bluuebunny/crossref_metadata_2025 huggingface dataset:
Performance of Emergency Medical Service Providers in Pediatric and Adult Simulation of Unstable Supraventricular Tachycardia
Authors: Khalil Paul A. , Berkovich Jennifer , Maniaci Vincenzo , Lozano Juan Manuel , Lowe David A.
Published: May 2019

Objective

The aim of the study was to compare emergency medical service resuscitation of pediatric and adult high-fidelity manikins in unstable supraventricular tachycardia. The primary objective was time to cardioversion. The secondary objective was to assess if the cardioversion was synchronized at the correct dosage for the manikin's weight.

Methods

Emergency medical service providers were voluntarily enrolled as part of an emergency medical service training program. Participants were randomized to either a pediatric or adult resuscitation as their study scenario. They then completed the second resuscitation as part of the training program. Participants completed presurvey and postsurvey. Resuscitations were videotaped and analyzed by a blinded reviewer. The study was powered to detect a 60-second difference in performance between pediatric and adult scenarios with a β of 0.8 and 2-tailed α of 0.05 using an independent-samples t test.

Results

A total of 37 participants were enrolled. Participants in the pediatric arm had a longer mean time to cardioversion, but the difference was not statistically significant. The mean delay to cardioversion in the pediatric scenario was 34 seconds (197 vs 163 seconds; difference 95% confidence interval [CI], −5 to 73 seconds; P = 0.09). There was no significant difference in the percentage of participants who administered a correct dose (32% vs 50%; difference 95% CI, −50% to 13%; P = 0.75) or regarding synchronization of cardioversion (74% vs 83%; difference 95% CI, −36% to 17%; P = 0.42).

Conclusions

Emergency medical service providers did not have a significant difference in time to cardioversion between pediatric and adult unstable supraventricular tachycardia simulations.
Emergency Department Visits for Pediatric Firearm Injuries by Trauma Center Type
Authors: Cutler Gretchen J. , Zagel Alicia L. , Spaulding Alicen B. , Linabery Amy M. , Kharbanda Anupam B.
Published: May 2019

Objectives

This study aimed to characterize pediatric visits to emergency departments (EDs) for firearm injuries and examine differences by trauma center type.

Methods

Analyses included all patients younger than 19 years from the National Trauma Data Bank, years 2009 to 2014. Trauma centers were categorized as adult, mixed adult and pediatric, or pediatric based on certification level. Baseline characteristics were compared between subgroups using χ2 tests. Multivariable logistic regression was used to examine risk of death.

Results

Of 466,403 pediatric ED visits, 21,416 (4.6%) resulted from a firearm injury. Most firearm injuries were treated at an adult (64.9%) or mixed trauma center (29.1%) and involved patients that were male (87.1%), in the 15- to 18-year age group (83.2%), and black or African American (61.3%). Most visits were for injuries resulting from assault (78.1%), followed by unintentional (12.6%) and self-inflicted (4.7%) injuries, undetermined intent (3.7%), and legal intervention (0.8%). Patients visiting EDs for firearm injuries had more than 7 times the odds of dying compared with patients with other injuries (odds ratio, 7.30; 95% confidence interval, 6.82–7.72), and firearm injuries were responsible for more than a quarter (26.1%) of the total pediatric deaths in the National Trauma Data Bank (n = 2866). Assault-related injuries resulted in the most deaths (n = 2010; 70.1%), but the case fatality rate was highest for self-inflicted (n = 453; 44.6%).

Conclusion

We identified more than 20,000 firearm-related ED visits by pediatric patients from 2009 to 2014, averaging nearly 10 visits per day. Findings from this study can inform strategic planning in hospitals focused on preventing firearm injuries in children and adolescents.
Feedback at the Point of Care to Decrease Medication Alert Rates in an Electronic Health Record
Authors: van Camp P. J. , Kirkendall Eric S. , Hagedorn Philip A. , Minich Thomas , Kouril Michal , Spooner S. Andrew , Gecili Emrah , Dexheimer Judith W.
Published: May 2019

Objective

Frequently overridden alerts in the electronic health record can highlight alerts that may need revision. This method is a way of fine-tuning clinical decision support. We evaluated the feasibility of a complementary, yet different method that directly involved pediatric emergency department (PED) providers in identifying additional medication alerts that were potentially incorrect or intrusive. We then evaluated the effect subsequent resulting modifications had on alert salience.

Methods

We performed a prospective, interventional study over 34 months (March 6, 2014, to December 31, 2016) in the PED. We implemented a passive alert feedback mechanism by enhancing the native electronic health record functionality on alert reviews. End-users flagged potentially incorrect/bothersome alerts for review by the study's team. The alerts were updated when clinically appropriate and trends of the impact were evaluated.

Results

More than 200 alerts were reported from both inside and outside the PED, suggesting an intuitive approach. On average, we processed 4 reviews per week from the PED, with attending physicians as major contributors. The general trend of the impact of these changes seems favorable.

Discussion

The implementation of the review mechanism for user-selected alerts was intuitive and sustainable and seems to be able to detect alerts that are bothersome to the end-users. The method should be run in parallel with the traditional data-driven approach to support capturing of inaccurate alerts.

