bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of mass effect, tumor location, age, and surgery on the cognitive outcome of patients with high-grade gliomas: a longitudinal study
Authors: Dallabona Monica , Sarubbo Silvio , Merler Stefano , Corsini Francesco , Pulcrano Giuseppe , Rozzanigo Umberto , Barbareschi Mattia , Chioffi Franco
Published: January 2017

Background

High-grade gliomas are the most frequently occurring brain tumors and carry unfavorable prognosis. Literature is controversial regarding the effects of surgery on cognitive functions.

Methods

We analyzed a homogenous population of 30 patients with high-grade glioma who underwent complete resection. Patients underwent extensive neuropsychological analysis before surgery, 7 days after surgery, and approximately 40 days after surgery, before adjuvant treatments. Thirty-four neuropsychological tests were administered in the language, memory, attention, executive functions, and praxis domains.

Results

The preoperative percentage of patients with impairment in the considered tests ranged from 0% to 53.3% (mean 20.9%). Despite a general worsening at early follow-up, a significant recovery was observed at late follow-up. Preoperative performances in language and verbal memory tasks depended on the joint effect of tumor volume, volume of surrounding edema, and tumor localization, with major deficits in patients with left lateralized tumor, especially insular and temporal. Preoperative performances in attention and constructive abilities tasks depended on the joint effect of tumor volume, volume of surrounding edema, and patient age, with major deficits in patients ≥ 65 years old. Recovery at late follow-up depended on the volume of resected tumor, edema resorption, and patient age.

Conclusions

Longitudinal neuropsychological performance of patients affected by high-grade glioma depends, among other factors, on the complex interplay of tumor volume, volume of surrounding edema, tumor localization, and patient age. Reported results support the definition of criteria for surgical indication based on the above factors. They may be used to propose more customized surgical, oncological, and rehabilitative strategies.
Osteomyelitis of the accessory and body of the navicular bone: a case report
Authors: Kumahashi Nobuyuki , Kuwata Suguru , Imade Shinji , Uchio Yuji
Published: January 2017

A 16-year-old boy developed left foot pain of unknown cause that was unresponsive to conservative treatment, associated with fever and difficulty walking. He was admitted to our hospital with osteomyelitis of the accessory and body of the navicular bone. Surgery could not be performed because the patient had been diagnosed with Wiskott–Aldrich syndrome. After antibiotic therapy, laboratory abnormalities and pain had resolved. One year after treatment, the patient had returned to his original level of sports activity. Both an accessory navicular and the body of the navicular bone may develop osteomyelitis in immunocompromised patients; early diagnosis is important for prescribing effective conservative treatment.
Physician-Assisted Suicide and Euthanasia in the ICU: A Dialogue on Core Ethical Issues*
Authors: Goligher Ewan C. , Ely E. Wesley , Sulmasy Daniel P. , Bakker Jan , Raphael John , Volandes Angelo E. , Patel Bhavesh M. , Payne Kate , Hosie Annmarie , Churchill Larry , White Douglas B. , Downar James
Published: January 2017

Objective:

Many patients are admitted to the ICU at or near the end of their lives. Consequently, the increasingly common debate regarding physician-assisted suicide and euthanasia holds implications for the practice of critical care medicine. The objective of this article is to explore core ethical issues related to physician-assisted suicide and euthanasia from the perspective of healthcare professionals and ethicists on both sides of the debate.

Synthesis:

We identified four issues highlighting the key areas of ethical tension central to evaluating physician-assisted suicide and euthanasia in medical practice: 1) the benefit or harm of death itself, 2) the relationship between physician-assisted suicide and euthanasia and withholding or withdrawing life support, 3) the morality of a physician deliberately causing death, and 4) the management of conscientious objection related to physician-assisted suicide and euthanasia in the critical care setting. We present areas of common ground and important unresolved differences.

Conclusions:

We reached differing positions on the first three core ethical questions and achieved unanimity on how critical care clinicians should manage conscientious objections related to physician-assisted suicide and euthanasia. The alternative positions presented in this article may serve to promote open and informed dialogue within the critical care community.
Long-Term Survival in Adults Treated With Extracorporeal Membrane Oxygenation for Respiratory Failure and Sepsis*
Authors: von Bahr Viktor , Hultman Jan , Eksborg Staffan , Frenckner Björn , Kalzén Håkan
Published: January 2017

Objective:

The use of extracorporeal membrane oxygenation in adults with respiratory failure and sepsis is steadily increasing, but the knowledge on long-term survival in this group is scarce. The aim of the present study was to investigate the 5-year survival rates and causes of late death in this group of patients.

