bluuebunny/crossref_metadata_2025 huggingface dataset:
Reflections on a Physician Assistant Entrance Exam: Does the Profession Need One?
Authors: VanderMeulen Stephane , Hills Karen , Snyder Jennifer A. , Kohlhepp William , Alexander Lisa Mustone , Bowser Jonathan , Lane Steven
Published: February 2021

Standardized entrance exams are used in many health professions as one way to objectively measure knowledge and facilitate comparisons across student groups. The physician assistant (PA) profession has historically not employed a profession-specific entrance exam, and the idea was never seriously explored until the Physician Assistant College Admissions Test was developed recently by a commercial assessment publisher, with field testing in some volunteer programs in 2018 and the exam's first administration in May of 2020.

 The 2020 Physician Assistant Education Association Presidents Commission chose to investigate the issues raised by a consensus-derived, PA-specific entrance exam to stimulate more informed discussion on the efficacy of such an exam. While it may have the potential to enhance efficiency in PA admissions and reduce variability in admissions requirements, a PA entrance exam would also likely introduce new challenges, including increased costs, impact on the diversity of the applicant pool, and incongruence with an increasingly holistic admissions process. The biggest barrier would likely be the lack of current consensus on the knowledge, skills, and attributes that matriculants need to be successful in the program and in clinical practice. Development of a consensus-derived PA entrance exam would be a complex, expensive, and time-consuming endeavor, requiring considerable attention to technical issues of psychometric quality, process transparency, and legal defensibility. Changes being made to health professions admissions practices due to the COVID-19 pandemic, including the dropping of test scores as a requirement by some institutions, may make some of the issues raised in this paper more timely than ever.
Physician Assistant Education in Bulgaria
Authors: Vracheva Penka , Hooker Roderick S.
Published: February 2021

The development of physician assistants (PAs) in the Republic of Bulgaria began in 2014 with the inauguration of the first class at Trakia University, Stara Zagora, and at Faculty of Public Health, Sofia. Modeled after North American and European education systems, the preparation of PAs complies with state requirements for higher medical education from the Bulgarian Ministry of Health. As of 2020, the PA training program is in the state's register of regulated professions. Three programs, in Ruse, Burgas, and Plovdiv, will start in the early 2020s, building on the success of the initial programs in Sofia and Stara Zagora. In the Bulgarian PA education system, a bachelor's degree includes 8 semesters and nearly 5000 combined classroom and clinical hours (254 credits). Accreditation is through the state system, and graduation is achieved by passing 3 national examinations, after which the PA is awarded a diploma. The quality of PA education is guaranteed by the Ordinance of Unified State Requirements for the acquisition of higher education with a bachelor's degree in the PA specialty. As of 2020, 2 PA cohorts have graduated and serve in ambulatory medical roles throughout the state. Newer roles in curative (hospital) centers are being explored. This new medical workforce is designed to contribute to the national health system as a cost-effective medical resource that replaces an older feldsher system.
How Do We Measure Success? A Review of Performance Evaluations for Lower-Limb Neuroprosthetics
Authors: Valgeirsdóttir Vigdís Vala , Sigurðardóttir Jóna Sigrún , Lechler Knut , Tronicke Lisa , Jóhannesson Ómar I. , Alexandersson Ásgeir , Kristjánsson Árni
Published: February 2021

Introduction

Neuroprostheses that can relay signals to and from the nervous system and work with lower-limb prostheses are currently being developed to provide users with sensory feedback and/or intent control over their prostheses. Such systems incorporate functions not available to persons with lower-limb amputation before, and many of their potential benefits have not yet been addressed in performance-based outcome measures. As such, the evaluation of neuroprosthetic systems is considerably more difficult than that of current devices, which are already difficult due to limitations of testing strategies. This review includes an overview of performance-based measures for lower-limb prostheses as well as an appraisal of their utility for neuroprosthetic assessment.

Methods

Electronic searches were conducted (2013–2019) in the PubMed (PM) database, the Web of Science (WOS), and Cochrane (CC), resulting in 72 included articles.

Conclusions

There is an urgent need for further development of performance tests and metrics, as well as new strategies specifically intended for the evaluation of lower-limb neuroprosthetic systems.
The Art of Connection: A Model for Teaching Therapeutic Alliance to Doctoral Physical Therapy Students Within an Acute Care Course
Authors: Gang Gina R. , Wilson Christine A. , Garcia Henry A. , Daher Noha S. , Johnson Eric G.
Published: February 2021

Background and Purpose.

The connection and collaborative relationship, or therapeutic alliance, between clinician and patient reflects physical therapy's core values and serves as a vehicle for the essential goal of patient-centered care. The purpose of this study was to assess the effectiveness of integrating therapeutic alliance education into an entry-level doctoral physical therapy acute care course.

Method/Model Description and Evaluation.

Sixty-seven students completed an 11-week acute care course that integrated therapeutic alliance through lecture, simulation, self-assessment, peer and faculty feedback, debriefing, standardized patient written feedback, and written reflection. Surveys were completed before and on completion of the course.

Outcomes.

Quantitative results indicated that there was a significant increase in median (minimum, maximum) students' knowledge (8[2,10] vs 0 [0,9], effect size r = 0.86, P < .001), and perception of importance (10 [6,10] vs 10 [1,10], z = −3.6, r = 0.44, P < .001), of therapeutic alliance. Qualitative analysis of student reflections revealed the following perceptions of therapeutic alliance: high-quality health care, a strong relationship, awareness of self, awareness of others, communication (nonverbal and verbal), and emotional responsiveness. Qualitative analysis also revealed spontaneous, strong verbal language to describe the importance of therapeutic alliance indicating high impact and value to students.