Conclusions

User-centered, context-specific alert feedback can be used for selecting suboptimal, interruptive medication alerts.
Mild Traumatic Brain Injury
Authors: Waldmeier-Wilhelm Sandra , Studer Martina , Weisstanner Christian , Heinks Theda , Grunt Sebastian , Steinlin Maja
Published: May 2019

Pediatric mild traumatic brain injury is a frequent cause for emergency consultations. Very often, management decisions focus only on acute neurological problems, without considering possible long-term impairment. Our case describes a 14-year-old girl who developed a pronounced and prolonged postconcussive syndrome and subsequent posttraumatic stress symptoms after (mild) traumatic brain injury. Early discharge without adequate instructions about the appropriate time to return to school and daily life activities promoted these striking problems. Only the delayed interventions including reduction of school workload and initiation of physiotherapy led to an improvement of symptoms.

Conclusions

Traumatologists, pediatricians, and general practitioners should call families' and teachers' attention to the risk of potential postconcussive syndrome and advise them on appropriate coping strategies. Thorough clinical examination should rule out potentially treatable physical impairments. Prescription of physical and cognitive rest at an early stage is mandatory and should be part of concussion management already at emergency department. Pediatricians or general practitioners should follow up patients and support their gradually working back into full activity.
Medical Errors and Malpractice Lawsuits
Authors: Rappaport David I. , Selbst Steven M.
Published: May 2019

Every pediatric emergency medicine provider will be involved in medical errors during their career and many will face the prospect of at least one malpractice lawsuit. These events can cause significant stress, including detrimental effects on providers' mental and physical health. This stress may also impact the provider's ability to care for future patients. In this installment of our series, “A Call to Restore Your Calling: Self-care of the Emergency Physician in the Face of Life-Changing Stress,” we examine how medical errors and malpractice lawsuits may affect providers and how individuals and organizations can address these events.
Hyperbaric Oxygen Improves Functional Recovery of the Injured Spinal Cord by Inhibiting Inflammation and Glial Scar Formation
Authors: Zhou Yue , Dong Qirong , Pan Zhenzhen , Song Yue , Su Peng , Niu Yanping , Sun Yongming , Liu Dong
Published: May 2019

Background

Inflammation and glial scar formation determine the recovery process after spinal cord injury. Hyperbaric oxygen is used as a rehabilitation therapy for various clinical diseases, including spinal cord injury. However, the relationship between hyperbaric oxygen therapy and inflammation or glial scar is not fully understood.

Objective

The aim of this study was to investigate the therapeutic effect and molecular mechanism of hyperbaric oxygen on spinal cord injury.

Methods

A total of 54 developing female Sprague-Dawley rats were randomly divided into sham group, spinal cord injury group, and hyperbaric oxygen group, with 18 rats in each group. The model of spinal cord injury was established using Allen’s method. Hyperbaric oxygen therapy was administered once a day until the rats were killed.

Results

The results demonstrated inflammation and glial scar formation are involved in secondary spinal cord injury. After hyperbaric oxygen treatment, there was a notable improvement of the locomotor function in rats. Hyperbaric oxygen reduced the inflammatory reaction and glial scar formation by inhibiting inflammation-related factors iNOS and COX-2 and glial scar–related components GFAP and NG2. This process may be achieved by inhibiting AKT and NF-kB pathways.

Conclusions

Hyperbaric oxygen effectively promotes the recovery of spinal cord injury by inhibiting inflammation and glial scar formation.
The Feasibility and Effects of Acupuncture on Muscle Soreness and Sense of Well-being in an Adolescent Football Population
Authors: Luetmer Marianne T. , Do Alexander , Canzanello Nick C. , Bauer Brent A. , Laskowski Edward R.
Published: May 2019

Objective

The aims of the study were to assess the feasibility of performing acupuncture on multiple adolescent athletes in a warm weather, high-intensity training environment and to measure perceived effects of acupuncture on delayed-onset muscle soreness and sense of well-being.

Design

This is a prospective feasibility study (registered clinical trial NCT03478800). Forty-two healthy male participants, aged 13–18 yrs, were involved in at least 1 of 5 treatment days for a total of 147 individual treatment sessions. Fifteen-minute treatments of traditional needle acupuncture were administered at the football field. Time, cost, adverse effects, and participant/provider ratio were observed. Effect on delayed-onset muscle soreness and sense of well-being were measured via pretreatment and posttreatment visual analog scale (0–10) rating analyses.

Results

The results are as follows: time required by research staff on treatment days, 75 mins; total cost, US $700; temperature range, 21°C–28°C; and largest participant to acupuncturist ratio, 7–10:1. No major adverse effects occurred; 55% reported minimal adverse effects, such as mild focal numbness or tingling. Overall pretreatment to posttreatment effect on delayed-onset muscle soreness (average over 5 days) demonstrated significantly improved posttreatment scores (pre 4.6 ± 2.0; post 2.9 ± 2.2, P < 0.001). There was no significant effect on sense of well-being (P = 0.12).

Conclusions

Effectively providing acupuncture to multiple adolescent football players in their training environment is feasible with appropriate staff and resources. Despite mild adverse effects, treatment was well tolerated. This study provides guidance on acupuncture delivery to other athletes in their training environments.
Energy Cost of Slow and Normal Gait Speeds in Low and Normally Functioning Adults
Authors: Rowley Taylor W. , Cho Chi , Swartz Ann M. , Staudenmayer John , Hyngstrom Allison , Keenan Kevin G. , Welch Whitney A. , Strath Scott J.
Published: May 2019

Objective

Slow walking speed paired with increased energy cost is a strong predictor for mortality and disability in older adults but has yet to be examined in a heterogeneous sample (ie, age, sex, disease status). The aim of this study was to examine energy cost of slow and normal walking speeds among low- and normal-functioning adults.

