bluuebunny/crossref_metadata_2025 huggingface dataset:
Transverse Versus Vertical Skin Incision for Planned Cesarean Hysterectomy: Does It Matter? [12S]
Authors: Szlachta-McGinn Alec W. , Mei Jenny Y. , Tabsh Khalil , Afshar Yalda
Published: May 2019

INTRODUCTION:

To investigate differences in perioperative outcomes by type of skin incision, transverse versus vertical, for planned cesarean hysterectomy for morbidly adherent placentation.

METHODS:

A retrospective cross-sectional study of women who underwent planned cesarean hysterectomy for abnormal placentation at a large academic hospital over five years (IRB#18-000872). Demographic data were chart abstracted and analyzed. The Student t-test compared continuous variables and Fisher exact test compared categorical variables. Continuous data were presented as median and compared using the Wilcoxon-rank sum test.

RESULTS:

42 planned cesarean hysterectomies were identified. Median gestational age at birth was 34.8 weeks. A transverse skin incision was made in 43% (n=18); a vertical skin incision was made in 57% (n=24), independent of placental location (P=0.82). Median estimated blood loss (EBL) was 1950 milliliters (mL) with a mean transfusion of 3 units of packed red blood cells (range 0-21). EBL was not associated with transverse versus vertical skin incision (2727 mL vs 2741 mL, P=0.8). There was significantly shorter operative time with transverse skin incision (180 vs 238 minutes, P=0.03), with no difference in intraoperative complications (RR 1.55; 95% CI 0.52-4.62, P=0.42). Postoperatively there was no difference in length of stay (4.75 vs 4.47 days, P=0.74) or opioid use (128 vs 179 morphine equivalents, P=0.31).

CONCLUSION:

Transverse skin incision is associated with shorter length of surgery for patients undergoing planned cesarean hysterectomy. There was no difference in EBL, intraoperative complications, postoperative length of stay, or opioid use. Given an increasing rate of cesarean hysterectomy, we must identify variables that optimize outcomes and resource utilization.
Accurate Gestational Dating at 12–14 Weeks: Crown-Rump Length Versus Composite Biometry [29S]
Authors: Khandelwal Meena , Kaigh Caroline , Safronova Elena , Gaughan John
Published: May 2019

INTRODUCTION:

Determining accurate gestational age (GA) is an essential for decision making in obstetrics. Fetus folds around 12 weeks. We wanted to determine whether crown-rump length (CRL) or a composite biometric measurement (CBM) including head, abdominal and femur measurements, or a combination of CRL and CBM, provides a more accurate GA estimation between 12.0 weeks to 13.9 weeks gestation.

METHODS:

Fetal biometry data on singleton pregnancies was collected from a retrospective well-dated pregnancy cohort. All CRL images were reviewed for accuracy. GA by both CRL and CBM was compared to the certain GA using the Bland-Altman test to assess regression to the mean, limits of agreement, and bias.

RESULTS:

Included 1716 pregnancies revealed an average bias of +0.7 (-9.95 to 11.4) days with CRL; +3.37 (-3.82 to 10.6) with CBM between 12w0d-13w6d. GA is overestimated by both methods at 12 weeks. CRL underestimates GA after 13weeks, while CBM underestimates after 14weeks. The true GA estimation for 13.1-14.0 weeks is a combination of CRL (negative bias) and CBM (positive bias). Results were not altered by body mass index nor by fetal position of CRL measurement (midsagittal, coronal or prone).

CONCLUSION:

Given the larger bias of composite biometry dating, CRL-based dating is more accurate up to 13 weeks. The ACOG Committee Opinion number 611 (2014) should be modified to reflect measurement of CRL till 13w, but composite of CRL and CBM between 13w1d to 14 weeks. In addition, for pragmatic reasons, CRL measurement in any feasible plane should be acceptable.
Spontaneous Uterine Artery Rupture Following an Uncomplicated Vaginal Delivery [33P]
Authors: Jones Sarah Brown
Published: May 2019

INTRODUCTION:

Spontaneous rupture of the uterine vessels is a rare and potentially fatal complication of pregnancy with maternal mortality rates reported between 30-40%. The signs and symptoms can be vague but rapid diagnosis is critical in reducing maternal morbidity and mortality.

METHODS:

This case report outlines a 44-year-old female who had a spontaneous vaginal delivery. Two hours after delivery she developed signs of severe anemia and abdominal pain and had significant deviation of the uterus to the left. CT revealed a hematoma in the right broad ligament greater than the size of the uterus. CT angiography showed that the right uterine artery had spontaneously ruptured and immediate uterine artery embolization was performed. The patient stabilized and was discharged home. 3 weeks later, the patient presented with abdominal pain and fevers. An exploratory laparotomy was performed that showed an infected hematoma and uterus. The hematoma was evacuated and the uterus was removed. The patient recovered well from this procedure and has had no further complications. Patient informed consent was obtained for submission of a case report.

CONCLUSION:

This case report highlights the presenting features of an unusual retroperitoneal hematoma from the spontaneous rupture of the uterine artery after a routine vaginal delivery. This scenario has not previously been reported. It illustrates not only the effectiveness of embolization for treatment of retroperitoneal hematoma, but also the risks.
Hemoglobinopathies and Maternal Outcomes: Retrospective Analysis of National Data [24K]
Authors: Emezienna Nkechinyere , Ranjit Anju , Lambert Calvin E. , Bada Oluwafunmilola T.
Published: May 2019

INTRODUCTION:

This study aims to evaluate maternal outcomes amongst pregnant patients with sickle cell disease, sickle cell trait, and thalassemias.

