bluuebunny/crossref_metadata_2025 huggingface dataset:
Drivers of Variability in 90-Day Cost for Elective Anterior Cervical Discectomy and Fusion for Cervical Degenerative Disease
Authors: Chotai Silky , Sivaganesan Ahilan , Parker Scott L , Sielatycki John A , McGirt Matthew J , Devin Clinton J
Published: March 2018

BACKGROUND

Value-based episode of care reimbursement models is being investigated to curb unsustainable health care costs. Any variation in the cost of index spine surgery can affect the payment bundling during the 90-d global period.

OBJECTIVE

To determine the drivers of variability in cost for patients undergoing elective anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine disease.

METHODS

Four hundred forty-five patients undergoing elective ACDF for cervical spine degenerative diagnoses were included in the study. The direct 90-d cost was derived as sum of cost of surgery, cost associated with postdischarge utilization. Multiple variable linear regression models were built for total 90-d cost.

RESULTS

The mean 90-d direct cost was $17685 ± $5731. In a multiple variable linear regression model, the length of surgery, number of levels involved, length of hospital stay, preoperative history of anticoagulation medication, health-care resource utilization including number of imaging, any complications and readmission encounter were the significant contributor to the 90-d cost. The model performance as measured by R2 was 0.616.

CONCLUSION

There was considerable variation in total 90-d cost for elective ACDF surgery. Our model can explain about 62% of these variations in 90-d cost. The episode of care reimbursement models needs to take into account these variations and be inclusive of the factors that drive the variation in cost to develop a sustainable payment model. The generalized applicability should take in to account the differences in patient population, surgeons’ and institution-specific differences.
Comparison of Outcomes Following Anterior vs Posterior Fusion Surgery for Patients With Degenerative Cervical Myelopathy: An Analysis From Quality Outcomes Database
Authors: Asher Anthony L , Devin Clinton J , Kerezoudis Panagiotis , Chotai Silky , Nian Hui , Harrell Jr. Frank E , Sivaganesan Ahilan , McGirt Matthew J , Archer Kristin R , Foley Kevin T , Mummaneni Praveen V , Bisson Erica F , Knightly John J , Shaffrey Christopher I , Bydon Mohamad
Published: March 2018

BACKGROUND

The choice of anterior vs posterior approach for degenerative cervical myelopathy that spans multiple segments remains controversial.

OBJECTIVE

To compare the outcomes following the 2 approaches using multicenter prospectively collected data.

METHODS

Quality Outcomes Database (QOD) for patients undergoing surgery for 3 to 5 level degenerative cervical myelopathy was analyzed. The anterior group (anterior cervical discectomy [ACDF] or corpectomy [ACCF] with fusion) was compared with posterior cervical fusion. Outcomes included: patient reported outcomes (PROs): neck disability index (NDI), numeric rating scale (NRS) of neck pain and arm pain, EQ-5D, modified Japanese Orthopedic Association score for myelopathy (mJOA), and NASS satisfaction questionnaire; hospital length of stay (LOS), 90-d readmission, and return to work (RTW). Multivariable regression models were fitted for outcomes.

RESULTS

Of total 245 patients analyzed, 163 patients underwent anterior surgery (ACDF-116, ACCF-47) and 82 underwent posterior surgery. Patients undergoing an anterior approach had lower odds of having higher LOS (P < .001, odds ratio 0.16, 95% confidence interval 0.08-0.30). The 12-mo NDI, EQ-5D, NRS, mJOA, and satisfaction scores as well as 90-d readmission and RTW did not differ significantly between anterior and posterior groups.

CONCLUSION

Patients undergoing anterior approaches for 3 to 5 level degenerative cervical myelopathy had shorter hospital LOS compared to those undergoing posterior decompression and fusion. Also, patients in both groups exhibited similar long-term PROs, readmission, and RTW rates. Further investigations are needed to compare the differences in longer term reoperation rates and functional outcomes before the clinical superiority of one approach over the other can be established.
Spinal Protein Kinase Mζ Regulates α-Amino-3-hydroxy-5-methyl-4-isoxazolepropionic Acid Receptor Trafficking and Dendritic Spine Plasticity via Kalirin-7 in the Pathogenesis of Remifentanil-induced Postincisional Hyperalgesia in Rats
Authors: Zhang Linlin , Guo Suqian , Zhao Qi , Li Yize , Song Chengcheng , Wang Chunyan , Yu Yonghao , Wang Guolin
Published: March 2018

Background

Intraoperative remifentanil anesthesia exaggerates postoperative pain sensitivity. Recent studies recapitulate the significance of protein kinase Mζ in α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor–mediated pathologic pain. Kalirin-7, a Rho guanine nucleotide exchange factor, coordinates AMPA receptor trafficking and dendritic spine plasticity. This study examines whether protein kinase Mζ and Kalirin-7 contribute to remifentanil-induced postincisional hyperalgesia via AMPA receptor.

Methods

Plantar incision was performed 10 min after the start of remifentanil infusion (1 µg · kg−1 · min−1 for 60 min). Paw withdrawal threshold (primary outcome), spinal protein kinase Mζ activity, Kalirin-7 expression, AMPA receptor trafficking, and spine morphology were assessed. Protein kinase Mζ inhibitor and Kalirin-7 knockdown by short hairpin RNA elucidated the mechanism and prevention of hyperalgesia. Whole-cell patch-clamp recording analyzed the role of protein kinase Mζ in spinal AMPA receptor–induced current.