Conclusion.

It is imperative that skills facilitating connection and patient-centered care become embedded within the physical therapy curriculum. By educating students in the affective domain of learning, tools are provided to facilitate the crucial therapist–patient connection. Including therapeutic alliance in entry-level doctoral physical therapy curriculum supports an academic culture promoting patient-centered care.
Effects of completing a postgraduate residency or fellowship program on primary care nurse practitioners' transition to practice
Authors: Park Jeongyoung , Faraz Covelli Asefeh , Pittman Patricia
Published: February 2021

Background:

To prepare new graduate nurse practitioners (NPs) for transition to practice, postgraduate residency or fellowship programs have been spreading across the nation in the past decade.

Purpose:

We examined the effects of completing a postgraduate residency or fellowship program on role perception, practice autonomy, team collaboration, job satisfaction, and intent to leave among primary care NPs (PCNPs).

Methods:

We analyzed 8,400 PCNP respondents, representing a total of 75,963 PCNPs nationwide, to the 2018 National Sample Survey of Registered Nurses. We conducted multivariate logistic regression analyses to examine whether completing a postgraduate training program was associated with increased role perception, greater practice autonomy, improved team collaboration, increased job satisfaction, and decreased intent to leave in their work, controlling for NP personal and practice characteristics.

Results:

About 10% of PCNPs completed some form of postgraduate training. Primary care NPs who had completed a residency or fellowship program were more likely to have a minority background (e.g., non-White and male) and also see more underserved populations (e.g., minority background, with limited English proficiency) than those without residency training. We found that PCNPs with residency training were more likely to report enhanced confidence in independent roles, greater practice autonomy, improved team collaboration, increased job satisfaction, and decreased intent to leave than those without residency training.

Implications for Practice:

This study supports further expansion of such programs, which would have positive effects for NPs, health care organizations, and patients, necessitating a long-overdue conversation about real public funding for primary care graduate nursing education.
The efficacy of docusate sodium and senna glycoside for the treatment of constipation after rotator cuff repair: A randomized controlled study
Authors: Weekes Danielle G. , Campbell Richard E. , Giunta Nicholas J. , Pepe Matthew D. , Tucker Bradford S. , Londahl-Ramsey Virginia E. , Tjoumakaris Fotios P.
Published: February 2021

Background:

Although stool softeners and laxatives are commonly prescribed for postoperative constipation, it is unclear if they are effective during the postoperative period. The data gained from this study will be beneficial for advanced practitioners when examining for postoperative constipation concerns.

Purpose:

This study aimed to investigate the efficacy of docusate sodium and senna glycoside in the prevention and treatment of constipation following rotator cuff repair (RCR).

Methods:

Patients (n = 107) were randomized to receive docusate sodium, senna glycoside, or nothing (control) in addition to a standardized postoperative protocol. Patients maintained a daily bowel-movement log for postoperative days 0–10. Constipation symptoms and quality of life were assessed preoperatively and at 2 and 6 weeks postoperatively using the Patient Assessment of Constipation Symptoms (PAC-SYM) and Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaires.

Results:

Sixty-seven percent of patients experienced constipation. There was no difference in the prevalence of constipation in the docusate, senna, and control groups (71.4%, 66.7%, and 64.3%, respectively; p = .88). Neither PAC-SYM nor PAC-QOL scores significantly differed between the 3 groups at any time point during 6-week follow-up (p > .05).

Implications for practice:

The majority (67%) of patients experience postoperative constipation following RCR. Although docustate sodium and senna glycoside are common first-line agents for the treatment of constipation, they are ineffective during the postoperative period. Providers need to explore other treatment modalities for postoperative constipation pain.
Addressing Unmet Basic Needs to Improve Colposcopy Adherence Among Women With Abnormal Cervical Cancer Screening
Authors: Kuroki Lindsay , Massad L. Stewart , Martin Anne , Liu Jingxia , Brown Dominique , Leon Andrea , Groesch Kathleen , Wilson Teresa , Zeino Yahia , Diaz-Sylvester Paula , Delfino Kristin , Hyon Katherine , Kreuter Matthew
Published: February 2021

Objectives

The aims of the study were to identify unmet basic needs (BNs) among women referred to colposcopy, to assess patient acceptability/satisfaction with assistance from a navigator to address unmet BNs, and to estimate adherence to colposcopy.

Methods

Women were recruited between September 2017 and January 2019 from 2 academic colposcopy centers, one serving a rural and one an urban area. Basic needs were assessed by phone before colposcopy appointments and considered unmet if unlikely to resolve in 1 month. Colposcopy adherence prestudy and poststudy implementation was abstracted over 4–6 months from administrative records. After a lead-in phase of 25 patients at each site, a BN navigator was offered to new participants with 1 or more unmet BNs. Primary outcome was adherence to initial appointment.

Results

Among 100 women, 59% had 1 or more unmet BNs, with similar prevalence between urban and rural sites. Adherence to initial colposcopy was 83% overall, 72% at the rural clinic, and 94% at the urban clinic (p = .006). These adherence rates were improved from 4 months before study launch (30/59 [51%] rural clinic and 68/137 [50%] urban clinic). Although acceptability of BN navigation was greater than 96% and women felt that it helped them get to their colposcopy visit, having a navigator was not associated with adherence. Women reporting no unmet BNs had the lowest adherence compared with women with 1 or more unmet BNs, regardless of navigator assistance (p = .03).