Design

Adults aged 20–90 yrs were recruited for this study. Participants completed a 10-m functional walk test at a self-selected normal walking speed and were categorized as low functioning or normal functioning based on expected age- and sex-adjusted average gait speed. Participants completed two successive 3-min walking stages, at slower than normal and normal walking speeds, respectively. Gas exchange was measured and energy cost per meter (milliliter per kilogram per meter) was calculated for both walking speeds.

Results

Energy cost per meter was higher (P < 0.0001) in the low-functioning group (n = 76; female = 59.21%; mean ± SD age = 61.13 ± 14.68 yrs) during the slower than normal and normal (P < 0.0001) walking speed bouts compared with the normal-functioning group (n = 42; female = 54.76%; mean ± SD age = 51.55 ± 19.51 yrs).

Conclusions

Low-functioning adults rely on greater energy cost per meter of walking at slower and normal speeds. This has implications for total daily energy expenditure in low-functioning, adult populations.
Early Detection of Diabetic Polyneuropathy Using Paired Stimulation Studies of the Sensory Nerves
Authors: Lee Ahry , Kwon Hee-Kyu
Published: May 2019

Objective

This study seeks to use the relative refractory period, a sensitive parameter for detecting early change in peripheral polyneuropathies, as a tool for early detection of diabetic polyneuropathy.

Design

The relative refractory period of the median and sural sensory nerves was measured in 57 diabetic patients (male 31, female 26) and 23 healthy controls (male 16, female 7). The shortest interstimulus interval, where the latency of the response to the second stimulus recovers to normal, was defined as the relative refractory period.

Results

The relative refractory period of the median and sural nerves were significantly longer in diabetic patients (3.6 msec, P < 0.001, and 3.8 msec, P < 0.001, respectively) than in the control group (3.0 msec in both nerves). Relative refractory period values of both nerves were also significantly prolonged compared with the control group, even in diabetic patients without diabetic polyneuropathy based on conventional conduction studies (3.3 msec, P = 0.002, for median nerve; 3.5 msec, P < 0.001, for sural nerve) or without any clinical symptoms and signs (3.3 msec, P = 0.007, for median nerve; 3.5 msec, P = 0.001, for sural nerve).

Conclusions

The relative refractory period was prolonged in diabetic patients even before other electrophysiologic abnormalities or clinical findings appeared. These results suggest that the relative refractory period can be a possible early indicator of diabetic polyneuropathy.
Needle EMG, a Jigsaw to Disclose Lipid Storage Myopathy Due to Multiple Acyl-CoA Dehydrogenase Deficiency
Authors: Santananukarn Manasawan , Amornvit Jakkrit , Pasutharnchat Nath , Jongpiputvanich Sungkom
Published: May 2019

Multiple acyl-CoA dehydrogenase deficiency is a rare autosomal recessive inborn error of metabolism. The late-onset multiple acyl-CoA dehydrogenase deficiency is frequently caused by mutations in ETFDH gene. Because of its clinical heterogeneity, diagnosis and treatment of late-onset multiple acyl-CoA dehydrogenase deficiency are often delayed. The authors described a previously healthy 40-yr-old Thai woman presenting with subacute severe weakness of bulbar-limb muscles and elevated serum creatine kinase. The authors emphasized the importance of needle EMG and prompt muscle histopathological evaluation, which rapidly led to the diagnosis and riboflavin therapy, resulting in a dramatic and rapid improvement before genetic study disclosed mutation in ETFDH gene.
Inhibiting Autophagy in Renal Cell Cancer and the Associated Tumor Endothelium
Authors: Russell Kira L. , Gorgulho Carolina Mendonça , Allen Abigail , Vakaki Marianna , Wang Yue , Facciabene Andrea , Lee Daniel , Roy Partha , Buchser William J. , Appleman Leonard J. , Maranchie Jodi , Storkus Walter J. , Lotze Michael T.
Published: May 2019

The clear cell subtype of kidney cancer encompasses most renal cell carcinoma cases and is associated with the loss of von Hippel-Lindau gene function or expression. Subsequent loss or mutation of the other allele influences cellular stress responses involving nutrient and hypoxia sensing. Autophagy is an important regulatory process promoting the disposal of unnecessary or degraded cellular components, tightly linked to almost all cellular processes. Organelles and proteins that become damaged or that are no longer needed in the cell are sequestered and digested in autophagosomes upon fusing with lysosomes, or alternatively, released via vesicular exocytosis. Tumor development tends to disrupt the regulation of the balance between this process and apoptosis, permitting prolonged cell survival and increased replication. Completed trials of autophagic inhibitors using hydroxychloroquine in combination with other anticancer agents including rapalogues and high-dose interleukin 2 have now been reported. The complex nature of autophagy and the unique biology of clear cell renal cell carcinoma warrant further understanding to better develop the next generation of relevant anticancer agents.
Adoptive Cell Therapy for Acute Myeloid Leukemia and T-Cell Acute Lymphoblastic Leukemia
Authors: Lulla Premal D. , Mamonkin Maksim , Brenner Malcolm K.
Published: May 2019