Results

Remifentanil reduced postincisional paw withdrawal threshold (mean ± SD, control vs. hyperalgesia, 18.9 ± 1.6 vs. 5.3 ± 1.2 g, n = 7) at postoperative 48 h, which was accompanied by an increase in spinal protein kinase Mζ phosphorylation (97.8 ± 25.1 vs. 181.5 ± 18.3%, n = 4), Kalirin-7 production (101.9 ± 29.1 vs. 371.2 ± 59.1%, n = 4), and number of spines/10 µm (2.0 ± 0.3 vs. 13.0 ± 1.6, n = 4). Protein kinase Mζ inhibitor reduced remifentanil-induced hyperalgesia, Kalirin-7 expression, and GluA1 trafficking. Incubation with protein kinase Mζ inhibitor reversed remifentanil-enhanced AMPA receptor-induced current in dorsal horn neurons. Kalirin-7 deficiency impaired remifentanil-caused hyperalgesia, postsynaptic GluA1 insertion, and spine plasticity. Selective GluA2-lacking AMPA receptor antagonist prevented hyperalgesia in a dose-dependent manner.

Conclusions

Spinal protein kinase Mζ regulation of GluA1-containing AMPA receptor trafficking and spine morphology via Kalirin-7 overexpression is a fundamental pathogenesis of remifentanil-induced hyperalgesia in rats.
Comparison of Placental and Neonatal Admission Complete Blood Cell Count and Blood Cultures
Authors: Newberry Desi M.
Published: March 2018

Background:

The utilization of placental blood for neonatal admission laboratory tests, specifically the complete blood cell (CBC) count and blood culture, has the potential to delay the onset of anemia of prematurity and intraventricular hemorrhage, frequency of blood transfusions and associated complications, and painful procedures related to laboratory sampling.

Purpose:

To determine the feasibility of drawing neonatal admission laboratory tests from the placenta rather than the neonate and to compare CBC count and blood culture results.

Methods:

All infants less than 35 weeks' gestational age and all term infants with a maternal history of chorioamnionitis or untreated, positive group B Streptococcus status were eligible to participate. Participating infants had paired CBC count and blood cultures obtained from the placenta and the infant.

Results:

All CBC count outcomes were significantly, positively correlated between placental and infant blood (all Ps < .05). The paired white blood cells, neutrophils, and lymphocytes were strongly correlated (r = 0.761, r = 0.797, and r = 0.815, respectively), whereas the hemoglobin, hematocrit, platelet, and eosinophils were moderately correlated (r = 0.554, r = 0.545, r = 0.563, and r = 0.478, respectively). Monocytes and basophils were only weakly correlated (r = 0.373 and r = 0.217, respectively). There were 13 (93%) pairs where placental blood culture was positive but the direct infant draw blood culture was negative, and 1 (7%) pair where the placental culture was negative but the direct infant draw blood culture was positive.

Implications for Practice:

The results of this and other studies suggest that placental blood can be reliably used to obtain neonatal admission CBC count and blood cultures.

Implications for Research:

Further research is needed regarding the prevention of blood culture contamination, especially in vaginally delivered placentas. Institutions that adopt this procedure should perform quality improvement initiatives to monitor outcomes and add to the growing body of literature on the utilization of placental blood for neonatal admission laboratory tests.
Universal versus selective ultrasound screening for developmental dysplasia of the hip: a single-centre retrospective cohort study
Authors: Westacott Daniel J. , Butler Daniel , Shears Emma , Cooke Stephen J. , Gaffey Andrew
Published: March 2018

A total of 28 068 infants were studied to investigate whether universal ultrasound screening for developmental dysplasia of the hip results in fewer delayed presentations than selective screening, and whether the screening protocol affects subsequent treatment. The rate of delayed presentation was not lower with selective screening compared with universal screening but all cases of delayed presentation in this cohort were administrative errors. There were no sonographic errors (false-negatives). The treatment rate was significantly higher with universal screening but infants were treated earlier and were significantly less likely to require any surgical intervention. Those requiring surgery were less likely to require open reduction or pelvic osteotomy.
The Impact of Comorbid Mental Health Disorders on Complications Following Cervical Spine Surgery With Minimum 2-Year Surveillance
Authors: Diebo Bassel G. , Lavian Joshua D. , Liu Shian , Shah Neil V. , Murray Daniel P. , Beyer George A. , Segreto Frank A. , Maffucci Fenizia , Poorman Gregory W. , Cherkalin Denis , Torre Barrett , Vasquez-Montes Dennis , Yoshihara Hiroyuki , Cukor Daniel , Naziri Qais , Passias Peter G. , Paulino Carl B.
Published: March 2018

Study Design.

Retrospective analysis.

Objective.

To improve understanding of the impact of comorbid mental health disorders (MHDs) on long-term outcomes following cervical spinal fusion in cervical radiculopathy (CR) or cervical myelopathy (CM) patients.

Summary of Background Data.

Subsets of patients with CR and CM have MHDs, and their impact on surgical complications is poorly understood.

Methods.

Patients admitted from 2009 to 2013 with CR or CM diagnoses who underwent cervical surgery with minimum 2-year surveillance were retrospectively reviewed using New York State's Statewide Planning and Research Cooperative System. Patients with a comorbid MHD were compared against those without (no-MHD). Univariate analysis compared demographics, complications, readmissions, and revisions between MHD and no-MHD cohorts. Multivariate binary logistic regression models identified independent predictors of outcomes (covariates: age, sex, Charlson/Deyo score, and surgical approach).

Results.