METHODS:

2013-2014 National Readmission Database was queried to identify all deliveries, women with sickle cell disease (SCD), sickle cell trait (SCT) and thalassemia using ICD-9 codes. Demographic and clinical characteristics along with maternal outcomes such as pregnancy induced hypertension (PIH), gestational diabetes, preterm delivery, postpartum hemorrhage (PPH) and severe acute maternal outcomes (SAMM) were compared between women with and without SCD, SCT and thalassemia using Chi Square test. Multivariable logistic regressions were used to determine the odds of listed maternal outcomes in mothers with SCD, SCT and thalassemia compared to mothers without SCT, SCD and thalassemia. IRB approved study.

RESULTS:

A total of 1,376,903 deliveries were identified representing 3,113,047 deliveries nationwide. Among them, 16,825 (0.5%) women had SCT, 1668 (0.05%) had SCD and 5546 (0.2%) had diagnosis of thalassemia. When compared to control group, women with SCT were more likely to have PIH (12.89 vs. 8.49%, aOR [CI]: 1.33 [1.22-1.44], p=<.001), and PPH (3.59 vs. 2.78%, aOR [CI]: 1.27 [1.11-1.47], p=<.001). When adjusted for patient demographic, clinical and hospital level characteristics, women with SCD (26.7% vs. 1.8%, aOR [CI]: 11.02 [9.04-13.4], p=<.001), SCT (3.8% vs. 1.8%, aOR [CI]: 1.56 [1.36-1.79], p=<.001) and thalassemia (4.84% vs. 1.8%, aOR [CI]: 2.40 [2.02-2.85], p=<.001) were more likely to have SAMM complications compared to the control group.

CONCLUSION:

Patients with SCD, SCT, and thalassemia have an increased risk of maternal morbidity. Appropriate screening methods for adequate diagnosis is essential for the prevention and mitigation of these outcomes.
Minimizing Trendelenburg Position for Laparoscopic Gynecologic Surgery [6L]
Authors: Wagner Elena , Chandler Jessica Nicole , Mihalov Linda S.
Published: May 2019

INTRODUCTION:

Trendelenburg position is needed for adequate exposure of pelvic anatomy during gynecologic surgery. Steep Trendelenburg can be associated with anesthetic challenges, physiologic changes and rare complications that increase risk. The degree of Trendelenburg for optimal exposure has not been described.

METHODS:

A single surgeon at our institution routinely placed patients in the minimal amount of Trendelenburg necessary to expose the anatomy measuring the degree with a smart phone app and documenting in the operative reports. All of the robotic cases from November 1, 2011 through July 31, 2018 performed by the surgeon were identified and operative notes and charts from each case were reviewed.

RESULTS:

Results: 338 out of 380 cases were identified that had degree of Trendelenburg dictated. Mean Trendelenburg was 15.4 degrees (range from 7 to 31) with a median of 15. 85% of cases (287/338) were completed 18 degrees or less of Trendelenburg. Addition of Modifier 22 to the case was associated with higher mean Trendelenburg from 15.2 (n= 255; range 7-31) to 16.0 (n=83; range 9-30) (p=0.05). BMI >30 was associated with higher mean Trendelenburg from 15.0 (n=218; range 7-25) to 16.3 (n=120; range 9-31) (p=0.001). Surgeries that included hysterectomy (mean Trendelenburg 15.4, n=309, range 7-31) showed no difference compared with other gynecologic procedures (mean Trendelenburg of 15.3; n=29, range 10-30) (p=0.9).

CONCLUSION:

Traditional “steep” Trendelenburg is not always needed to adequately expose anatomy for surgery. BMI and case difficulty were associated with requiring steeper Trendelenburg.
Improved Birth Outcomes Through Health Plan and Community Hub Partnerships [18L]
Authors: Lucas Brad , Detty Amber
Published: May 2019

INTRODUCTION:

An analysis to determine if Medicaid health plan clinical program activity combined with community based care coordination (community hubs) can improve birth outcomes by reducing non-clinical/social determinant barriers to care.

METHODS:

We conducted a retrospective cohort study of 3702 deliveries in Lucas County, Ohio. All deliveries in these areas between March 2013-February 2017 were included. Outcomes were derived from medical claims. Levels of community-based social services were obtained from our community hub partner. We used bivariate and multivariate analysis to identify Odds Ratios for Neonatal/NICU Admission by select predictors for all deliveries and separately for deliveries to high-risk, moderate-risk, low-risk, and unknown risk mothers in the service area.

RESULTS:

High-risk mothers in these service areas where the member was not exposed to any community hub activity were 1.55 times more likely to deliver a baby needing Special Care Nursery or NICU care when compared to high risk members who received hub services through delivery.

CONCLUSION:

Medicaid health plan care management alone can be insufficient in helping high risk pregnant women and their providers in reducing their risks of preterm delivery. Partnerships with community hubs reduces non-clinical/social determinant barriers in high-risk pregnancy. This data shows Community Hub activity combined with Medicaid health plan clinical program/care management activity improves birth outcomes in high risk pregnancies compared to high risk pregnancies that are not exposed to this intervention.
Fertility Knowledge of Women in the United States [6M]
Authors: Zinaman Michael J. , Johnson Sarah , Foster Lesley , Zanzi Giulia , Mollard Celine
Published: May 2019

INTRODUCTION:

The demographics of women seeking to conceive has changed, with many women now seeking pregnancy when older. This can lead to disappointment, with the sentiment “I wish I had known more about fertility”. This study sought to assess US women basic understanding of fertility.

METHODS:

On behalf of SPD, Ipsos Suisse SA interviewed a representative sample of 1,000 US women aged from 20 to 45 years old who are able to have children (with quotas set upon age and region). Interviews were conducted online (computer assisted web interview) via online Panel.

