bluuebunny/crossref_metadata_2025 huggingface dataset:
Direct oral anticoagulants in patients with antiphospholipid syndrome: a retrospective study in a real-life patient cohort
Authors: Franke Benjamin , Luxembourg Beate , Heidinger Kathrin , Kemkes-Matthes Bettina , Sachs Ulrich J.
Published: February 2021

The current mainstay for the treatment of thrombotic antiphospholipid syndrome (APS) is anticoagulation with vitamin K antagonists (VKAs). The use of direct oral anticoagulants (DOACs) is under debate. We aimed to assess whether DOACs would be safe in APS patients presenting to the thrombosis clinic. A retrospective cohort study was conducted. All patients presenting to our thrombosis clinic between 2010 and 2017 with a diagnosis of APS taking either VKAs or DOACs were included. APS diagnosis was based on the revised Sapporo criteria. Clinical and laboratory data were collected from the electronic and physical patient files. Out of 200 patients, 81 received VKAs, and 119 DOACs. The two cohorts did not differ with regard to their initial clinical manifestation or additional prothrombotic risk factors. Only a small minority of patients was antiphospholipid antibody triple positive (VKA, 7.0% vs. DOAC, 4.2%). Numberofon-treatment events was low (3 vs. 2). The hazard ratio for any thromboembolic event for patients taking DOACs was 0.78 (95% confidence interval, 0.12–5.19). Treatment with DOACs was not associated with an increased risk of recurrent thromboembolism in comparison with VKAs in this retrospective study. Our observation supports the assumption that in nontriple positive (low risk) APS patients, DOACs might be safe. Prospective data are urgently needed.
Prevalence of masked hypertension evaluated by home blood pressure monitoring in a large sample of patients with office blood pressure <140/90 mmHg
Authors: Magalhães Jéssica A. , Lins-Filho Ozéas de L. , de Couto Tarcya L.G. , Silva Marcus V de F P , Lustosa Thais C. , Barroso Weimar K.S. , Brandão Andréa A. , Miranda Roberto D. , Barbosa Eduardo C.D. , Gomes Marco A.M. , Nadruz Wilson , Feitosa Audes D.M. , Pedrosa Rodrigo P.
Published: February 2021

Aim

Patients with masked hypertension have a higher incidence of target organ damage, including increased left ventricular mass and carotid atherosclerosis and cardiovascular events when compared with normotensive patients. The adverse cardiovascular risks are even greater in patients already taking antihypertensive medication.

Objective

To identify the prevalence and clinical characteristics of masked hypertension in a large multicenter Brazilian sample that underwent office and home blood pressure monitoring.

Methods

This was an observational cross-sectional analytical study based on secondary data from the teleMRPA online platform, which included 32 cities from 15 states in the five regions of Brazil. The database included 3704 outpatient participants with office blood pressure <140/90 mmHg who performed home blood pressure monitoring for diagnostic investigation (diagnosis group; n = 1819) or treatment (treatment group; n = 1885) of hypertension in 2018.

Results

The prevalence of masked hypertension was 18.0% in the whole studied population and 15.4% and 20.4% in the diagnostic and treatment group, respectively. Masked hypertension was more frequently detected in patients with office blood pressure classified as high normal [systolic blood pressure (SBP) = 130–139 mmHg or diastolic blood pressure (DBP) = 85–89 mmHg], followed by those classified as normal (SBP = 120–129 mmHg or DBP = 80–84 mmHg) and optimal (SBP < 120 mmHg and DBP < 80 mmHg), with respective prevalence of 28.3, 13.4 and 4.4% in the diagnostic group and 30.8, 18.8 and 7.1% in the treatment group.

Conclusion

Masked hypertension has a significant prevalence among individuals with office blood pressure <140/90 mmHg, which is greater with patients with high normal office blood pressure and even higher in patients already using antihypertensive medication.
Comparison of the Effect of Holder Pasteurization and High-Pressure Processing on Human Milk Bacterial Load and Bioactive Factors Preservation
Authors: Dussault Nathalie , Cayer Marie-Pierre , Landry Patricia , de Grandmont Marie-Joëlle , Cloutier Marc , Thibault Louis , Girard Mélissa
Published: February 2021

Objectives:

This project aims at comparing the impact of Holder pasteurization (HoP) and high-pressure processing (HPP) on bacterial load and retention of immunological components in human milk.

Methods:

Human milk samples discarded by the Public Mothers’ milk bank (Montreal, Canada) for bacterial purpose were pooled (n = 6) and pasteurized either by heating in a water bath (62.5°C, 30 minutes) or by HPP treatment (425 MPa, four cycles of 6 minutes, initial milk temperature of 4°C or 37°C). Bacterial load, lysozyme activity, and levels of immunoglobulins, lactoferrin, lipase, and 26 cytokines were analyzed. Untreated milk samples from same pools served as control.

Results:

HPP treatment of milk allows a similar elimination of bacteria than HoP; bacterial counts were under the detection limit [<3 colony-forming units (CFU)/mL] in 50% of milk pools after HPP treatment, compared to 17% for HoP. With initial heating of samples to 37°C before HPP treatment, inactivation to an extent under the detection limit was reached in 67% of pools. There is no significant difference in IgA, lysozyme, and cytokines concentrations between untreated milk and all treatment methods. While no significant difference was observed in the amount of lipase (P > 0.07) and IgG (P > 0.11) between untreated milk and HPP-treated milk samples, HoP seems to be damaging for these factors (P < 0.04). IgM is well preserved in HPP-4°C samples compared to untreated milk (P = 0.07) whereas a decrease is observed for this immunoglobulin levels in HPP-37°C and HoP samples (P < 0.01). Lactoferrin activity, is well maintained in HPP-37°C milk samples in comparison to untreated milk samples (P = 0.52). A decrease in activity of this molecule is noted for samples treated with HPP at 4°C (P = 0.02) and this decrease is even more pronounced for HoP samples (P = 0.004).