Design:

Single-center retrospective cohort study.

Setting:

Karolinska University Hospital, Stockholm, Sweden.

Patients:

Adult patients treated with extracorporeal membrane oxygenation for respiratory failure and sepsis between the service being established for adults in 1995 and December 2013.

Interventions:

None.

Measurements and Main Results:

Survival status was attained from a national Causes of Death registry. Minimal patient background data, along with data on survival and causes of death were collected. Survival rates were calculated using the Kaplan-Meier method. Of 255 subjects, 64% survived to discharge. The median follow-up time in survivors was 4.4 years. There was a high mortality rate within the first months after discharge. In the group of patients who survived the first 90 days after treatment, the 5-year survival rate was 87% and was particularly beneficial in patients treated for infectious diseases (88–100%). Late deaths were seen in most diagnostic groups, but the Kaplan-Meier curves flattened out over time.

Conclusions:

Extracorporeal membrane oxygenation treatment in adult patients with respiratory failure and sepsis can be lifesaving in appropriately selected patients. For patients who survive the first months after extracorporeal membrane oxygenation treatment, long-term survival seems good, especially in patients treated for infections.
Collapse of the Microbiome, Emergence of the Pathobiome, and the Immunopathology of Sepsis
Authors: Alverdy John C. , Krezalek Monika A.
Published: January 2017

The definition of sepsis has been recently modified to accommodate emerging knowledge in the field, while at the same time being recognized as challenging, if not impossible, to define. Here, we seek to clarify the current understanding of sepsis as one that has been typically framed as a disorder of inflammation to one in which the competing interests of the microbiota, pathobiota, and host immune cells lead to loss of resilience and nonresolving organ dysfunction. Here, we challenge the existence of the idea of noninfectious sepsis given that critically ill humans never exist in a germ-free state. Finally, we propose a new vision of the pathophysiology of sepsis that includes the invariable loss of the host’s microbiome with the emergence of a pathobiome consisting of both “healthcare-acquired and healthcare-adapted pathobiota.” Under this framework, the critically ill patient is viewed as a host colonized by pathobiota dynamically expressing emergent properties which drive, and are driven by, a pathoadaptive immune response.
The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families
Authors: Ely E. Wesley
Published: January 2017

Over the past 20 years, critical care has matured in a myriad of ways resulting in dramatically higher survival rates for our sickest patients. For millions of new survivors comes de novo suffering and disability called “the postintensive care syndrome.” Patients with postintensive care syndrome are robbed of their normal cognitive, emotional, and physical capacity and cannot resume their previous life. The ICU Liberation Collaborative is a real-world quality improvement initiative being implemented across 76 ICUs designed to engage strategically the ABCDEF bundle through team- and evidence-based care. This article explains the science and philosophy of liberating ICU patients and families from harm that is both inherent to critical illness and iatrogenic. ICU liberation is an extensive program designed to facilitate the implementation of the pain, agitation, and delirium guidelines using the evidence-based ABCDEF bundle. Participating ICU teams adapt data from hundreds of peer-reviewed studies to operationalize a systematic and reliable methodology that shifts ICU culture from the harmful inertia of sedation and restraints to an animated ICU filled with patients who are awake, cognitively engaged, and mobile with family members engaged as partners with the ICU team at the bedside. In doing so, patients are “liberated” from iatrogenic aspects of care that threaten his or her sense of self-worth and human dignity. The goal of this 2017 plenary lecture at the 47th Society of Critical Care Medicine Congress is to provide clinical ICU teams a synthesis of the literature that led to the creation of ICU liberation philosophy and to explain how this patient- and family-centered, quality improvement program is novel, generalizable, and practice changing.
Global Collaboration in Acute Care Clinical Research: Opportunities, Challenges, and Needs
Authors: Marshall John C.
Published: January 2017