Refractory and relapsed acute myeloid leukemia (AML) and T-lineage leukemia have poor prognosis and limited therapeutic options. Adoptive cellular immunotherapies are emerging as an effective treatment for patients with chemotherapy refractory hematological malignancies. Indeed, the use of unselected donor lymphocyte infusions has demonstrated successes in treating patients with AML and T-lineage leukemia post–allogeneic transplantation. The development of ex vivo manipulation techniques such as genetic modification or selection and expansion of individual cellular components has permitted the clinical translation of a wide range of promising cellular therapies for AML and T-cell acute lymphoblastic leukemia. Here, we will review clinical studies to date using adoptive cell therapy approaches and outline the major challenges limiting the development of safe and effective cell therapies for both types of acute leukemia.
T-Cell Receptor–Based Immunotherapy for Hematologic Malignancies
Authors: Biernacki Melinda A. , Brault Michelle , Bleakley Marie
Published: May 2019

Adoptive immunotherapy with engineered T cells is at the forefront of cancer treatment. T cells can be engineered to express T-cell receptors (TCRs) specific for tumor-associated antigens (TAAs) derived from intracellular or cell surface proteins. T cells engineered with TCRs (TCR-T) allow for targeting diverse types of TAAs, including proteins overexpressed in malignant cells, those with lineage-restricted expression, cancer-testis antigens, and neoantigens created from abnormal, malignancy-restricted proteins. Minor histocompatibility antigens can also serve as TAAs for TCR-T to treat relapsed hematologic malignancies after allogeneic hematopoietic cell transplantation. Moreover, TCR constructs can be modified to improve safety and enhance function and persistence of TCR-T. Transgenic T-cell receptor therapies targeting 3 different TAAs are in early-phase clinical trials for treatment of hematologic malignancies. Preclinical studies of TCR-T specific for many other TAAs are underway and offer great promise as safe and effective therapies for a wide range of cancers.
Escape From ALL-CARTaz
Authors: Zheng Sisi , Asnani Mukta , Thomas-Tikhonenko Andrei
Published: May 2019

Chimeric antigen receptor (CAR) T-cell therapy has been transformative for the treatment of B-cell malignancies, with CD19- and CD22-directed CARs being prime examples. However, immunoediting and ensuing antigen loss remain the major obstacles to curative therapy in up to 25% of patients. For example, to achieve the CD19-negative phenotype, malignant cells can pick from a broad array of mechanisms, including focal loss-of-function mutations, dysregulated trafficking to the cell surface, alternative splicing, and lineage switching. In other cases, where resistance is mediated by insufficient antigen density, trogocytosis has been proposed as a possible underlying mechanism. To overcome these barriers, compensatory strategies will be needed, which could include using combinatorial CARs, harnessing epitope spreading, and targeting tumor neoantigens.
Toward the Development of the Perfect Medical Team: Critical Components for Adaptation
Authors: Gregory Megan E. , Hughes Ashley M. , Benishek Lauren E. , Sonesh Shirley C. , Lazzara Elizabeth H. , Woodard LeChauncy D. , Salas Eduardo
Published: May 2019

Objective

Medical teams play a vital role in the delivery of safe and effective patient care. Toward the goal of becoming a high-reliability health system, the authors posit that the “perfect” medical team is one that develops their attitudes, behaviors, and cognitions (ABCs) to facilitate adaptation.

Methods

The authors synthesized the literature (frameworks, measures, and conceptual models) on teamwork in healthcare (k = 161) to develop an evidence-based model of ABCs, which current evidence suggests, are requisite for medical team adaptation. Clinical vignettes were garnered from the media and other sources to illustrate how these ABCs—or failure in using these ABCs—can lead to positive or negative events in healthcare.

Results

The resulting model contains the most frequently included ABCs in healthcare teamwork models, measures, and frameworks: psychological safety (41, 25.5%), situation assessment (66, 41.0%), shared mental models (56, 34.8%), team leadership behaviors (78, 48.4%), role awareness (64, 39.7%), team decision-making (61, 37.9%) and planning (41, 25.5%), conflict management (51, 31.7%), task coordination (71, 44.1%), adaptation (46, 28.6%), and backup behavior (54, 33.5%). The authors posit that communication and organizational conditions—other highly cited components—(141, 87.6%, and 90, 55.9%, respectively) serve as moderators of these relationships.

Conclusions

The authors argue that each of these ABCs is critical for enhancing team adaptation and subsequently increasing patient safety. A list of practical tools and educational strategies that teams and organizations can use to improve their performance on each of these ABCs is provided.
Patients Own Safety Incidents Reports to the Danish Patient Safety Database Possess a Unique but Underused Learning Potential in Patient Safety
Authors: Christiansen Anders Bech , Simonsen Simon , Nielsen Gert Allan
Published: May 2019

Objective

The aim of the study was to analyze how patients’ own reports of safety incidents to the Danish Patient Safety Database can contribute to patient safety.

Background

Patient involvement enhances patient safety; however, there is a shortage of tools capable of systematically capturing and usage of patients’ own reports. Since 2012, the Danish Patient Safety Database (DPSD) has comprised such a tool.

Methods

A total of 209,263 incident reports were compared across the following four reporting groups: patients, relatives, doctors, and nurses. Using thematic comparison, 300 narratives from each group were compared with respect to differences and similarities in the wording of the safety incident.