Conclusions:

HPP is a promising alternative to HoP for treatment of human milk intended to preterm babies. Our results demonstrate that HPP treatment of human milk provides safe milk with less detrimental effects on the biochemically and immunologically active milk components than HoP.
Therapeutic Drug Monitoring of Adalimumab During Long‐term Follow‐up in Paediatric Patients With Crohn Disease
Authors: Kim Mi Jin , Kim Eunsil , Kang Ben , Choe Yon Ho
Published: February 2021

Objectives:

We investigated the therapeutic drug monitoring of adalimumab (ADL) on clinical remission (CR) and mucosal healing (MH) rates in paediatric patients with Crohn disease (CD). Furthermore, long‐term treatment efficacy of ADL in paediatric CD was evaluated through 3‐year follow‐up.

Methods:

We conducted a prospective study of 31 patients with CD who received ADL maintenance therapy and underwent endoscopic evaluation of MH and pharmacokinetic analysis. Patients in CR were identified based on Paediatric Crohn Disease Activity Index (PCDAI) scores less than 10. Patients with MH were identified based on Simple Endoscopic Scores for Crohn Disease (SES‐CD) of less than 2.

Results:

At 4 months and 1 year of ADL treatment, 28 and 26 patients, respectively, were under CR; 13 and 17 patients, respectively, achieved MH. The median trough levels (TLs) of ADL were higher in patients in CR (7.6 ± 3.5 μg/mL) than in patients with active disease (5.1 ± 2.2 μg/mL). ADL TLs were significantly higher in patients who achieved MH than in those who did not (14.2 ± 7.6 vs 7.8 ± 5.2 μg/mL). The optimal cut‐point for predicting MH at 1 year of ADL treatment was 8.18 μg/mL. During long‐term follow‐up, ADL TLs were stably maintained over 10 μg/mL; not only CR and MH but also histologic remission was obtained at a high rate. ADL administration maintained a positive effect on growth during the maintenance period.

Conclusions:

ADL TLs were significantly higher in paediatric patients with CD who achieved CR or MH. ADL treatment showed long‐term stable efficacy and positive effects on growth indicators.
Extragenital Screening of Chlamydia trachomatis and Neisseria gonorrhoeae Among Women in the College Health Setting
Authors: Huxta Rebecca A. , Soniyi Omotoyosi , Halbritter Ashlee , Nguyen Giang T.
Published: February 2021

Background

Despite high frequencies of oral and receptive anal intercourse among young women, the Centers for Disease Control and Prevention does not recommend routine oropharyngeal or anorectal screening for CT and GC. Risk-based extragenital screening of women has not been adopted at the majority of college health centers, and existing research has not focused on the female or college population.

Methods

We examined health records of women at a college health center in a large urban university for 3 years to evaluate the effectiveness of CT and GC screening. We also evaluated the proportion of CT and GC infections that would have been missed if risk-based extragenital screening was not performed. Decisions to screen at extragenital sites were based on patient-reported risk behavior.

Results

For 8027 unique chlamydia screens and 7907 unique gonorrhea screens, approximately 20% of the visits used extragenital screening in response to self-reported risk behaviors. More than 44% of patients were non-Hispanic White, and approximately 48% fell within the 20- to 24-year age group. The case positivity rates for CT were 2.85% with urogenital-only screening and 1.30% with risk-prompted extragenital screening (1.1% throat, 4.3% rectal). The case positivity rates for GC were 0.11% with urogenital-only screening and 0.37% with risk-prompted extragenital screening (0.37% throat, 0% rectal). If the college health center had relied solely on urogenital screening rather than adding risk-based extragenital screening, 4.41% of CT infections would have been missed and 28.57% of GC infections would have been missed.

Conclusions

Nearly 1 of 22 CT infections and nearly 1 of 3 GC infections would have been missed without extragenital screening in this analysis of college women. Inclusion of risk-prompted extragenital screening in asymptomatic STD screening protocols can help clinicians diagnose CT and GC infections that would be have been missed with urogenital-only screening. Although rectal GC infections among women seem to be less common, oropharyngeal testing, in particular, for GC is suggested for women based on sexual risk. However, clinicians might only identify these risks if they ask patients directly about these potential exposures. Because guidelines exist only for men, future studies should focus on extragenital screening in college women to build the evidence that this particular population of patients may benefit from this practice, given the high risk of STDs in young adults.
Immunohistochemical Expression of MMP-9, TIMP-1, and Vimentin and its Correlation With Inflammatory Reaction and Clinical Parameters in Oral Epithelial Dysplasia
Authors: Miguel Andressa F.P. , Embaló Bubacar , Alves Dias Helison B. , Rivero Elena R.C.
Published: February 2021

