bluuebunny/crossref_metadata_2025 huggingface dataset:
Deep long asymmetric occultation in EPIC 204376071
Authors: Rappaport S , Zhou G , Vanderburg A , Mann A , Kristiansen M H , Oláh K , Jacobs T L , Newton E , Omohundro M R , LaCourse D , Schwengeler H M , Terentev I A , Latham D W , Bieryla A , Soares-Furtado M , Bouma L G , Ireland M J , Irwin J
Published: February 2019

We have discovered a young M star of mass 0.16 M⊙ and radius 0.63 R⊙, likely in the Upper Sco Association, that exhibits only a single 80 per cent deep occultation of 1-d duration. The star has frequent flares and a low-amplitude rotational modulation, but is otherwise quiet over 160 d of cumulative observation during K2 campaigns C2 and C15. We discuss how such a deep eclipse is not possible by one star crossing another in any binary or higher order stellar system in which no mass transfer has occurred. The two possible explanations we are left with are (1) orbiting dust or small particles (e.g. a disc bound to a smaller orbiting body, or unbound dust that emanates from such a body); or (2) a transient accretion event of dusty material near the corotation radius of the star. In either case, the time between such occultation events must be longer than ∼80 d. We model a possible orbiting occulter both as a uniform elliptically shaped surface (e.g. an inclined circular disc) and as a ‘dust sheet’ with a gradient of optical depth behind its leading edge. The required masses in such dust features are then ≳3 × 1019 g and ≳1019 g, for the two cases, respectively.
Molecular profiling and targeted therapy in pediatric gliomas: review and consensus recommendations
Authors: Miklja Zachary , Pasternak Amy , Stallard Stefanie , Nicolaides Theodore , Kline-Nunnally Cassie , Cole Bonnie , Beroukhim Rameen , Bandopadhayay Pratiti , Chi Susan , Ramkissoon Shakti H , Mullan Brendan , Bruzek Amy K , Gauthier Angela , Garcia Taylor , Atchison Christie , Marini Bernard , Fouladi Maryam , Parsons D William , Leary Sarah , Mueller Sabine , Ligon Keith L , Koschmann Carl
Published: February 2019

As the field of neuro-oncology makes headway in uncovering the key oncogenic drivers in pediatric glioma, the role of precision diagnostics and therapies continues to rapidly evolve with important implications for the standard of care for clinical management of these patients. Four studies at major academic centers were published in the last year outlining the clinically integrated molecular profiling and targeting of pediatric brain tumors; all 4 demonstrated the feasibility and utility of incorporating sequencing into the care of children with brain tumors, in particular for children and young adults with glioma. Based on synthesis of the data from these studies and others, we provide consensus recommendations for the integration of precision diagnostics and therapeutics into the practice of pediatric neuro-oncology. Our primary consensus recommendation is that next-generation sequencing should be routinely included in the workup of most pediatric gliomas.
Association Between Baseline Creatinine Clearance and Treatment Failure in Patients With Hepatitis C Virus Treated With Ledipasvir and Sofosbuvir
Authors: Jansen Jeffrey W , Linneman Travis W , Powderly Gillian M , Moenster Ryan P , Nayak Leela
Published: February 2019

Background

Hepatitis C remains a major cause of liver disease globally and is responsible for approximately 500 000 deaths annually. Newer direct-acting antivirals achieve cure rates at or above 90% with excellent tolerability for most patients. The literature focusing on identification of predictors of efficacy and safety with specific hepatitis C therapies has been inconclusive and often conflicting.

Methods

A retrospective, single-center, case–control analysis of all veteran patients aged ≥18 through ≤89 years who completed a treatment course of 8, 12, or 24 weeks with ledipasvir and sofosbuvir (LDV/SOF) combination therapy for hepatitis C infection was conducted. Patients who were identified and met inclusion criteria were assigned to either the case group (SVR12 failure; hepatitis C viral load detectable at least 11 weeks after therapy completion) or the control group (SVR12 success; hepatitis C viral load undetectable at least 11 weeks after therapy completion).

Results

Twenty-nine SVR12 failures and 411 SVR12 successes were included in the analysis. The overall failure rate was consistent with the current literature, at 6.6% (29/440). Bivariate analysis identified only baseline creatinine clearance >80 mL min-1 (Cockcroft-Gault) as a possible predictor of SVR12 failure (P = .026). In the multivariate analysis, pretreatment creatinine clearance >80 mL min-1 remained independently associated with SVR12 failure (odds ratio, 2.95; 95% confidence interval, 1.17–7.46; P = .023).

Conclusions

In hepatitis C patients treated with LDV/SOF, a pretreatment creatinine clearance of >80 mL min-1 was associated with SVR12 failure.
Evaluating older adult self-care capacity
Authors: Moore Amy , Merrill Emily
Published: February 2019

In multiple settings, nurses have opportunities to observe patients' abilities to make decisions and live safely at home.
Sleep hygiene in patients with chronic respiratory disease
Authors: Dobson Linda , Stutzman Sonja E. , Hicks Amber D. , Olson DaiWai M.
Published: February 2019

Purpose:

This study assessed the effectiveness of patient-directed interventions for improving sleep quality in patients with cystic fibrosis and pulmonary hypertension.

Methods:

A nonrandomized, prospective pilot study was used to monitor the effectiveness of patient-initiated sleep preferences in 15 hospitalized patients.