Results

Only a tiny proportion of safety incidents were reported by patients’ themselves (1.4%). Most of these (86%) were accepted for processing in the DPSD. Almost 90% of the accepted incidents were classified successfully. Patients’ own reports were longer, more often “less severe incidents,” and more often reported by female patients. Thematic content analyses revealed incident descriptions from health professionals as terse, unemotional, and extensively using medical terminology and abbreviations. In contrast patients’ reports were lengthy, emotional, and focused on relations to health personal, health consequences, and communication errors.

Conclusions

Despite the very low ratio of patients reporting an observed incident to DPSD, the finding that most patients own reports are accepted and classified makes the DPSD a promising, comprehensive tool to capture patients’ own reports. However, the rich, contextualized descriptions seem insufficiently captured by established nomenclature.
Association Between Bilirubin, Atazanavir, and Cardiovascular Disease Events Among People Living With HIV Across the United States
Authors: Crane Heidi M. , Nance Robin M. , Heckbert Susan R. , Ritchings Corey , Rosenblatt Lisa , Budoff Matthew , Wood Brian R. , Tirschwell David L. , Kim H. Nina , Mathews William C. , Geng Elvin , Moore Richard D. , Hunt Peter W. , Eron Joseph J. , Burkholder Greer A. , Drozd Daniel R. , Chow Felicia C. , Becker Kyra J. , Zunt Joseph R. , Ho Emily L. , Kalani Rizwan , Huffer Andrew , Whitney Bridget M. , Saag Michael S. , Kitahata Mari M. , Delaney Joseph A. C.
Published: May 2019

Objective:

Bilirubin is an antioxidant that may suppress lipid oxidation. Elevated bilirubin is associated with decreased cardiovascular events in HIV-uninfected populations. We examined these associations in people living with HIV (PLWH).

Methods:

Potential myocardial infarctions (MIs) and strokes were centrally adjudicated. We examined MI types: type 1 MI (T1MI) from atherosclerotic plaque instability and type 2 MI (T2MI) in the setting of oxygen demand/supply mismatch such as sepsis. We used multivariable Cox regression analyses to determine associations between total bilirubin levels and outcomes adjusting for traditional and HIV-specific risk factors. To minimize confounding by hepatobiliary disease, we conducted analyses limited to bilirubin values <2.1 mg/dL; among those with fibrosis-4 values <3.25; and among everyone. We repeated analyses stratified by hepatitis C status and time-updated atazanavir use.

Results:

Among 25,816 PLWH, there were 392 T1MI and 356 T2MI during follow-up. Adjusted hazard ratios for the association of higher bilirubin levels with T1MI were not significant. Higher bilirubin levels were associated with T2MI. By contrast, among PLWH on atazanavir, higher bilirubin levels were associated with fewer T2MI (hazard ratio 0.56:0.33–1.00). Higher bilirubin levels among those on atazanavir were associated with fewer T1MI combined with ischemic stroke.

Limitations:

Analyses were conducted with total rather than unconjugated bilirubin.

Conclusions:

Among PLWH, higher bilirubin levels were associated with T2MI among some subgroups. However, among those on atazanavir, there was a protective association between bilirubin and T2MI. These findings demonstrate different associations between outcomes and elevated bilirubin due to diverse causes and the importance of distinguishing MI types.
Mortality After Cryptococcal Infection in the Modern Antiretroviral Therapy Era
Authors: Hevey Matthew A. , Presti Rachel M. , O'Halloran Jane A. , Larson Lindsey , Raval Krunal , Powderly William G. , Spec Andrej
Published: May 2019

Background:

The prevalence of cryptococcosis in people living with HIV (PLWH) in the developed world has decreased considerably in the modern antiretroviral therapy (ART) era. Although early mortality of PLWH with opportunistic infections is well understood, overall mortality has not been previously evaluated.

Methods:

We conducted a retrospective cohort study of cryptococcosis in PLWH from January 1, 2002, to July 1, 2017. Data were also evaluated before and after 2008 to evaluate the possible effect of modern ART on outcomes. Death date was obtained from the hospital's medical informatics database and the Social Security Death Index. Participants were grouped as survivors, early-mortality (death <90 days), and late-mortality (death ≥90 days) individuals.

Results:

We reviewed 105 PLWH with cryptococcosis, with 55 survivors (52.4%), 17 early-mortality (16.2%), and 33 late-mortality individuals (31.4%). Overall, mortality was 47.6% (n = 50) with a median follow-up of 3.7 years (interquartile range 1.1, 8.1 years). Late-mortality individuals were less likely to be virally suppressed at the last observation compared with survivors (24% vs 62%, P < 0.001). Individuals diagnosed in the modern ART era had significantly lower mortality (hazard ratio 0.5, confidence interval: 0.2 to 0.8) and were more likely to be virally suppressed at the last observation (57% vs 29%, P = 0.003). Individuals with government-provided insurance had a higher mortality compared to those with private insurance (hazard ratio 2.8, confidence interval: 1.1 to 7.2, P = 0.013).

Conclusions:

Despite improvements in ART, PLWH have high mortality after cryptococcal infection that persists beyond their initial hospitalization. Lower mortality was associated with increased HIV viral suppression and private insurance in the modern ART era.
New and novel rapid diagnostics that are impacting infection prevention and antimicrobial stewardship
Authors: Sullivan Kaede V. , Dien Bard Jennifer
Published: May 2019

Purpose of review

The current review summarizes advances in rapid diagnostic testing that impacts infection prevention and antimicrobial stewardship programs.

