bluuebunny/crossref_metadata_2025 huggingface dataset:
Peripheral Nerve Blocks in Chronic Pain
Authors: Tumber Paul Singh , Peng Philip W. H.
Published: April 2017

Ultrasound-guided nerve blockade for chronic pain offers advantages over blind landmark-based and fluoroscopic techniques. It allows visualization of soft-tissue structures and spread of the injectate while limiting ionizing radiation exposure. Interventionalists must have both a clear understanding of the anatomy that is being visualized on the ultrasound image and the ability to safely place a needle to the desired target site. Neural blockade of the suprascapular nerve can be useful in the management of chronic shoulder pain such as adhesive capsulitis, frozen shoulder, rotator cuff tear, and glenohumeral arthritis. Intercostal nerve blocks can be helpful for painful conditions that affect the thorax or upper abdomen. The lateral femoral cutaneous nerve local anesthetic block may provide analgesia for procedures involving the region, such as skin harvesting. The pudendal nerve block may be useful for diagnostic or therapeutic purposes in certain cases of chronic pelvic pain involving pudendal neuralgia.
Sacroiliac Joint Injections: Computed Tomography
Authors: Herman Mira , Vydyanathan Amaresh , Brook Allan L.
Published: April 2017

Sacroiliac (SI) joint disease is a common cause of low back pain. It is not easily diagnosed by physical examination, as the joint has limited mobility and referral patterns are not sufficiently delineated from other pathological conditions implicated in low back pain. The accuracy of provocative testing of the sacroiliac joint is controversial. Many physicians use injection of the SI joint with local anesthetic and/or steroid as a diagnostic and therapeutic tool in treating SI joint–related pain. Historically, SI joint intra-articular injections have been performed without imaging guidance. Imaging-guided techniques, often using CT fluoroscopy, increase the precision of these procedures and help confirm needle placement while achieving better results and reduced complications rates. Sacroiliac joint injection is routinely performed on an outpatient basis. The patient is questioned regarding previous steroid use (oral, cutaneous, or injected) to avoid iatrogenic Cushing syndrome. Repeat injections can be administered depending on patient’s response.
Knee Joint Injections: Ultrasound
Authors: Shankar Hariharan , Abdulraheem Khalid
Published: April 2017

Knee pain secondary to arthritis is a major cause of suffering. Obesity and trauma are the leading factors of knee joint arthritis. Some patients have a genetic predisposition to degenerative arthritis secondary to alteration in their collagen. Conservative measures include braces, pharmacological therapies, and exercises. Interventional options, including injections of steroids and viscosupplementation, have been attempted to delay joint replacement. Complications are rare, and the ultrasound-based technique does not subject the patient to added risk. It is always prudent to avoid blunting the adrenocortical axis with the use of steroid injections.
Ankle and Foot Injections: Ultrasound
Authors: Bodor Marko , Colio Sean , Toy Andrew
Published: April 2017

Ultrasonography can be highly useful in diagnosing and treating common musculoskeletal conditions affecting the foot and ankle, ranging from plantar fasciitis to osteoarthritis of the metatarsophalangeal joint of the great toe, as well as uncommon ones such as impingement of a tendon or nerve by fixation screw. One of the greatest advantages of ultrasonography is its high resolution for muscle, tendon, nerve, and bony surfaces and the opportunity to simultaneously identify, image, and evaluate tender structures. It can be used in a clinic setting and in the presence of metallic hardware. The short-axis injection approach is best for superficial, vertically oriented joints such as the cuneiform-metatarsal joints, whereas the long-axis approach is best for relatively deeper structures such as the tibiotalar joint and when it is important that the needle be visualized at all times, such as when performing a tibial nerve block.
Shoulder Injections: Ultrasound
Authors: Peng Philip W. H.
Published: April 2017

This chapter reviews the anatomy and ultrasound-guided techniques of various shoulder injections, including the glenohumeral joints, subacromial subdeltoid bursa, long head of biceps, and acromioclavicular joint. Ultrasonography is a very useful tool allowing accurate localization of the various target structures for shoulder injections and real-time guidance of the needle insertion. A good understanding of the anatomy and sonoanatomy is of paramount importance in performing the ultrasound-guided injections.
Elbow Injections: Ultrasound
Authors: Smith Jay , Sellon Jacob
Published: April 2017

This chapter discusses sonographically guided elbow, tendon, and joint procedures used in the management of patients presenting with tendon and joint disorders of the elbow. Two sonographically guided corticosteroid injection techniques have been used for common extensor tendinosis, a superficial technique and a deep technique. Sonographically guided percutaneous longitudinal tenotomy has also been described for chronic flexor-pronator tendinosis. Distal biceps tendinopathy is a broad term that includes both inflammatory (tendinitis) and chronic degenerative (tendinosis) conditions. As the proximal portion of the distal biceps tendon can be easily palpated anteriorly, an anterior injection approach will typically provide uncomplicated access to the tendon and/or adjacent bursal fluid. Common elbow conditions are amenable to intra-articular elbow aspiration and injections (typically with corticosteroid).
Hand and Wrist Injections: Ultrasound
Authors: Bodor Marko , Colio Sean , Bonzon Christopher
Published: April 2017