A total of 20,342 patients (MHD: n = 4819; no-MHD: n = 15,523) were included. MHDs identified: depressive (57.8%), anxiety (28.1%), sleep (25.2%), and stress (2.9%). CR patients had greater prevalence of comorbid MHD than CM patients (P = 0.015). Two years postoperatively, all patients with MHD had significantly higher rates of complications (specifically: device-related, infection), readmission for any indication, and revision surgery (all P < 0.05); regression modeling corroborated these findings and revealed combined surgical approach as the strongest predictor for any complication (CR, odds ratio [OR]: 3.945, P < 0.001; CM, OR: 2.828, P < 0.001) and MHD as the strongest predictor for future revision (CR, OR: 1.269, P = 0.001; CM, OR: 1.248, P = 0.008) in both CR and CM cohorts.

Conclusion.

Nearly 25% of patients admitted for CR and CM carried comorbid MHD and experienced greater rates of any complication, readmission, or revision, at minimum, 2 years after cervical spine surgery. Results must be confirmed with retrospective studies utilizing larger national databases and with prospective cohort studies. Patient counseling and psychological screening/support are recommended to complement surgical treatment.

Level of Evidence: 3
What Faces Reveal: A Novel Method to Identify Patients at Risk of Deterioration Using Facial Expressions*
Authors: Madrigal-Garcia Maria Isabel , Rodrigues Marcos , Shenfield Alex , Singer Mervyn , Moreno-Cuesta Jeronimo
Published: March 2018

Objectives:

To identify facial expressions occurring in patients at risk of deterioration in hospital wards.

Design:

Prospective observational feasibility study.

Setting:

General ward patients in a London Community Hospital, United Kingdom.

Patients:

Thirty-four patients at risk of clinical deterioration.

Interventions:

A 5-minute video (25 frames/s; 7,500 images) was recorded, encrypted, and subsequently analyzed for action units by a trained facial action coding system psychologist blinded to outcome.

Measurements and Main Results:

Action units of the upper face, head position, eyes position, lips and jaw position, and lower face were analyzed in conjunction with clinical measures collected within the National Early Warning Score. The most frequently detected action units were action unit 43 (73%) for upper face, action unit 51 (11.7%) for head position, action unit 62 (5.8%) for eyes position, action unit 25 (44.1%) for lips and jaw, and action unit 15 (67.6%) for lower face. The presence of certain combined face displays was increased in patients requiring admission to intensive care, namely, action units 43 + 15 + 25 (face display 1, p < 0.013), action units 43 + 15 + 51/52 (face display 2, p < 0.003), and action units 43 + 15 + 51 + 25 (face display 3, p < 0.002). Having face display 1, face display 2, and face display 3 increased the risk of being admitted to intensive care eight-fold, 18-fold, and as a sure event, respectively. A logistic regression model with face display 1, face display 2, face display 3, and National Early Warning Score as independent covariates described admission to intensive care with an average concordance statistic (C-index) of 0.71 (p = 0.009).

Conclusions:

Patterned facial expressions can be identified in deteriorating general ward patients. This tool may potentially augment risk prediction of current scoring systems.
Understanding and Treating Supralevator Fistula-in-Ano: MRI Analysis of 51 Cases and a Review of Literature
Authors: Garg Pankaj
Published: March 2018

BACKGROUND:

Supralevator fistulas are highly complex. The delineation of the supralevator fistula has become accurate because of MRI.

OBJECTIVE:

The aim of the study was to analyze the pathophysiology and treatment of different types of supralevator fistulas.

DESIGN:

This was a prospective study.

SETTINGS:

The study was conducted at a specialized fistula treatment center in North India.

PATIENTS:

All of the patients with fistula-in-ano who presented in the outpatient department were assessed with a physical examination and MRI scan. The patients in whom the supralevator extension was confirmed on MRI were included in the study.

MAIN OUTCOME MEASURES:

The MRI scans of patients included in the study were analyzed in detail to assess the types of supralevator fistulas and other characteristics of these fistulas. The patients who were operated on were followed for cure rate and deterioration in incontinence.

RESULTS:

Of 702 patients with fistula-in-ano who were analyzed by MRI over a period of 3 years, 51 patients with supralevator fistula-in-ano were identified. The mean age was 44.3 ± 12.1 years and the male:female ratio was 16:1. The incidence of supralevator fistulas was 7.26% (51 of 702). In supralevator fistulas, the supralevator extension (upper part) was found to be in the intersphincteric plane in all of the patients. This upper part could be successfully managed by laying it open through the transanal route. The infralevator (lower) part could be of 3 types: intersphincteric (n = 13), low transsphincteric (n = 3), or high transsphincteric (n = 35). The lower part could be managed conventionally. There were no extrasphincteric fistulas. An extensive review of the literature revealed only 2 studies (total fistulas = 16) in which supralevator fistula was studied.

LIMITATIONS:

This was a retrospective study.

CONCLUSIONS:

The upper supralevator extension in all of the supralevator fistulas is almost always in the intersphincteric plane. This upper part could be laid open through the transanal route. The lower infralevator part could be of 3 types, intersphincteric, low transsphincteric, or high transsphincteric, which could be managed conventionally. Thus, supralevator fistulas could be managed successfully and easily. See Video Abstract at http://links.lww.com/DCR/A630.
Mucinous Histology Signifies Poor Oncologic Outcome in Young Patients With Colorectal Cancer
Authors: Soliman Basem G. , Karagkounis Georgios , Church James M. , Plesec Thomas , Kalady Matthew F.
Published: March 2018

BACKGROUND:

The incidence of colorectal cancer in the young (under age 40) is increasing, and this population has worse oncologic outcomes. Mucinous histology is a potential prognostic factor in colorectal cancer, but has not been evaluated specifically in young patients.