Results:

During their stay, 53.3% of patients reported better sleep associated with the intervention, supporting the need for and efficacy of patient-driven sleep interventions.

Conclusion:

Patients unanimously recognized the need for sleep interventions and were open to seeking a good sleep hygiene regimen to improve their sleep quality while in the hospital.
Failure to Rescue as a Surgical Quality Indicator
Authors: Portuondo Jorge I. , Shah Sohail R. , Singh Hardeep , Massarweh Nader N.
Published: February 2019

Over the past decade, failure to rescue—defined as the death of a patient after one or more potentially treatable complications—has received increased attention as a surgical quality indicator. Failure to rescue is an appealing quality target because it implicitly accounts for the fact that postoperative complications may not always be preventable and is based on the premise that prompt recognition and treatment of complications is a critical, actionable point during a patient’s postoperative course. Although numerous patient and macrosystem factors have been associated with failure to rescue, there is an increasing appreciation of the key role of microsystem factors. Although failure to rescue is believed to contribute to observed hospital-level variation in both surgical outcomes and costs, further work is needed to delineate the underlying patient-level and system-level factors preventing the timely identification and treatment of postoperative complications. Therefore, the goals of this narrative review are to provide a conceptual framework for understanding failure to rescue, to discuss various associated patient- and system-level factors, to delineate the reasons it has become recognized as an important quality indicator, and to propose future directions of scientific inquiry for developing effective interventions that can be broadly implemented to improve postoperative outcomes across all hospitals.
International Multicenter Survey of Perioperative Management of External Ventricular Drains: Results of the EVD Aware Study
Authors: Lele Abhijit V. , Mills Brianna , Qiu Qian , Schloemerkemper Nina , Naik Bhiken Ishwarlal , Williams James , Venkat-Raghavan Lakshmikumar , Vavilala Monica S.
Published: February 2019

Introduction:

The perioperative management of patients with external ventricular drains (EVDs) is not well defined, and adherence to published management guidelines unknown. This study investigates practice, patterns, and variability in the perioperative management of patients with EVDs.

Methods:

A 31-question survey was sent to 1830 anesthesiologists from 27 institutions in North America, Europe, and Asia. A perioperative EVD Guideline Adherence Score was calculated for the preoperative, transport and intraoperative periods. Differences in management practices between neuroanesthesiologists and non-neuroanesthesiologists, and factors affecting EVD guideline adherence, were examined using bivariate significance tests and linear regression.

Results:

Among a sample of 599 anesthesiologists (survey response rate, 32.7%), compared with non-neuroanesthesiologists, neuroanesthesiologists were more likely to include baseline neurological examination (P=0.023), hourly cerebrospinal fluid output (P=0.006) and color (P<0.001), intracranial pressure trends (P<0.001), and EVD clamp trial (P<0.001) data in their routine preanesthetic assessment of patients with EVDs. There was a low prevalence of routine intracranial pressure monitoring during patient transport of patients with EVDs (14.4%). Overall, 25.9% of respondents were aware of EVD guidelines, and 21% reported receiving formal training in EVD management. The EVD Guideline Adherence Score was highest among anesthesiologists who reported being very comfortable in managing patients with EVDs compared with those who reported being uncomfortable (9.93 vs. 6.93, P<0.001).

Conclusions:

The EVD Aware study identifies opportunities for improvement in the perioperative management of patients with EVDS, including global awareness, formal EVD training, and dissemination of educational tools.
Intubating Laryngeal Mask Airway-assisted Flexible Bronchoscopic Intubation Is Associated With Reduced Cervical Spine Motion When Compared With C-MAC Video Laryngoscopy-guided Intubation: A Prospective Randomized Cross Over Trial
Authors: Swain Amlan , Bhagat Hemant , Gupta Vivek , Salunke Pravin , Panda Nidhi B. , Sahu Seelora
Published: February 2019

Background:

In the evolving research into cervical spine mechanics during airway intervention, new devices are being constantly added to the armamentarium of anesthesiologists. In this study we compared cervical spine movement during orotracheal intubation using an intubating laryngeal mask airway (LMA Fastrach) assisted flexible bronchoscope or video laryngoscope.

Materials and Methods:

In total, 40 consenting patients without history of abnormalities of cervical spine and planned for elective neuroradiologic interventions in the angiography suite were enrolled in this randomized crossover trial. Every patient was subjected to LMA Fastrach-guided flexible bronchoscopic as well as video laryngoscopy guided intubation. Cervical spine motion at the occipital bone, C1-C5 vertebrae, the occiput-C1, C1-C2, C2-C3 and C4-C5 junctions was investigated using continuous fluoroscopy during intubation. The primary outcome of the study was combined craniocervical motion from occiput to C5 between the 2 intubation techniques.

Results:

There was less (62%) combined craniocervical movement from occiput to C5 during the LMA Fastrach-flexible bronchoscopy-guided technique as compared with video laryngoscopy-guided intubation (17.55±14.23 vs. 28.95±11.58 degrees, respectively; P<0.001). The LMA Fastrach flexible bronchoscopy-guided technique also produced significantly less movement as compared to the video laryngoscope at the occiput-C1 (9.75±8.59 vs. 15.00±10.48 degrees; P=0.000) and C1-C2 level (3.95±7.51 vs. 7.53±9.1 degrees; P=0.003).