Conclusions

Disadvantaged women who need colposcopy have unmet BNs and value navigator assistance for initial appointments. However, when appointment scheduling includes telephone reminders and inquiring about BNs, a navigator may not add value.
Assessment of Tumor Volume Dynamics and Outcome After Radiosurgery for the Treatment of Vestibular Schwannoma: A Single-Center Experience
Authors: Ermiş Ekin , Egger Riccarda , Leiser Dominic , Anschuetz Lukas , Raabe Andreas , Abu-Isa Janine , Manser Peter , Aebersold Daniel M. , Wagner Franca , Herrmann Evelyn
Published: February 2021

Objective:

To assess the factors affecting early local and audiometric outcomes in vestibular schwannoma (VS) patients treated with stereotactic radiosurgery (SRS).

Study Design:

A retrospective review of medical records.

Setting:

Tertiary referral center.

Patients:

Records of all adult patients who underwent SRS between 2010 and 2016 for the treatment of VS were retrospectively reviewed. Patients treated with microsurgery or multi-fractionation schemes, and those who had neurofibromatosis type 2, were excluded.

Intervention:

SRS, tumor volume/size measurements.

Main Outcome Measures:

The impact of tumor volume dynamics on the early local and hearing-related outcomes, together with the factors that influence them following SRS, and comparison of different tumor size measurement methods.

Results:

From 2010 to 2016, 53 patients underwent single fraction SRS of 12 Gy. Median follow-up time was 32 months (range, 6–79). At the last follow-up, only one patient had clinical progression. Age less than or equal to 65 years (p = 0.04; odds ratio [OR]: 0.17; 95% confidence interval [CI]: 0.03–0.93) and baseline pure-tone average (PTA) level less than or equal to 30 dB (p = 0.03; OR: 0.90; 95% CI: 0.84–0.96) were associated with maintenance of serviceable hearing. On multivariate analysis, PTA remained significant (p = 0.01; OR: 0.04; 95% CI: 0.003–0.45). In patients with a loss of serviceable hearing, the mean volume increase tended to be higher than in the patients whose hearing was maintained. The linear measurement method underestimated, and the A × B × C/2 equation overestimated, the radiological progression compared with 3D-volumetric delineations.

Conclusion:

During the median observation period of almost 3 years, we reported our early outcome results. Tumor volume increase may have an impact on serviceable hearing loss after SRS. Currently there is no widely accepted method for the evaluation of post-SRS response. Linear measurement and the A × B × C/2 equation produce less reliable estimates of radiological progression compared with 3D-volumetric delineations. Accurate volume measurements with 3D delineations should be considered as part of clinical routine for assessing progression and deciding on salvage therapies.
Study on the Bone Metabolism Indices and Otoconin-90 in Benign Paroxysmal Positional Vertigo
Authors: Bi Jingtao , Liu Bo , Zhang Yi , Zhou Qian
Published: February 2021

Objective:

To investigate the correlation between benign paroxysmal positional vertigo (BPPV) and abnormal bone metabolism and to evaluate the value of otoconial protein otoconin-90 in the pathogenesis research and clinical treatment of BPPV.

Study Design:

Prospective pilot clinical trial (Level of Evidence: 2b).

Setting:

Outpatient otolaryngologic department.

Patients:

Twenty seven patients with a diagnosis of BPPV referred to the otolaryngologic department and 25 controls with no history of dizziness from 2018.4 to 2018.9 were reviewed.

Interventions:

No.

Main Outcome Measures:

Dual-energy x-ray absorptiometry scanning (DEXA), bone mineral density (BMD) measurement, and assessment of serum levels of otoconin-90 and bone metabolism indices (osteocalcin, OC; 25-OH Vitamin D; total procollagen type 1 N-peptide, TP1NP; β-C-terminal telopeptide of type 1 collagen, β-CTX).

Results:

1) The average serum level of otoconin-90 in the BPPV group was significantly higher than that in the control group (p < 0.05), whereas both the BMD T scores and serum 25-OH Vitamin D levels of the BPPV group were significantly lower than those of the control group (p < 0.05). 2) There was a strong positive correlation between serum otoconin-90 and age (r = 0.44, p < 0.05) and a moderate negative correlation between otoconin-90 and the bone metabolism indices OC (r = –0.33, p > 0.05), 25-OH Vitamin D (r = –0.35, p > 0.05), and TP1NP (r = –0.30, p > 0.05). 3) Logistic regression analysis showed that serum otoconin-90 level was an independent risk factor for BPPV (odd ratio = 0.998, 95% confidence interval 0.997–0.999, p < 0.01).

Conclusion:

A correlation between BPPV and abnormal bone metabolism was found. Moreover, otoconin-90 could serve as a research tool for BPPV.
Predictors of Postoperative Electrode Deactivation Among Adult Cochlear Implantees
Authors: Wen Christopher , Hwa Tiffany Peng , Kaufman Adam C. , Brant Jason A. , Eliades Steven J. , Bigelow Douglas C. , Ruckenstein Michael J.
Published: February 2021

Objective:

To characterize postoperative electrode functionality after adult cochlear implantation; to identify rationale and risk factors for electrode deactivation.

Study Design:

Retrospective Chart Review.

Setting:

Academic Cochlear Implant Center.

Subject Population:

Five hundred nineteen cochlear implants in 433 adult patients over 5 years.

Interventions:

Unilateral or bilateral cochlear implantation.

Main Outcome Measures:

Rate of electrode deactivation after adult cochlear implantation.