The aim of this study was to investigate the immunoexpression of matrix metalloproteinase 9 (MMP-9), tissue inhibitor of metalloproteinase 1 (TIMP-1), and vimentin (VIM) and its association with the inflammatory reaction (IR) and clinical parameters in oral epithelial dysplasia (ED). The sample was composed of 66 cases of ED, 27 oral squamous cell carcinoma (OSCC), and 28 non-neoplastic epithelium (NNE). ED was graded according to the binary system as low-risk ED (n=42) and high-risk epithelial dysplasia (HRED: n=24). The IR was defined as the median number of inflammatory cells present on the connective tissue in 5 consecutive fields. Tissue sections of paraffin-embedded samples were immunohistochemically stained; MMP-9 and TIMP-1 expression was analyzed separately in the epithelium and the connective tissue; VIM was analyzed in the epithelium. Clinical parameters such as age, sex, lesion site and clinical presentation, alcohol/tobacco use, and malignant transformation of ED were retrospectively obtained from medical records. Nonhomogeneous leukoplakia presented higher odds (3.857; 95% confidence interval: 1.16-12.85) of being graded as HRED than did homogeneous lesions. The IR was higher in OSCC and ED than in NNE, and correlated with the epithelial expression of VIM. HRED and nonhomogeneous leukoplakias presented higher IR than did low-risk ED and homogeneous leukoplakias. Alcohol users had higher IR than nonalcohol users. Smokers had higher epithelial expression of MMP-9 and VIM. High IR in OSCC and HRED, and its positive correlation with VIM expression suggest a contribution of the IR in the progression of OSCC. Moreover, the high expression of MMP-9 and VIM in smokers implies its involvement in tobacco carcinogenesis.
Expanding Our Understanding of Nevogenesis
Authors: Olson Luke C. , Lefferts Joel A. , LeBlanc Robert E. , Yan Shaofeng , Momtahen Shabnam , Sriharan Aravindhan , Linos Konstantinos
Published: February 2021

As the landscape of melanomagenesis becomes better refined through increasingly detailed schema grounded in distinct clinicopathologic-molecular pathways, the stepwise process and variations of molecular nevogenesis have largely remained elusive. Herein, we present a series of 8 melanocytic nevi in patients ranging from 40 to 74 years of age (median: 59.5 y), which demonstrated a reproducible constellation of histomorphologic features as well as a copy number gain of the long arm of chromosome 15 (15q). The most characteristic histologic feature was sclerosis with maturation at the base of the lesion. All cases demonstrated a dome-shaped configuration and epidermal acanthosis with hyperpigmentation. However, the cytologic features ranged in their appearances from that of a banal nevus with ovoid nuclei, inconspicuous nucleoli, and minimal cytoplasm to enlarged, epithelioid forms with central nucleoli and abundant cytoplasm. No lesions showed staining with BRAF V600E or NRAS Q61R immunohistochemistry. Single-nucleotide polymorphism–based chromosome microarray analysis revealed a monoaberrant 15q gain in all cases. The histology was sufficiently distinctive in the initial 6 cases encountered to allow for prospective identification of 2 additional cases harboring a 15q gain. The clinical follow-up did not reveal recurrence in any case. Although adverse outcomes were not observed in our cohort, future studies are needed to more adequately characterize the clinical and biological behavior of these lesions.
Dysgerminoma of the Ovary
Authors: Warnnissorn Malee , Watkins Jaclyn C. , Young Robert H.
Published: February 2021

One-hundred fourty pure dysgerminomas were evaluated with particular focus on the microscopic features as seen in 125 cases with available slides. The patients ranged from 8 to 59 years of age (mean, 24.1 y). The tumors, bilateral in 4% of the cases and with a mean tumor diameter of 13 cm, were typically soft, lobulated, homogeneous, and creamy white to tan to yellow but necrosis was found in 13%, hemorrhage in 20%, and focal cystic change in 15%. On microscopic examination, the patterns and other notable features encountered, including their frequency, were as follows: an alveolar pattern resulting from delicate fibrovascular septa (51%), diffuse (33%), macronodular (14%), insular (26%), cords (28%), solid tubular (17%), microspaces (sometimes simulating glands) (12%), follicle-like spaces (5%), prominent fibrous bands (65%), stromal edema (56%), stromal luteinization (9%), granulomatous infiltrate (46%), lymphocytic infiltrate (100%), Langhans cell type giant cells (35%), syncytiotrophoblast giant cells (6%), prominent population of cells with pale to clear cytoplasm (73%), cells with amphophilic to eosinophilic cytoplasm (53%) and vacuolated occasionally signet ring-like cells (7%). Various constellations of the above findings often resulted in an appearance different from that usually portrayed in the literature and certain tumors of very different nature being in the differential such as undifferentiated carcinoma not otherwise specified, small cell carcinoma of hypercalcemic type, and malignant lymphoma. The correct diagnosis can be arrived at by considering the usual relative youth of the patient, often rather characteristic gross features, and most crucially careful attention to the microscopic features and awareness of variant morphologic findings. Those that are particularly problematic based on this study are diffuse growth with inconspicuous fibrovascular septa, macronodules, cords, solid tubular formations, spaces ranging from small to large, and mimicking glands or follicles, prominent fibrous to edematous stroma, and cells with amphophilic to eosinophilic cytoplasm. According to the degree of difficulty and confidence of the interpreter, well-known immunohistochemical features of dysgerminoma, which largely differ from those of other neoplasms in the differential, will aid if felt indicated.
Pediatric Patients Brought by Emergency Medical Services to the Emergency Department
Authors: Ramgopal Sriram , Varma Selina , Janofsky Stephen , Martin-Gill Christian , Marin Jennifer R.
Published: February 2021

Background/Objective

To describe the epidemiology of emergency department (ED) visits by pediatric patients transported from the out-of-hospital setting (ie, scene) by emergency medical services (EMS), and identify factors associated with EMS transport.

Methods

We performed a cross-sectional study of ED visits from 2014 to 2017 utilizing a nationally representative probability sample survey of visits to US EDs. We included pediatric patients (<18 years old) and compared encounters transported from the scene by EMS to those who arrived to the ED by all other means. We performed multivariable logistic regression to identify factors associated with scene EMS transport.