Two basic ultrasound-guided approaches are used for procedures to diagnose and treat chronic pain in the upper extremity. The short-axis approach is best for injections of superficial, vertically oriented joints, whereas the long-axis approach is best for relatively deep injections and more open joints or whenever it is necessary for the needle to be seen at all times. Ultrasound can guide injections for nerve compressions. Carpal tunnel syndrome is the most common peripheral nerve entrapment syndrome. Ulnar tunnel syndrome occurs in the setting of space-occupying lesions. Ultrasonography can identify a space-occupying lesion, while electrodiagnostic studies can help differentiate ulnar neuropathy at the wrist from ulnar neuropathy at the elbow. Ultrasound can also guide injections at joints such as the basilar join of the thumb, phalangeal joints, and wrist joints. Ultrasound-guided injections are also useful for tendon dysfunctions including de Quervain’s Tenosynovitis, trigger finger, intersection syndrome, and tendon impingement.
Piriformis Muscle Injections: Fluoroscopy
Authors: Bolash Robert B. , Chapman Kenneth B.
Published: April 2017

Piriformis syndrome is an entrapment neuropathy caused by compression or irritation of the sciatic nerve as it courses in proximity to the piriformis muscle. Conservative treatment modalities for piriformis syndrome include the use of anti-inflammatory analgesic medications or muscle relaxants. Physical therapy is often employed to correct the abnormal pelvic biomechanics and focus on stretching the piriformis muscle. Prior to proceeding with invasive surgical approaches, this chapter advocates the use of piriformis muscle injection. The technique both confirms the diagnosis and offers therapeutic value while avoiding the risks, expense, and potential adverse outcomes associated with surgical interventions. A combined fluoroscopic and nerve stimulator guided technique is recommended to identify bony landmarks, verify the perisciatic location, confirm intramuscular spread of the injectate, and avoid intravascular injection of particulate steroid. Transient sciatic nerve block caused by spillover of the local anesthetic administered into the piriformis muscle is a common complication.
Management of Severe Bleeding in Patients Treated with Direct Oral Anticoagulants
Authors: Albaladejo Pierre , Samama Charles-Marc , Sié Pierre , Kauffmann Sophie , Mémier Vincent , Suchon Pierre , Viallon Alain , David Jean Stéphane , Gruel Yves , Bellamy Lorenn , de Maistre Emmanuel , Romegoux Pauline , Thoret Sophie , Pernod Gilles , Bosson Jean-Luc ,   on behalf of the GIHP-NACO Study Group
Published: April 2017

Background

The use of prothrombin complex concentrates and the role of plasma concentration of anticoagulants in the management of bleeding in patients treated with direct oral anticoagulants are still debated. Our aim was to describe management strategies and outcomes of severe bleeding events in patients treated with direct oral anticoagulants.

Methods

We performed a prospective cohort study of 732 patients treated with dabigatran, rivaroxaban, or apixaban hospitalized for severe bleeding, included prospectively in the registry from June 2013 to November 2015.

Results

Bleeding was gastrointestinal or intracranial in 37% (212 of 732) and 24% (141 of 732) of the cases, respectively. Creatinine clearance was lower than 60 ml/min in 61% (449 of 732) of the cases. The plasma concentration of direct oral anticoagulants was determined in 62% (452 of 732) of the cases and was lower than 50 ng/ml or higher than 400 ng/ml in 9.2% (41 of 452) and in 6.6% (30 of 452) of the cases, respectively. Activated or nonactivated prothrombin complex concentrates were administered in 38% of the cases (281 of 732). Mortality by day 30 was 14% (95% CI, 11 to 16).

Conclusions

Management of severe bleeding in patients treated with direct oral anticoagulants appears to be complex. The use of prothrombin complex concentrates differs depending on bleeding sites and direct oral anticoagulant plasma concentrations. Mortality differs according to bleeding sites and was similar to previous estimates.
Improved Survival in a Long-Term Rat Model of Sepsis Is Associated With Reduced Mitochondrial Calcium Uptake Despite Increased Energetic Demand
Authors: Pinto Bernardo B. , Dyson Alex , Umbrello Michele , Carré Jane E. , Ritter Cristiane , Clatworthy Innes , Duchen Michael R. , Singer Mervyn
Published: April 2017

Objectives:

To investigate the relationship between prognosis, changes in mitochondrial calcium uptake, and bioenergetic status in the heart during sepsis.

Design:

In vivo and ex vivo controlled experimental studies.

Setting:

University research laboratory.

Subjects:

Male adult Wistar rats.

Interventions:

Sepsis was induced by intraperitoneal injection of fecal slurry. Sham-operated animals served as controls. Confocal microscopy was used to study functional and bioenergetic parameters in cardiomyocytes isolated after 24-hour sepsis. Electron microscopy was used to characterize structural changes in mitochondria and sarcoplasmic reticulum. The functional response to dobutamine was assessed in vivo by echocardiography.

Measurements and Main Results:

Peak aortic blood flow velocity measured at 24 hours was a good discriminator for 72-hour survival (area under the receiver operator characteristic, 0.84 ± 0.1; p = 0.03) and was used in ex vivo experiments at 24 hours to identify septic animals with good prognosis. Measurements from animals with good prognostic showed 1) a smaller increase in mitochondrial calcium content and in nicotinamide adenine dinucleotide fluorescence following pacing and 2) increased distance between mitochondria and sarcoplasmic reticulum on electron microscopy, and 3) nicotinamide adenine dinucleotide redox potential and adenosine triphosphate/adenosine diphosphate failed to reach a new steady state following pacing, suggesting impaired matching of energy supply and demand. In vivo, good prognosis animals had a blunted response to dobutamine with respect to stroke volume and kinetic energy.