Results:

One hundred twenty (27.7%) patients experienced electrode deactivation postoperatively, involving a total of 447 electrodes. The most common reasons for deactivation were bothersome nonauditory symptoms (n = 170, 38.0%), perceived benefit by patients (n = 64, 14.3%), and bothersome auditory symptoms (n = 60, 13.4%). Four hundred nineteen (93.7%) of involved electrodes remained deactivated at most recent follow-up, whereas 28 (6.3%) were able to be reactivated. Deactivation was most likely to occur within the first 4 weeks after activation (n = 90 patients,75.0%; p < 0.01). Among affected patients, the average number of electrodes deactivated was 3.44 (range 1–13; SD 2.50). Age was not associated with electrode deactivation.

Conclusions:

While 98% of cochlear implants had full insertions, more than a quarter of implantees may experience electrode deactivation postoperatively for a multitude of reasons, with bothersome nonauditory symptoms most prevalent. Deactivation of five or more electrodes and simultaneous deactivation of two or three electrodes seems to increase the odds of subsequent device failure. However, deactivation encompasses a wide range of issues that likely include patient factors, surgical technique, and device-specific issues. Prognosis varies greatly at the individual level and further evaluation is required to better identify the issues underlying deactivation and identify true predictors of failure.
Usage Patterns of CT and MRI in the Evaluation of Otologic Disease
Authors: Moroco Annie E. , Saadi Robert A. , Baker Aaron R. , Zhu Junjia , Isildak Huseyin
Published: February 2021

Objective:

To evaluate the current trends and usage patterns of radiographic imaging for otologic disease by specialty, length of practice, practice setting, geographic region, and pediatric volume.

Study Design:

Cross-sectional study.

Setting:

Survey of physicians.

Subjects:

General Otolaryngologists and Otologists/Neurotologists (O/N) of the American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS).

Methods and Outcome Measures:

An electronic questionnaire was distributed to AAO-HNS members. Respondents were separated into groups by specialty, length of practice, practice setting, region, and pediatric exposure. Chi-square tests were performed for the determination of significance.

Results:

The survey was sent to 5,168 members of AAO-HNS. The response rate was 10.6% (n = 546) and 18.1% for only O/N (n = 143). Most respondents were generalists (74%), in practice >20 years (51%), with a primarily adult practice (95%). O/N were more often academics (44 versus 17% combined, 40% private; p < 0.001) and saw fewer children (80 fewer than 25%; p < 0.001). Compared with generalists, O/N were more likely to respond with more frequent and earlier magnetic resonance imaging (MRI) utilization in the workup of the majority of otologic diseases. Significant differences in usage patterns for various conditions were demonstrated across all categories, but specialty training was the most common. Generalists (34 versus 12% of O/N; p < 0.001), physicians practicing >20 years (32 versus 18% of < 5 yrs; p = 0.006), and private practice physicians (34 versus 14–20% of others; p < 0.001) relied more heavily on the radiology report to interpret MRI scans.

Conclusion:

Subspecialty training seems to be the main variable correlating with significant differences in the use of MRI and computed tomography imaging in patients with otologic disease.
Rising Resonance Frequency Is the Sole Sign of Early Middle Ear Disease in Children With Adenoid Hypertrophy
Authors: Kourelis Konstantinos , Avgeri Aikaterini , Kourelis Theodoros
Published: February 2021

Objective:

The present study seeks to estimate the potential of multifrequency tympanometry in the diagnosis of primal otologic disorder in children with adenoid hypertrophy (AH).

Study Design:

Prospective observational study.

Setting:

Tertiary pediatric institution.

Patients:

One hundred thirty-one children presenting consecutively at the otolaryngology clinic were divided on the basis of AH into 98 patients and 33 controls.

Interventions:

Middle ear status was assessed using pneumatic otoscopy, standard, and wide band tympanometry.

Main Outcome Measures:

Tympanogram type/intratympanic pressure, and resonance frequency (RF) were correlated with each other as well as with a set of clinical parameters. Receiver operating characteristic analysis was employed to reveal the diagnostic value of RF.

Results:

Mean RF declined in chronic otitis media with effusion by 43.25% (p < 0.001). In our entire cohort, children with AH under the age of 7 years presented with a relative risk = 2.43 of producing “B” tympanogram (p = 0.016) than their older peers. In patients’ ears with normal, type “A,” tympanogram, RF was the sole tympanometric marker of AH, being elevated by 28.26% in mean value (p = 0.010). On receiver operating characteristic analysis of RF's discriminating capability, the area under the curve was equal to 0.647 (p = 0.010). The optimal cut-off value of RF was set at 899 Hz.

Conclusion:

AH may induce middle ear stiffening, as RF's increase indicates. Wide band tympanometry output could be a warning sign of ongoing compliance reduction to the sound transmission apparatus, at a time point when physical examination and 226 Hz tympanometry are still unremarkable.
Audiometric Pattern in Moderate and Severe Tympanic Membrane Retraction
Authors: Canali Inesângela , Rosito Letícia Petersen Schmidt , Longo Vittoria Dreher , da Costa Sady Selaimen
Published: February 2021

Objective:

To evaluate the audiometric pattern in moderate/severe retractions of the tympanic membrane and correlate it with the severity of the otoscopy findings.

Study Design:

Cross-sectional study.

Setting:

Tertiary hospital.

Patients:

Consecutive patients with moderate or severe tympanic membrane retraction in at least one ear (451 ears) between August 2000 and January 2019, and no surgical history or effusion (mean [standard deviation] age, 32.8 [20.2] yr; 54% female and 42.4% children).