Recent findings

A variety of rapid diagnostic technologies to identify organisms in cultured blood are now available. When coupled with antimicrobial stewardship (ASP), these rapid technologies can optimize antimicrobial utilization and patient outcomes. Two rapid molecular panels that detect organisms related to pneumonia are available and may impact infection prevention surveillance definitions. Three molecular tests are available for the detection of meningitis and encephalitis pathogens. Still, the clinical impact of these broad, multiplexed panels need additional clarification. For Clostridioides difficile infections, ultrasensitive toxin A/B assays may provide enhanced sensitivity and specificity compared with enzyme immunoassay and molecular testing respectively. Finally, the adoption of Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry (MALDI TOF MS) for rapid organism identification is growing. Recent US Food and Drug Administration-clearance of a MALDI TOF MS platform for identification of Nocardia, Mycobacteria, and molds may expedite antimicrobial decisions for infections that traditionally required days to weeks for an identification.

Tests with broad diagnostic scope and swift turnaround time are rapidly entering the market. Many impact infection prevention and ASP programs. Collaboration with the microbiology laboratory is crucial to ensure that new tests successfully optimize patient care.
Hepatic Angiomyolipoma Having FDG Uptake at the Similar Level of the Normal Liver Parenchyma
Authors: Wang Xuezhu , Wang Jingnan , Cheng Xin , Li Fang , Huo Li
Published: May 2019

A middle-aged woman underwent a contrast CT to evaluate a palpable upper abdominal mass. The images showed large lesion in the left lobe of the liver, and malignancy was among differential diagnoses. For this reason, FDG PET/CT was performed. Surprisingly, the level of FDG uptake by the large hepatic lesion was similar to the normal part of the liver. Pathological examination demonstrated hepatic angiomyolipoma.
18F-FDG PET/CT Imaging of Trichoblastic Carcinoma With Nodal Metastasis
Authors: Nguyen Ba Duong , Seetharam Mahesh , Ocal Tolgay I.
Published: May 2019

Trichoblastic carcinoma is an uncommon malignant neoplasm arising from follicular germinative cells. The high-grade trichoblastic carcinoma has been reported with lymphatic and hematogenous dissemination. The authors present a 59-year-old man with gluteal cleft trichoblastic carcinoma and highlight the useful role of serial 18F-FDG PET/CT examinations in the demonstration of initial and subsequent nodal metastasis in the inguina and pelvis.
The Finding of the “Mini Brain” May Not Be a Unique Anatomic Appearance of Spinal Plasmacytoma
Authors: Zhong Xiao , Jia Zhiyun , Su Minggang
Published: May 2019

MRI and 18F-FDG PET/CT were performed on a 37-year-old man who was suspected with malignant spinal tumor on x-ray examination. An FDG-avid expansile lytic lesion was found in his T12 vertebra. The lesion showed a characteristic “mini-brain” appearance on MRI and CT. This extremely high specificity sign and consistent manifestation on PET image indicated plasmacytoma as the most optimal diagnosis. But finally, a giant cell tumor was confirmed after surgery. The case cautions that the specificity of the diagnostic characteristics of “mini-brain” sign for plasmacytoma or multiple myeloma may not be as high as previously reported.
State Tested Nursing Assistants’ Workplace Experiences That Threaten or Support Intent to Stay
Authors: Senecal Megan Benner , McBride Kimberly , Steiner Victoria , Pierce Linda , Saltzman Barbara
Published: May 2019

Purpose

Over 1 million Americans utilize skilled nursing facilities (SNFs) annually. Within SNFs, State Tested Nursing Assistants (STNAs) are primary caregivers; however, low retention rates are notable and threaten patient care.

Design

A phenomenological, qualitative study was conducted to explore intrinsic factors that influence STNAs’ intent to stay in their positions.

Methods

Ten STNAs employed at for-profit SNFs participated in semistructured face-to-face interviews. Data were analyzed to identify broad concepts and recurrent themes.

Findings

Findings suggest that intrinsic factors supporting and threatening intent to stay included the fulfillment of basic psychological needs. Supporting themes included self-confidence, appreciation, positive relationships, and a willingness to go beyond required duties. Threatening themes included frustration, lack of support, and career advancement opportunities.

Conclusions

Findings provide an understanding of factors that influence STNAs' intent to stay.

Clinical Relevance

The results may help guide the development of responsive strategies that improve quality and continuity of care in SNFs.
Prospective Evaluation of Health After Breast Reduction Surgery Using the Breast-Q, Short-Form 36, Breast-Related Symptoms Questionnaire, and Modified Breast Evaluation Questionnaire
Authors: Lewin Richard , Lidén Mattias , Lundberg Jonas , Hansson Emma , Selvaggi Gennaro , Thorarinsson Andri , Elander Anna
Published: May 2019

Introduction

Breast hypertrophy is a condition associated with physical, psychological, and psychosocial problems. The primary aims of this study were to determine the impact of breast hypertrophy and the effects of breast reduction, performed on the basis of well-described inclusion criteria, on general and breast-related health, using both general and diagnosis-specific validated questionnaires. We used a prospective, longitudinal paired study design. A secondary aim was to analyze the relationship between preoperative breast volume, body mass index, sternal notch-to-nipple distance and the weight of resected tissue on the one hand and improvements in health on the other.

Methods

Three hundred forty-eight consecutive patients undergoing breast reduction were included and the Short-Form 36 (SF-36), Breast-Related Symptoms Questionnaire (BRSQ), Modified Breast Evaluation Questionnaire (mBEQ) and BREAST-Q were distributed preoperatively and 1 year postoperatively.