Conclusions:

In situations of higher energetic demand decreased mitochondrial calcium uptake may constitute an adaptive cellular response that confers a survival advantage in response to sepsis at a cost of decreased oxidative capacity.
Concept Communication and Interpretation of Illness
Authors: Nordby Halvor
Published: April 2017

To ensure patient communication in nursing, certain conditions must be met that enable successful exchange of beliefs, thoughts, and other mental states. The conditions that have received most attention in the nursing literature are derived from general communication theories, psychology, and ethical frameworks of interpretation. This article focuses on a condition more directly related to an influential coherence model of concept possession from recent philosophy of mind and language. The basic ideas in this model are (i) that the primary source of understanding of illness experiences is communicative acts that express concepts of illness, and (ii) that the key to understanding patients' concepts of illness is to understand how they depend on patients' lifeworlds. The article argues that (i) and (ii) are especially relevant in caring practice since it has been extensively documented that patients' perspectives on disease and illness are shaped by their subjective horizons. According to coherentism, nurses need to focus holistically on patients' horizons in order to understand the meaning of patients' expressions of meaning. Furthermore, the coherence model implies that fundamental aims of understanding can be achieved only if nurses recognize the interdependence of patients' beliefs and experiences of ill health. The article uses case studies to elucidate how the holistic implications of coherentism can be used as conceptual tools in nursing.
Postoperative Evaluation of Bilateral Reading Performance With Two Intraocular Lenses: Twelve-Month Results
Authors: Akkaya Turhan Semra , Toker Ebru
Published: April 2017

Purpose:

The aim of this study was to compare the bilateral reading performances within the first 12 months after the implantation of two intraocular lens (IOL) models.

Methods:

The patients involved in this research had bilateral phacoemulsification and implantation of the Acriva Reviol MFM 613 IOL (group 1) or AcrySof ReSTOR SN6AD1 apodized multifocal IOL (group 2). The bilateral reading performance was evaluated preoperatively and postoperatively using the MNREAD acuity charts. The reading speed, critical print size, and reading acuity were measured binocularly at 40 and 60 cm. In addition, the binocular uncorrected visual acuities (far, UDVA; intermediate, UIVA; and near, UNVA) were also measured.

Results:

Each IOL model was implanted in 30 eyes (15 patients), and 30 patients were included in this study. Overall, there were no statistically significant postoperative differences in the mean UDVA, UIVA and mean (P>0.05). There were statistically significant postoperative differences in the mean reading acuity (group 1, 0.07±0.10 logMAR; group 2, 0.02±0.08 logMAR; P=0.019) at 40 cm. When tested at 60 cm, the reading acuity (0.13±0.10 logMAR and 0.21±0.11 logMAR, respectively; P=0.021) and critical print size (0.25±0.13 logMAR and 0.39±0.16 logMAR, respectively; P=0.005) were significantly better in group 1 than in group 2.

Conclusion:

Both of the IOLs achieved good visual performances. However, the Acriva Reviol MFM 613 IOL performed better than the AcrySof ReSTOR SN6AD1 at an intermediate distance, whereas the AcrySof ReSTOR SN6AD1 provided better near distance results.
Donor Endothelial Cell Count Does Not Correlate With Descemet Stripping Automated Endothelial Keratoplasty Transplant Survival After 2 Years of Follow-up
Authors: Potapenko Ivan O. , Samolov Branka , Armitage Margareta Claesson , Byström Berit , Hjortdal Jesper
Published: April 2017

Purpose:

To analyze the influence of low endothelial cell density (ECD) of donor cornea tissue, donor age, and sex on the transplant survival rate after Descemet stripping automated endothelial keratoplasty (DSAEK).

Methods:

Graft ECD, age, and sex of donors used for DSAEK (n = 1789) during 7 years (2007–2014) in 4 Scandinavian hospitals were assessed for potential association with transplant survival at 2 years of follow-up using a Cox regression model correcting for confounding factors. The data were obtained from The Swedish Cornea Transplant Registry.

Results:

Transplant failure occurred in 196 patients, with 69 early failures during the first 3 postoperative months, and 127 late secondary failures. Twenty-five of the late secondary failures were due to rejection. Reversible rejections occurred in 67 patients. There was no significant impact of donor age [hazard ratio (HR) 1.0, 95% confidence interval (CI), 0.99–1.02,P= 0.32] or endothelial cell count (HR 1.00, 95% CI, 0.99–1.01,P= 0.3) on the survival rate of DSAEK transplants at 2 years of follow-up. The use of donor grafts with low ECD (<2300 cells/mm2) did not influence the survival rate (HR 1.3, 95% CI, 0.76–2.35,P= 0.31). Male donor sex was associated with lower 2-year graft survival (HR 1.5, 95% CI, 1.04–2.28,P= 0.03), but not with rejection events (P= 0.26).

Conclusions:

Based on data from The Swedish Cornea Transplant Registry, low donor ECD was not detrimental to graft survival, whereas donor sex seemed to influence the outcome at the end of the 2-year follow-up.
Reactivation of Herpes Zoster Keratitis With Corneal Perforation After Zoster Vaccination
Authors: Jastrzebski Andre , Brownstein Seymour , Ziai Setareh , Saleh Solin , Lam Kay , Jackson W. Bruce
Published: April 2017

Purpose:

We present a case of reactivated herpes zoster keratouveitis of 6 years duration with corneal perforation requiring penetrating keratoplasty shortly after inoculation with herpes zoster vaccine (Zostavax, Merck, Quebec, Canada).