Results

Of 130.2 million pediatric ED encounters, 4.7 million (3.8%) arrived by EMS. Most patients were White (61.1%), non-Hispanic (77.5%), and publicly insured (52.2%). Multivariable analysis demonstrated associations with EMS transport: Black (vs White) race (adjusted odds ratio [aOR], 1.48; 95% confidence interval [CI], 1.16–1.89), ages 1 to younger than 5 years (aOR, 0.52; 95% CI, 0.37–0.72) and 5 to younger than 12 years (aOR, 0.56; 95% CI, 0.40–0.80) (vs adolescents), pediatric (aOR, 0.60; 95% CI, 0.42–0.85) and nonmetropolitan hospital status (aOR, 0.52; 95% CI, 0.35–0.78), blood testing (aOR, 2.34; 95% CI, 1.71–3.19), time to evaluation (31–60 minutes [aOR, 0.56; 95% CI, 0.39–0.80] and >60 minutes [aOR, 0.51; 95% CI, 0.33–0.77] compared with 0–30 minutes), admission (aOR, 3.20; 95% CI, 2.33–4.38), and trauma (1.80; 95% CI, 1.43–2.28).

Conclusions

Four percent of pediatric ED patients are transported to the ED by EMS from the scene. These patients receive a rapid and resource intense diagnostic evaluation, suggesting that higher acuity. Black patients, adolescents, and those with trauma were more likely to be transported by EMS.
Change in Cardiopulmonary Resuscitation Performance Over Time During Simulated Pediatric Cardiac Arrest and the Effect of Just-in-Time Training and Feedback
Authors: Duff Jonathan P. , Bhanji Farhan , Lin Yiqun , Overly Frank , Brown Linda L. , Bragg E. Alexis , Kessler David , Tofil Nancy M. , Bank Ilana , Hunt Elizabeth A. , Nadkarni Vinay , Cheng Adam ,   for the INSPIRE CPR Investigators
Published: February 2021

Objectives

Effective cardiopulmonary resuscitation (CPR) is critical to ensure optimal outcomes from cardiac arrest, yet trained health care providers consistently struggle to provide guideline-compliant CPR. Rescuer fatigue can impact chest compression (CC) quality during a cardiac arrest event, although it is unknown if visual feedback or just-in-time training influences change of CC quality over time. In this study, we attempt to describe the changes in CC quality over a 12-minute simulated resuscitation and examine the influence of just-in-time training and visual feedback on CC quality over time.

Methods

We conducted secondary analysis of data collected from the CPRCARES study, a multicenter randomized trial in which CPR-certified health care providers from 10 different pediatric tertiary care centers were randomized to receive visual feedback, just-in-time CPR training, or no intervention. They participated in a simulated cardiac arrest scenario with 2 team members providing CCs. We compared the quality of CCs delivered (depth and rate) at the beginning (0–4 minutes), middle (4–8 minutes), and end (8–12 minutes) of the resuscitation.

Results

There was no significant change in depth over the 3 time intervals in any of the arms. There was a significant increase in rate (128 to 133 CC/min) in the no intervention arm over the scenario duration (P < 0.05).

Conclusions

There was no significant drop in CC depth over a 12-minute cardiac arrest scenario with 2 team members providing compressions.
Settling the Score
Authors: Hatchimonji Justin S. , Luks Valerie L. , Swendiman Robert A. , Allukian Myron , Nance Michael L. , Nace Gary W.
Published: February 2021

Objectives

Recent work has questioned the accuracy of the Injury Severity Score (ISS) and the Abbreviated Injury Scale (AIS) in the pediatric population. We sought to determine mortality rates in pediatric trauma patients at ISSs considered “severe” in adults and whether mortality would vary substantially between adults and children sustaining injuries with the same AIS.

Methods

Univariate logistic regression was used to generate mortality rates associated with ISS scores, for children (<16 years of age) and adults, using the 2016 National Trauma Data Bank. Mortality rates at an ISS of 15 were calculated in both groups. We similarly calculated ISS scores associated with mortality rates of 10%, 25%, and 50%. Receiver operating characteristic curves were constructed to compare the discriminative ability of ISS to predict mortality after blunt and penetrating injuries in adults and children. Mortality rates associated with 1 or more AIS 3 injuries per body region were defined.

Results

There were 855,454 cases, 86,414 (10.1%) of which were children. The ISS associated with 10%, 25%, and 50% mortality were 35, 44, and 53, respectively, in children; they were 27, 38, and 48 in adults. At an ISS of 15, pediatric mortality was 1.0%; in adults, it was 3.1%. A 3.1% mortality rate was not observed in children until an ISS of 25. On receiver operating characteristic analysis, the ISS performed better in children compared with adults (area under the curve, 0.965 vs 0.860 [P < 0.001]). Adults consistently suffered from higher mortality rates than did children with the same number of severe injuries to a body region, and mortality varied widely between specific selected AIS 3 injuries.

Conclusions

Although the ISS predicts mortality well, children have lower mortality than do adults for the same ISS, and therefore, the accepted definition of severe injury is not equivalent between these 2 cohorts. Mortality risk is highly dependent on the specific nature of the injury, with large variability in outcomes despite identical AIS scores.
Comprehensive Care Improvement for Oncologic Fever and Neutropenia from a Pediatric Emergency Department
Authors: Kuehnel Nicholas A. , McCreary Erin , Henderson Sheryl L. , Vanderloo Joshua P. , Hoover-Regan Margo L. , Sharp Brian , Ross Joshua
Published: February 2021

Introduction:

Rapid time to antibiotics (TTA) for pediatric patients with fever and neutropenia in an emergency department decreases in-hospital mortality. Additionally, national guidelines recommend outpatient antibiotic management strategies for low-risk fever and neutropenia (LRFN). This study had two specific aims: (1) improve the percent of patients with suspected fever and neutropenia who receive antibiotics within 60 minutes of arrival from 55% to 90%, and (2) develop and operationalize a process for outpatient management of LRFN patients by October 2018.