The most impactful research in critical care comes from trials groups led by clinician-investigators who study questions arising through the day-to-day care of critically ill patients. The success of this model reflects both “necessity”—the paucity of new therapies introduced through industry-led research—and “clinical reality”—nuanced modulation of standard practice can have substantial impact on clinically important outcomes. Success in a few countries has fueled efforts to build similar models around the world and to collaborate on an unprecedented scale in large international trials. International collaboration brings opportunity—the more rapid completion of clinical trials, enhanced generalizability of the results of these trials, and a focus on questions that have evoked international curiosity. It has changed practice, improved outcomes, and enabled an international response to pandemic threats. It also brings challenges. Investigators may feel threatened by the loss of autonomy inherent in collaboration, and appropriate models of academic credit are yet to be developed. Differences in culture, practice, ethical frameworks, research experience, and resource availability create additional imbalances. Patient and family engagement in research is variable and typically inadequate. Funders are poorly equipped to evaluate and fund international collaborative efforts. Yet despite or perhaps because of these challenges, the discipline of critical care is leading the world in crafting new models of clinical research collaboration that hold the promise of not only improving the care of the most vulnerable patients in the healthcare system but also transforming the way that we conduct clinical research.
Use of Engineered Exosomes Expressing HLA and Costimulatory Molecules to Generate Antigen-specific CD8+ T Cells for Adoptive Cell Therapy
Authors: Kim Sueon , Sohn Hyun-Jung , Lee Hyun-Joo , Sohn Dae-Hee , Hyun Seung-Joo , Cho Hyun-Il , Kim Tai-Gyu
Published: January 2017

Dendritic cell-derived exosomes (DEX) comprise an efficient stimulator of T cells. However, the production of sufficient DEX remains a barrier to their broad applicability in immunotherapeutic approaches. In previous studies, genetically engineered K562 have been used to generate artificial antigen presenting cells (AAPC). Here, we isolated exosomes from K562 cells (referred to as CoEX-A2s) engineered to express human leukocyte antigen (HLA)-A2 and costimulatory molecules such as CD80, CD83, and 41BBL. CoEX-A2s were capable of stimulating antigen-specific CD8+ T cells both directly and indirectly via CoEX-A2 cross-dressed cells. Notably, CoEX-A2s also generated similar levels of HCMV pp65-specific and MART1-specific CD8+ T cells as DEX in vitro. The results suggest that these novel exosomes may provide a crucial reagent for generating antigen-specific CD8+ T cells for adoptive cell therapies against viral infection and tumors.
Does the distribution pattern of brain metastases during BRAF inhibitor therapy reflect phenotype switching?
Authors: Haueis Silvia A. , Kränzlin Pascale , Mangana Joanna , Cheng Phil F. , Urosevic-Maiwald Mirjana , Braun Ralph P. , Levesque Mitchell P. , Dummer Reinhard , Goldinger Simone M.
Published: January 2017

Brain metastases (brain mets) are frequent in metastatic melanoma patients. The aim of this study was to investigate the morphology and progression pattern of brain mets in melanoma patients treated with BRAF inhibitors (BRAFi) compared with patients who did not receive targeted therapy (BRAFi group and control group). The number and size of brain mets were compared between a baseline and a comparative MRI at progression. The number of brain mets was grouped into seven number classes (N=1–4, N=5–10, N=11–20, N=21–30, N=31–40, N=41–50, and N>50) and its difference was reported as the change of class that occurred. The mean size of the newly developed lesions was determined by representative measurements and the evolution of three persisting target lesions was assessed on the basis of modified RECIST criteria. Of 96 patients studied, 42 were in the BRAFi group and 54 were in the control group. Patients under BRAFi treatment had a significantly greater increase in the number of brain mets, where the median change of class for the BRAFi compared with the control group was 2 versus 0 (P<0.01). The mean size of the new lesions was smaller in the BRAFi group. Pre-existing target lesions did not show any prominent or different patterns of how they evolved in either group. Brain mets in patients treated with BRAFi showed a progression pattern characterized by a high propensity to disseminate, which might reflect an in-vivo manifestation of phenotype switching in response to targeted therapy, with a predominance of the invasive/migratory tumor cell phenotype. Drivers of invasiveness may present promising targets for therapeutic interventions.
Totally Implantable Venous Access Devices
Authors: Tabatabaie Omidreza , Kasumova Gyulnara G. , Eskander Mariam F. , Critchlow Jonathan F. , Tawa Nicholas E. , Tseng Jennifer F.
Published: January 2017

Objective:

Totally implantable venous access devices (portacaths, or “ports”), are widely used for intermittent central venous access especially for cancer patients. Although ports have a superior safety margin compared with other long-term venous access devices, there are a number of complications associated with their use.