OBJECTIVE:

The objective of the study was to determine factors associated with poor outcome in young patients with colorectal cancer (≤40 years) and to determine relationships between mucinous histology and oncologic outcomes in this population.

DESIGN:

This is a retrospective study.

SETTING:

Patients from a single-institution tertiary care center were studied.

PATIENTS:

A total of 224 patients with colorectal cancer under 40 years of age diagnosed between 1990 and 2010 were included (mean age, 34.7 years; 51.3% female). 34 patients (15.2%) had mucinous histology.

INTERVENTIONS(S):

There were no interventions.

MAIN OUTCOME MEASURES:

Oncologic outcomes were analyzed according to the presence of mucinous histology.

RESULTS:

The mucinous and nonmucin colorectal cancer study populations were statistically similar in age, sex, tumor location, pathological stage, differentiation, and adjuvant chemotherapy use. Five-year disease-free survival was 29.1% versus 71.3% (p < 0.0001) and 5-year overall survival was 54.7% versus 80.3% (p < 0.0001) for mucinous and nonmucinous patients, respectively. Mucinous colorectal cancers recurred earlier at a median time of 36.4 months versus 94.2 months for nonmucin colorectal cancers (p < 0.001). On multivariate analysis, pathological stage (stage II HR, 3.61; 95% CI, 1.37–9.50; stage III HR, 5.27; 95% CI, 2.12–12.33), positive margins (HR, 1.95; 95% CI, 1.12–3.23), angiolymphatic invasion (HR, 2.15; 95% CI, 1.26–3.97), and mucinous histology (HR, 2.36; 95% CI, 1.44–3.96) were independently associated with worse disease-free and overall survival.

LIMITATIONS:

This is a retrospective study without genetic information.

CONCLUSIONS:

Mucinous histology is a negative prognostic factor in young patients with colorectal cancer. This is associated with early and high recurrence rates, despite use of standard neoadjuvant and adjuvant regimens. Physicians need to be aware of this association and potentially explore novel treatment options. See Video Abstract at http://links.lww.com/DCR/A575.
A Systematic Review and Meta-analysis of Mesenchymal Stem Cell Injections for the Treatment of Perianal Crohn’s Disease: Progress Made and Future Directions
Authors: Lightner Amy L. , Wang Zhen , Zubair Abba C. , Dozois Eric J.
Published: March 2018

BACKGROUND:

There has been a surge in clinical trials studying the safety and efficacy of mesenchymal stem cells for the treatment of perianal Crohn’s disease.

OBJECTIVE:

The purpose of this work was to systematically review the literature to determine safety and efficacy of mesenchymal stem cells for the treatment of refractory perianal Crohn’s disease.

DATA SOURCES:

Sources included PubMed, Cochrane Library Central Register of Controlled Trials, and Embase.

STUDY SELECTION:

Studies that reported safety and/or efficacy of mesenchymal stem cells for the treatment of perianal Crohn’s disease were included. Two independent assessors reviewed eligible articles.

INTERVENTION:

The study intervention was delivery of mesenchymal stem cells to treat perianal Crohn’s disease.

MAIN OUTCOMES MEASURES:

Safety and efficacy of mesenchymal stem cells used to treat perianal Crohn’s disease were measured.

RESULTS:

Eleven studies met the inclusion criteria and were included in the systematic review. Three trials with a comparison arm were included in the meta-analysis. There were no significant increases in adverse events (OR = 1.07 (95% CI, 0.61–1.89); p = 0.81) or serious adverse events (OR = 0.53 (95% CI, 0.28–0.98); p = 0.04) in patients treated with mesenchymal stem cells. Mesenchymal stem cells were associated with improved healing as compared with control subjects at primary end points of 6 to 24 weeks (OR = 3.06 (95% CI, 1.05–8.90); p = 0.04) and 24 to 52 weeks (OR = 2.37 (95% CI, 0.90–6.25); p = 0.08).

LIMITATIONS:

The study was limited by its multiple centers and heterogeneity in the study inclusion criteria, mesenchymal stem cell origin, dose and frequency of delivery, use of scaffolding, and definition and time point of fistula healing.

CONCLUSIONS:

Although there have been only 3 trials conducted with control arms, existing data demonstrate improved efficacy and no increase in adverse or serious adverse events with mesenchymal stem cells as compared with control subjects for the treatment of perianal Crohn’s disease.
Aggressive Digital Papillary Adenocarcinoma: Population-Based Analysis of Incidence, Demographics, Treatment, and Outcomes
Authors: Rismiller Kyle , Knackstedt Thomas J.
Published: March 2018

BACKGROUND

As a rare cutaneous malignancy, epidemiologic and outcomes data for aggressive digital papillary adenocarcinoma (ADPA) are limited and no treatment guidelines exist.

OBJECTIVE

To provide a population-based study of ADPA incidence and outcomes with a subgroup comparison of patients with localized versus regional disease.

METHODS

Data from 18 registries within the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program were examined for patients with ADPA (1995–2013) to provide demographic- and cancer-related information, and to calculate race- and age-specific rate ratios, incidence, and mortality. Patients were stratified by the stage for further comparison.