Methods:

Using Lean methodologies, we implemented Plan-Do-Check-Act cycles focused on guideline development, electronic medical record reminders, order-set development, and a LRFN pathway as root causes for improvements. We used statistical process control charts to assess results.

Results:

The project conducted from July 2016 to October 2018 showed special cause improvement in December 2016 on a G-chart. Monthly Xbar-chart showed improvement in average TTA from 68.5 minutes to 42.5 minutes. A P-chart showed improvement in patients receiving antibiotics within 60 minutes, from 55% to 86.4%. A LRFN guideline and workflow was developed and implemented in October 2017.

Conclusions:

Implementation of guidelines, electronic medical record reminders, and order sets are useful tools to improve TTA for suspected fever and neutropenia. Utilizing more sensitive statistical process control charts early in projects with fewer patients can help recognize and guide process improvement. The development of workflows for outpatient management of LRFN may be possible, though it requires further study.
What Do We Really Know About Crew Resource Management in Healthcare?: An Umbrella Review on Crew Resource Management and Its Effectiveness
Authors: Buljac-Samardžić Martina , Dekker-van Doorn Connie M. , Maynard M. Travis
Published: February 2021

Objective

The aim of this article was to present an overview of the crew resource management (CRM) literature in healthcare. The first aim was to conduct an umbrella review on CRM literature reviews. The second aim was to conduct a new literature review that aims to address the gaps that were identified through the umbrella review.

Methods

First, we conducted an umbrella review to identify all reviews that have focused on CRM within the healthcare context. This step resulted in 16 literature reviews. Second, we conducted a comprehensive literature review that resulted in 106 articles.

Results

The 16 literature reviews showed a high level of heterogeneity, which resulted in discussing 3 ambiguities: definition, outcome, and information ambiguity. As a result of these ambiguities, a new comprehensive review of the CRM literature was conducted. This review showed that CRM seems to have a positive effect on outcomes at Kirkpatrick’s level 1, 2, and 3. In contrast, whether CRM has a positive effect on level 4 outcomes and how level 4 should be measured remains undetermined. Recommendations on how to implement and embed CRM training into an organization to achieve the desired effects have not been adequately considered.

Conclusions

The extensive nature of this review demonstrates the popularity of CRM in healthcare, but at the same time, it highlights that research tends to be situated within certain settings, focuses on particular outcomes, and has failed to address the full scope of CRM as a team intervention and a management concept.
Influence of Organizational Climate and Clinician Morale on Seclusion and Physical Restraint Use in Inpatient Psychiatric Units
Authors: Anderson Ekaterina , Mohr David C. , Regenbogen Ilana , Swamy Lakshmana , Smith Eric G. , Mourra Sarah , Rinne Seppo T.
Published: February 2021

Objectives

Reducing seclusion and restraint use is a prominent focus of efforts to improve patient safety in inpatient psychiatry. This study examined the poorly understood relationship between seclusion and restraint rates and organizational climate and clinician morale in inpatient psychiatric units.

Methods

Facility-level data on hours of seclusion and physical restraint use in 111 U.S. Department of Veterans Affairs (VA) hospitals in 2014 to 2016 were obtained from the Centers for Medicare & Medicaid Services. Responses to an annual census survey were identified for 6646 VA inpatient psychiatry clinicians for the same period. We examined bivariate correlations and used a Poisson model to regress hours of seclusion and restraint use on morale and climate measures and calculated incident rate ratios (IRRs).

Results

The average physical restraint hours per 1000 patient hours was 0.33 (SD, 1.27; median, 0.05). The average seclusion hours was 0.31 (SD, 0.84; median, 0.00). Physical restraint use was positively associated with burnout (IRR, 1.76; P = 0.04) and negatively associated with engagement (IRR, 0.22; P = 0.01), psychological safety (IRR, 0.48; P < 0.01), and relational climate (IRR, 0.69; P = 0.04). Seclusion was positively associated with relational climate (IRR, 1.69; P = 0.03) and psychological safety (IRR, 2.12; P = 0.03). Seclusion use was also nonsignificantly associated with lower burnout and higher engagement.

Conclusions

We found significant associations between organizational climate, clinician morale, and use of physical restraints and seclusion in VA inpatient psychiatric units. Health care organization leadership may want to consider implementing a broader range of initiatives that focus on improving organizational climate and clinician morale as one way to improve patient safety.
Prevalence and Outcomes for Heavily Treatment-Experienced Individuals Living With Human Immunodeficiency Virus in a European Cohort
Authors: Pelchen-Matthews Annegret , Borges Álvaro H. , Reekie Joanne , Rasmussen Line D. , Wiese Lothar , Weber Jonathan , Pradier Christian , Degen Olaf , Paredes Roger , Tau Luba , Flamholc Leo , Gottfredsson Magnus , Kowalska Justyna , Jablonowska Elzbieta , Mozer-Lisewska Iwona , Radoi Roxana , Vasylyev Marta , Kuznetsova Anastasiia , Begovac Josip , Svedhem Veronica , Clark Andrew , Cozzi-Lepri Alessandro ,   for the EuroSIDA study
Published: February 2021

Background:

Although antiretroviral treatments have improved survival of persons living with HIV, their long-term use may limit available drug options. We estimated the prevalence of heavily treatment-experienced (HTE) status and the potential clinical consequences of becoming HTE.

