bCPAP group (P = 0.002); there was also a significant decrease in the use of sedative medications in the bCPAP group compared with the conventional ventilation only group (mean = 5.20 doses, SD = 31.97 vs mean = 1.43, SD = 9.98; P < 0.001).

Conclusion:

The use of bCPAP results in significant decreases in the use of conventional ventilation, the risk for CLD, and the need for sedative medication.
Trends in the Surgical Management of Lower Extremity Gustilo Type IIIB/IIIC Injuries
Authors: Burns Jack C. , DeCoster Ryan C. , Dugan Adam J. , Davenport Daniel L. , Vasconez Henry C.
Published: April 2020

Background:

Over the past 20 years, innovations in microsurgical technique have coincided with advances in orthoplastic approaches. However, no single algorithm exists to guide management of limb salvage versus amputation. As such, one would expect these procedures to be performed at equal rates given studies showing similar outcomes. Anecdotally, the observation at the authors’ institution is that amputations are being performed more frequently. The purpose of this study was to determine trends in lower extremity trauma management.

Methods:

A retrospective cohort study was conducted at a Level I trauma center on patients with Gustilo type IIIB/IIIC lower extremity trauma from 2005 to 2014. Overall, 148 patients were included. Patients were subdivided into amputation (n = 69) and reconstruction (n = 79) cohorts. The Spearman rank correlation coefficient was used to compare trends in amputation and reconstruction groups. Plastic surgery consultation data were analyzed using the Mann-Whitney U and chi-square tests and the Pearson correlation coefficient.

Results:

Amputation was performed more frequently over the study period (r = 0.292; p < 0.001). Plastic surgeons were consulted in 67.5 percent of cases. A plastic surgery consultation was obtained in only 30 percent of amputation cases (p < 0.001).

Conclusions:

Although the data show a trend toward amputation and a shift in management of lower extremity trauma, the observed trend may be attributable in part to deviation from an orthoplastic approach to lower extremity trauma. However, lower extremity reconstruction remains a viable option in select patients, and advances in microsurgery can provide excellent outcomes in the face of severe lower extremity trauma.
Extrinsic and Behavioral Fall Risk Factors in People With Parkinson’s Disease: An Integrative Review
Authors: Kuljeerung Orawan , Lach Helen W.
Published: April 2020

Aim

The aim of the study was to explore extrinsic and behavioral risks for falls in older adults with Parkinson’s disease (PD).

Background

Falls that cause injury and disability in people with PD are common. Understanding the role of extrinsic and behavioral factors is important for fall prevention.

Design

Integrative literature review with search of CINAHL, MEDLINE, and SCOPUS and ancestry searching was performed.

Methods

The methodology of Whittemore and Knafl guided the review; ten studies were included.

Findings

Falls occur indoors and outdoors, commonly during daily activities in familiar home environments, but also when out in the community. Common challenges include uneven and unfamiliar environments and risky behavior like hurrying.

Conclusion

Extrinsic risk factors combined with behavioral and intrinsic factors contribute to falls in people with PD both at home and in the community.

Clinical Relevance

Rehabilitation of people with PD should include assessment of falls, function, extrinsic risk factors, and fit with their environment to develop fall prevention plans.
Congenital Descending Aorta to Pulmonary Vein Fistula
Authors: DeFilipp Miriam , Machnicki Stephen
Published: April 2020

Congenital descending aorta to pulmonary vein fistula (cDAPVF) is an extremely rare vascular abnormality that is usually diagnosed in infancy. Patients can become symptomatic, presenting with heart failure and hemoptysis. It is important to differentiate cDAPVF from its potential mimickers due to differences in treatment implications. In this pictorial essay, we will highlight the pathophysiology and key imaging findings of cDAPVF and how to separate it from its more common mimickers using cases that presented at our institution.
Impact of Facilitation of Early Mobilization on Postoperative Pulmonary Outcomes After Colorectal Surgery
Authors: Balvardi Saba , Pecorelli Nicolò , Castelino Tanya , Niculiseanu Petru , Alhashemi Mohsen , Liberman Alexander Sender , Charlebois Patrick , Stein Barry , Carli Franco , Mayo Nancy E. , Feldman Liane S. , Fiore Julio F.
Published: April 2020

Objective:

To estimate the extent to which staff-directed facilitation of early mobilization impacts recovery of pulmonary function and 30-day postoperative pulmonary complications (PPCs) after colorectal surgery.