Methods:

Retrospective case report.

Results:

A 67-year-old woman with a 5-year history of recurrent unilateral herpes zoster keratouveitis in her right eye presented with another recurrence 2 weeks after Zostavax vaccination. Three months later, she developed descemetocele and 2 months afterward, corneal perforation, which was managed by penetrating keratoplasty. Immunohistopathological examination disclosed positive staining for varicella zoster virus in most of the keratocytes adjacent to the descemetocele and perforation, most vividly in the deeper two-thirds of the stroma where the keratocytes were most dense, but not in corneal epithelium or endothelium. Electron microscopic examination showed universally severely degenerated corneal keratocytes in the corneal stroma adjacent to the perforation with variable numbers of herpes virus capsids present in half of these cells. Only a rare normal-appearing keratocyte was identified in the more peripheral corneal stroma.

Conclusions:

We present a case of reactivation of herpes keratouveitis shortly after vaccination with Zostavax in a patient with previous herpes zoster ophthalmicus. We demonstrate, for the first time, ultrastructural evidence consistent with inactive virus capsids in diffusely degenerated keratocytes in the extracted corneal tissue.
Estimation of Prevalence of Meibomian Gland Dysfunction in Japan
Authors: Amano Shiro , Inoue Kenji
Published: April 2017

Purpose:

To estimate the prevalence of meibomian gland dysfunction (MGD) in the Japanese population using new diagnostic criteria, including lid margin abnormalities and signs of occlusion of the meibomian gland orifices as essential signs.

Methods:

The participants were consecutive patients scheduled for cataract surgery at Inouye Eye Hospital. All participants were aged 50 years or older. The participants completed a symptoms questionnaire and underwent a comprehensive slit-lamp examination. MGD was diagnosed when both of the following 2 factors were positive: lid margin abnormalities and signs of occlusion of the meibomian gland orifices.

Results:

The study included 510 participants (205 men, 305 women) of mean age 71.1 ± 8.5 (range 50–93) years. The prevalence rates of symptomatic MGD and total (symptomatic + asymptomatic) MGD were 18.0% and 47.5%, respectively. The prevalence of total MGD increased significantly with increasing patient age (P < 0.0001). The ratio of men to women and the prevalence of systemic disease did not differ between participants who were positive or negative for MGD. For the total MGD group, slit-lamp findings (lid margin abnormality, shift of the mucocutaneous junction, telangiectasia, and plugging) were more frequent; tear film breakup time was shorter; and the meiboscore was higher than in participants without MGD.

Conclusions:

The prevalence of MGD is high in the Japanese population aged 50 years or older.
Factors Associated With Visual Field Progression in Cirrus Optical Coherence Tomography-guided Progression Analysis: A Topographic Approach
Authors: Shin Joong Won , Sung Kyung Rim , Lee Jiyun , Kwon Junki
Published: April 2017

Purpose:

To identify factors associated with visual field (VF) progression in optical coherence tomography (OCT)-guided progression analysis (GPA) using a topographic approach.

Methods:

Topographic components of OCT-GPA maps (Cirrus HD-OCT; Carl Zeiss Meditec) were classified according to location (temporal, superotemporal, superonasal, nasal, inferornasal, and inferotemporal), size (small, medium, and large), shape (wedge and irregular types), and pattern of retinal nerve fiber layer (RNFL) progression (widening, deepening, and new development). All positive findings in OCT-GPA (RNFL thickness maps, profiles, and average RNFL thickness) were defined as strong RNFL progression. VF progression was determined by linear regression analysis of VF mean deviation over time. Univariate and multivariate logistic regression analyses were performed to evaluate the association of VF progression with OCT-GPA parameters.

Results:

In total, 276 primary open-angle glaucoma patients were followed up for 5.1 years. According to OCT-GPA, 89 eyes were found to have RNFL progression. Of these, VF progression was detected in 27 (30.3%) eyes. Eyes with progressed VF group showed topographically different characteristics, which were wedge-shaped (80.6%), large-sized (40.0%), and widening (69.5%) or deepening (11.1%) pattern of RNFL progression in the inferotemporal (44.4%) and superotemporal (30.6%) regions, compared with eyes with non-progressed VF group. In multivariate analysis, strong RNFL progression and widening or deepening pattern of RNFL progression were significantly associated with VF progression (P=0.012 and 0.016, respectively).

Conclusions:

Topographic analysis in OCT-GPA maps showed different characteristics between progressed VF and nonprogressed VF groups. Glaucoma patients with widening or deepening pattern of RNFL progression should be carefully monitored for greater risk of VF progression.
Decrease in Pneumococcal Otitis Media Cultures With Concomitant Increased Antibiotic Susceptibility in the Pneumococcal Conjugate Vaccines Era
Authors: Jabarin Basel , Pitaro Jacob , Lazarovitch Tzilia , Gavriel Haim , Muallem-Kalmovich Limor , Eviatar Ephraim , Marom Tal
Published: April 2017

Objective:

To study the change in the incidence and antibiotic susceptibility patterns of Streptococcus pneumoniae (Spn) in cultures obtained from children with otitis media (OM) during the pneumococcal conjugate vaccines (PCVs) era.