Methods:

This is a narrative review. We searched PubMed and Google Scholar for articles about complications related to the use of portacaths. “Similar articles” feature of PubMed and reference list of the existing literature were also reviewed for additional relevant studies.

Results:

In this review, we provide the latest evidence regarding the most common ones of these adverse events and how to diagnose and treat them. Immediate complications including pneumothorax, hemothorax, arterial puncture, and air embolism as well as late complications such as port infection, malfunction, and thrombosis are covered in detail.

Conclusions:

Physicians should be familiar with port complications and their diagnosis and management.
The Brief Early Childhood Screening Assessment: Preliminary Validity in Pediatric Primary Care
Authors: Fallucco Elise M. , Wysocki Tim , James Lauren , Kozikowski Chelsea , Williams Andre , Gleason Mary M.
Published: January 2017

Objective:

Brief, well-validated instruments are needed to facilitate screening for early childhood behavioral and emotional problems (BEPs). The objectives of this study were to empirically reduce the length of the Early Childhood Screening Assessment (ECSA) and to assess the validity and reliability of this shorter tool.

Methods:

Using caregiver ECSA responses for 2467 children aged 36 to 60 months seen in primary care, individual ECSA items were ranked on a scale ranging from “absolutely retain” to “absolutely delete.” Items were deleted sequentially beginning with “absolutely delete” and going up the item prioritization list, resulting in 35 shorter versions of the ECSA. A separate primary care sample (n = 69) of mothers of children aged 18 to 60 months was used to determine the sensitivity and specificity of each shorter ECSA version using psychiatric diagnosis on the Diagnostic Infant and Preschool Assessment as the gold standard. The version with the optimal balance of sensitivity, specificity, and length was selected as the Brief ECSA. Associations between Brief ECSA scores and other pertinent measures were evaluated to estimate reliability and validity.

Results:

A 22-item measure reflected the best combination of brevity, sensitivity and specificity. A cutoff score of 9 or higher on the 22-item Brief ECSA demonstrated acceptable sensitivity (89%) and specificity (85%) for predicting a psychiatric diagnosis. Brief ECSA scores correlated significantly and in expected directions with scores on pertinent measures and with demographic variables.

Conclusion:

The results indicate that the Brief ECSA has sound psychometric properties for identifying young children with BEPs in primary care.
Perception and Acceptability of Medical Photography in Chinese Dermatologic Patients: A Questionnaire Survey
Authors: Wang Yue , Tan Huan , Yang Xichuan
Published: January 2017

BACKGROUND

Medical photography is increasingly used by physicians, but studies assessing the perception and acceptability of medical photography by Chinese dermatologic patients are scarce.

OBJECTIVE

To assess the perception and acceptability of medical photography in Chinese dermatologic patients.

MATERIALS AND METHODS

From July to December 2014, adult patients visiting the Dermatology Clinic of The First Affiliated Hospital of Third Military Medical University were included in this study. They were required to fill an anonymous questionnaire regarding perception and acceptability of medical photography.

RESULTS

A total of 509 consecutive patients completed the questionnaire, with 35 and 474 declining and undergoing medical photography, respectively. Meanwhile, 81.0% of the patients preferred to be photographed by attending physicians; 63.3% favored clinic-owned cameras, and 81.0% would rather have their photographs stored in the department's database. Besides, most patients allowed their photographs to be used in case studies (92.8%) or medical record keeping (90.3%).

CONCLUSION

Most Chinese dermatologic patients accept medical photography. However, the principles of privacy protection and informed consent should be strictly enforced in clinical practice, and appropriate photographic devices and storage methods should be used, for better acceptance.
PNEUMATIC VITREOLYSIS FOR RELIEF OF VITREOMACULAR TRACTION
Authors: Chan Clement K. , Crosson Jason N. , Mein Calvin E. , Daher Noha
Published: January 2017

Purpose:

To evaluate the outcome of perfluoropropane (C3F8) gas injection for symptomatic vitreomacular traction (VMT) with or without Stage 2 macular hole (MH).

Methods:

A retrospective review of eyes with VMT treated with 0.3 mL of C3F8 gas was performed. Patients avoided the supine position until gas resolution. Patients with small MH maintained partial face-down positioning.