RESULTS:

When asked “what would you say is the most accurate description, for you personally, of a menstrual cycle?”, only 14% selected the right answer from the five options presented, with 16% selecting “the days on which there is bleeding”. Only 20% knew there were fertile 3-6 days during a menstrual cycle, with 25% thinking pregnancy was possible following intercourse on any day of the cycle; for the 20-24 age group 38% thought pregnancy possible on any day. Only 27% of women could correctly state when the fertile days were in a cycle.

CONCLUSION:

This survey found a basic gap in fertility knowledge for many US women. Especially worrying was the proportion of these women who believed that pregnancy was possible following intercourse on any day of the cycle, as this could hinder conception chances.
The Fatty Acid Composition of Vegetable Oils and Their Potential Use in Wound Care
Authors: Alves Anselmo Queiroz , da Silva Valdemiro Amaro , Góes Alexandre José Silva , Silva Mariza Severina , de Oliveira Gibson Gomes , Bastos Isla Vanessa Gomes Alves , de Castro Neto Antonio Gomes , Alves Antonio José
Published: May 2019

OBJECTIVE

To evaluate the similarities among fatty acid compositions of vegetable oils sold in the Brazilian market and those present in a reference health product used to treat wounds.

METHODS

The relative amounts of fatty acids in 21 types of vegetable oils, purchased in the Brazilian market, were assessed using gas chromatography-mass spectrometry and flame ionization detection.

MAIN RESULTS

The studied oils had similar fatty acid compositions to the reference product (caprylic acid, 18.8%; capric acid, 17.4%; oleic acid, 27.5%; and linoleic acid, 28.1%). The presence of caprylic acid (10.45% ± 0.07%), capric acid (5.8% ± 0.75%), lauric acid (45.63% ± 0.93%), and myristic acid (16.33% ± 2.23%) were detected in all the vegetable oils tested. Oleic acid (52.94% ± 12.54%) was present in andiroba, avocado, canola, copaiba, olive, palm, pequi, and pracaxi oils and featured prominently in olive oil (75.8%). Linoleic acid (57.09% ± 8.47%) was present in corn, cottonseed, grapeseed, passion fruit, and sunflower oils and in mixed oils (olive with soybean and sunflower with corn and canola).

CONCLUSIONS

Most of the vegetable oils tested are products of plants from tropical climates, where they are abundant and easy to cultivate. It is possible that a balanced composition of fatty acids obtained from natural sources could be an effective alternative treatment for wounds.
Types, Frequency, Duration, and Dosage of Probiotics to Prevent Necrotizing Enterocolitis in Preterm Infants Among Countries
Authors: Kutylowksi Julie , Yahia Najat
Published: May 2019

Background:

Probiotic use in the neonatal intensive care unit (NICU) has been linked to reduced rates of necrotizing enterocolitis in preterm infants. Currently, in the United States, probiotic use within the NICU is limited despite being commonly used in other countries.

Purpose:

To provide an overview of the current practices of using probiotics in preterm infants for the prevention of NEC in the NICU in preselected countries.

Methods:

A comprehensive literature search was conducted on PubMed and clinicaltrials.gov. Also, studies from 2 recent meta-analyses on the topic were reviewed for inclusion. Selection criteria were as follows: studies involving preterm infants using probiotics in the NICU, reporting on the impact of probiotic use on the incidence of necrotizing enterocolitis, published within the last 10 years and in the English language, and originating from the United States, Canada, or any European country.

Results:

Twenty-three studies were selected. The most common types of probiotics used were Bifidobacterium infantis and Lactobacillus rhamnosus. The most common frequency of administration was daily or twice day. Duration ranged from 10 days to the entire NICU stay. The dosage was commonly 1 billion colony-forming units daily but ranged from 12 million daily to 12 billion per kilogram daily.

Implications for Practice:

Examining the current practices of probiotic use in the NICU provides useful information as this adjunctive therapy rises in popularity.

Implications for Research:

Refining methods of probiotic research for necrotizing enterocolitis prevention will improve safety and effectiveness and provide a framework for future clinical trials.
Neonatal Abstinence Syndrome
Authors: Jackson Heather J. , López Cristina , Miller Sarah , Englehardt Barbara
Published: May 2019

Background:

The current opioid epidemic in the United States has given rise to a growing incidence of neonatal abstinence syndrome (NAS). Treatments for this condition optimize nonpharmacologic therapies in an effort to improve withdrawal symptoms and reduce or eliminate the need for opioid medications, thereby reducing hospital length of stay and improving healthy neonatal outcomes.

Purpose:

The purpose of this review was to evaluate the current evidence for neonatal acupuncture treatments and identify essential characteristics that must be included in a treatment protocol for NAS.

Methods/Search Strategy:

An integrative review was conducted under the guidance of the Whittemore and Knafl methodology and near-term infant conceptual framework. An evaluation of the quality and levels of evidence was also included.

Findings/Results:

A total of 10 studies were identified in this review. Four of these studies were randomized controlled trials, and utilized acupuncture in the neonatal population to evaluate impact on pain, NAS, and weight gain.

Implications for Practice:

This review provided the essential elements for the development of a complementary acupuncture treatment protocol for the management of NAS.

Implications for Research:

Future research should include the identified essential characteristics in high-quality, blinded, randomized controlled trials to assess the treatment effect of acupuncture on neonates experiencing withdrawal symptoms.
Cutaneous manifestations of pediatric lupus
Authors: Arkin Lisa M. , Nguyen Cordellia , Klein-Gitelman Marisa
Published: May 2019

Purpose of review

To review recent evidence on cutaneous manifestations of lupus, with a focus on evidence for pediatric patients.