Study Design:

Retrospective.

Setting:

Secondary medical care center.

Patients:

Children less than 8 years who presented with OM and had positive pneumococcal cultures during January 1, 2007 to December 12, 2014 were identified. Data recorded included demographics, preadmission antibiotics, culture source, and antibiotic susceptibility tests. We compared the pre-PCV years (2007–2008) with the transition years (2009–2011) and the post-PCV13 years (2012–2014).

Interventions:

PCV7 (2009), PCV13 (2010), therapeutic.

Main Outcome Measure(s):

Annual rate of Spn cultures, antibiotic susceptibility patterns.

Results:

We identified 134 children (76 boys, 57%) who contributed 162 pneumococcal cultures. There was a downward trend in the annual incidence rate of Spn cultures between the pre-PCV years, transition years, and post-PCV13 years: 11.12, 8.48, and 4.11/1000 hospitalized children/year, respectively (p = 0.08, p = 0.04). Had there been no interventions, and based on the 2007 to 2009 average, the observed over the expected Spn cultures ratio rates for 2010 to 2014 were 0.59, 0.45, 0.40, 0.40, and 0.25, respectively. In parallel, the susceptibility of Spn strains to four commonly tested antibiotics significantly increased from the pre-PCV years to the transition years and the post-PCV13 years. In each period, Spn strains were penicillin sensitive in 37, 51, and 100%; for erythromycin, 46, 71, and 82%; for trimethoprim/sulfamethoxazole, 32, 71, and 97%; and for ceftriaxone, 95, 96, and 100%, respectively.

Conclusion:

The introduction of PCVs significantly decreased the incidence rate of pneumococcal OM, and increased Spn susceptibility to common antibiotics.
Current Management Practices in Ménière's Disease
Authors: Clyde Joseph W. , Oberman Benjamin S. , Isildak Huseyin
Published: April 2017

Objective:

To evaluate current trends in managing Ménière's disease (MD) by both general otolaryngologists and otologists/neurotologists and discuss treatment modalities.

Study Design:

Cross-sectional study.

Setting:

Survey of physicians.

Subjects and Methods:

An electronic questionnaire was disseminated to all members of American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS).

Results:

Eight hundred and sixty members replied for a response rate of 14.5% for generalists and 35% for neurotologists. Thirty-nine percent of respondents think that diet and lifestyle changes are effective in controlling symptoms in more than 50% of their MD patients. Overall, 72.8% of respondents used hydrochlorothiazide/triamterene (HCTZ/TAT) “often” or “always” with neurotologists using HCTZ/TAT more often than generalists (p < 0.001). Half of neurotologists used IT steroids “often” or “always,” compared with only 10% of generalists (p < 0.001). Endolymphatic sac procedures are the most common surgeries and are used more often by neurotologists than by generalists (p < 0.001). The Medtronic Meniett device is used more by neurotologists (p < 0.001) but it is not commonly used overall (69.2% “never” use).

Conclusion:

Many options are available for the treatment of MD. Neurotologists tend to use a wider variety of medications in their treatment protocols than generalists. Neurotologists tend to perform surgical interventions more frequently than generalists. Our evidence shows significant heterogeneity for treatment of Ménière's disease among otolaryngologists. A guideline that outlines appropriate therapeutic options, dosing, and treatment escalation is warranted.
Short article: Viral dynamics among hepatitis C virus chronic infected patients during direct-acting antiviral agents therapy: impact for monitoring and optimizing treatment duration
Authors: Tabernilla Andres , Grandal Marta , Pernas Berta , Castro-Iglesias Angeles , Rodríguez-Osorio Iria , Mena Alvaro , Delgado Manuel , Cid Purificacion , Pedreira Jose D. , Poveda Eva
Published: April 2017

Objectives

Direct-acting antiviral agents (DAAs) have provided an ultimate treatment duration of 12 weeks for most hepatitis C virus (HCV)-infected patients. The opportunity to reduce treatment duration to 6 or 8 weeks is being evaluated. Here, the HCV viral dynamics at short times during HCV therapies and its implications for monitoring and optimizing treatment duration have been assessed.

Patients and methods

HCV chronic infected patients who began HCV therapy (March 2014 to June 2015) at a reference hospital of the Northwest of Spain were selected. HCV-RNA was quantified at different short time points during HCV therapy using Abbott RealTime HCV assay. Epidemiological, clinical, and virological data were recorded.

Results

Eleven HCV-infected patients were included; 90.9% had cirrhosis (>12.5 kPa) and 72.7% were treatment-experienced. HCV genotype 1b was the most prevalent (72.7%). All of the combinations were pegylated interferon-free and all included ribavirin. The median HCV-RNA (log IU/ml) at baseline was 5.8 (5.4–6.1); the decline between baseline and day 3, weeks 4, 8, and 12 was 3.2, 4.8, 5.1, and 5.6, respectively. Fewer than 50% of patients achieved undetectable viral load at weeks 4 and 8; however, all patients achieved a sustained virologic response at 12 weeks.

Conclusion

Rapid and high HCV-RNA decline was observed among HCV-infected patients under DAA-based regimens, especially for those without cirrhosis. Despite low rates of patients with undetectable HCV-RNA at weeks 4 and 8, all achieved a sustained virologic response at 12 weeks. These findings suggest that the time points to monitor HCV-RNA during DAA therapies and the treatment duration need to be optimized.
Patterns of Buprenorphine-Naloxone Treatment for Opioid Use Disorder in a Multistate Population
Authors: Saloner Brendan , Daubresse Matthew , Caleb Alexander G.
Published: April 2017

Background:

Buprenorphine-naloxone treatment for opioid use disorder has rapidly expanded, yet little is known about treatment outcomes among patients in the general population.