Setting:

EuroSIDA, a European multicenter prospective cohort study.

Methods:

A composite definition for HTE was developed, based on estimates of antiretroviral resistance and prior exposure to specific antiretroviral regimens. Risks of progressing to clinical outcomes were assessed by Poisson regression, comparing every HTE individual with 3 randomly selected controls who never became HTE.

Results:

Of 15,570 individuals under follow-up in 2010–2016, 1617 (10.4%, 95% CI: 9.9% to 10.9%) were classified as HTE. 1093 individuals became HTE during prospective follow-up (HTE incidence rate 1.76, CI: 1.66 to 1.87 per 100 person-years of follow-up). The number of HTE individuals was highest in West/Central Europe (636/4019 persons, 15.7%) and lowest in East Europe (26/2279 persons, 1.1%). Although most HTE individuals maintained controlled viral loads (<400 copies/mL), many had low CD4 counts (≤350 cells/µL). After controlling for age, immunological parameters and pre-existing comorbidities, HTE status was not associated with the risk of new AIDS (adjusted incidence rate ratio, aIRR 1.44, CI: 0.86 to 2.40, P = 0.16) or non-AIDS clinical events (aIRR 0.96, CI: 0.74 to 1.25, P = 0.77).

Conclusions:

HTE prevalence increased with time. After adjusting for key confounding factors, there was no evidence for an increased risk of new AIDS or non-AIDS clinical events in HTE. Additional therapeutic options and effective management of comorbidities remain important to reduce clinical complications in HTE individuals.
Brief Report: Herpes Simplex Virus Type-2 Shedding and Genital Ulcers During Early HIV in Zimbabwean Women
Authors: Nowak Rebecca G. , Liska Tobias A. , Bentzen Søren M. , Kim Esther , Chipato Tsungai , Salata Robert A. , Celentano David D. , Morrison Charles S. , Gravitt Patti E.
Published: February 2021

Background:

Herpes simplex virus type-2 (HSV-2) seropositive persons have a 3- to 5-fold higher risk of acquiring HIV, possibly because of HSV-2–induced inflammation and recruitment of susceptible immune cells to exposure sites. We hypothesized that cervical HSV-2 activation (ie, viral DNA shedding and/or ulcers) preceded HIV acquisition in the hormonal contraception and HIV cohort.

Methods:

Zimbabwean women who acquired HIV were matched to HIV-negative women on visit, age, and bacterial sexually transmitted infections. Up to 5 cervical swabs bracketing first polymerase chain reaction detection of HIV DNA (the index visit) were selected (t-6months, t-3months, t
index, t+3months, t+6months). Women with HSV-2 immunoglobulin G+ before t
index were polymerase chain reaction tested for viral shedding. Self-reported and clinician-diagnosed ulcers were documented. Multivariable logistic regression, accounting for matching, estimated adjusted odds ratios (aOR) and 95% confidence intervals (CIs) at each visit.

Results:

Of 387 HSV-2 seropositive women, most had prevalent as compared with incident HSV-2 (91% vs. 9%, respectively). HSV-2 viral shedding was more common among HIV seroconverters than HIV-negative women (26% vs. 14%, P < 0.01). Shedding occurred around HIV acquisition (t-3months aOR, 2.7; 95% CI, 0.8 to 8.8; t
index aOR, 2.6; 95% CI, 1.1 to 6.5; t+3months aOR, 2.6; 95% CI, 1.0 to 6.6). Genital ulcers were reported more often among HIV seroconverters than HIV-negative women (13% vs. 7%; P = 0.06) and detection was after HIV acquisition (t+6months aOR, 14.5; 95% CI, 1.6 to 133.9).

Conclusions:

HSV-2 shedding appeared synergistic with HIV acquisition followed by presentation of ulcers. Evaluating all sexually transmitted infections rather than HSV-2 alone may clarify the relationship between inflammation and HIV acquisition.
Trajectories of Depressive Symptoms, Neurocognitive Function, and Viral Suppression With Antiretroviral Therapy Among Youth With HIV Over 36 months
Authors: Kohn Jordan N. , Loop Matthew Shane , Kim-Chang Julie J. , Garvie Patricia A. , Sleasman John W. , Fischer Bernard , Rendina H. Jonathon , Woods Steven Paul , Nichols Sharon L. , Hong Suzi
Published: February 2021

Background:

Depression and neurocognitive impairment are highly prevalent among persons living with HIV and associated with poorer clinical outcomes; however, longitudinal studies of depression–neurocognition relationships in youth living with HIV (YLWH), and the role of antiretroviral therapy (ART), are lacking. This study tested whether (1) depressive symptomatology, across somatic, cognitive, and affective symptom domains, improved with ART and (2) more severe depressive symptoms at baseline were associated with poorer neurocognitive function and poorer HIV suppression.

Setting:

Data were collected from 181 YLWH (18–24 years) who were treatment-naive, a subset of whom (n = 116) initiated ART.

Methods:

Participants were categorized into elevated (DS) or nonelevated (non-DS) depressive symptom groups at entry (Beck Depression Inventory-II ≥14) and followed for 36 months. Neurocognition (5-domain battery) and depressive symptoms were repeatedly assessed. Longitudinal models examined depressive symptomatology, neurocognition, and odds of HIV nonsuppression by group.