Recent findings

Cutaneous manifestations of SLE are common and may precede signs or symptoms of systemic disease. Early recognition and initiation of therapy improves quality of life by reducing cutaneous disease activity. Antimalarials are first line for moderate-to-severe disease. Photo protection is a critical component of therapy and perhaps the only modifiable risk factor for SLE. Recognition of cutaneous vasculopathy may reduce mortality from vascular occlusion.

There is a critical need for better understanding of pathogenesis, risk factors and outcomes in cutaneous lupus to determine optimal treatment and surveillance strategies. Correlation of clinical phenotypes with biomarkers may help to stratify patients, optimize targeted interventions, and influence prognosis.
Clinical Features of Rituximab-associated Gastrointestinal Toxicities
Authors: Mallepally Niharika , Abu-Sbeih Hamzah , Ahmed Osman , Chen Ellie , Shafi Mehnaz A. , Neelapu Sattva S. , Wang Yinghong
Published: May 2019

Background:

Rituximab is effective in treating several cancers. Little is known about gastrointestinal adverse events associated with rituximab. We describe the clinical, endoscopic, and histologic features of rituximab-associated colitis (RC) at a tertiary care cancer center.

Methods:

We conducted a retrospective study of cancer patients who had received rituximab and had undergone a colonoscopy between 2000 and 2018. Patients with competing etiologies for colitis were excluded.

Results:

Of the 13,717 patients who had received rituximab during the study period, 1660 had undergone colonoscopy. Among them, 70 (4%) had RC. Median time from rituximab treatment to RC onset was 181 days. Fifty-three patients had clinical gastrointestinal symptoms: 39 had diarrhea, 19 had abdominal pain, 11 had blood per rectum, and 5 had a concurrent fever. The median duration of symptoms was 21 days. Fifty patients (71%) received treatment for RC: immunosuppressive therapy in 12, antimicrobial agents in 21, antimotility agents in 42, and supportive care in 42. Nine patients had mucosal ulceration on endoscopy, and 52 had features of active inflammation on histology. Thirty-nine patients needed hospital admission, and 2 needed intensive care unit admission. One patient had colonic perforation that required surgical intervention. Patients who had abnormal endoscopic findings needed more frequent hospitalization (P=0.024) and more treatment for RC (P=0.001).

Conclusions:

RC is usually a mild disease requiring supportive care only. Nonetheless, on rare occasions, it can be severe enough to lead to colonic perforation and intensive care unit admission. Steroids used with the chemotherapeutic regimen can hamper RC severity.
A Case of Methotrexate-Associated Lymphoproliferative Disorder (Lymphomatoid Granulomatosis) of the Skin
Authors: Nishida Haruto , Oyama Yuzo , Kusaba Takahiro , Kadowaki Hiroko , Arakane Motoki , Yokoyama Shigeo , Hatano Yutaka , Daa Tsutomu
Published: May 2019

Iatrogenic lymphoproliferative disorder (LPD) can develop in patients treated with immunosuppressive drugs for autoimmune or other inflammatory diseases. Here, we report a case of lymphomatoid granulomatosis of the skin that occurred as a methotrexate (MTX)-associated LPD. We also review the relevant literature. A 73-year-old woman presented to our department with an approximately 10-year history of MTX therapy for rheumatoid arthritis. Three months earlier, she noticed a small nodule in her right upper arm. It gradually enlarged, and the center began to decay. Grossly, the lesion was 40 × 40 mm in size with ulceration, and the surrounding skin presented dark red erythema. A biopsy specimen was taken for definitive diagnosis. Histologically, infiltrating growth of medium-to-large atypical lymphocytes was observed underneath the ulceration and was accompanied by small reactive lymphocytes. The atypical lymphocytes demonstrated a tendency to infiltrate the vessels, which showed an angiocentric pattern. Immunohistochemistry revealed that the atypical lymphoid cells were positive for CD79a, CD20, and CD30. In addition, in situ hybridization for Epstein–Barr virus (EBV) revealed expression of EBV-encoded small RNAs. The patient was diagnosed with MTX-associated LPD (lymphomatoid granulomatosis), owing to her history of MTX treatment, the expression of the atypical lymphocytes for B-cell markers and EBV-encoded small RNA, and the angiocentric infiltrating pattern. The lesion reportedly disappeared after withdrawal of MTX.
Telomere length and socioeconomic status at neighborhood and individual levels among 80,000 adults in the Genetic Epidemiology Research on Adult Health and Aging cohort
Authors: Alexeeff Stacey E. , Schaefer Catherine A. , Kvale Mark N. , Shan Jun , Blackburn Elizabeth H. , Risch Neil , Ranatunga Dilrini K. , Jorgenson Eric , Hoffmann Thomas J. , Sakoda Lori C. , Quesenberry Charles P. , Van Den Eeden Stephen K.
Published: May 2019

Background:

Telomere length (TL) may serve as a biologic marker of aging. We examined neighborhood and individual-level socioeconomic status (SES) in relation to TL.

Methods:

The study included 84,996 non-Hispanic white subjects from the Genetic Epidemiology Research on Adult Health and Aging (GERA) cohort, part of the Research Program on Genes, Environment and Health. Relative TL (T/S) was log2 transformed to improve normality and standardized to have mean 0 and variance 1. Neighborhood SES was measured using the Neighborhood Deprivation Index (NDI), and individual SES was measured by self-reported education level. We fit linear regression models of TL on age, sex, smoking, body mass index, comorbidities, NDI, and education level. We tested for differences in the associations by sex and nonlinearity in the association of NDI with TL.