Objective:

To examine predictors of treatment duration, dosage, and continuity in a diverse community setting.

Research Design:

We examined QuintilesIMS Real World Data, an all-payer, pharmacy claims database, to conduct an analysis of individuals age 18 years and above initiating buprenorphine-naloxone treatment between January 2010 and July 2012 in 11 states. We used logistic regression to assess treatment duration longer than 6 months. We used accelerated failure time models to assess risk of treatment discontinuation. We used ordinary least squares regression to assess mean daily dosage. For patients with ≥3 fills, we also used logistic regression to assess whether ;an individual had a medication possession ratio of <80% and/or gaps in treatment >14 days. Models adjusted for individual demographics, prescribing physician specialty, state, and county-level variables.

Results:

Overall, 41% of individuals were retained in treatment for at least 6 months and the mean treatment length was 266 days. Compared with individuals who paid primarily for treatment with cash, adjusted odds of 6 month retention were significantly lower for individuals with primary payment from Medicaid fee-for-service, Medicare part D, and third-party commercial. There were substantial differences in 6-month retention across states with the lowest in Arizona and highest in New York. Low-possession ratios occurred for 30% of individuals and 26% experienced treatment episodes with gaps >14 days. Odds of low-possession and treatment gaps were largely similar across demographic groups and geographic areas.

Conclusions:

Current initiatives to improve access and quality of buprenorphine-naloxone treatment should examine geographic barriers as well as the potential role of insurance benefit design in restricting treatment length.
Distinct subtype distribution and somatic mutation spectrum of lymphomas in East Asia
Authors: Ren Weicheng , Li Wei , Ye Xiaofei , Liu Hui , Pan-Hammarström Qiang
Published: April 2017

Purpose of review

Here, we give an updated overview of the subtype distribution of lymphomas in East Asia and also present the genome sequencing data on two major subtypes of these tumors.

Recent findings

The distribution of lymphoma types/subtypes among East Asian countries is very similar, with a lower proportion of B-cell malignancies and a higher proportion of T/natural killer (NK)-cell lymphomas as compared to Western populations. Extranodal NK/T-cell lymphoma is more frequently observed in East Asia, whereas follicular lymphoma and chronic lymphocytic leukemia, are proportionally lower. The incidence rate of lymphoma subtypes in Asians living in the US was generally intermediate to the general rate in US and Asia, suggesting that both genetic and environmental factors may underlie the geographical variations observed.

Key cancer driver mutations have been identified in Asian patients with diffuse large B-cell lymphoma or extranodal NK/T-cell lymphoma through genome sequencing. A distinct somatic mutation profile has also been observed in Chinese diffuse large B-cell lymphoma patients.

The incidence and distribution of lymphoma subtypes differed significantly between patients from East Asia and Western countries, suggesting subtype-specific etiologic mechanisms. Further studies on the mechanism underlying these geographical variations may give new insights into our understanding of lymphomagenesis.
Current opinions in the infection control of carbapenem-resistant Enterobacteriaceae species and Pseudomonas aeruginosa
Authors: Gholizadeh Pourya , Maftoon Hamideh , Aghazadeh Mohammad , Asgharzadeh Mohammad , Kafil Hossein Samadi
Published: April 2017

Pseudomonas aeruginosa and some of the species of Enterobacteriaceae are Gram-negative hospital-acquired pathogens that are mostly difficult to treat. Carbapenem drugs are a group of β-lactams class that affect cell wall and are administered in the treatment of infections caused by these organisms. These organisms can be resistant to carbapenem drugs via mechanisms such as carbapenemase enzymes and multidrug efflux systems. Detection methods for carbapenem-resistant isolates are the modified Hodge test, Carba NP test, and PCR. This review will describe the current opinion in the treatment of multidrug-resistant and carbapenemase-producing Enterobacteriaceae and P. aeruginosa and suggest some available antibiotics to be administered in the treatment of infections involving these organisms. Based on carbapenem susceptibility patterns found in previous studies, some drugs such as antipseudomonal agents, colistin, or combined therapy have been suggested for carbapenemase-producing P. aeruginosa, and tigecycline, colistin, and fosfomycin have been suggested for carbapenemase-producing Enterobacteriaceae.
Perceived Stress, Parent-Adolescent/Young Adult Communication, and Family Resilience Among Adolescents/Young Adults Who Have a Parent With Cancer in Taiwan
Authors: Chen Chin-Mi , Du Bao-Feng , Ho Ching-Liang , Ou Wei-Jen , Chang Yue-Cune , Chen Wei-Ching
Published: April 2017

Background:

Family resilience helps family members successfully overcome adversity, for example, chronic disease or unpleasant situations. However, few studies have identified correlates of family resilience among adolescents/young adults having a parent with cancer.

Objective:

This longitudinal study explored (1) relationships among family resilience, adolescents’ perceived stress, and parent-adolescent/young adult communication; (2) trends in family resilience with data collection time; and (3) differences in parent-adolescent/young adult communication by parent gender (ie, father or mother).

Methods:

Participants were teenagers and young adults (12–25 years) with a parent who had cancer. Data were collected using structured questionnaires at 3 times for 4 to 5 months, with 2 months between each collection.