Results

A total of 284 (83%) patients answered the questionnaires either preoperatively or postoperatively, or both, and 159 (46%) patients answered both. The breast hypertrophy patients had significantly lower scores preoperatively than the matched normal population when it came to all dimensions of the SF-36 and mBEQ. The preoperative scores for both the BRSQ and BREAST-Q were low.

After breast reduction, there were significant improvements in all dimensions of the BRSQ, mBEQ, and Breast-Q and in several dimensions of the SF-36.

Conclusions

Breast reduction reduces or removes disease-associated pain. It improves or normalizes perceived health and psychosocial self-esteem in slightly obese women or women of normal weight with preoperative breast volumes around 1000 mL. Women with higher preoperative breast volumes and longer sternal notch-to-nipple distances appear to be more satisfied with the cosmetic result postoperatively.
A Systematic Review of Outcomes After Genital Lymphedema Surgery
Authors: Guiotto Martino , Bramhall Russell J. , Campisi Corrado , Raffoul Wassim , di Summa Pietro Giovanni
Published: May 2019

Introduction

Genital lymphedema (GL) surgery can be either palliative or functional. Palliative procedures involve excision of the affected tissue and reconstruction by either local flaps or skin grafts. Reconstructive procedures aim to restore lymphatic flow through microsurgical lymphaticovenous anastomoses (LVAs). This systematic analysis of outcomes and complication rates aims to compare outcomes between these surgical treatment options for GL.

Methods

A systematic review of the PubMed database was performed with the following search algorithm: (lymphorrhea or lymphedema) and (genital or scrotal or vulvar) and (microsurgery or “surgical treatment”), evaluating outcomes, and complications after surgical treatment of GL.

Results

Twenty studies published between 1980 and 2016 met the inclusion criteria (total, 151 patients). Three main surgical treatments for GL were identified. Surgical resection and primary closure or skin graft was the most common procedure (46.4%) with a total complication rate of 10%. Surgical resection and flap reconstruction accounted for 39.1% of the procedures with an overall complication rate of 54.2%. Lympho venous shunt (LVA) procedures (14.5%) had a total complication rate of 9%.

Conclusions

This review demonstrates a lack of consensus in both the preoperative assessment and surgical management of GL. Patients receiving excisional procedures tended to be later stage lymphedema. Patients in the excision and flap reconstruction group seemed to have the highest complication rates. Microsurgical LVAs may represent an alternative approach to GL, either alone or in combination with traditional procedures.
The Economic Impact of Flexor Tendon Lacerations of the Hand in the United States
Authors: Mehrzad Raman , Mookerjee Vikram , Schmidt Scott , Jehle Charles C. , Kiwanuka Elizabeth , Liu Paul Y.
Published: May 2019

Purpose

Flexor tendon lacerations are a common and debilitating injury for thousands of Americans annually. Despite this, no study has attempted to estimate the economic impact of these injuries. The objective of this study was to estimate the economic impact of flexor tendon lacerations in America.

Methods

The cost of flexor tendon lacerations to society was estimated using a validated prevalence-based cost of illness model. The primary cohort was defined as all patients in the United States presenting with complete flexor tendon lacerations who underwent surgical repair. The secondary cohort was defined by all patients who required reoperation within 1 year of their initial operation. For these groups, both direct and indirect costs (lost income, missed workdays, and disability payments) were measured.

Results

Flexor tendon lacerations incur an estimated cost of between US $240.8 and US $409.1 million annually to the American medical system. The total direct cost per injury is estimated to be US $13,725, whereas estimates to the indirect costs range from US $60,786 to US $112,888.

Conclusions

Flexor tendon lacerations represent an important economic burden to our health care system, even when compared with other common hand conditions. Specifically, indirect costs, such as missed workdays, are the major contributor toward the total cost these injuries incur on society, accounting for upward of 89% of the total cost. This suggests that we should focus our efforts to improve treatments and rehabilitation protocols which decrease these indirect costs.
Risk Factors for Adult Postintubation Tracheal Stenosis
Authors: Songu Murat , Ozkul Yilmaz
Published: May 2019

Background:

To identify risk factors for developing adult postintubation tracheal stenosis (TS) and determine if there were patient characteristics that could serve as prognostic indicators of clinical outcomes in this patient population.

Methods:

A total of 55 patients with postintubation TS admitted to our institution between February 2009 and March 2017 (TS group) and randomly selected 86 patients admitted to the intensive care unit and intubated over the same period in whom TS was ruled out (control group) were compared. Causal factors of intubation were noted. Patient-, treatment-, and procedure/cuff site-related risk factors of TS were compared.

Results:

Both groups did not differ from each other by means of age and gender (P = 0.640, and P = 0.724, respectively). Compared to controls, patients with TS had a significantly higher BMI (32.8 ± 7.64 kg/m2 versus 25.9 ± 6.68 kg/m2; p = 0.002) and were more likely to have diabetes (28.4% vs 9.82%; p = 0.0011). Patients who were previously intubated for more than 48 hours (P = 0.016) and patients treated with irradiation (P = 0.028) were significantly more likely to develop TS than control patients.