Conclusions:

There was significantly less movement in the craniocervical and upper cervical spine during LMA Fastrach assisted flexible bronchoscopic intubation compared to video laryngoscopic intubation.
Analysis of three-dimensional computed tomography talar morphology in relation to pediatric pes planovalgus deformity
Authors: Lee Kyoung Min , Chung Chin Youb , Park Moon Seok , Sung Ki Hyuk , Koo Seungbum , Moon Sang Il , Wang Soon Do , Jung Ki Jin
Published: February 2019

Intraosseous alignment of the tarsal bone has not been investigated in relation to various foot deformities. This study aimed to investigate three-dimensional computed tomography (3D CT) talar morphology in children with idiopathic and neuromuscular pes planovalgus. Eleven children [nine boys, two girls; mean (SD) age: 10.5 (2.8) years] with idiopathic pes planovalgus and 15 children [three boys, 12 girls; mean (SD) age: 10.8 (3.4) years] with neuromuscular pes planovalgus were included. All patients underwent 3D CT and weight-bearing anteroposterior, lateral, and axial radiography. Demographic data and talar 3D CT and radiographic measurements were compared between both groups. The correlation between the measurements was also analyzed. The neuromuscular group showed significantly more severe deformity than the idiopathic group in the radiographic and 3D sagittal talus measurements. The 3D coronal talus measurement showed a significant negative correlation with the axial hindfoot alignment in the idiopathic group while the 3D transverse talus measurement was significantly correlated with the lateral talocalcaneal angle in the neuromuscular group. 3D intraosseous alignment of the talus is correlated with pes planus deformity. Longitudinal and biomechanical studies including a control group are necessary to elucidate the role of 3D talar morphology on a dynamic imbalance in pes planovalgus.
Efficacy of antifibrinolytics in pediatric orthopedic surgery: a systematic review and meta-analysis
Authors: Gausden Elizabeth B. , Brusalis Christopher M. , Qudsi Rameez A. , Swarup Ishaan , Fu Michael , Dodwell Emily , Fabricant Peter D.
Published: February 2019

Antifibrinolytics (AFs) stabilize blood clot formation and reduce bleeding. The purpose of this systematic review and meta-analysis was to determine the impact of AF use on intraoperative blood loss and the need for blood transfusion in pediatric orthopedic surgery. A systematic review was performed using Medline and Embase to identify studies that utilized AFs during pediatric orthopedic surgery. The primary outcome measure was intraoperative blood loss in ml. Secondary outcomes included blood transfusion and thromboembolic events. Pooled estimates were derived from a random-effects model. Heterogeneity was assessed using the CochraneQandI2statistic. Meta-regression assessed if age or study quality modified the effect of AFs on blood loss. Publication bias was assessed using a funnel plot, Egger regression analysis, and the Kendallτ-test. Twenty studies, with a total of 1356 patients, were included. The mean difference in intraoperative blood loss was 653 ml [95% confidence interval (CI): 464–842 ml,P < 0.001]. Similarly, the mean difference in percent of blood volume lost was 22% less in patients treated with AFs compared with controls (95% CI: 12–32,P < 0.001). Patients treated with AFs had a lower odds of transfusion compared to controls (OR: 0.324; 95% CI: 0.105–0.997,P = 0.049). The use of AF in pediatric orthopedic surgery results in decreased intraoperative blood loss and a lower risk of blood transfusion. The majority of studies included involve spine surgery; the benefits of AFs in extremity surgery in the pediatric population have yet to be delineated. Level of Evidence: Level II.
The unstable slipped capital femoral epiphysis: does the rate of osteonecrosis really depend on the timing of surgery and surgical technique?
Authors: Xiang Ng Wei , Yuan Kau Chung , Chien Lin Ho Vivienne , Wei Peng Ng Jordan , Jia Ying Lee Beatrice , Kim Luan Lee Nicole , Boon Leong Lim Kevin
Published: February 2019

The aim of this study was to investigate whether the timing of surgery and surgical technique affect the rate of osteonecrosis in unstable slipped capital femoral epiphysis (SCFE). This is a retrospective review of all unstable slips that were treated at our institution over 8.5 years with a minimum follow-up period of 12 months. Patients with stable slips were excluded from this analysis. Demographic data, time to surgery, and surgical technique were analyzed. Twenty-three unstable slips were included for study after excluding 40 stable slips. There were 17 males and six females, with an average age of 11.9 years; 13 patients had right SCFEs. The average time from diagnosis to surgery was 57.7 h. Nine (39.1%) surgeries were performed within 24 h of admission, whereas 14 (60.9%) surgeries were performed after 24 h. Minimum follow-up was 23 months. Two patients developed osteonecrosis: one underwent surgery within 24 h of admission and the other after 24 h. Both underwent in-situ screw fixation. In the group that did not develop osteonecrosis, 76.2% underwent in-situ screw fixation and 23.8% underwent manipulative reduction. The rate of developing osteonecrosis following screw fixation in unstable SCFE was unrelated to whether surgery was performed before or after 24 h of admission (P = 1.0), or whether in-situ screw fixation or manipulative reduction pre-fixation was performed (P = 0.605). The results of this small series challenge the practice of stabilizing unstable SCFEs emergently and the belief that gentle manipulative reduction pre-fixation is not recommended because it may increase the rate of osteonecrosis. Level of Evidence: Level IV Evidence.
Addition of Intrathecal Morphine for Postoperative Pain Management in Pediatric Spine Surgery
Authors: Musa Arif , Acosta Frank L. , Tuchman Alexander , Movahedi Rana , Pendi Kasim , Nassif Leila , Farhan Saif Aldeen , Muallem Emile , Gucev Gligor
Published: February 2019

Study Design:

Meta-analysis.