Results:

Of 96 adolescent/young adult participants enrolled at T1, only 32 completed all measurements at T3. We found that (1) family resilience was negatively associated with adolescents’ perceived stress (B = −0.35) and positively associated with adolescent/young adult communication with both the father (B = 0.58) and the mother (B = 0.36), (2) the degree of family resilience at T3 was significantly lower than at T1 (B = −4.79), and (3) at all 3 data collection times, the degree of adolescent/young adult communication was higher with mothers than with fathers, whether the mother had cancer or did not have cancer.

Conclusions:

Family resilience was positively associated with parent-adolescent/young adult communication and negatively related to perceived stress. Family resilience tended to decline with longer parental survival since cancer diagnosis.

Implications for Practice:

We suggest nursing interventions to reduce adolescent/young adult stress and develop optimal parent-adolescent/young adult communication to enhance family resilience.
Self-Identity After Bereavement
Authors: Boelen Paul A.
Published: April 2017

There is evidence that both the centrality of a loss-event as well as reduced self-concept clarity are involved in emotional problems after the death of a loved one. One issue that is still unexplored is the relative importance of these two concepts in predicting bereavement outcome. The current study examined the degree to which both concepts contribute to emotional distress after loss, both concurrently and longitudinally. Data were available from 124 individuals, all bereaved within the previous half year, who completed measures of prolonged grief, posttraumatic stress, and depression at inclusion into the study and again 6 months later. Loss-centrality and self-unclarity were associated with all three outcome measures, in cross-sectional analyses. Longitudinal analyses indicated that loss-centrality predicted symptom levels of prolonged grief, self-unclarity predicted symptom levels of depression, and both loss-centrality and self-unclarity were associated with posttraumatic stress 6 months after baseline. Implications of these findings are discussed.
Implementation of an ICU Bundle: An Interprofessional Quality Improvement Project to Enhance Delirium Management and Monitor Delirium Prevalence in a Single PICU*
Authors: Simone Shari , Edwards Sarah , Lardieri Allison , Walker L. Kyle , Graciano Ana Lia , Kishk Omayma A. , Custer Jason W.
Published: April 2017

Objectives:

To examine the impact of an ICU bundle on delirium screening and prevalence and describe characteristics of delirium cases.

Design:

Quality improvement project with prospective observational analysis.

Setting:

Nineteen-bed PICU in an urban academic medical center.

Patients:

All consecutive patients admitted from December 1, 2013, to September 30, 2015.

Interventions:

A multidisciplinary team implemented an ICU bundle consisting of three clinical protocols: delirium, sedation, and early mobilization using the Plan-Do-Study-Act cycles as part of a quality improvement project. The delirium protocol implemented in December 2013 consisted of universal screening with the Cornell Assessment of Pediatric Delirium revised instrument, prevention and treatment strategies, and case conferences. The sedation protocol and early mobilization protocol were implemented in October 2014 and June 2015, respectively.

Measurements and Main Results:

One thousand eight hundred seventy-five patients were screened using the Cornell Assessment of Pediatric Delirium revised tool. One hundred forty patients (17%) had delirium (having Cornell Assessment of Pediatric Delirium revised scores ≥ 9 for 48 hr or longer). Seventy-four percent of delirium positive patients were mechanically ventilated of which 46% were younger than 12 months and 59% had baseline developmental delays. Forty-one patients had emerging delirium (having one Cornell Assessment of Pediatric Delirium revised score ≥ 9). Statistical process control was used to evaluate the impact of three ICU bundle process changes on monthly delirium rates over a 22-month period. The delirium rate decreased with the implementation of each phase of the ICU bundle. Ten months after the delirium protocol was implemented, the mean delirium rate was 19.3%; after the sedation protocol and early mobilization protocols were implemented, the mean delirium rate was 11.84%.

Conclusions:

Implementation of an ICU bundle along with staff education and case conferences is effective for improving delirium screening, detection, and treatment and is associated with decreased delirium prevalence.
Ultrasound-Guided S1 Transforaminal Epidural Injection Using the In-Plane Approach and Color Doppler Imaging
Authors: Park Donghwi
Published: April 2017

Recently, several studies have investigated the effectiveness of the ultrasound-guided lumbosacral transforaminal epidural injection. However, the ultrasound-guided S1 transforaminal epidural injection using an out-of-plane approach, which was previously reported, may cause an intestinal injury or intravascular injection because the needle tip tends to be invisible in the out-of-plane approach. In this study, therefore, we report a new method of ultrasound-guided S1 transforaminal epidural injection using the in-plane approach and color Doppler. In addition, we also report the usefulness of color Doppler imaging for finding the S1 foramen and confirming the accuracy of the injection.
Association of Need for Tracheotomy With Decreasing Mechanical In-Exsufflation Flows in Amyotrophic Lateral Sclerosis
Authors: Bach John R. , Upadhyaya Neelam
Published: April 2017