Summary Background Data:

Early mobilization after surgery is believed to improve pulmonary function and prevent PPCs; however, adherence is low. The value of allocating resources (eg, staff time) to increase early mobilization is unknown.

Methods:

This study involved the analysis of a priori secondary outcomes of a pragmatic, observer-blind, randomized trial. Consecutive patients undergoing colorectal surgery were randomized 1:1 to usual care (preoperative education) or facilitated mobilization (staff dedicated to assist transfers and walking during hospital stay). Forced vital capacity, forced expiratory volume in 1 second (FEV1), and peak cough flow were measured preoperatively and at 1, 2, 3 days and 4 weeks after surgery. PPCs were defined according to the European Perioperative Clinical Outcome Taskforce.

Results:

Ninety-nine patients (57% male, 80% laparoscopic, median age 63, and predicted FEV1 97%) were included in the intention-to-treat analysis (usual care 49, facilitated mobilization 50). There was no between-group difference in recovery of forced vital capacity [adjusted difference in slopes 0.002 L/d (95% CI −0.01 to 0.01)], FEV1 [−0.002 L/d (−0.01 to 0.01)] or peak cough flow [−0.002 L/min/d (−0.02 to 0.02)]. Thirty-day PPCs were also not different between groups [adjusted odds ratio 0.67 (0.23–1.99)].

Conclusions:

In this randomized controlled trial, staff-directed facilitation of early mobilization did not improve postoperative pulmonary function or reduce PPCs within an enhanced recovery pathway for colorectal surgery.

Trial Registration:

ClinicalTrials.gov Identifier: NCT02131844.
Pitfalls and novel experimental approaches to optimize microbial interventions for chemotherapy-induced gastrointestinal mucositis
Authors: da Silva Ferreira Ana R. , Wardill Hannah R. , Tissing Wim J.E. , Harmsen Hermie J.M.
Published: April 2020

Purpose of review

There is a growing number of studies implicating gut dysbiosis in mucositis development. However, few studies have shed light on the causal relationship limiting translational potential. Here, we detail the key supportive evidence for microbial involvement, candidate mechanisms by which the microbiome may contribute to mucositis and emerging approaches to model host–microbe interactions with clinical relevance and translational potential.

Recent findings

Synthesis of existing clinical data demonstrate that modulating the microbiome drastically alters the development and severity of mucositis, providing a strong rationale for its involvement. Review of the literature revealed potential microbiome-dependent mechanisms of mucosal injury including altered drug metabolism, bile acid synthesis and regulation of the intestinal barrier. Current studies are limited in their mechanistic insight due to cross-sectional and would benefit from longitudinal analyses and baseline phenotyping.

The causative role of the microbiome in mucositis development remains unclear. Future studies must adopt comprehensive microbial analyses with functional assessment, and utilize emerging ex-vivo models to interrogate host–microbe interactions in mucositis.
Sequence of Pelvic Examination Does Not Affect Patients With Baseline Vulvovaginal Syndromes: A Randomized Clinical Trial
Authors: Rinko Rebecca , Spector Chelsea , Cook Ellen , Mancenido Briana , Gracely Edward J. , Nyirjesy Paul
Published: April 2020

Objective

The purpose of this study is to determine the optimal sequence in performing a pelvic examination to reduce discomfort in patients with baseline vaginal pain.

Methods

A randomized controlled trial of women presenting for a new appointment at the Drexel Vaginitis Center was conducted. Women were assigned to either group A, a Q-tip touch test, speculum examination, then bimanual examination, or group B, a Q-tip touch test, bimanual examination, then speculum examination. The primary outcome was visual analog scales to assess pain at baseline and after each portion of the examination. Secondary outcomes were responses to questionnaires for self-esteem, quality of life, and sexual function.