Objective:

The objective of this study was to determine whether adjunctive intrathecal morphine (ITM) reduces postoperative analgesic consumption following pediatric spine surgery.

Summary of Background Data:

Previous studies that have tested supplemental ITM to manage pain after pediatric spine surgery have been limited by small sample sizes.

Methods:

A comprehensive search of PubMed, Web of Science, Clinicaltrials.gov, and the Cochrane Central Register of Controlled Trials was performed for clinical trials and observational studies. Time to first analgesic demand, postoperative analgesic use, pain scores, and complication data were abstracted from each study. Mean difference (MD) and 95% confidence interval (CI) were used to compare continuous outcomes and odds ratios (OR) and 95% CI were used for dichotomous outcomes.

Results:

A total of 5 studies, including 3 randomized controlled trials and 2 retrospective chart reviews, containing 636 subjects, were incorporated into meta-analysis. Subjects that were administered ITM in addition to postoperative analgesics (ITM group) were compared with those receiving postoperative analgesics only (control group). In the ITM group, time to first analgesic demand was longer (MD, 8.79; 95% CI, 4.20-13.37; P<0.001), cumulative analgesic consumption was reduced at 24 hours (MD, −0.40; 95% CI, −0.56 to −0.24; P<0.001), and cumulative analgesic consumption was reduced at 48 hours (MD, −0.43; 95% CI, −0.59 to −0.27; P<0.001). Neither postoperative pain scores at 24 hours (P=0.16) nor 48 hours (P=0.18) were significantly different between ITM and control groups. Rates of respiratory depression, nausea, vomiting, and pruritus were not different between groups (all Ps>0.05).

Conclusions:

Addition of ITM in pediatric spine surgery produced a potent analgesic effect in the immediate postoperative period. Patients administered ITM did not request opiates as early as control and consumed fewer opiates by the second postoperative day. Furthermore, use of ITM did not increase complications such as respiratory depression, nausea, vomiting, or pruritus.
Minimally Invasive Lateral Lumbar Interbody Fusion for Clinical Adjacent Segment Pathology
Authors: Park Hyung-Youl , Kim Young-Hoon , Ha Kee-Yong , Kim Sang-Il , Min Hyung-Ki , Oh In-Soo , Seo Jun-Yeong , Chang Dong-Gune , Park Jong-Tae
Published: February 2019

Study Design:

This was a retrospective comparative study.

Objective:

The main objective of this article was to evaluate the clinical and radiologic efficacies of minimally invasive lateral lumbar interbody fusion (LLIF) for clinical adjacent segment pathology (ASP).

Summary of Background Data:

Minimally invasive techniques have been increasingly applied for spinal surgery. No report has compared LLIF with conventional posterior lumbar interbody fusion for clinical ASP.

Methods:

Forty patients undergoing LLIF with posterior fusion (hybrid surgery) were compared with 40 patients undergoing conventional posterior lumbar interbody fusion (posterior surgery). The radiologic outcomes including indirect decompression in hybrid surgery group, and clinical outcomes such as the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) were assessed. Postoperative major complications and reoperations were also compared between the 2 groups.

Results:

Correction of coronal Cobb’s angle and segmental lordosis in the hybrid surgery were significantly greater postoperatively (2.8 vs. 0.9 degrees, P=0.012; 7.4 vs. 2.5 degrees, P=0.009) and at the last follow-up (2.4 vs. 0.5 degrees, P=0.026; 4.8 vs. 0.8 degrees, P=0.016) compared with posterior surgery. As regards indirect decompression of the LLIF, significant increases in thecal sac (83.4 vs. 113.8 mm2) and foraminal height (17.8 vs. 20.9 mm) were noted on postoperative magnetic resonance imaging. Although postoperative back VAS (4.1 vs. 5.6, P=0.011) and ODI (48.9% vs. 59.6%, P=0.007) were significantly better in hybrid surgery, clinical outcomes at the last follow-up were similar. Moreover, intraoperative endplate fractures developed in 17.7% and lower leg symptoms occurred in 30.0% of patients undergoing hybrid surgery.

Conclusions:

Hybrid surgery for clinical ASP has advantages of segmental coronal and sagittal correction, and indirect decompression compared with conventional posterior surgery. However, LLIF-related complications such as endplate fracture and lower leg symptoms also developed. LLIF should be performed considering advantages and approach-related complications for the clinical ASP.
Optical Topographic Imaging for Spinal Intraoperative 3-Dimensional Navigation in the Cervical Spine
Authors: Guha Daipayan , Jakubovic Raphael , Alotaibi Naif M. , Deorajh Ryan , Gupta Shaurya , Fehlings Michael G. , Mainprize Todd G. , Yee Albert , Yang Victor X.D.
Published: February 2019

Summary of Background Data:

Computer-assisted 3-dimensional navigation may guide spinal instrumentation. Optical topographic imaging (OTI) is a novel navigation technique offering comparable accuracy and significantly faster registration workflow relative to current navigation systems. It has previously been validated in open posterior thoracolumbar exposures.

Objective:

To validate the utility and accuracy of OTI in the cervical spine.

Study Design:

This is a prospective preclinical cadaveric and clinical cohort study.