RESULTS

Ninety-four cases of ADPA were identified. Overall, ADPA incidence was 0.08 per 1,000,000 person-years, 4 times higher in males than in females (0.13 vs 0.03, p < .001), and most common in Caucasians. Regional disease spread occurred in 22.3% of patients and disease-specific mortality in 2.1% of patients. Patients with regional versus localized disease at diagnosis did not differ significantly in sex, age, race, primary site, tumor size, or mortality.

CONCLUSION

Aggressive digital papillary adenocarcinoma is a rare malignancy with increasing incidence. Regional disease spread is not infrequent, but mortality is rare. Identification of patients best suited for additional diagnostic procedures or more extensive surgical resection remains challenging.
Skin and Soft Tissue Surgery in the Office Versus Operating Room Setting: An Analysis Based on Individual-Level Medicare Data
Authors: Kantor Jonathan
Published: March 2018

BACKGROUND

The relative volume of skin and soft tissue excision and reconstructive procedures performed in the outpatient office versus facility (ambulatory surgical center or hospital) differs by specialty, and has major implications for quality of care, outcomes, development of guidelines, resident education, health care economics, and patient perception.

OBJECTIVE

To assess the relative volume of surgical procedures performed in each setting (office vs ambulatory surgery center [ASC]/hospital) by dermatologists and nondermatologists.

METHODS

A cross-sectional analytical study was performed using the Medicare public use file (PUF) for 2014, which includes every patient seen in an office, ASC, or hospital in the United States billed to Medicare part B. Data were divided by physician specialty and setting.

RESULT

A total of 9,316,307 individual encounters were included in the Medicare PUF. Dermatologists account for 195,001 (2.1%) of the total. Dermatologists were more likely to perform surgical procedures in an office setting only (odds ratio 5.48 [95% confidence interval 5.05–5.95], p < .0001) than other specialists in aggregate.

CONCLUSION

More than 90% of surgical procedures are performed in an office setting, and dermatologists are more than 5 times as likely as other specialists to operate in an office setting.
Quantification of Apixaban, Dabigatran, Edoxaban, and Rivaroxaban in Human Serum by UHPLC-MS/MS—Method Development, Validation, and Application
Authors: Lindahl Sofia , Dyrkorn Roar , Spigset Olav , Hegstad Solfrid
Published: March 2018

Background:

Direct oral anticoagulants (DOACs) are prescribed for anticoagulation in patients with atrial fibrillation and venous thromboembolic disease. Fixed doses are recommended, but measuring their serum drug concentrations as a basis for dose adjustments may be useful in some clinical settings.

Methods:

An ultra–high-performance liquid chromatography-tandem mass spectrometry method for the analysis of the DOACs apixaban, dabigatran, edoxaban, and rivaroxaban in human serum was developed and validated. A 100-µL serum sample was handled using a pipetting robot. Protein precipitation was performed with 375 µL of 1% formic acid in acetonitrile (vol/vol), and phospholipid removal was performed using a Waters Ostro 96-well plate. The injection volume was 1 µL, and run time was 3.0 minutes.

Results:

The calibration range was 5–800 nmol/L. The between-day precision relative SDs were in the range of 3.3%–10%. Recoveries ranged from 85% to 105%, and matrix effects from 88% to 102%, when corrected with internal standard. Edoxaban was, in contrast to the other DOACs, unstable when stored for more than 6 hours at 30°C. The suitability of the method was demonstrated by analyzing routine samples from 345 patients undergoing anticoagulation treatment.

Conclusions:

The developed method fulfilled the set validation criteria, and its suitability was demonstrated in a routine setting. The instability of edoxaban may complicate the transport of routine samples to the laboratory.
Accurate Prediction of Submental Lymph Nodes Using Magnetic Resonance Imaging for Lymphedema Surgery
Authors: Asuncion Mora-Ortiz , Chu Sung-Yu , Huang Yen-Ling , Lin Chia-Yu , Cheng Ming-Huei
Published: March 2018

Background:

Submental lymph node transfer has proved to be an effective approach for the treatment of lymphedema. This study was to investigate the anatomy and distribution of vascularized submental lymph node (VSLN) flap using magnetic resonance imaging (MRI) and their clinical outcome.

Methods:

Fifteen patients who underwent 19 VSLN flap transfers for upper or lower limb lymphedema were retrospectively analyzed. The number of submental lymph nodes was compared among preoperative MRI, preoperative sonography, intraoperative finding, postoperative sonography, and postoperative computed tomography angiography. The outcome was compared between preoperatively and postoperatively.

Results:

All 19 VSLN flaps survived. Two hundred fifteen lymph nodes were identified in 30 submandibular regions by MRI. The mean number of submental lymph nodes on preoperative MRI was 7.2 ± 2.4, on preoperative sonography was 3.2 ± 1.1, on intraoperative finding was 3.1 ± 0.6, postoperative sonography was 4.6 ± 1.8, and postoperative CTA was 5.2 ± 1.9. Sixty-one percent of the lymph nodes were located in the central two-quarters of the line drawn from the mental protuberance to the mandibular angle. The actual harvest rate of submental lymph nodes was 72.2%. At a 12-month follow-up, mean episodes of cellulitis were improved from 2.7 ± 0.6 to 0.8 ± 0.2 (P < 0.01); mean of circumferential difference was improved 3.2 ± 0.4 cm (P < 0.03). The overall lymphedema quality-of-life was improved 4.9 ± 0.3 (P < 0.04).