Intervention:

Pure-tone audiometry.

Main Outcome Measures:

Air conduction (AC) and bone conduction thresholds, and air-bone gap (ABG) measured at the four-frequency pure-tone average.

Results:

The median in decibel hearing level (dB HL) (minimum–maximum) of the AC, BC, and ABG were 25 dB HL (0–120 dB HL), 10 dB HL (0–75 dB HL), and 12.5 dB HL (0–55 dB HL), respectively. Seventy-two percent of the ears had an ABG ≤ 20 dB HL. For severity of the retraction of pars flaccida (PF), the AC, bone conduction, and ABG were similar across groups, with a weak correlation. For the pars tensa (PT), there was a global difference in the medians of AC and ABG in terms of the degree of severity, with a moderate correlation. Retraction in PF and PT at the same time was observed in 6 4% of the ears. ABG median was lower in ears with PF retraction (6.25 dB HL) than PT retraction, isolated (15 dB HL) or not (13.75 dB HL; p < 0.05).

Conclusion:

The ABG pure-tone average median was higher when PT was involved. We found a significant correlation between the retraction severity and worsening of AC and ABG thresholds, only for PT.
Tissue Factor Pathway Inhibitor Levels During Veno-Arterial Extracorporeal Membrane Oxygenation in Adults
Authors: Mazzeffi Michael , Judd Miranda , Rabin Joseph , Tabatabai Ali , Menaker Jay , Menne Ashley , Chow Jonathan , Shah Aakash , Henderson Reney , Herr Daniel , Tanaka Kenichi
Published: February 2021

Tissue factor pathway inhibitor (TFPI) has multiple anticoagulant properties. To our knowledge, no studies have measured TFPI levels in adult veno-arterial (VA) extracorporeal membrane oxygenation patients. We hypothesized that adult VA ECMO patients would have increased TFPI levels and slowed tissue factor triggered thrombin generation. Twenty VA ECMO patients had TFPI levels and thrombin generation lag time measured on ECMO day 1 or 2, day 3, and day 5. TFPI levels and thrombin generation lag time were compared against healthy control plasma samples. Mean TFPI levels were significantly higher in ECMO patients on ECMO day 1 or 2 = 81,877 ± 19,481 pg/mL, day 3 = 73,907 ± 26,690 pg/mL, and day 5 = 77,812 ± 23,484 pg/mL compared with control plasma = 38,958 ± 9,225 pg/mL (P < 0.001 for all comparisons). Median thrombin generation lag time was significantly longer in ECMO patients on ECMO day 1 or 2 = 10.0 minutes [7.5, 13.8], day 3 = 9.0 minutes [6.8, 12.1], and day 5 = 10.7 minutes [8.3, 15.2] compared with control plasma = 3.6 minutes [2.9, 4.2] (P < 0.001 for all comparisons). TFPI is increased in VA ECMO patients and tissue factor triggered thrombin generation is slowed. Increased TFPI levels could contribute to the multifactorial coagulopathy that occurs during ECMO.
The Clinical Importance of Hyponatremia in Patients with Left Ventricular Assist Devices
Authors: Kanelidis Anthony J. , Imamura Teruhiko , Yang Benjamin , Miller Tamari A. , Bharmal Murtaza , Kim Gene , Sayer Gabriel , Uriel Nir
Published: February 2021

Hyponatremia is associated with increased morbidity and mortality in heart failure (HF) patients. The implication of hyponatremia during left ventricular assist device (LVAD) therapy remains unknown. In this retrospective study, consecutive LVAD patients implanted between April 2014 and March 2018 were stratified by the presence of hyponatremia (serum sodium <135 mEq/L) at 30 days post-LVAD. Incidence of HF readmissions and survival during 1-year follow-up were compared between the groups. Of 204 patients identified, 170 were included. Serum sodium levels improved significantly from pre-LVAD to 1-year post-LVAD (136 [133, 139] mEq/L to 137 [135, 140] mEq/L, p < 0.001). At 30 days, 35 patients (21%) were in the hyponatremia group. No difference was observed for 1-year survival between groups (77% vs. 81%, p = 0.66). However, the incidence of HF readmissions was significantly higher in the hyponatremia group (44% vs. 15%, p = 0.001). Among the patients with pre-LVAD hyponatremia (N = 60), those with normalized serum sodium levels (N = 42) had a lower incidence of HF readmissions compared with those with persistent hyponatremia (12% vs. 44%, p = 0.008). Hyponatremia in LVAD patients is associated with a higher incidence of HF readmissions. Further studies are needed to elucidate whether therapies directed at hyponatremia (e.g., vasopressin antagonists) would improve outcomes in LVAD patients.
Agreement Between the TEG 6s and TEG 5000 Analyzers in Extracorporeal Membrane Oxygenation
Authors: Chandel Abhimanyu , Desai Mehul , King Christopher S. , Patolia Saloni , Raja Anika I. , Singh Ramesh , Dalton Heidi J.
Published: February 2021