Results:

Each SD increase in NDI was associated with a decrease of 0.0192 in standardized TL, 95% confidence interval (CI) = −0.0306, −0.0078. There was no evidence of nonlinearity in the association of NDI with TL. We further found that less than high school education was associated with a decrease of 0.1371 in standardized TL, 95% CI = −0.1919, −0.0823 as compared to a college education. There were no differences in the associations by sex.

Conclusions:

We found evidence that both lower neighborhood SES and lower individual-level SES are associated with shorter TL among non-Hispanic whites. Our findings suggest that socioeconomic factors may influence aging by contributing to shorter TL.
Discriminative stimulus properties of the typical antipsychotic haloperidol compared to other antipsychotic drugs in C57BL/6 mice
Authors: Donahue Timothy J. , Webster Kevin A. , Hillhouse Todd M. , De Oliveira Eliseu O. , Porter Joseph H.
Published: May 2019

Haloperidol (HAL) was developed in 1958 for the treatment of schizophrenia and is classified as a typical antipsychotic drug (APD). Effective in treating positive symptoms of schizophrenia, it does not treat negative symptoms and produces extrapyramidal motor side-effects. Atypical APDs like clozapine treat both positive and negative symptoms of schizophrenia, have reduced extrapyramidal motor side-effects and possess other clinical advantages. This study used a drug discrimination assay to allow a direct comparison between the subjective effects of HAL and other APDs. Eleven C57BL/6 mice were trained to discriminate 0.05 mg/kg HAL from the vehicle in a two-lever drug discrimination task. The HAL generalization curve (0.001563–0.2 mg/kg) yielded an ED50=0.0024 mg/kg (95% confidence interval: 0.0012–0.0048 mg/kg). The typical APD chlorpromazine produced full substitution at 4.0 mg/kg with 82.7% drug-lever responding (%DLR) with significant rate suppression and partial substitution (73.9% DLR) at 1.0 mg/kg with no rate suppression. The atypical APD clozapine produced partial substitution at 2.5 mg/kg (64.8% DLR) with significant rate suppression. The atypical APD amisulpride failed to substitute for HAL with a maximum %DLR of 57.9% at 40 mg/kg with no rate suppression. The atypical APD aripiprazole partially substituted with a maximum of 75.9% DLR at 1.25 mg/kg with significant rate suppression. These results demonstrate that HAL can be trained as a discriminative stimulus in C57BL/6 mice, and its discriminative cue appears to be unique and distinct from that of atypical APDs.
Sleep and female reproduction
Authors: Willis Sydney Kaye , Hatch Elizabeth Elliott , Wise Lauren Anne
Published: May 2019

Purpose of review

Sleep disturbances are increasing in prevalence in North America. There is growing evidence that poor sleep quality and short sleep duration may adversely affect circadian rhythms, which in turn may affect female reproduction. The objective of this review is to evaluate recent literature on the association between sleep disturbances and female reproduction.

Recent findings

There is accumulating evidence that sleep quality and duration are important for female reproduction, but epidemiologic research is limited. Recent studies provide suggestive evidence that sleep disorders are associated with increased menstrual irregularity, subfertility/infertility, and poor pregnancy and birth outcomes. Mechanisms underlying these associations are likely to be multifactorial and complex. In addition to genetics, circadian disruption may impact reproductive outcomes through dysregulation of the hypothalamic-pituitary-adrenal axis, insulin resistance, oxidative stress, and systemic inflammation. Recommendations for future studies include: use of prospective study designs; assessment of populations not already experiencing reproductive disorders; more detailed and accurate assessments of sleep such as validated self-reported measures or objective sleep measures (e.g. actigraphy); comprehensive assessment of potential confounders and mediators; and elucidation of biologic mechanisms.

There is a growing body of literature showing evidence that sleep disturbances influence female reproduction, although further epidemiologic research is needed.
Harvesting Split-thickness Skin from the Scalp Using a Scalpel
Authors: Maruyama Seiichi
Published: May 2019

Background:

Split-thickness skin grafts (STSGs) from the scalp may be an attractive option for patients who do not want scars on their limbs or trunk. However, not all institutions have the equipment typically used to perform STSGs.

Methods:

Between January 2015 and June 2017, STSGs were harvested with a No. 15 blade under local anesthesia from the scalps of 4 patients and grafted on small skin defects from facial trauma, a tattoo, and scarring, and on a large defect from burns. Epithelialization of the donor sites and graft take, secondary contraction, and color and texture match of the recipient sites were observed. Thickness of the harvested skin was confirmed by histopathologic examination.

Results:

Mean patient age was 39.8 years; 2 patients were male. Epithelialization of the donor sites took a mean of 8.75 days. No hypertrophic scarring or alopecia was observed. Good graft take and relatively good color and texture match of the recipient site were achieved. Mild secondary contraction was noted in 2 cases. Histopathologic examination showed no damage to the hair follicles. The thickness of the harvested skin varied from 0.3 to 0.7 mm.