Conclusions:

The preoperative MRI is a useful tool for the detection of mean 7.2 submental lymph nodes. Mean 72.2% of submental lymph nodes can be successfully transferred for extremity lymphedema with optimal functional recovery.
Acceptance Testing of Thermoluminescent Dosimeter Holders
Authors: Romanyukha Alexander , Grypp Matthew D. , Sharp Thad J. , DiRito John N. , Nelson Martin E. , Mavrogianis Stanley T. , Torres Jeancarlo , Benevides Luis A.
Published: March 2018

The U.S. Navy uses the Harshaw 8840/8841 dosimetric (DT‐702/PD) system, which employs LiF:Mg,Cu,P thermoluminescent dosimeters (TLDs), developed and produced by Thermo Fisher Scientific (TFS). The dosimeter consists of four LiF:Mg,Cu,P elements, mounted in Teflon® on an aluminum card and placed in a plastic holder. The holder contains a unique filter for each chip made of copper, acrylonitrile butadiene styrene (ABS), Mylar®, and tin. For accredited dosimetry labs, the ISO/IEC 17025:2005(E) requires an acceptance procedure for all new equipment. The Naval Dosimetry Center (NDC) has developed and tested a new non-destructive procedure, which enables the verification and the evaluation of embedded filters in the holders. Testing is based on attenuation measurements of low-energy radiation transmitted through each filter in a representative sample group of holders to verify that the correct filter type and thickness are present. The measured response ratios are then compared with the expected response ratios. In addition, each element’s measured response is compared to the mean response of the group. The test was designed and tested to identify significant nonconformities, such as missing copper or tin filters, double copper or double tin filters, or other nonconformities that may impact TLD response ratios. During the implementation of the developed procedure, testing revealed a holder with a double copper filter. To complete the evaluation, the impact of the nonconformities on proficiency testing was examined. The evaluation revealed failures in proficiency testing categories III and IV when these dosimeters were irradiated to high-energy betas.
RELATIONSHIP OF CLINICAL FEATURES AND BASELINE TUMOR SIZE WITH GENE EXPRESSION PROFILE STATUS IN UVEAL MELANOMA
Authors: Berry Duncan , Seider Michael , Stinnett Sandra , Mruthyunjaya Prithvi , Schefler Amy C. ,   the Ocular Oncology Study Consortium
Published: March 2018

Purpose:

To study the relationship between gene expression profile subclass and clinical features in a multicenter cohort of patients with uveal melanoma.

Methods:

A retrospective, multicenter study was undertaken with patients entered from nine major ocular oncology centers from across the United States. Eligible patients had uveal melanoma and underwent I-125 plaque brachytherapy with concurrent tumor biopsy with gene expression profile testing between January 1, 2010, and October 28, 2014. Data were collected regarding patient demographics, baseline tumor clinical features, and gene expression profile results. Statistical analyses were performed using the Fisher's exact test, Wilcoxon rank-sum test, Kruskal–Wallis test, and proportional-odds cumulative logit modeling.

Results:

Inclusion criteria were met for 379 patients. Gene expression profile class divided the cohort into two main groups, Class 1 (n = 263) and Class 2 (n = 113). Class 1 tumors were further subdivided into Class 1a (n = 186) and Class 1b (n = 77). The differences between Class 1 and Class 2 tumors were similar to previous studies, except the finding of Class 2 tumors being more likely to have associated exudative retinal detachment (P < 0.001). There was no statistically significant difference between Class 1 and Class 2 tumors based on the presence of lipofuscin, drusen, or subretinal fluid. Class 1a tumor patients, compared with Class 1b, were significantly older (P = 0.034). Class 2 tumors, when compared with Class 1b, were associated with increasing patient age (P < 0.001), larger tumor height (P = 0.010), ciliary body involvement (P = 0.001), exudative retinal detachment (P = 0.024), and anterior tumor location (P < 0.001). When the tumors were grouped into Collaborative Ocular Melanoma Study size categories, increasing tumor size category was significantly associated with Class 2 status: 6% of small tumors, 32% of medium tumors, and 53% of large tumors were Class 2.

Conclusion:

In a multi-institutional setting, we found that the only significant difference in clinical features between Class 1a and Class 1b tumors was that patients with Class 1a tumors were older at the time of diagnosis. We also found that Class 1a and Class 1b have clinical features distinct from Class 2 tumors. The distribution of the gene expression profile subclasses among the size groups was similar to reported time-to-metastasis data among the same size groupings. Our clinical findings support the current molecular classification-based survival data previously reported in uveal melanoma.
PENETRATING OCULAR INJURY WITH RETAINED INTRAOCULAR FOREIGN BODY FROM DRYWALL
Authors: Syed Reema , Kim Sung-Hye , Palacio Agustina , Nunery William R. , Schaal Shlomit
Published: March 2018

Purpose:

To present a case of open globe injury and retained intraocular foreign body secondary to drywall.

Methods:

Interventional case report.

Results:

A 21-year-old man presented with corneal laceration, iris defect, and vitreous hemorrhage after hammering drywall. Computed tomography scan was negative for intraocular foreign body, but a drywall intraretinal foreign body was found on 25-gauge vitrectomy. Intraoperative findings and 6-month follow-up are presented.

Conclusion:

Intraocular foreign body must always be suspected in all cases of penetrating ocular trauma. Although magnetic resonance imaging is ideal in diagnosing nonmetallic foreign bodies, computed tomography scan with Hounsfield units should be used in an emergency setting.
Evaluating Physician Attitudes and Practices Regarding Herpes Zoster Vaccination
Authors: Tsui Edmund , Gillespie Colleen , Perskin Michael , Zabar Sondra , Wu Mengfei , Cohen Elisabeth J.
Published: March 2018

Purpose:

To investigate the knowledge, attitudes, and practice patterns of primary care physicians regarding administration of the herpes zoster (HZ) vaccine at NYU Langone Health (NYULH).