Thromboelastography (TEG) evaluates viscoelastic properties of blood clot formation. The TEG 5000 analyzer is commonly used but prone to errors related to vibration or operator error. The TEG 6s was developed to overcome these limitations. Performance of TEG 6s compared with TEG 5000 has not been reported in extracorporeal membrane oxygenation (ECMO). We compared the agreement between devices via a single-center prospective observational study in hospitalized adult patients on ECMO. Data for both devices were collected daily for 3 days after ECMO initiation. Standard tests for method comparison were used. Thirty-four matching samples were available for analysis. Minimal bias was noted; however, the limit of agreement was wide for TEG parameters. Visually, agreement was better for values within the reference ranges of the tests. Lin’s coefficients demonstrated moderate correlation for reaction time and alpha angle (0.58; 95% confidence interval [CI], 0.31–0.76 and 0.63; 95% CI, 0.40–0.78, respectively). Excellent correlation was demonstrated for kinetic time and maximum amplitude (0.88; 95% CI, 0.79–0.94 and 0.89; 95% CI, 0.79–0.94). The TEG 6s device may represent an acceptable surrogate for the TEG 5000 in patients on ECMO. However, limitations in reliability were noted, and the devices may not be interchangeable when results fall outside of the reference values.
Automated reanalysis, a novel way to diagnose an ultra-rare condition: Fibronectin-1-related spondylometaphyseal dysplasia (SMD-FN1)
Authors: Sabir Ataf H. , Singhal Juhi , Man Jessica , Mensah Nana Ekuntan , Ahn Joo Wook , Cheung Moira S. , Irving Melita
Published: February 2021

We report a further case of spondylometaphyseal dysplasia – corner fracture type due to the fibronectin-1 gene (SMD-FN1) in a child originally thought to have metaphyseal chondrodysplasia-Brussels type (MCD Brussels). We highlight phenotypic differences with the SMD-FN1 published reports. This case is unique in terms of the method of molecular confirmation. Findings from the 100 000 Genomes Project were originally negative (in both tier 1 and 2); however, subsequent reanalysis, initiated by an automated search for new gene-disease associations in PanelApp, highlighted a candidate diagnostic variant. Our child had short stature, facial dysmorphism, spondylometaphyseal dysplasia and corner fractures and a heterozygous de novo missense variant in FN1 (c.675C>G p.(Cys225Trp), which was likely pathogenic. The variant matched the clinical and radiological features and a diagnosis of SMD-FN1 was confirmed. We explore the diagnostic journey of this patient, compare her findings with the previous 15 patients reported with SMD-FN1 and discuss the diagnostic utility of automated reanalysis. We consider differences and similarities between MCD Brussels and SMD-FN1, by reviewing literature on both conditions and assess whether they are in fact the same disorder.
Efficacy and Safety of Statin for Hepatocellular Carcinoma Prevention Among Chronic Liver Disease Patients
Authors: Wong Yu-Jun , Qiu Tian-Yu , Ng Gin-Kee , Zheng Qishi , Teo Eng Kiong
Published: February 2021

Introduction and Aim:

Hepatocellular carcinoma (HCC) is a deadly complication among patients with chronic liver disease (CLD). Controversies on the efficacy and safety of statin to prevent HCC among patients with CLD remain despite the growing evidences. We aim to investigate the efficacy and safety of using statin for HCC prevention among adult with CLD.

Methods:

We performed a systematic search of 4 electronic databases (PubMed/MEDLINE, EMBASE, Cochrane library, and ClinicalTrial.gov) up to April 15, 2020. We selected all types of studies evaluating the statin use and the risk of HCC among CLD patients, regardless of language, region, publication date, or status. The primary endpoint was the pooled risk of HCC. The secondary endpoint was the risk of statin-associated myopathy.

Result:

From 583 citations, we included a total of 13 studies (1,742,260 subjects, 7 types of statins), fulfilling the inclusion criteria, evaluating efficacy and safety of statin in CLD patients for HCC prevention. All studies were observational (2 nested case-control studies, 11 cohort studies), and no randomised trial was identified. We found that statin user has a lower pooled risk of HCC development (hazard ratio=0.57, 95% confidence interval: 0.52-0.62, I
2=42%). HCC reduction was consistent among statin users in cirrhosis, hepatitis B virus, and hepatitis C virus infections. The risk of statin-associated myopathy was similar between statin user and nonuser (hazard ratio=1.07, 95% confidence interval=0.91-1.27).

Conclusion:

Statin use was safe and associated with a lower pooled risk of HCC development among adults with CLD. Given the bias with observation studies, prospective randomised trial is needed to confirm this finding.
Large-scale food fortification has great potential to improve child health and nutrition
Authors: Keats Emily C. , Charbonneau Kimberly D. , Das Jai K. , Bhutta Zulfiqar A.
Published: February 2021

Purpose of review

Undernutrition, including micronutrient deficiencies, continues to plague children across the world, particularly in low and middle-income countries (LMICs). The situation has worsened alongside the SARS-CoV-2 pandemic because of major systemic disruptions to food supply, healthcare, and employment. Large-scale food fortification (LSFF) is a potential strategy for improving micronutrient intakes through the addition of vitamins and minerals to staple foods and improving the nutritional status of populations at large.

Recent findings

Current evidence unquestionably supports the use of LSFF to improve micronutrient status. Evidence syntheses have also demonstrated impact on some functional outcomes, including anemia, wasting, underweight, and neural tube defects, that underpin poor health and development. Importantly, many of these effects have also been reflected in effectiveness studies that examine LSFF in real-world situations as opposed to under-controlled environments. However, programmatic challenges must be addressed in LMICs in order for LSFF efforts to reach their full potential.