Conclusions:

Using the scalpel technique, surgeons can perform STSGs with only several blades, minimizing surgical costs. The hair follicles remain intact because the thickness of the graft skin is <1 mm. Epithelialization of the donor site is quick, and there is no visible wound on the limb or trunk. It is especially useful to cover small defects.
Organizational Strategies to Create a Burnout-resistant Environment
Authors: BINKLEY PHILIP F. , LEVINE EDWARD
Published: May 2019

Burnout afflicts a significant number of academic faculty and clinicians. There are many efforts the individual can undertake to prevent or lessen burnout. However, it not likely these will be successful without the institutional environment that promotes and atmosphere that assures self-efficacy, a sense of value and meaning and clear communication between leaders and members of the organization. This review discusses the factors that organizations and their leaders can leverage to create such an environment. Such measures are critically important not only for the health of the individual but to the organization as well.
The Mini-Balance Evaluation System Test Can Predict Falls in Clinically Stable Outpatients With COPD
Authors: Pereira Ana Carolina A. C. , Xavier Rafaella F. , Lopes Aline C. , da Silva Cibele C. B. M. , Oliveira Cristino C. , Fernandes Frederico L. A. , Stelmach Rafael , Carvalho Celso R. F.
Published: May 2019

Purpose:

This study evaluated the accuracy of the Mini-Balance Evaluation System Test (Mini-BESTest) for predicting falls in patients with chronic obstructive pulmonary disease (COPD) and investigated whether postural balance is a risk factor for falls.

Methods:

Postural balance was evaluated by the Mini-BESTest at baseline, and the incidence of falls over a 12-mo period was prospectively measured by a self-reported falls diary and confirmed by telephone calls. A discriminative power analysis was performed using receiver operating characteristic (ROC) curve and logistic regression analysis.

Results:

Sixty-seven outpatients with COPD (mean age ± SD = 67 ± 9.3 yr) were included. Twenty-five patients (37.3%) experienced ⩾1 fall, and 28.2% of the falls resulted in injuries. The Mini-BESTest predicted falls in patients with COPD at the 6- and 12-mo follow-ups with a cut-off score of 22.5 (area under the curve = 0.85 and 0.87) with good sensitivity and specificity (85.7% and 66.7%; 84% and 73.8%, respectively). Higher scores on the Mini-BESTest were associated with a lower risk of falls at 12 mo (OR = 0.50; 95% CI, 0.36–0.70; P < .001).

Conclusions:

Postural balance assessed by the Mini-BESTest is a good predictor of falls in patients with COPD. Our results imply that impaired balance contributes to the risk of falling and that balance training and fall prevention programs may be required for this population.
Postdeployment Polytrauma Diagnoses Among Soldiers and Veterans Using the Veterans Health Affairs Polytrauma System of Care and Receipt of Opioids, Nonpharmacologic, and Mental Health Treatments
Authors: Adams Rachel Sayko , Larson Mary Jo , Meerwijk Esther L. , Williams Thomas V. , Harris Alex H. S.
Published: May 2019

Objectives:

To determine the proportion of Army soldiers who utilized care in the Veterans Health Administration (VHA) Polytrauma System of Care (PSC) within the postdeployment year and to describe prevalence of polytrauma diagnoses, and receipt of opioids, nonpharmacologic treatments (NPTs), and mental health treatments in the VHA during the year following first PSC utilization.

Setting:

VHA's 4-tiered integrated PSC network of specialized rehabilitation services for military members and veterans with polytrauma.

Participants:

Soldiers and veterans who used the PSC during the postdeployment year after an Afghanistan or Iraq deployment ending in fiscal years 2008-2011.

Design:

Population-based cohort study.

Main Measures:

Prevalence of polytrauma diagnoses (ie, traumatic brain injury [TBI], posttraumatic stress disorder [PTSD], and chronic pain [CP]), VHA utilization rates of opioid prescriptions, NPT, and specialty mental health treatment within 1 year of PSC utilization.

Results:

In total, 2.6% of the sample (n = 16 590) used the PSC during the postdeployment year. Among PSC users, CP (76.5%), PTSD (53.1%), and TBI (48.6%) were common and more frequently found together than in isolation; 26.6% filled an opioid prescription, 35.5% received at least 1 NPT, and 83.8% received specialty mental health treatment in the VHA within 1 year of PSC utilization.

Conclusion:

CP was the most common polytrauma condition among PSC users, highlighting the importance of incorporating interdisciplinary pain management approaches within the PSC, with an effort to reduce reliance on long-term opioid therapy and improve rehabilitation.
Developing a Therapeutic Approach Toward Active Engagement for Veterans With Mild Traumatic Brain Injury
Authors: Tapia Rebecca , Garg Deep , Eapen Blessen
Published: May 2019

Background:

Treatment of chronic mild traumatic brain injury (mTBI) or postdeployment syndrome can be challenging to frontline providers who care for our nation's war heroes. There is ample guidance available for symptom-based interventions, but relatively little information regarding the structure and language of the clinical encounter. Dynamic patient education centered upon relatable language, accessible analogies, and brain health can move the visit beyond historical diagnostics into a shared understanding of postdeployment barriers to reintegration.

Objective:

We aim to describe a practical, education-based clinical approach for chronic mTBI or postdeployment syndrome (mTBI/PDS). The foundation of this method is gathering the veteran's narrative, validating and normalizing his or her experience, highlighting neurobehavioral changes from combat that may represent barriers to full community reintegration, and transitioning to an emphasis on overall brain health.

Conclusion:

The chronic mTBI or PDS clinical encounter can be enhanced by empowering the patient with relatable terms and concepts to describe his or her reintegration challenges and emphasizing factors of brain health. This approach can provide the patient with a base of understanding regarding his or her current symptoms, promote focus on factors for cognitive health, and orient the clinical encounter toward improved community reintegration and long-term cognitive wellness.
Is Performing Femtosecond Laser–Assisted In Situ Keratomileusis on the Day of the Initial Consultation Visit Safe, Predictable and Efficacious?
Authors: Gershoni Assaf , Mimouni Michael , Reitblat Olga , Livny Eitan , Ehrlich Rita , Bahar Irit
Published: May 2019

Objectives:

Our aim is to evaluate the safety, efficacy, predictability, and clinical outcome of femtosecond laser–assisted in situ keratomileusis (FS-LASIK) procedures performed on the day of the initial consultation relative to procedures performed at subsequent visits.