Results:

Forty-nine consecutive patients (50 eyes) with symptomatic VMT underwent pneumatic vitreolysis between 2010 and 2016. A posterior vitreous detachment developed in 43 eyes (86.0%) after a single gas injection, at a median of 3.0 weeks. Twenty-eight of 35 eyes (80.0%) with VMT only and all 15 eyes (100%) with a small Stage 2 MH developed a posterior vitreous detachment, with MH closure in 10 of 15 eyes (66.7%). Median baseline and last best spectacle–corrected visual acuities were 20/50 and 20/40, respectively (P < 0.001). Mean follow-up time was 11.1 ± 9.9 months. Rate of posterior vitreous detachment was reduced with presence of diabetes mellitus (25%) and with thick cellophane membrane (50%). Univariate analysis showed increased VMT release for eyes with VMT extent within 1 disk area (χ2 = 13.1, P = 0.002), eyes with absence of diabetes mellitus (χ2 = 8.8, P = 0.007), and eyes with Stage 2 MH (χ2 = 5.47, P = 0.019); there was a trend between success and lack of thick cellophane membrane (χ2 = 3.32, P = 0.068). Results using logistic regression also showed younger age (P = 0.012), followed by better baseline best spectacle–corrected visual acuity (P = 0.044), lack of diabetes mellitus (P = 0.077), and female gender (P = 0.045) to be predictors of increased VMT release. One VMT-only eye formed a MH and another VMT-only eye developed a retinal detachment. Both eyes responded to vitrectomy.

Conclusion:

Pneumatic vitreolysis with limited face-down position is a viable option for treating VMT with few adverse events. More studies are needed to elucidate its indications, benefits, and risks.
Risk Factors for Acanthamoeba Keratitis—A Multistate Case–Control Study, 2008–2011
Authors: Brown Allison C. , Ross Jonathan , Jones Daniel B. , Collier Sarah A. , Ayers Tracy L. , Hoekstra Robert M. , Backensen Bryon , Roy Sharon L. , Beach Michael J. , Yoder Jonathan S. ,   for The Acanthamoeba Keratitis Investigation Team
Published: January 2017

Objective:

To identify modifiable risk factors contributing to Acanthamoeba keratitis (AK) infection.

Methods:

A case–control investigation was conducted. Case patients were soft contact lens wearers with laboratory-confirmed AK. Control were soft contact lens wearers ≥12 years of age, with no history of AK. Case patients were recruited from 14 ophthalmology referral centers and a clinical laboratory. Control were matched on state of residence and type of primary eye care provider (ophthalmologist or optometrist). Participants were interviewed using a standardized questionnaire. Univariable and multivariable conditional logistic regression analyses were conducted. Matched odds ratios (mORs) were calculated.

Results:

Participants included 88 case patients and 151 matched control. Case patients were more likely to be aged <25 years (unadjusted mOR 2.7, 95% confidence interval 1.3–5.5) or aged >53 years (mOR 2.5, 1.1–5.7), and more likely to be men (mOR 2.6, 1.4–4.8). Unadjusted analyses identified multiple risk factors: rinsing (mOR 6.3, 1.3–29.9) and storing lenses in tap water (mOR 3.9, 1.2–12.3), topping off solution in the lens case (mOR 4.0, 2.0–8.0), having worn lenses ≤5 years (mOR 2.4, 1.3–4.4), rinsing the case with tap water before storing lenses (mOR 2.1, 1.1–4.1), and using hydrogen peroxide (mOR 3.6, 1.1–11.7) versus multipurpose solution. Significant risk factors in multivariable modeling included age >53 years, male sex, topping off, and using saline solution.

Conclusions:

Numerous modifiable risk factors for AK were identified, mostly involving hygiene practices. To reduce the risk of AK, lens wearers should observe recommended lens care practices.
Mini-Bentall: An Interesting Approach for Selected Patients
Authors: Mikus Elisa , Micari Antonio , Calvi Simone , Salomone Maria , Panzavolta Marco , Paris Marco , Del Giglio Mauro
Published: January 2017

Objective

Minimally invasive surgery through an upper hemisternotomy for aortic valve replacement has become the routine approach with excellent results. Actually, the same minimally invasive access is used for complex ascending aorta procedures only in few centers. We report our experience with minimally invasive approach for aortic valve and ascending aorta replacement using Bentall technique.