Results:

Greater improvements in depressive symptoms were observed in the DS group over 36 months [beta = −0.14, (−0.24 to −0.03)], particularly within cognitive and affective domains. Verbal learning performance increased in the DS group [beta = 0.13, (0.01 to 0.24)], whereas psychomotor function improved somewhat in the non-DS group [beta = −0.10, (−0.22 to 0.00)]. Adjusted for ART adherence, odds of HIV nonsuppression did not significantly differ by group [odds ratio = 0.22, (0.04 to 1.23)]; however, greater somatic symptoms at study entry were associated with an increased risk of nonsuppression over time [odds ratio = 2.33 (1.07 to 5.68)].

Conclusion:

Depressive symptoms were associated with differential neurocognitive trajectories, and somatic depressive symptoms at baseline may predict poorer subsequent HIV suppression. Identifying and treating depressive symptoms at ART initiation may benefit neurocognitive and clinical outcomes in YLWH.
99mTc-Mebrofenin Hepatobiliary Scintigraphy Combined With SPECT/CT to Assess Liver Function in Heterotopic Segmental Liver Transplantation in the Splenic Fossa
Authors: Serenari Matteo , Calabrò Diletta , Bonfiglioli Rachele , Fanti Stefano , Ravaioli Matteo
Published: February 2021

Recent studies have shown that the inclusion of a noninvasive and low-cost functional test such as hepatobiliary scintigraphy is considered more reliable than volume alone to predict posthepatectomy liver failure especially in light of new liver regeneration techniques. We herein reported the unique case of a 40-year-old man who underwent heterotopic liver transplantation of segments 2 and 3 in the splenic fossa after splenectomy for unresectable colorectal liver metastases. 99mTc-mebrofenin hepatobiliary scintigraphy combined with SPECT/CT was performed after liver transplantation to monitor graft function and regeneration before removal of the native liver.
Central Nervous System Complications of Erdheim-Chester Disease
Authors: Filizoglu Nuh , Ozguven Salih , Ones Tunc , Turoglu Halil Turgut , Erdil Tanju Yusuf
Published: February 2021

Erdheim-Chester disease is an uncommon non-Langerhans cell histiocytosis. The diagnosis depends on imaging and histological criteria. The most common presentation is the multiple bone lesions with involvement of at least 1 more organ. We present the FDG PET/CT findings of a 19-year-old man who presented with central nervous system symptoms such as progressive polyuria, polydipsia, gait disturbances, and eye pain and was later diagnosed with Erdheim-Chester disease.
A Dual-Surgeon Approach to Breast Cancer Surgery in a Transmale
Authors: Parmeshwar Nisha , Alcon Andre , Kim Esther A.
Published: February 2021

With increasing numbers of gender-affirming chest surgery, new questions regarding breast cancer management and surgical practice arise. Guided by our case report, we present a comprehensive review of breast cancer surgery in a transman to educate both plastic and breast surgeons on various factors to consider when caring for these patients.

Our case involves a 31-year-old transmale patient who presented for plastic surgery consultation for gender-affirming mastectomy but was subsequently found to have a right breast mass. This is the first case in the literature of a transmale on hormone therapy with breast cancer interested in gender-affirming surgery, thus requiring a dual-surgeon approach for oncologic and gender-affirming mastectomy. With a multidisciplinary patient-centered approach involving breast surgery, plastic surgery, medical oncology, and radiology, we devised a surgical plan to safely remove his breast tissue with consideration for his gender-affirming goals. He underwent a right skin-sparing mastectomy with sentinel node biopsy and left prophylactic skin-sparing mastectomy through skin markings by the plastic surgeon, with bilateral free nipple grafts. Final pathology confirmed estrogen and progesterone receptor–positive and androgen receptor–positive invasive ductal carcinoma with clear margins and negative sentinel node. The patient did not require adjuvant chemotherapy or radiation but was started on adjuvant hormone therapy targeting his hormone receptor positive cancer. He elected to stay on low-dose masculinizing hormone therapy with continued surveillance examinations.

We follow our case with a review of the current literature involving breast cancer in transmales to explore current screening practices, surgical recommendations, adjuvant therapies, continuation of masculinizing hormone therapy, and postoperative surveillance guidelines in the hopes of informing plastic surgeons in having these discussions with their transmale patients and thus improving informed cancer care for this population.
Biological Targets for Dupuytren Disease
Authors: Lee Hannah H. , Satish Latha
Published: February 2021

Dupuytren disease is a connective tissue disorder occurring on the palm, causing flexion contractures of fingers. There is a pressing need for therapeutic interventions that can slow, stop, or even incrementally reverse the progression of the disease. Numerous in vitro studies have shed light on cellular and molecular agents that contribute to contractures. This article comprehensively reviews various growth factors that can be targeted to prevent and limit the progression and recurrence of Dupuytren contracture (DC). Fibroblasts are the major cell population that has been reported for the contractures in DC, and they are also known to exacerbate the cytokine production. Limiting the fibroblast function by targeting the growth factor production will be of great benefit in treating DC. This review will focus on the studies that have shown to limit the exaggerated function of fibroblasts by reducing the expression of profibrotic growth factors by using antagonizing agents.
Computed Tomography in Patients With Craniosynostosis
Authors: Makar Katelyn G. , Garavaglia Hannah E. , Muraszko Karin M. , Waljee Jennifer F. , Vercler Christian J. , Buchman Steven R.
Published: February 2021

Background

In patients with craniosynostosis, imaging remains up to the discretion of the plastic surgeon or neurosurgeon. To inform best practice guidelines, we sought to obtain data surrounding the frequency at which craniofacial surgeons order computed tomography (CT), as well as indications. We hypothesized that we would identify considerable variation in both imaging and associated indications.