Methods:

A retrospective cohort study design was used. The study group included patients with myopia of different severities who were treated with FS-LASIK in 2013 through 2014 in an optical outpatient clinic of a large private medical service. Inclusion criteria were at least 18 years of age, a stable refraction for 12 months, no history of autoimmune disease, ocular surgery, or eye disease, and complete medical records. Background, clinical, and outcome data were collected from the patient files.

Results:

Femtosecond laser–assisted in situ keratomileusis was performed in 80 patients (160 eyes) at the first visit and 361 patients (719 eyes) at a subsequent visit. The mean±SD spherical equivalent (SE) refraction before surgery was −3.74±2.03 D in the first-visit group and −3.73±1.87 D in the subsequent-visit group (P=0.99). Efficacy index values were 0.97±0.15 in the first-visit group and 0.98±0.13 in the subsequent-visit group (P=0.92), and corresponding safety index values were 0.99±0.15 and 0.99±0.12 (P=0.81). The final SE measured −0.09±0.58 D in the first-visit group and −0.19±0.55 D in the subsequent-visit group (P=0.05). Types and rates of complications were similar in the two groups.

Conclusions:

There is no significant difference in the results of refractive surgery with FS-LASIK between procedures performed at the initial or subsequent visits. In both conditions, FS-LASIK surgery is associated with excellent safety, efficacy, and predictability profiles.
Central and Peripheral Corneal Endothelial Cell Analysis With Slit-Scanning Wide-Field Contact Specular Microscopy: Agreement With Noncontact Specular Microscopy
Authors: Lee Jinhee , Mori Yosai , Ogata Miyuki , Minami Keiichiro , Miyata Kazunori
Published: May 2019

Purpose:

The prospective case series aimed to examine the agreement between the use of a slit-scanning contact specular microscope and a noncontact specular microscope in corneal endothelial cell (CEC) analysis and to evaluate the differences between the central and peripheral regions in normal corneas.

Methods:

After confirming normal corneal endothelium with slit-lamp microscopy, CEC images of 56 eyes of 56 cataractous patients were analyzed in the central and 4 peripheral regions using a slit-scanning contact specular microscope. A noncontact specular microscope was used for the analysis in the central region. The endothelial cell density (ECD), the percentage of hexagonal shape cells (HEX), and the coefficient of variation (CV) in the central region were compared. Differences between central and peripheral CECs were also evaluated.

Results:

The mean ECD was 2778 cell/mm2 and was not different from the results using the noncontact specular microscope (2736 cell/mm2, P = 0.051). There was a significant correlation (P < 0.001, R2 = 0.72). The analysis of HEX resulted in larger values with the slit-scanning contact microscope (53.13% vs. 48.89%, P < 0.001), whereas there was no difference in the CV (38.48 vs. 38.04, P = 0.56). On comparing the central and peripheral regions, there was no significant difference in the ECD, whereas significant differences were found in the superior region in the HEX and CV (P < 0.001) and in the nasal region in CV (P = 0.023).

Conclusions:

The analysis of ECD with the use of the slit-scanning contact specular microscope did not differ from the noncontact specular microscope, and the results demonstrated no difference between the central and peripheral ECD.
Comparison of Descemet Stripping Automated Endothelial Keratoplasty and Descemet Membrane Endothelial Keratoplasty in the Treatment of Failed Penetrating Keratoplasty
Authors: Einan-Lifshitz Adi , Mednick Zale , Belkin Avner , Sorkin Nir , Alshaker Sara , Boutin Tanguy , Chan Clara C. , Rootman David S.
Published: May 2019

Purpose:

To compare the outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) with Descemet membrane endothelial keratoplasty (DMEK) for the treatment of failed penetrating keratoplasty (PKP).

Methods:

This is a retrospective chart review of patients with failed PKP who underwent DMEK or DSAEK. The median follow-up time for both groups was 28 months (range 6–116 months). Data collection included demographic characteristics, number of previous corneal transplants, previous glaucoma surgeries, best-corrected visual acuity, endothelial cell density, graft detachment and rebubble rate, rejection episodes, and graft failure.

Results:

Twenty-eight eyes in the DMEK group and 24 eyes in the DSAEK group were included in the analysis. Forty-three percent of eyes in the DMEK group and 50% of eyes in the DSAEK group had to be regrafted because of failure (P = 0.80). The most common reason for failure was persistent graft detachment (58%) in the DMEK group and secondary failure (58%) in the DSAEK group; hence, the time between endothelial keratoplasty and graft failure differed significantly between the groups (P = 0.02). Six eyes (21%) in the DMEK group and 7 eyes (29%) in the DSAEK group developed graft rejection (P = 0.39). Rejection was the cause of failure in 67% and 71% in the DMEK and DSAEK groups, respectively. The best-corrected visual acuity 6 months after surgery was better in the DMEK group compared with the DSAEK group (P = 0.051).

Conclusions:

Both DSAEK and DMEK have a role in treating PKP failure. Primary failure due to persistent graft detachment was significantly higher in the DMEK group, although the overall failure rate in the medium term was similar.
Anterior Segment Optical Coherence Tomography Images in Microsporidial Keratoconjunctivitis
Authors: Thanathanee Onsiri , Laohapitakvorn Suparat , Anutarapongpan Orapin , Suwan-apichon Olan , Bhoomibunchoo Chavakij
Published: May 2019

Purpose:

To describe the findings of anterior segment optical coherence tomography (AS-OCT) in patients with microsporidial keratoconjunctivitis.