Methods:

Standard midline open posterior cervical exposures were performed, with segmental OTI registration at each vertebral level. In cadaveric testing, OTI navigation guidance was used to track a drill guide for cannulating screw tracts in the lateral mass at C1, pars at C2, lateral mass at C3–6, and pedicle at C7. In clinical testing, translaminar screws at C2 were also analyzed in addition. Planned navigation trajectories were compared with screw positions on postoperative computed tomographic imaging, and quantitative navigation accuracies, in the form of absolute translational and angular deviations, were computed.

Results:

In cadaveric testing (mean±SD) axial and sagittal translational navigation errors were (1.66±1.18 mm) and (2.08±2.21 mm), whereas axial and sagittal angular errors were (4.11±3.79 degrees) and (6.96±5.40 degrees), respectively.

In clinical validation (mean±SD) axial and sagittal translational errors were (1.92±1.37 mm) and (1.27±0.97 mm), whereas axial and sagittal angular errors were (3.68±2.59 degrees) and (3.47±2.93 degrees), respectively. These results are comparable to those achieved with OTI in open thoracolumbar approaches, as well as using current spinal neuronavigation systems in similar applications. There was no radiographic facet, canal or foraminal violations, nor any neurovascular complications.

Conclusions:

OTI is a novel navigation technique allowing efficient initial and repeat registration. Accuracy even in the more mobile cervical spine is comparable to current spinal neuronavigation systems.
Tips for Improving the Writing and Reporting Quality of Systematic, Scoping, and Narrative Reviews
Authors: Horsley Tanya
Published: February 2019

The evidence base in health professions education continues to accumulate at an unprecedented rate. Summaries of evidence in the form of scoping, systematic and narrative reviews are also increasingly common. Unfortunately, many submissions go unpublished and for reasons that may be irreversible post-peer review. The goal of this commentary is to offer insights to review authors for improving the likelihood of publication success. These tips will not guarantee success; however, insights address common errors authors make along the continuum of review production that result in either requests for major revision or rejection.
A Novel Combined Light-Based Treatment of Acne Vulgaris With 1,450-nm Diode Laser and 450-nm Blue Light
Authors: Kwon Hyuck Hoon , Choi Sun Chul , Jung Jae Yoon , Bae Youin , Park Gyeong-Hun
Published: February 2019

BACKGROUND

Nonablative 1,450-nm diode laser (DL) and visible blue light (BL) have been effectively used for acne with superior safety profiles.

OBJECTIVE

To evaluate synergistic effects of sequential DL and BL application for acne.

METHODS

A 20-week, randomized split-face study was conducted to compare clinical courses between 2 facial sides either receiving sequential application of DL and BL or BL alone in 24 patients with mild to moderate facial acne vulgaris. Patients were scheduled to receive 3 consecutive sessions at 4-week intervals. Objective assessments, including revised Leeds grades, lesion counts, and sebum output measurements, and patients' subjective satisfaction were investigated.

RESULTS

Both combination and BL sides demonstrated steady improvement of inflammatory acne lesions with 62.3% and 35.2% decreases at the 12-week follow-up visit compared with baseline respectively. For noninflammatory lesions and seborrhea, only combination regimen demonstrated improvement. Patients' subjective assessments paralleled objective findings. For safety profiles, no severe adverse effect was observed on both sides, and mild symptoms resolved spontaneously within a day.

CONCLUSION

The combination regimen demonstrated synergistic efficacies for acne and seborrhea, with satisfactory safety profiles. Therefore, a few sessions of these light-based applications would be a viable option for acne treatments.
Selecting Optimal Subgroups for Treatment Using Many Covariates
Authors: VanderWeele Tyler J. , Luedtke Alex R. , van der Laan Mark J. , Kessler Ronald C.
Published: February 2019

We consider the problem of selecting the optimal subgroup to treat when data on covariates are available from a randomized trial or observational study. We distinguish between four different settings including: (1) treatment selection when resources are constrained; (2) treatment selection when resources are not constrained; (3) treatment selection in the presence of side effects and costs; and (4) treatment selection to maximize effect heterogeneity. We show that, in each of these cases, the optimal treatment selection rule involves treating those for whom the predicted mean difference in outcomes comparing those with versus without treatment, conditional on covariates, exceeds a certain threshold. The threshold varies across these four scenarios, but the form of the optimal treatment selection rule does not. The results suggest a move away from the traditional subgroup analysis for personalized medicine. New randomized trial designs are proposed so as to implement and make use of optimal treatment selection rules in healthcare practice.
INTRAVITREAL DEXAMETHASONE IMPLANT MIGRATION INTO THE ANTERIOR CHAMBER
Authors: Gonçalves Mariana Batista , Alves Bruno de Queiroz , Moura Raphael , Magalhães Octaviano , Maia André , Belfort Rubens , de Ávila Marcos Pereira , Zas Marcelo , Saravia Mario , Lousas Marcia , Wu Lihteh , Arevalo J. Fernando , Pacheco Katia Delalibera , Johnson Taylor , Farah Michel Eid , Rodriguez Francisco Jose , Maia Mauricio ,   for the Pan-American Collaborative Retina Study Group
Published: February 2019

Purpose:

To establish the prevalence and risk factors for intravitreal dexamethasone implant migration into the anterior chamber in eyes with macular edema.

Methods:

This was a multicenter, retrospective, observational chart review of data that included patients with macular edema who had been treated with at least one intravitreal dexamethasone injection. Patients with incomplete chart information during the follow-up period were excluded.