Results

Two hundred women were enrolled in the trial. For both group A and group B, each portion of the examination was similarly scored regardless of whether the speculum examination was performed before or after bimanual examination. Pain during the speculum examination was higher than pain during the other components of the examination, although not significant (P = 0.65).

When looking at reported pain outcomes, outcomes did not differ as a whole or between groups in relation to sexual activity, sexual orientation, and previous hysterectomy. The data were not significantly different between groups for self-esteem scores, sexual dysfunction, or quality of life scores.

Conclusion

In women with baseline vaginal pain, there was no difference in pain scores between the different components of the pelvic examination, nor is there a significant difference in pain during the examination compared with their baseline pain. Most patients reported minimal pain during each component.
Intra-abdominal Pressure and Pelvic Floor Health: Should We Be Thinking About This Relationship Differently?
Authors: Dietze-Hermosa Martin , Hitchcock Robert , Nygaard Ingrid E. , Shaw Janet M.
Published: April 2020

Objectives

Intra-abdominal pressure (IAP) increases during physical activity. Activities with high IAP are often restricted for women because of potential pelvic floor overloading. Researchers categorize high IAP activities using absolute values (in centimeters of water). Although essential for descriptive purposes, absolute IAP may not be ideal for individualized exercise recommendations. For oxygen consumption, a well-established measure of fitness, exercise scientists use a percentage of the maximal value observed during exercise to create relative exercise intensity prescriptions for an individual. Relative exercise intensity correlates inversely to the maximal value observed. We explore whether this approach and response pattern extend to IAP observed during exercise.

Methods

Fifty-five women completed 16 exercises while wearing a vaginal sensor to measure IAP. The highest mean IAP occurred during seated Valsalva/strain (IAPSTRAIN). We calculated relative IAP (in percent) for each participant by dividing the maximal IAP during each exercise by IAPSTRAIN. We examined relationships between relative IAP and IAPSTRAIN for each activity using Pearson r correlations.

Results

Mean age was 30.4 ± 9.4 years, and body mass index was 22.4 ± 2.6 kg/m2. For most women, IAP was greater during strain than during exercises. Relative IAPs negatively correlated with IAPSTRAIN. Excluding one exercise because of small sample sizes, r for all others ranged from −0.35 to −0.80, all statistically significant.

Conclusions

The relative IAP responses to many exercises exhibit an inverse relationship to the highest IAP values during strain, consistent with other variables measured during exercise. Relative IAP may provide an alternative to absolute IAP in understanding IAP’s effect on pelvic floor health.
Pregnancy in Women With Prior Treatments for Pelvic Floor Disorders
Authors: Wieslander Cecilia K. , Weinstein Milena M. , Handa Victoria L. , Collins Sarah A.
Published: April 2020

Although the peak incidence of surgery for pelvic floor disorders does not occur until after menopause, an increasing number of younger women are seeking treatment for these problems. Whereas most surgeons would recommend delaying surgery until the completion of childbearing, published cases and case series address outcomes after subsequent pregnancies in women who have been treated for urinary incontinence and pelvic organ prolapse. This document synthesizes the available evidence on the impact of pregnancy on women with prior treatment for pelvic floor disorders and on the impact of these prior treatments on subsequent pregnancy. Pregnancy after the repair of obstetrical anal sphincter laceration is also discussed. Consensus recommendations are presented based on available literature review and expert involvement.
Streamlining Postoperative Void Trials: A Study Comparing Standard Backfill Versus Backfill in the Operating Room
Authors: Meekins A. Rebecca , Amundsen Cindy L. , Weidner Alison C.
Published: April 2020

Objective

The standard backfill void trial (VT) performed after urogynecologic surgery is time-consuming. We adopted a new VT protocol in which the bladder is backfilled in the operating room (OR). We hypothesized that this protocol would result in (1) shorter postoperative care unit (PACU) stay and (2) lower rates of postoperative catheterization compared with standard VT.