Although patients with lower motor neuron and myopathic disorders can prolong their lives by depending on continuous noninvasive ventilatory support, most patients with amyotrophic lateral sclerosis (ALS) cannot and must use tracheostomy mechanical ventilation to prolong survival. This case demonstrates that this occurs because amyotrophic lateral sclerosis patients' upper motor neuron reflex laryngeal closure and stridor cause upper airway collapse that renders mechanical insufflation-exsufflation (MIE) ineffective in expulsing airway secretions as well as for permitting continuous noninvasive ventilatory support. A decrease in MIE-exsufflation flows is a marker for a decrease in upper airway patency that renders MIE ineffective. As airway secretions accumulate and baseline oxyhemoglobin saturation decreases, tracheotomy becomes necessary for further survival. This case demonstrates an association between diminishing MIE-exsufflation flow and need to resort to tracheotomy.
Subjective General Health and the Social Regulation of Hypothalamic Activity
Authors: Brown Casey L. , Beckes Lane , Allen Joseph P. , Coan James A.
Published: April 2017

Objective

Social support is associated with better health. This association may be partly mediated through the social regulation of adrenomedullary activity related to poor cardiovascular health and glucocorticoid activity known to inhibit immune functioning. These physiological cascades originate in the hypothalamic areas that are involved in the neural response to threat. The aim of the study investigated whether the down regulation, by social support, of hypothalamic responses to threat is associated with better subjective health.

Methods

A diverse community sample of seventy-five individuals, aged 23 to 26 years, were recruited from an ongoing longitudinal study. Participants completed the Short Form Health Survey, a well-validated self-report measure used to assess subjective general health. They were scanned, using functional magnetic resonance imaging, during a threat of shock paradigm involving various levels of social support, which was manipulated using handholding from a close relational partner, a stranger, and an alone condition. We focused on a hypothalamic region of interest derived from an independent sample to examine the association between hypothalamic activity and subjective general health.

Results

Results revealed a significant interaction between handholding condition and self-reported general health (F(2,72) = 3.53, p = .032, partial η2 = 0.05). Down regulation of the hypothalamic region of interest during partner handholding corresponded with higher self-ratings of general health (ß = −0.31, p = .007).

Conclusions

Higher self-ratings of general health correspond with decreased hypothalamic activity during a task that blends threat with supportive handholding. These results suggest that associations between social support and health are partly mediated through the social regulation of hypothalamic sensitivity to threat.
Improved HIV and TB Knowledge and Competence Among Mid-level Providers in a Cluster-Randomized Trial of One-on-One Mentorship for Task Shifting
Authors: Naikoba Sarah , Senjovu Kaggwa D. , Mugabe Pallen , McCarthy Carey F. , Riley Patricia L. , Kadengye Damazo T. , Dalal Shona
Published: April 2017

Introduction:

Health worker shortages pose a challenge to the scale up of HIV care and treatment in Uganda. Training mid-level providers (MLPs) in the provision of HIV and tuberculosis (TB) treatment can expand existing health workforce capacity and access to HIV services.

Methods:

We conducted a cluster-randomized trial of on-site clinical mentorship for HIV and TB care at 10 health facilities in rural Uganda. Twenty MLPs at 5 randomly assigned to an intervention facilities received 8 hours a week of one-on-one mentorship, every 6 weeks over a 9-month period; and another 20 at 5 control facilities received no clinical mentorship. Enrolled MLPs' clinical knowledge and competence in management of HIV and TB was assessed using case scenarios and clinical observation at baseline and immediately after the 9-month intervention. The performance of the study health facilities on 8 TB and HIV care indicators was tracked over the 9-month period using facility patient records.

Results:

Thirty-nine out 40 enrolled MLPs had case scenario and clinical observation scores for both the baseline and end of intervention assessments. Mentorship was associated with a mean score increase of 16.7% (95% confidence interval: 9.8 to 23.6, P < 0.001) for the case scenario assessments and 25.9% (95% confidence interval: 14.4 to 37.5, P < 0.001) for the clinical observations. On-site clinical mentorship was significantly associated with an overall improvement for 5 of the 8 health facility TB and HIV indicators tracked.

Conclusions:

One-on-one on-site mentorship improves individual knowledge and competence, has a downstream effect on facility performance, and is a simple approach to training MLPs for task shifting.
Evaluation of the Angus ICD9-CM Sepsis Abstraction Criteria
Authors: Horng Steven , Nathanson Larry A. , Sontag David A. , Shapiro Nathan I.
Published: April 2017

Objective

Validate the infection component of the Angus International Classification of Diseases, Ninth Revision, Clinical Modification (ICD9-CM) sepsis abstraction criteria

Design

Observational cohort study

Setting

55,000 visits/year Adult Emergency Department (ED)

Patients

All consecutive ED patient visits between 12/16/2011 and 08/13/2012 were included in the study. Patients were excluded if there was a missing outcome measure.

Interventions

None.

Measurements and Main Results

The primary outcome measure was suspected infection at conclusion of the ED work-up as judged by the physician. There were 34,796 patients who presented to the ED between 12/16/11 and 8/13/12, of which 31,755 (91%) patients were included and analyzed. The original Angus sepsis abstraction criteria had a sensitivity of 55%, specificity of 97%, PPV of 82%, NPV of 88%, accuracy of 87%, and a F1score of 0.66. The modified Angus sepsis abstraction criteria which includes codes added after the original publication had a sensitivity of 65%, specificity of 96%, PPV of 81%, NPV of 91%, accuracy of 89%, and F1score of 0.72.

Conclusions

In our study, the Angus abstraction criteria have high specificity (97%), but moderate sensitivity (55%) in identifying patients with suspected infection as defined by physician at the time of disposition from the emergency department. Given these findings, it is likely that we are underestimating the true incidence of sepsis in the United States and worldwide.