Results:

The prevalence of implant migration in 468 patients, considering the number of injections, was 1.6%, with significant associations between implant migration and cataract surgery (P= 0.043) and intraocular lens status (P= 0.005) and a trend toward statistical significance (P= 0.057) with vitrectomy. A higher rate of implant migration into the anterior chamber was observed in vitrectomized eyes (4.8%) when compared with patients who did not undergo a vitrectomy (1.6%). The implants that migrated were removed with forceps with/without viscoelastic expression or with 20-gauge cannulas connected to the vitreous cutter machine.

Conclusion:

The risk of implant migration into the anterior chamber was 1.6%. Risk factors were a history of cataract surgery or vitrectomy and aphakia. When anterior migration occurs, rapid removal is advised, especially if corneal edema is present.
Validation of Alternative Methods for Detecting Meibomian Gland Dropout Without an Infrared Light System: Red Filter for Simple and Effective Meibography
Authors: Lee Sang-Mok , Park Inwon , Goo Yong Ho , Choi Dongchul , Shin Min Chul , Kim Eun Chul , Alkwikbi Hassan Fallaj , Kim Man Soo , Hwang Ho Sik
Published: February 2019

Purpose:

To evaluate the validity and reliability of alternative methods for evaluating meibomian gland (MG) dropout without using an infrared light system: red-filtered or isolated red-channel images (RCIs) of the everted eyelid.

Methods:

We evaluated MG dropout in the everted upper and lower eyelids of 125 eyes of 64 patients with good-quality infrared meibography images (IMIs) and color digital photographs with and without a red filter. Red-filtered images (RFIs) were converted to black and white and adjusted for contrast/brightness [adjusted red-filtered images (aRFIs)]. RCIs were computationally isolated from color digital photographs obtained without a red filter. After randomization, the total meiboscore (0–6) was evaluated by 2 independent evaluators (interobserver reliability) masked to the image origin, and again after a 30-day interval (intraobserver reliability).

Results:

The meiboscores evaluated using the RFI, aRFI, and RCI were strongly positively correlated with those evaluated using the IMI (RFI: ρ = 0.788; aRFI: ρ = 0.735; RCI: ρ = 0.630; all P < 0.001, Spearman correlation analysis). Linear-weighted κ-values (κw) showed substantial agreement between the RFI and IMI (κw = 0.676, 95% CI = 0.594–0.759). The RFI had substantial intraobserver reliability (κw = 0.735, 95% CI = 0.685–0.785) and moderate interobserver reliability (κw = 0.467, 95% CI = 0.371–0.563). Computational adjustment of RFIs did not enhance the validity or reliability, and RCIs had limitations in some cases.

Conclusions:

MGs were successfully visualized using a red filter on a slit lamp and showed substantial agreement with visualization using the standard infrared method. Although interobserver reliability was only moderate, this alternative technique may be useful for evaluating MG dropout when an infrared meibography device is not available.
Perceived Stress Among Patients With Heart Failure Who Have Low Socioeconomic Status
Authors: Dickens Carolyn , Dickson Victoria Vaughan , Piano Mariann R.
Published: February 2019

Background:

Patient populations with low socioeconomic status (SES) experience psychological stress because of social determinants of health. Social determinants of health contribute to self-care—especially among patients with heart failure (HF).

Objective:

We sought to describe the influence of stress and social determinants of health on self-care in patients with HF who have low SES.

Methods:

In this mixed-methods, concurrent embedded study, participants (N = 35) were recruited from 2 urban hospitals in Chicago if they had low SES and were readmitted within 120 days of an exacerbation of HF. We conducted semistructured interviews to collect qualitative data about stressors associated with patients' living circumstances, strategies patients used to foster self-care, family dynamics, and coping strategies patients used to decrease stress. We measured psychological stress (Perceived Stress Scale [PSS-10]), and self-care (Self-care of Heart Failure Index). Content analysis was used to analyze the qualitative data, and descriptive statistics were used to describe the sample. In the final analytic phase, the qualitative and quantitative data were integrated.

Results:

Self-care was poor: 91.5% of participants had Self-care of Heart Failure Index subscale scores lower than 70. Perceived stress was high: 34% of participants had PSS-10 scores of 20 or higher. Several social determinants of health emerged as affecting self-care: financial stress, family personal health, past impactful deaths, and a recent stressful event (eg, child's death). Participants lived in areas with high crime and violence, and participants described many stressful events. However, among participants whose PSS-10 scores were lower than 20 (indicating lower stress), there was discordance among the description of factors impacting self-care and their PSS-10 score.

Conclusions:

Social determinants of health negatively impact the ability of low-SES patients to manage their HF symptoms and adhere to a medication and dietary regimen. It is important that healthcare providers assess patients' stressors so appropriate referral to services can occur.
“Why Would I Choose Death?”
Authors: Hadler Rachel A. , Goldstein Nathan E. , Bekelman David B. , Riegel Barbara , Allen Larry A. , Arnold Robert M. , Harinstein Matthew E. , Kavalieratos Dio
Published: February 2019

Background:

Although cardiology organizations recommend early introduction of palliative care for patients with heart failure (HF), integration has remained challenging, particularly in patients with cardiac devices such as cardiac implantable electronic devices and left ventricular assist devices. Study authors suggest that patients often have limited and erroneous understanding of these devices and their implications for future care.

Objective:

The aim of this study was to assess perceptions of cardiac devices in patients with HF and how these perceptions impacted advance care planning and future expectations.