LSFF is an important strategy that has the potential to improve the health and nutrition of entire populations of vulnerable children. Now more than ever, existing programs should be strengthened and new programs implemented in areas with widespread undernutrition and micronutrient deficiencies.
Fibrosis-4 index and mortality in coronavirus disease 2019: a meta-analysis
Authors: Pranata Raymond , Yonas Emir , Huang Ian , Lim Michael Anthonius , Nasution Sally Aman , Kuswardhani Raden Ayu Tuty
Published: February 2021

Background/aims

In this meta-analysis, we aimed to evaluate the prognostic value of fibrosis-4 index (FIB-4) in COVID-19.

Methods

We performed a comprehensive literature search of PubMed, Embase, and Scopus databases on 26 November 2020. FIB-4 was calculated by [age (years) × AST (IU/L)]/[platelet count (109/L) × √ALT (U/L)]. A value above cutoff point was considered high and a value below cutoff point was considered low. The main outcome was mortality, the association between high FIB-4 and mortality was reported in odds ratio (OR). Sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic OR (DOR), area under the curve (AUC) were generated.

Results

There were 963 patients from five studies included in this systematic review and meta-analysis. Meta-analysis showed that high FIB-4 was associated with increased mortality [OR 3.96 (2.16–7.27), P < 0.001; I2: 41.3%]. High FIB-4 was associated mortality with a sensitivity of 0.56 (0.40–0.70), specificity of 0.80 (0.72–0.86), PLR 2.8 (1.8–4.2), NLR 0.55 (0.39–0.78), DOR 5 (2–10), and AUC of 0.77 (0.73–0.81). Fagan’s nomogram indicated that for a pre-test probability (mortality) of 30%, a high FIB-4 was associated with 54% post-test probability and a low FIB-4 was associated with 19%, respectively. The funnel-plot analysis was asymmetrical, trim-and-fill analysis by imputation of a study on the left side using linear estimator resulted in an OR of 3.48 (1.97–6.14). Egger’s test showed no indication of small-study effects (P = 0.881).

Conclusion

High FIB-4 was associated with mortality in patients with COVID-19.
Population-based incidence and prevalence of inflammatory bowel diseases in Milan (Northern Italy), and estimates for Italy
Authors: Crocetti Emanuele , Bergamaschi Walter , Russo Antonio Giampiero
Published: February 2021

Objective

A reliable measure of the burden of inflammatory bowel diseases (IBDs), including ulcerative colitis and Crohn’s disease, are essential to monitor their epidemiology and plan appropriate health services.

Methods

This is a population-based study carried out in the Milan Agency for Health Protection. Incident and prevalent cases were identified according to specific codes in hospital discharges and copayment exemptions. Age-standardized incidence rates were computed for 2015–2018 and yearly rates from 2010 to 2018, as well as annual prevalence and prevalence on 31 December 2018. Incidence and prevalence estimates for Italy were also produced.

Results

During 2015–2018, 3434 citizens had an IBD diagnosis, 2154 (62.7%) ulcerative colitis and 1.280 (37.3%) Crohn’s disease. Age-adjusted incidence rates were 15.3 [95% confidence interval (CI), 14.7–16.0] for ulcerative colitis and 9.4 (8.9–9.9) for Crohn’s disease. Incidence was stable during 2010–2018 for both diseases. On 31 December 2018, there were 15 141 prevalent patients, corresponding to a proportion of 442.3 every 100 000 inhabitants/year (95% CI, 435.6–449.8). Prevalence proportion has increased to around +10% per year from 2010 to 2018. Projections for Italy assessed the burden of IBD in more than 15 000 new cases/year (55% ulcerative colitis) and around 260 000 prevalent cases (62% ulcerative colitis).

Conclusions

The exploitation of administrative data provides reliable and up-to-date measures of the burden of disease. Incidence of IBDs is stable while prevalence notably grows. The burden of IBDs and the consequent need for care and follow-up is going to increase in the future.
Advantages of gravity-assisted diuretic renogram: F + 10 (seated position) method
Authors: Tartaglione Girolamo , Foschi Nazario , Recupero Salvatore M. , Ieria Francesco P. , Tarantino Giulio , Bassi Pierfrancesco
Published: February 2021

Introduction

In 1978, O’Reilly introduced the diuretic renogram using the F + 20 method. Initially, the patient was examined in the seated position. A dose of 40 mg furosemide was injected intravenously 20 min following tracer injection and dynamic acquisition was prolonged for 15–20 min. In 1992, the guidelines suggested to study patients in the supine position to avoid risk of diuretic-induced hypotension and reduce patient movement. Unfortunately, equivocal findings were reported in 15–30% of cases. Side effects such as bladder fullness and disruption because of voiding were reported. Several methods had been proposed in the supine position, such as the well-tempered diuretic renogram F + 20, F − 15, F0 and F + 2, with different time in minute of diuretic administration in relation to tracer injection. However, as confirmed by many studies, there was no clear evidence suggesting superiority among these methods. We suggest using the diuretic renogram with the F ± 10(sp) method for the diagnosis of obstruction in adult patients with hydronephrosis and for the follow-up in patients who underwent a surgical treatment of the urinary tract.

Methods

We searched all international guidelines and articles of most influential authors published from 1978 to October 2020 on diuretic renogram.

Results

We selected 60 articles.