Methods:

The observational study included 13 eyes from 13 patients. Slit-lamp photography and AS-OCT were performed using the Swept source OCT before corneal scraping. All cases were positive for Gram-chromotrope (modified trichrome) staining for Microsporidia spp.

Results:

Three significant AS-OCT findings were observed. First, hyperreflective dots were limited to the epithelial layers of the cornea, and second, there were no extensions into the stromal layer in all cases. Last, hyperreflective dots slightly raised above the epithelial surface were observed in most cases (12/13%, 92.3%).

Conclusions:

AS-OCT represents an alternative, noninvasive tool to diagnose microsporidial keratoconjunctivitis, especially if corneal scraping is not possible.
Safety, Tolerability and Immunogenicity of an MF59-adjuvanted, Cell Culture-derived, A/H5N1, Subunit Influenza Virus Vaccine: Results From a Dose-finding Clinical Trial in Healthy Pediatric Subjects
Authors: Chanthavanich Pornthep , Anderson Edwin , Kerdpanich Phirangkul , Bulitta Michael , Kanesa-thasan Niranjan , Hohenboken Matthew
Published: May 2019

Background:

A/H5N1 influenza virus has significant pandemic potential, and vaccination is the main prophylactic measure. This phase 2, randomized, observer-blind, multicenter study evaluated the safety and immunogenicity of two MF59-adjuvanted, cell culture-derived H5N1 (aH5N1c) vaccine formulations in healthy pediatric subjects 6 months to 17 years old.

Methods:

Subjects (N = 662) received 2 aH5N1c doses 3 weeks apart, containing either 7.5 μg (full dose) or 3.75 μg (half dose) hemagglutinin antigen per dose. Local reactions and adverse events (AEs) were assessed by age. Antibody responses were measured by hemagglutination inhibition assay and assessed as geometric mean titers, geometric mean ratios (GMRs) and percentages of subjects achieving titers ≥1:40 and seroconversion (NCT01776554).

Results:

No vaccine-related serious AEs occurred. Incidence of solicited local reactions and systemic AEs were similar across vaccine groups. Tenderness and irritability in <6-year olds, and injection site pain, myalgia and fatigue in 6–17-year olds were the most commonly reported reactions in both full- and half-dose recipients. Frequencies of AEs were lower after the second dose than the first dose in all vaccine and age groups. Three weeks after the administration of a second dose, both full- and half-dose formulations met the Center for Biologics Evaluation Research and Review (United States) and Committee for Medicinal Products for Human Use (EU) licensure criteria for titers ≥1:40 (full dose 96% subjects; half dose 86%), seroconversion (full dose 96% subjects; half dose 86%), and GMR (full dose GMR 262; half dose 84). Antibody responses were highest in 6–35-month olds.

Conclusions:

In pediatric subjects, both aH5N1c vaccine formulations were well tolerated and highly immunogenic, meeting both US and EU licensure criteria for pandemic influenza vaccines.
The Praxis of Physical Therapy
Authors: Smith James M.
Published: May 2019

In neurorehabilitation, praxis embodies establishing a goal, planning, taking action, analyzing the impact of the action, revising the plan, and reacting accordingly until the desired outcome is achieved. That is an apt metaphor for physical therapy, whether planning a single intervention for a patient, establishing a plan of care, or managing the trajectory of a career.

Through reflections on goals, plans, and actions, this lecture presents challenges to physical therapists and physical therapist assistants to achieve praxis when providing rehabilitation and wellness services. Through reflections on the needs of patients and clients, this lecture proposes the value of the unique identity and services that are acute care physical therapy. Central to these themes, this lecture provides the challenge to embrace the honor that comes with being an acute care physical therapist and a physical therapist assistant.
Generation and characterization of Men1 mutant mouse models for studying MEN1 disease
Authors: Luo Ya-kun , Ziki Razan A. , Zhang Chang X.
Published: May 2019

Patients with multiple endocrine neoplasia type 1 (MEN1) mutations are predisposed to MEN1 syndrome affecting various endocrine cell lineages. Following its identification in the late 1990s, laboratories around the world, including our own, used gene-targeting approaches in murine models to study the MEN1 gene and its related diseases. Subsequently, this field of research witnessed an upsurge in the use of Men1 mutant mouse models to dissect MEN1 functions. These studies led to unraveling the natural history of MEN disease, and highlighted cellular and molecular mechanisms underlying the development of the disease. In this review, we present the currently available data concerning the generation and characterization of Men1 mutant mouse models in connection with MEN1 syndrome.
Using the Trauma Quality Improvement Program Metrics Data to Enhance Clinical Practice
Authors: Blackmore Abigail R. , Leonard Jan , Madayag Robert , Bourg Pamela W.
Published: May 2019

The American College of Surgeons Trauma Quality Improvement Program (TQIP) provides trauma centers with hospital-specific performance data and the ability to compare their performance data with that of similar hospitals nationwide. Utilizing the TQIP data and drill down feature can lead to changes in clinical practice and improved care. The purpose of this article is to provide a guide that demonstrates how using the TQIP hospital-specific data can improve outcomes. We recommend 4 separate categories by which data and reports should be evaluated: processes of care, quality of care, data coding, and data mapping. We discuss these categories using 4 targeted examples. Utilizing our guidelines, trauma programs participating in the TQIP should be able to (1) identify trends and focus on outliers in their institutional data, (2) create processes and implement practice improvements, and (3) evaluate the results of their corrective action plan. This topic may be of special interest to those involved in the management of programs or systems-level policies as reduction in costs and improving quality are program drivers.