Methods:

This study used qualitative semistructured interviews with 18 community-dwelling patients with New York Heart Association stage II to IV HF.

Results:

We interviewed 18 patients (mean ejection fraction, 38%; mean age, 64 years; 33% female; 83% white; 39% New York Heart Association class II, 39% class III, and 22% class IV). All had a cardiac implantable electronic device (6% permanent pacemaker, 56% implantable cardioverter-defibrillator, 28% biventricular implantable cardioverter-defibrillator); 11% had left ventricular assist devices. Patients with devices frequently misunderstood the impact of their device on cardiac function. A majority expressed the belief that the device would forestall further deterioration, regardless of whether this was the case. This anticipation of stability was often accompanied by the expectation that emerging technologies would continue to preempt decline. Citing this faith in technology, these patients frequently saw limited value in advance care planning.

Conclusions:

In our sample, patients with cardiac devices overestimated the impact of their devices on preventing disease progression and death and deprioritized advance care planning as a result.
Nurse-led Motivational Telephone Follow-up After Same-day Percutaneous Coronary Intervention Reduces Readmission and Contacts to General Practice
Authors: Mols Rikke Elmose , Hald Marianne , Vistisen Heidi Sønderby , Lomborg Kirsten , Maeng Michael
Published: February 2019

Background:

Same-day discharge of patients undergoing percutaneous coronary intervention (PCI) may challenge preparation of patients for discharge.

Objective:

The objective of this study was to investigate whether nurse-led telephone follow-up influenced patients' self-management post-PCI.

Methods:

We performed a randomized study with an allocation rate of 1:1. A standardized nurse-led motivational telephone consultation was conducted between 2 and 5 days after PCI to support adherence to medical therapy, follow-up activities, emotional well-being, and healthy lifestyle. The control group received usual care and discharge procedures. Primary outcome was adherence to use of P2Y12 inhibitor (clopidogrel or ticagrelor) therapy at 30 days of follow-up.

Results:

We consecutively included 294 elective patients (83%) undergoing PCI and with planned same-day discharge. Adherence to P2Y12 inhibitors was not influenced by the intervention (intervention vs control, 95% vs 93%, respectively; P = .627). However, the proportion of patients readmitted (8% vs 16%, P = .048), as well as self-initiated contacts to general practitioners (29% vs 42%, P = .020), was lower in the intervention group compared with the control group. Patients in the intervention group were more likely to know how to manage symptoms of angina pectoris (90% vs 80%, P = .015), and a higher proportion of patients in the intervention group commenced healthy physical activities (53% vs 41%, P = .043).

Conclusion:

Nurse-led motivational telephone follow-up did not influence adherence to antiplatelet medical therapy after PCI. However, the intervention positively influenced self-management of angina pectoris and reduced hospital readmissions and self-initiated contacts to general practitioners and hospitals.
Pediatric Sexual Abuse: An Interprofessional Approach to Optimizing Emergency Care
Authors: Jordan Kathleen S. , Steelman Sara H. , Leary Marlea , Varela-Gonzalez Lina , Lassiter Shannon L. , Montminy Lucy , Bellow Emily F.
Published: February 2019

Introduction:

Pediatric sexual abuse can lead to devastating lifelong consequences for the child, their caregivers, and society at large. To achieve the goal of optimizing patient outcomes, strategies to enhance teamwork, education, and mentorship are essential. The ultimate goal of child safety and protection through an evidence-based approach will only be attained when interprofessional alignment of expertise and resources is implemented.

Methods:

This project was implemented in a mixed-method design in two phases. Phase 1 was a face-to-face, evidence-based, 3.5-hour educational intervention involving members of the interprofessional emergency care team. Phase 2 consisted of focus groups to discover specific concerns emergency care providers encounter and to provide a forum for discussion on methods to improve care delivery. Data analysis was conducted to examine changes before and after education intervention and to identify themes discovered in focus groups.

Results:

There was a significant increase in the knowledge, confidence, and self-efficacy of the interprofessional emergency care team regarding sexual abuse after the education intervention. General themes identified in the focus groups included (a) the importance of advancing one's knowledge and skill set in this specialized area, (b) the importance of interprofessional collaboration in the emergency department and with community partners, (c) implementation of evidence-based national guidelines, and (d) ideas for improved quality and safety in the care of the sexually abused child.

Discussion:

Education and collaboration through an interprofessional approach are required for the promotion of quality and safety for the child presenting with alleged sexual abuse.
The Clinical Role of LASER for Vulvar and Vaginal Treatments in Gynecology and Female Urology: An ICS/ISSVD Best Practice Consensus Document
Authors: Preti Mario , Vieira-Baptista Pedro , Digesu Giuseppe Alessandro , Bretschneider Carol Emi , Damaser Margot , Demirkesen Oktay , Heller Debra S. , Mangir Naside , Marchitelli Claudia , Mourad Sherif , Moyal-Barracco Micheline , Peremateu Sol , Tailor Visha , Tarcan Tufan , De Elise J. B. , Stockdale Colleen K.
Published: February 2019