Discussion

F + 10(sp) method improves patient compliance avoiding bladder fullness-related problems, without need of catheterization. It allows for a more reliable quantification of the renal output, thanks to outflow indices that are favored by gravity effects.
Differences in diagnostic impact of dual-tracer PET/computed tomography according to the extrahepatic metastatic site in patients with hepatocellular carcinoma
Authors: Yoo Su Woong , Kim Dong-Yeon , Pyo Ayoung , Jeon Subin , Kim Jahae , Kang Sae-Ryung , Cho Sang-Geon , Lee Changho , Kim Geun-Joong , Song Ho-Chun , Bom Hee-Seung , Min Jung-Joon , Kwon Seong Young
Published: February 2021

Objectives

We compared the diagnostic performance of C-11 acetate and F-18 fluorodeoxyglucose (FDG) PET/computed tomography (CT) for the detection of extrahepatic metastasis in patients with hepatocellular carcinoma (HCC) and evaluated whether the improvement in the diagnostic performance of dual tracer PET/CT differs by the metastatic site.

Methods

Fifty-eight patients who had extrahepatic metastasis on either C-11 acetate or F-18 FDG PET/CT were enrolled, and 193 metastatic lesions were analyzed in this retrospective study. The metastatic lesions were categorized based on six sites of involvement. According to each involved site, the tracer avidity of the metastatic lesions was compared using the maximum standardized uptake value (SUVmax).

Results

Bone was the most frequent categorized metastatic site (44.8%), followed by lymph node (39.7%), lung (34.5%), soft tissue (27.6%), adrenal gland (6.9%), and vascular category (3.4%). C-11 acetate PET/CT showed a higher SUVmax than F-18 FDG PET/CT in metastatic bone lesions (P = 0.003). F-18 FDG uptake was significantly higher than C-11 acetate uptake in metastatic lymph node lesions (P < 0.001). The detection rate of dual tracer PET/CT was significantly higher in the metastatic lung (93.6%) and soft tissue (100%) lesions. However, the diagnostic performance of dual tracer PET/CT was limited in the metastatic bone and lymph node lesions because each tracer’s detection rate was very high (bone: 94.6% in C-11 acetate, lymph node: 94.1% in F-18 FDG).

Conclusions

The tracer avidity of metastatic lesions differed according to the involved site. This difference affected the complementary role of dual tracer PET/CT in the diagnosis of extrahepatic metastases in patients with HCC.
Infectious diseases affecting the small bowel – what not to miss
Authors: Keuchel Martin , Bota Marc , Baltes Peter
Published: February 2021

Purpose of review

This review summarizes infectious diseases involving the small bowel (SB) with a focus on recent literature related to diagnosis and pathophysiology.

Recent findings

Typical symptom for SB infections is diarrhea, mostly self-limiting. Pathogens include bacteria, viruses, fungi, protozoan parasites, and helminths. Host–pathogen interaction is of special interest in infections with potentially severe or prolonged course. Research uses increasingly enterocyte cell culture systems. SARS-CoV2 can also infect enterocytes via angiotensin converting enzyme 2 (ACE2) receptor and causes gastrointestinal complaints in some patients. Chronic SB infections as tuberculosis, Cytomegalovirus, or Epstein–Barr virus have to be differentiated from Crohn's and other diseases. Severe rare fungal and protozoan parasitic infections can cause relevant morbidity in immunocompromised patients. Soil-transmitted helminthic infections are a special issue in endemic areas.

Many infections involve the SB, typically causing mild and self-limiting diarrhea. Symptomatic therapy, hygiene, and isolation are the mainstay of management. However, some patients develop severe or chronic disease. Immunosuppression is a major cause for severe, but also for rare opportunistic systemic infections that can also affect the SB.
Acute-on-chronic liver failure: update on pathogenesis, therapeutic targets, predictive models, and liver transplantation
Authors: Shah Shivani , Goldberg David S.
Published: February 2021

Purpose of review

Acute-on-chronic liver failure (ACLF) is a clinical syndrome in patients with chronic liver disease that is associated with multiple organ failures and a high short-term mortality. Systemic inflammation is suggested to play a key role in its pathogenesis, although the precise causative mechanism is unknown. The purpose of this review is to present and discuss new findings related to: mechanisms underlying ACLF, therapeutic targets, risk prediction models for developing ACLF, and liver transplantation for ACLF.

Recent findings

Recent studies of ACLF pathophysiology classified the immunosuppressive phenotype in monocytes. Investigation of therapeutic strategies identified inhibition of toll-like receptor-4 (TLR-4) and glutamine synthetase (GLUL) as potential targets. Recent studies identified novel risk prediction models for developing ACLF and enhanced our understanding of liver transplantation for ACLF to guide clinicians in determining that patients will benefit from transplantation.

Improved knowledge on the pathogenesis of ACLF and identification of TLR-4 and GLUL may lead to clinical trials to study the efficacy of these novel therapeutic targets for patients with ACLF. Liver transplantation is the only current treatment for ACLF. Given the limited availability of donor organs, recent studies have identified ACLF patients who may merit the highest waitlist priority.
Heterogeneity of fetal hemoglobin production in adult red blood cells
Authors: Khandros Eugene , Blobel Gerd A.
Published: February 2021

Purpose of review

Small amounts of fetal hemoglobin can be expressed in a subset of adult red blood cells called F-cells. This review examines the potential mechanisms and clinical implications of the heterogeneity of fetal hemoglobin expression.

Recent findings

Although the heterocellular nature of fetal hemoglobin expression in adult red blood cells has been noted for over 70 years, the molecular basis of this phenomenon has been unclear. Recent discoveries of novel regulators of fetal hemoglobin as well as technological advances have shed new light on these cells.

Fetal hemoglobin reactivation in adult red blood cells through genetic or pharmacological approaches can involve both increasing the number of F-cells and cellular fetal hemoglobin content. New technologies enable the study and eventually the improvement of these parameters in patients with sickle cell disease and β-thalassemia.