Methods:

A cross-sectional online survey was distributed from January to March 2017 to all physicians in the Division of General Internal Medicine and Clinical Innovation at NYULH across 5 different practice settings.

Results:

The response rate was 26% (138 of 530). Of the surveyed physicians, 76% (100/132) agreed that the HZ vaccine was an important clinical priority, compared with 93% and 94% for influenza and pneumococcal vaccination, respectively (P < 0.001). Only 35% (47/132) strongly agreed that it was important, compared with 68% (90/132) and 74% (98/132) who strongly agreed that pneumococcal and influenza vaccines, respectively, were important. Respondents estimated that 43% of their immunocompetent patients aged 60 or older received the HZ vaccine, whereas only 11% of patients aged 50 to 59 received the HZ vaccine (P < 0.001). The rate of HZ vaccination was lower in public hospitals (26%) than in the NYULH faculty group practice (46%) (P = 0.007). A greater percent (67% and 72%) of their patients have received influenza and pneumococcal vaccines, respectively (P < 0.001). Almost all doctors (99%, 131/132) consider the Centers for Disease Control and Prevention recommendations important in determining vaccination practices.

Conclusions:

HZ vaccination rates remain relatively low compared with rates of influenza and pneumonia vaccination. The recommendation for vaccination against zoster by the Centers for Disease Control and Prevention for individuals aged 50 years and older and stronger recommendations by primary care physicians for administration of zoster vaccines are needed to increase HZ vaccination rates.
Chronic pain impairs cognitive flexibility and engages novel learning strategies in rats
Authors: Cowen Stephen L. , Phelps Caroline E. , Navratilova Edita , McKinzie David L. , Okun Alec , Husain Omar , Gleason Scott D. , Witkin Jeffrey M. , Porreca Frank
Published: March 2018

Cognitive flexibility, the ability to adapt behavior to changing outcomes, is critical to survival. The prefrontal cortex is a key site of cognitive control, and chronic pain is known to lead to significant morphological changes to this brain region. Nevertheless, the effects of chronic pain on cognitive flexibility and learning remain uncertain. We used an instrumental paradigm to assess adaptive learning in an experimental model of chronic pain induced by tight ligation of the spinal nerves L5/6 (spinal nerve ligation model). Naive, sham-operated, and spinal nerve ligation (SNL) rats were trained to perform fixed-ratio, variable-ratio, and contingency-shift behaviors for food reward. Although all groups learned an initial lever-reward contingency, learning was slower in SNL animals in a subsequent choice task that reversed reinforcement contingencies. Temporal analysis of lever-press responses across sessions indicated no apparent deficits in memory consolidation or retrieval. However, analysis of learning within sessions revealed that the lever presses of SNL animals occurred in bursts, followed by delays. Unexpectedly, the degree of bursting correlated positively with learning. Under a variable-ratio probabilistic task, SNL rats chose a less profitable behavioral strategy compared with naive and sham-operated animals. After extinction of behavior for learned preferences, SNL animals reverted to their initially preferred (ie, less profitable) behavioral choice. Our data suggest that in the face of uncertainty, chronic pain drives a preference for familiar associations, consistent with reduced cognitive flexibility. The observed burst-like responding may represent a novel learning strategy in animals with chronic pain.
Efficacy of the Nav1.7 blocker PF-05089771 in a randomised, placebo-controlled, double-blind clinical study in subjects with painful diabetic peripheral neuropathy
Authors: McDonnell Aoibhinn , Collins Susie , Ali Zahid , Iavarone Laura , Surujbally Raulin , Kirby Simon , Butt Richard P.
Published: March 2018

The effect of PF-05089771, a selective, peripherally restricted Nav1.7 sodium channel blocker on pain due to diabetic peripheral neuropathy was investigated in a randomised, placebo and active-controlled parallel group clinical trial (NCT02215252). A 1-week placebo-run in the period was followed by a 4-week treatment period and a 1-week placebo run-out/taper-down period. Single-blind placebo was administered throughout run-in and run-out periods. Subjects were randomised to receive either PF-05089771 150 mg twice daily, pregabalin 150 mg twice daily, or placebo during the 4-week treatment period. One hundred thirty-five subjects were randomised. The primary endpoint was the average pain score derived from subjects' Numerical Rating Scale scores over the past 7 days of week 4 of the double-blind treatment period. Predefined efficacy criteria for the trial were the effect of PF-05089771 being >0.5 units better than placebo at interim analysis after completion of the first part of the study. Although a trend for a reduction in the weekly average pain score in the PF-05089771 treatment group was observed, this was not statistically significant when compared with placebo at week 4, with a mean posterior difference of −0.41 (90% credible interval: −1.00 to 0.17). The effect of PF-05089771 was smaller than that seen with pregabalin, which was statistically significant when compared with placebo at week 4, with a mean posterior difference of −0.53 (90% credible interval: −0.91 to −0.20). As predefined efficacy criteria were not met, the study did not proceed to the second part. PF-05089771 was well tolerated. Possible reasons for the modest efficacy observed with PF-05089771 are discussed.
Hip Joint Effusion-Synovitis Is Associated With Hip Pain and Sports/Recreation Function in Female Professional Ballet Dancers
Authors: Mayes Susan , Ferris April-Rose , Smith Peter , Cook Jill
Published: March 2018

Objective:

To compare hip joint effusion-synovitis prevalence in professional ballet dancers with nondancing athletes and to evaluate the relationship between effusion-synovitis and clinical measures and cartilage defects.