In this best practice document, we propose recommendations for the use of LASER for gynecologic and urologic conditions such as vulvovaginal atrophy, urinary incontinence, vulvodynia, and lichen sclerosus based on a thorough literature review. Most of the available studies are limited by their design; for example, they lack a control group, patients are not randomized, follow-up is short term, series are small, LASER is not compared with standard treatments, and most studies are industry sponsored. Because of these limitations, the level of evidence for the use of LASER in the treatment of these conditions remains low and does not allow for definitive recommendations for its use in routine clinical practice. Histological evidence is commonly reported as proof of tissue regeneration after LASER treatment. However, the histological changes noted can also be consistent with reparative changes after a thermal injury rather than necessarily representing regeneration or restoration of function. The use of LASER in women with vulvodynia or lichen sclerosus should not be recommended in routine clinical practice. There is no biological plausibility or safety data on its use on this population of women. The available clinical studies do not present convincing data regarding the efficacy of LASER for the treatment of vaginal atrophy or urinary incontinence. Also, although short-term complications seem to be uncommon, data concerning long-term outcomes are lacking. Therefore, at this point, LASER is not recommended for routine treatment of the aforementioned conditions unless part of well-designed clinical trials or with special arrangements for clinical governance, consent, and audit.
Effect of adding daclatasvir in sofosbuvir-based therapy in genotype 3 hepatitis C: real-world experience in Pakistan
Authors: Sarwar Shahid , Tarique Shandana , Aleem Abdul , Khan Anwaar A.
Published: February 2019

Objective

To determine real-world effect of adding daclatasvir (DCV) to chronic hepatitis C treatment by comparing sustained viral response of sofosbuvir (SOF)/DCV±ribavirin (RBV) and SOF+RBV combination in patients with genotype 3 hepatitis C.

Patients and methods

Patients with chronic hepatitis C, genotype 3, presenting at the DHMC Hepatology Clinic from October 2014 till March 2018 were treated initially with 6 months of SOF/RBV, and once DCV was available, with SOF/DCV±RBV for 3 or 6 months. Negative hepatitis C virus RNA by PCR, sustained viral response 12 weeks after treatment (SVR12), was the primary end point for per-protocol analysis.

Results

The mean age of the 440 enrolled patients was 51.04 (±11.9) years, and male to female ratio was 0.97/1 (217/223). Liver cirrhosis was present in 260 (59.1%) patients, and 89 (20.2%) had decompensated liver disease. Treatment-experienced patients were 124 (28.2%). We included 398 (90.4%) patients with completed follow-up in final analysis, excluding either dropped out, failed to complete therapy or died during follow-up. SVR12 was achieved in 366 (91.9%), being significantly lower (P=0.001) in patients with cirrhosis at 89.9% (205/228), and even lower SVR12 (P=0.006) in decompensated cirrhosis at 87.01% (67/77). SVR12 was also inferior (P=0.005) in treatment experienced patients at 85.8% (97/113) than treatment-naive patients at 94.3% (269/285). Among 285 patients treated with SOF/RBV, SVR12 was achieved in 264 (92.6%), which is not significantly different from SVR12 with SOF/DCV±RBV at 90.2% (102/113) (P=0.57).

Conclusion

In patients with chronic hepatitis C genotype 3, SOF/RBV and SOF/DCV±RBV have similar sustained viral response, and patients with liver cirrhosis and past treatment experience have suboptimal response in Pakistan.
A randomized double-blinded sham-controlled cross-over trial of tined-lead sacral nerve stimulation testing for chronic constipation
Authors: Yiannakou Yan , Etherson Kevin , Close Helen , Kasim Adetayo , Mercer-Jones Mark , Plusa Stefan , Maier Rebecca , Green Susan , Cundall Jeremy , Knowles Charles , Mason James
Published: February 2019

Objectives

Sacral nerve stimulation (SNS) may provide long-term symptom relief to patients suffering from chronic constipation. Patients are currently selected for SNS using a 2-week peripheral nerve evaluation (PNE) comprising stimulation by temporary leads. However, only 40% of test responders receive long-term benefit from treatment meaning that healthcare costs per successfully treated patient are too high. The primary objective was to assess tined-lead testing to predict benefit from SNS for chronic constipation.

Patients and methods

A randomized double-blind sham-controlled cross-over design evaluated enhanced PNE (ePNE) using tined quadripolar electrode leads over 6 weeks. The design differentiated between patients with discriminate and indiscriminate responses to testing. A score improvement of 25% or more was considered to be a positive response within a stimulation period. The primary outcome was the proportion of patients showing a reduction of at least 0.5 in constipation symptom score at 6 months.

Results

A total of 45 patients were randomized, of whom 29 (64.4%) were test-phase responders. Of these, 27 were implanted providing permanent SNS. During ePNE, seven (18%) were discriminate responders, 22 (56%) were indiscriminate responders and 10 (26%) were nonresponders. Six patients were withdrawn during the test phase because of infection or noncompliance. At 6 months, there was no significant difference in primary outcome between discriminate and indiscriminate responders (60 vs. 57%, P=0.76). The study was terminated prematurely because of a persistent infection rate of 10 (22%) during ePNE of which nine (20%) were severe.

Conclusion

ePNE is a poor predictor of treatment response at 6 months. This suggests a strong and persistent placebo response during both SNS PNE and treatment. An extended 6-week PNE poses a high risk of infection.
DAISY Faculty
Authors: Sweeney Cynthia Divens
Published: February 2019

There is a growing need for nurses who have the knowledge, skills, and abilities to serve as faculty in schools of nursing. The DAISY Award for Extraordinary Faculty honors these nurses who are dedicated to ensuring that there will be a next generation of nurses to care for patients, families, and communities. Recognizing nursing faculty for their compassionate and clinically skilled care in the academic setting serves to retain and recruit inspirational nursing faculty for the benefit of all!