Methods

We surveyed members of the American Society of Maxillofacial Surgeons and the American Society of Craniofacial Surgeons to measure the frequency of preoperative and postoperative head CTs, as well as indications. Initial items were piloted with 2 craniofacial surgeons and 1 neurosurgeon, using interviews to ensure content validity. χ2 Tests were used to measure associations between operative volume, years in practice, and imaging.

Results

Eighty-five craniofacial surgeons responded (13.8% response rate), with the majority (63.5%) having performed a craniosynostosis operation in the last month. Only 9.4% of surgeons never order preoperative CTs. Of those who do, the most common indications included diagnosis confirmation (31.2%) and preoperative planning (27.3%). About 25% of surgeons always obtain postoperative head CTs, usually to evaluate surgical outcomes (46.7%). Only 13.3% of respondents order 2 or more postoperative scans. Higher operative volume was associated with a lower likelihood of ordering preoperative head CTs (P = 0.008).

Conclusions

The majority of surgeons obtain preoperative head CTs, whereas only 25% obtain CTs postoperatively, often to evaluate outcomes. Because outcomes may be evaluated clinically, this is a poor use of resources and exposes children to radiation. Consensus guidelines are needed to create best practices and limit unnecessary studies.
Osteotomy of the Premaxilla in Bilateral Cleft Lip: A Useful Technique Following Failure of Primary Lip Closure
Authors: Emodi Omri , Shoshani-Dror Dana , Ohayon Chaim , Aizenbud Dror , Shilo Dekel , van Aalst John A. , Rachmiel Adi
Published: February 2021

Objectives:

Successful aesthetic repair of the bilateral cleft lip and palate (BCLP) is one of the most challenging cases encountered by a surgeon. This challenge is heightened when the premaxilla is anteriorly protruded in relation lateral maxillary segments. Our aim is to demonstrate a useful technique for reducing the cleft size before secondary lip repair. We use a premaxillary osteotomy to posteriorly reposition the premaxilla between the lateral segments

Methods:

Six patients with BCLP underwent repositioning of the protruded premaxilla. Five patients had previous primary lip closure procedures with unsatisfactory results. The cleft size was reduced by premaxillary osteotomy from nasal septum and partial removal of the vertical vomer. The osteotomized premaxilla was then repositioned, fixed with a custom-made orthodontic appliance. Following this procedure, the lip was closed in a traditional fashion.

Results:

All patients demonstrated satisfying lip closure without tension. In each case, the premaxilla was vital and exhibited partial stabilization during follow-up

Conclusions:

In this study the authors demonstrate the usefulness of a premaxillary segment setback as an adjunct to improved function and aesthetics in bilateral lip repair. This method serves as useful technique for previously unsuccessful closure of BCLP
Odontogenic Necrotizing Fasciitis of Face and Scalp
Authors: Amponsah Emmanuel Kofi , Sodnom-Ish Buyanbileg , Nguyen Truc Thi Hoang , Kim Soung Min
Published: February 2021

Necrotizing fasciitis of the face and scalp is a severe bacterial infection that can result in long-term morbidity or even mortality if not properly managed. In a third-world country like Ghana, where most of the population relies on daily income for livelihood, citizens with diseases that have long-term morbidity suffer financial difficulty, particularly when the patient is the breadwinner.

This brief clinical study demonstrates the severity of necrotizing fasciitis of the face and scalp originated from oral infection, and its capability to affect any part of the body if proper treatment is not established at early onset of disease. Correct diagnosis, patient education, early antibiotic treatment, and timely surgery are crucial for controlling infection and for preventing irreparable damage. Therefore, public education is crucial in preventing such infection by discouraging use of over-the-counter medication in such situations.
Outcomes of COVID-19 in Solid Organ Transplant Recipients: A Propensity-matched Analysis of a Large Research Network
Authors: Hadi Yousaf B. , Naqvi Syeda F.Z. , Kupec Justin T. , Sofka Sarah , Sarwari Arif
Published: February 2021

Background.

Organ transplant recipients comprise an immunocompromised and vulnerable cohort. Outcomes of coronavirus disease 2019 (COVID-19) in solid organ transplant (SOT) recipients remain understudied.

Methods.

We used a multicenter federated research network to compare clinical outcomes of COVID-19 in patients with SOT to a propensity--matched cohort of patients without SOT.

Results.

We identified 2307 SOT recipients and 231 047 nontransplant patients with COVID-19. Transplant patients were more likely to be male individuals, older, have a body mass index >30 kg/m2, and have comorbid hypertension, diabetes, nicotine dependence, heart failure, and ischemic heart disease compared with the nontransplant group (P < 0.05). One-to-one matching was performed for diabetes, hypertension, chronic lung diseases, race, nicotine dependence, heart failure, ischemic heart disease, and gender. There was no difference in the composite outcome of intubation or mechanical ventilation at 30 days (risk ratio [RR], 1.04; 95% confidence interval [CI], 0.86-1.26) or 60 days (RR, 1.03; 95% CI, 0.86-1.24) between the 2 groups. Hospitalization rate was higher in the transplant cohort (30.97% versus 25.47%; RR, 1.22; 95% CI, 1.11-1.34). There was no difference in mortality at 30 days (6.45% versus 5.29%; RR, 1.22; 95% CI, 0.88-1.68) or 60 days postdiagnosis (RR, 1.05; 95% CI, 0.83-1.32). More patients in the SOT group developed acute renal injury compared with non-SOT cohort (24.73% versus 14.29%; RR, 1.73; 95% CI, 1.53-1.96).

Conclusions.

Patients with SOT have high COVID-19-related mortality; however, propensity-matched analyses reveal that this increased risk is secondary to higher burden of comorbidities. SOT status independently increases risk of hospital admission and acute kidney injury.