Conclusion:

Patients with TS had a significantly higher BMI, and were more likely to have diabetes compared to controls. Patients who were previously intubated for more than 48 hours and patients treated with irradiation were more likely to develop TS than control patients.
Removal of Foreign Bodies in Orbit-Zygomatic-Maxillary Complex
Authors: Pessoa Neto José Valdir , Cetira Filho Edson Luiz , Sampaio Fernando Delgado , Mello Manoel de Jesus Rodrigues , Menezes Junior José Maria Sampaio
Published: May 2019

Trauma is one of the leading causes of death worldwide. Due to its anatomy and position in the facial skeleton, the orbit becomes a region susceptible to trauma which may also involve the penetration of foreign bodies (FBs). These events can have serious repercussions depending on their extent due to the proximity of the orbit with other noble structures of the face and skull. Because of this, a system of prehospital management of traumas must be established, in order to promote a better prognosis for patients. The present study aims to report the case of a patient suffering from a motorcycle accident with multiple fragments of FBs in the region of orbit-zygomatic-maxillary complex. The emergency surgical removal of the fragments was performed by a multidisciplinary team, involving Ophthalmology and Oral and Maxillofacial Surgery and Traumatology (OMST). Wound cleansing and debridement were performed with subsequent removal of the foreign bodies by the OMST team, in addition to the reduction and fixation of related fractures. As for Ophthalmology, the evisceration of the affected eye was performed due to its anatomical and functional impairment. The patient is 12 months postoperatively, with no aesthetic or functional complaints regarding OMST. The anatomical knowledge of the traumatized region, besides the establishment of the conduct regarding the removal of possible associated foreign bodies are required so that the success of the treatment can be obtained, aiming to minimize the damages to the patient.
Head Shape Retention Following Helmet Therapy for Deformational Plagiocephaly
Authors: Naidoo Sybill D. , Skolnick Gary B. , Galli Anthony D. , Patel Kamlesh B.
Published: May 2019

Background:

The aim of the present study was to evaluate whether any change can be expected in the 6-month period after completing treatment with a molding helmet for deformational plagiocephaly. A retrospective review of helmeted patients from a deformational plagiocephaly clinic from May 2010 to June 2011.

Methods:

A total of 71 individuals with 6-month follow-up after completion of molding helmet treatment were identified. About 51 males and 20 females ranged in age from 2 to 10 months at initial treatment. The main outcome measure was the amount of change in head shape in the 6-month period following molding helmet therapy.

Results:

During the course of helmet treatment cephalic index and cranial vault asymmetry both decreased significantly (P < 0.001). Posthelmet follow-ups revealed a further decrease in cephalic index (P < 0.001). Although the cranial vault asymmetry decreased slightly between the final helmeting visit and the follow-up visit, this change was not statistically significant (P = 0.292). Controlling for other factors, continued normalization was not significantly related to helmeting duration.

Conclusion:

Findings revealed both cephalic index and cranial vault asymmetry improved while in the helmet. During the 6 months following helmet treatment, cephalic index continued to improve; cranial vault asymmetry changed only insignificantly in this same period.
Preadmission Antihypertensive Drug Use and Sepsis Outcome: Impact of Angiotensin-Converting Enzyme Inhibitors (ACEIs) and Angiotensin Receptor Blockers (ARBs)
Authors: Hsieh Ming-Shun , How Chorng-Kuang , Hsieh Vivian Chia-Rong , Chen Pau-Chung
Published: May 2019

Background:

Several studies have reported improved sepsis outcomes when certain preadmission antihypertensive drugs, namely, calcium channel blockers (CCBs), are used. This study aims to determine whether preadmission antihypertensive drug use, especially angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), is associated with decreased total hospital mortality in sepsis.

Methods:

This study was conducted using the unique database of a sepsis cohort from the National Health Insurance Research Database in Taiwan. Frequency matching for age and sex between preadmission antihypertensive drug users (study cohort) and nonusers (comparison cohort) was conducted. The primary outcome was total hospital mortality. Logistic regression analyses were performed to calculate the odds ratios (ORs) of important variables. Further joint effect analyses were carried out to examine the impacts of different combinations of antihypertensive drugs.

Results:

A total of 33,213 sepsis antihypertensive drug use patients were retrieved as the study cohort, and an equal number of matched sepsis patients who did not use antihypertensive drugs were identified as the comparison cohort. The study cohort had a higher incidence rate of being diagnosed with septic shock compared with the comparison cohort (4.36%–2.31%, P < 0.001) and a higher rate of total hospital mortality (38.42%–24.57%, P < 0.001). In the septic shock condition, preadmission antihypertensive drug use was associated with a decreased adjusted OR (OR = 0.66, 95% confidence interval [CI], 0.55–0.80) for total hospital mortality, which was not observed for the nonseptic shock condition. Compared with antihypertensive drug nonusers, both ACEI and ARB users had decreased adjusted ORs for total hospital mortality in sepsis (adjusted OR = 0.93, 95% CI, 0.88–0.98 and adjusted OR = 0.85, 95% CI, 0.81–0.90); however, CCB, beta-blocker, and diuretic users did not. In the septic shock condition, ACEI, ARB, CCB, and beta-blocker users all had decreased ORs for total hospital mortality. Joint effect analysis showed ACEI use, except in combination with diuretics, to be associated with a decreased adjusted OR for total hospital mortality in sepsis. Similar results were observed for ARB users.

Conclusions:

Preadmission ACEI or ARB use is associated with a decreased risk of total hospital mortality, regardless of a nonshock or septic shock condition.