Methods

We performed a retrospective cohort study of women who underwent same-day urogynecologic surgery between August 2018 and March 2019. Basic demographic and procedure information was collected. Patients were divided into 2 groups based on VT performed. Continuous and categorical variables were compared using Student t tests and χ2 tests, respectively. A linear regression model for PACU length of stay was used to control for confounders.

Results

Two hundred twenty-five women were included. One hundred eleven (49.3%) had the OR backfill VT and 114 (50.7%) had the standard VT. There were no statistically significant between-group differences in demographics or procedures performed. The average time in PACU was 15 minutes shorter in the OR backfill compared with the standard VT group (154.8 ± 60.6 vs 169.8 ± 83.2, P = 0.12). After adjusting for confounders, having the OR backfill VT resulted in a 23-minute reduction in PACU time (β = −23.7; 95% confidence interval, −41.3 to −6.1; P = 0.009). The overall VT failure rate was 21.3% and was not significantly different between groups (24.3% vs 18.4%, P = 0.28).

Conclusions

The OR backfill VT resulted in a shorter stay in PACU without increasing the incidence of postoperative catheterization. With the transition to enhanced recovery after surgery protocols, streamlining PACU activities is a priority.
Extracorporeal membrane oxygenation use in Trauma Quality Improvement Program centers: Temporal trends and future directions
Authors: Guttman Matthew P. , Tillmann Bourke W. , Pannell Dylan , Vallelonga Mark , Nathens Avery B. , Haas Barbara
Published: April 2020

BACKGROUND

Increased clinical experience and the decreased need for systemic anticoagulation have renewed interest in the use of extracorporeal membrane oxygenation (ECMO) for posttraumatic respiratory and cardiopulmonary failure. The objectives of this study were to describe the incidence and temporal trends of ECMO use at trauma centers, the outcomes of trauma patients undergoing ECMO, and the characteristics of trauma centers providing ECMO.

METHODS

Data were derived from the American College of Surgeons Trauma Quality Improvement Program data set. We included adults with at least one severe injury admitted to a level I or II trauma center between 2012 and 2016 who received at least 1 day of mechanical ventilation. Patients were categorized based on whether or not they received ECMO during their admission. The primary outcome was change in the incidence of ECMO across study years. We also evaluated patient outcomes and variation in ECMO volumes across centers.

RESULTS

Of 194,314 severely injured patients undergoing mechanical ventilation across 450 centers, 269 (0.14%) received ECMO. Extracorporeal membrane oxygenation patients had significantly higher mortality than non-ECMO patients (32% vs. 19%). The standardized rate of ECMO from 2012 to 2016 increased significantly from 75.2 to 179.0 cases per 100,000 severely injured patients undergoing mechanical ventilation. The average annual growth rate was 24%. Of the 82 centers(18%) reporting at least 1 ECMO trauma case, 34 (41%) reported only a single case.

CONCLUSION

The use of ECMO for trauma, although rare, is rapidly increasing. Two thirds of patients who receive ECMO following traumatic injury survive their hospitalization. These data suggest that ECMO represents a potential treatment strategy for trauma patients with respiratory or cardiopulmonary failure. However, given the rarity of the procedure, there exists an opportunity to develop practice guidelines regarding the indications for, and approach to, ECMO in the setting of trauma.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.
The Validity and Reliability of the Six-Spot Step Test (SSST) in Older Adults
Authors: Kondori Rana Ebrahimi , Cetin Sebahat Yaprak , Erel Suat
Published: April 2020

Objective:

To investigate the validity and reliability of the Six-Spot Step Test (SSST) in older adults.

Methods:

The study included 100 adults (60 males and 40 females) with a mean age of 68.91 years. The cognitive level of the older adults was evaluated with the Standardized Mini Mental Examination. Intraclass correlation coefficient (ICC) was used for reliability of the SSST. For the convergent validity of the SSST, the Timed Up and Go Test (TUG), the 10-m walk test (10MWT), the Four-Square Step Test (FSST), and the Tinetti Balance and Gait test were used.