Design:

Case–control study.

Setting:

Elite ballet and sport.

Participants:

Forty-nine professional ballet dancers and 49 age-matched and sex-matched athletes.

Independent Variables:

Group (dancers/athletes), sex, age, years of training, Copenhagen Hip and Groin Outcome Scores (HAGOSs), hip rotation range of motion (ROM), generalized joint hypermobility (GJH), and hip cartilage defect scores.

Main Outcome Measures:

Hip joint effusion-synovitis (absent, grade 1 = 2-4 mm, grade 2 = >4 mm) scored with 3-Tesla magnetic resonance imaging.

Results:

Hip joint effusion-synovitis was found in 22 (45%) dancers and 13 (26.5%) athletes (P = 0.06). Grade 2 effusion-synovitis was only found in dancers (n = 8, r = 0.31, P = 0.009). The prevalence of effusion-synovitis was similar in men (n = 11, 26%) and women (n = 24, 43%, P = 0.09). Female dancers with effusion-synovitis had lower HAGOS pain (r = 0.63, P = 0.001) and sports/recreation scores (r = 0.66, P = 0.001) compared with those without effusion-synovitis. The HAGOS scores were not related to effusion-synovitis in male dancers or female and male athletes (P > 0.01 for all). Effusion-synovitis was not related to hip ROM, GJH, or cartilage defect scores (P > 0.05 for all).

Conclusions:

Hip joint effusion-synovitis was related to higher levels of pain and lower sports/recreation function in female ballet dancers. Effusion-synovitis was not related to hip rotation ROM, GJH or cartilage defects. Larger sized joint effusion-synovitis was exclusively found in dancers.
Nerve Growth Factor and Selected Cytokines in Women With and Without Vulvodynia
Authors: Reed Barbara D. , Plegue Melissa A. , Sen Ananda , Haefner Hope K. , Siddiqui Javed , Remick Daniel G.
Published: March 2018

Objective

The aim of the study was to assess the association between cytokines/neurokines after in vitro stimulation with Candida antigen or lipopolysaccharide (LPS) in blood samples among women with and without vulvodynia.

Materials and Methods

Women with vulvodynia and asymptomatic controls at three offices at the University of Michigan were examined clinically and completed a comprehensive survey in this cross-sectional study. Cytokine/neurokine levels were determined on blood samples using established ELISA protocols. Analysis of 48 cases and 42 ethnically matched controls included descriptive statistics (median, minimal, and maximal levels of cytokines/neurokines), overall and in cases and controls. Because of left-censored measurements, interval censored survival analysis was used to assess the association between case/control status and pain characteristics with cytokine/neurokine levels.

Results

Participants ranged in age from 19 to 60 years. Levels of IL1β, IL1-RA, TNFα, IL-6, and IL-8 increased substantially after LPS stimulation, whereas no response was seen on IFNγ or nerve growth factor (NGF). Each increased after Candida antigen stimulation, although responses to Candida antigen stimulation of IL1β, IL-6, and TNFα were less robust than after LPS. Only NGF was significantly increased in vulvodynia cases compared with controls (Exp β (95% CI) = 2.08 [1.08–3.98]) after 24-hour Candida antigen stimulation and persisted when controlled for age, use of oral contraceptives, or history of Candida vulvovaginitis. No association between cytokine/neurokine levels and pain characteristics was found.

Conclusions

Compared with that of control women, whole blood from women with vulvodynia demonstrates an enhanced production of NGF, but not of a set of inflammation-related cytokines, in response to Candida antigen stimulation.
Low Risk of Cervical Cancer/Precancer Among Most Women Under Surveillance Postcolposcopy
Authors: Demarco Maria , Cheung Li C. , Kinney Walter K. , Wentzensen Nicolas , Lorey Thomas S. , Fetterman Barbara , Poitras Nancy E. , Befano Brian , Castle Philip E. , Schiffman Mark
Published: March 2018

Objective

To inform impending postcolposcopy guidelines, this analysis examined the subsequent risk of CIN 3+ among women with a grade lower than CIN 2 (< CIN 2) colposcopy results, taking into account the referring results that brought them to colposcopy and cotest results postcolposcopy.

Methods

We analyzed 107,005 women from 25 to 65 years old, recommended for colposcopy at Kaiser Permanente Northern California. We estimated absolute risks of CIN 3+ among women: (1) recommended for colposcopy (precolposcopy), (2) following colposcopy and with histology results < CIN 2 (postcolposcopy), and (3) with cotest results 12 months after a < CIN 2 colposcopy (return cotest).

Results

After colposcopy showing < CIN 2 (n = 69,790; 87% of the women at colposcopy), the 1-year risk of CIN 3+ was 1.2%, compared with 6.3% at the time of colposcopy recommendation. Negative cotest results 1 year after colposcopy identified a large group (37.1%) of women whose risk of CIN 3+ (i.e., <0.2% at 3 years after postcolposcopy cotest) was comparable with women with normal cytology in the screening population. These risks are consistent with current guidelines recommending repeat cotesting 12 months after colposcopy < CIN 2 and a 3-year return for women with a negative postcolposcopy cotest.

Conclusions

Most women are at low risk of subsequent CIN 3+ after a colposcopy showing < CIN 2, especially those who are human papillomavirus–negative postcolposcopy, consistent with current management guidelines for repeat testing intervals. Before the finalizing the upcoming guidelines, we will consider additional rounds of postcolposcopy cotesting.