Results:

According to the results of the study, the ICC was 0.96 for the right foot and 0.93 for the left foot. This result shows that the ICC value for the right and left feet is excellent. The SSST, which was performed separately with right and left feet, was found to have excellent correlation with the TUG, high-level correlation with the 10MWT, moderate-level correlation with the FSST, moderate-level correlation with the Tinetti test, and high-level correlation with the gait test.

Conclusions:

According to these results, it was concluded that the SSST is a valid and reliable test for older adults.
Mechanisms underlying progression in multiple sclerosis
Authors: Absinta Martina , Lassmann Hans , Trapp Bruce D.
Published: April 2020

Purpose of review

In multiple sclerosis, currently approved disease-modifying treatments are effective in modulating peripheral immunity, and coherently, in reducing clinical/radiological relapses, but still, they perform poorly in preventing disease progression and overall disability accrual. This review provides an up-to-date overview of the neuropathology of progressive multiple sclerosis, including a summary of the main mechanisms of disease progression.

Recent findings

Clinical progression in multiple sclerosis is likely related to the accumulation of neuro-axonal loss in a lifelong inflammatory CNS environment (both adaptive and innate) and relative un-balance between damage, repair and brain functional reserve. A critical driver appears to be the T-cell and B-cell-mediated compartmentalized inflammation within the leptomeninges and within the parenchyma. Recent perspective highlighted also the role of the glial response to such lifelong inflammatory injury as the critical player for both pathological and clinical outcomes.

The neuropathological and biological understanding of disease progression in multiple sclerosis have progressed in the last few years. As a consequence, new therapeutic approaches are emerging outside the modulation of T-cell activity and/or the depletion of B cells.
Neuromodulation in primary headaches: current evidence and integration into clinical practice
Authors: Rimmele Florian , Jürgens Tim P.
Published: April 2020

Purpose of review

Neuromodulatory approaches add to our armamentarium of therapeutic tools for the treatment of primary headaches. This review provides a comprehensive overview of current controlled studies on the different neuromodulation techniques and recommendations for clinical practice.

Recent findings

Evidence for efficacy of transcutaneous vagal nerve stimulation (tVNS) is limited to acute use in migraine with ambiguous results and episodic cluster headache as well as chronic cluster headache if applied in addition to conventional treatment. Transcutaneous stimulation of the supraorbital and supratrochlear nerve was effective in both acute and preventive stimulation (the latter with ambiguous results) in episodic migraines. Thus, invasive procedures should be reserved for severe and refractory cases only. Occipital nerve stimulation for chronic refractory cluster headache is the only available invasive approach with a Conformité Européenne mark.

Neuromodulation can complement conventional therapy, with noninvasive procedures being used preferably. Given the limited number of studies for each modality and the lack of head-to-head studies, it is difficult to place neuromodulation techniques in a conventional treatment algorithm.
COVID-19. Transport of respiratory droplets in a microclimatologic urban scenario
Authors: Guerrero Nicolás , Brito José M. , Cornejo Pablo
Published: April 2020

Although there are some recent studies which intent to address the spread of respiratory droplets through the air, these correspond to indoor conditions or outdoor situations which not take into account realistic scenario. Less attention has been paid to the spread of respiratory droplets in outdoor environments under microclimatologic turbulent wind and which is of growing importance given the current COVID-19 epidemic. We implement a computational model describing a sneezing person in an urban scenario under a medium intensity climatological wind. Turbulence was described with a wall-modeled Large Eddy Simulation model and the spread of respiratory droplets by using a lagrangian approach. Results show the spread of respiratory droplets is characterized by the dynamics of two groups of droplets of different sizes: larger droplets (400 – 900 μm) are spread between 2–5 m during 2.3 s while smaller (100 – 200 μm) droplets are transported a larger range between 8–11 m by the action of the turbulent wind in 14.1 s average. Given the uncertainty of potential contagion over this way and with this reach, these efforts are an intent to contribute to shine a light on the possibility of adopting stricter self-care and distancing measures.