Methods

From January 2010 to November 2015, a total of 238 patients received ascending aorta and aortic valve replacement using Bentall De Bono procedure at our institution. Low- and intermediate-risk patients underwent elective surgery with a minimally invasive approach. The “J”-shaped partial upper sternotomy was performed through a 6-cm skin incision from the notch to the third right intercostal space. Patients who had previous cardiac surgery or affected by active endocarditis were excluded. The study included 53 patients, 44 male (83 %) with a median age of 63 years [interquartile range (IQR), 51–73 years]. A bicuspid aortic valve was diagnosed in 27 patients (51%).

Results

A biological Bentall using a pericardial Mitroflow or Crown bioprosthesis implanted in a Valsalva graft was performed in 49 patents. The remaining four patients were treated with a traditional mechanical conduit. Median cardiopulmonary bypass time and median cross-clamp time were respectively 84 (IQR, 75–103) minutes and 73 (IQR, 64–89) minutes. Hospital mortality was zero as well as 30-day mortality. Median intensive care unit and hospital stay were 1.9 and 8 days, respectively. The study population compared with patients treated with standard full sternotomy and similar preoperative characteristics showed similar results in terms of postoperative outcomes with a slightly superiority of minimally invasive group mainly regarding operative times, incidence of atrial fibrillation, and postoperative ventilation times.

Conclusions

A partial upper sternotomy is considered a safe option for aortic valve replacement. Our experience confirms that a minimally invasive approach using a partial upper J-shaped sternotomy can be a safe alternative approach to the standard in selected patients presenting with complex aortic root pathology.
Initial Experience with Minimally Invasive Surgical Exclusion of the Left Atrial Appendage with an Epicardial Clip
Authors: Smith Nathan E. , Joseph Jeevan , Morgan John , Masroor Saqib
Published: January 2017

Objective

Atrial fibrillation (AF) is the primary cardiac abnormality associated with ischemic stroke. Atrial fibrillation affects 2.7 million people with a stroke rate of 3.5% per year. Most of the emboli in patients with nonvalvular AF originate in the left atrial appendage (LAA). Surgical exclusion of the LAA decreases the yearly risk of stroke to 0.7% when combined with a Maze procedure. Traditional oversewing the LAA from inside the left atrium is associated with a significant number of recanalizations of LAA. An alternate technique is epicardial clipping, which has been approved through sternotomy for permanent exclusion of LAA. We present our initial experience of epicardial clipping of the LAA using a minimally invasive approach.

Methods

Between May 2012 and December 2015, a total of 24 consecutive patients underwent minimally invasive, echo-guided epicardial clipping. Indications for the procedure were persistent (n = 12) or paroxysmal (n = 12) AF in patients who could not tolerate full anticoagulation because of a combination of gastrointestinal bleeding (n = 7), hemorrhagic stroke (n = 5), ischemic stroke (n = 5), intramuscular bleeding (n = 3), falls (n = 2), urinary tract bleeding (n = 2), subdural hematoma (n = 1), traumatic aortic intramural hematoma (n = 1), and lifestyle and career practices inconsistent with anticoagulation (n = 1). The clipping was performed through three 5-mm ports in the left seventh intercostal space (n = 22) or a 5-cm incision in the fifth intercostal space (n = 2). Echocardiography was performed to exclude the presence of LAA thrombus and to confirm exclusion of LAA before final deployment of the clip.

Results

The mean age was 73.6 years. The mean CHA2DS2VASC score was 4.7 and the mean HAS-BLED score was 3.8. The mean postoperative length of stay was 6.4 days. One patient died of stroke-related complications 10 days after successful clipping, and two patients required thoracentesis to drain recurrent pleural effusions. All patients had successful exclusion of LAA defined as residual sac of less than 1 cm.

Conclusions

Isolated epicardial left atrial clipping is a safe treatment option in high-risk patients with AF. Long-term success in preventing stroke is still to be determined, but short-term results are very encouraging.
Transitioning to Second-line Antiretroviral Therapy Among Adolescents in Copperbelt Province, Zambia
Authors: Stalter Randy M. , Katayamoyo Patrick , Packer Catherine , Banda Harry , Chen Pai-Lien , Mwansa Jonathan K. , McCarraher Donna R. , Denison Julie A.
Published: January 2017

Background:

Adolescents living with HIV (ALHIV) experience less favorable antiretroviral therapy (ART) outcomes than other age groups. First-line treatment failure complicates ART management as second-line regimens can be costlier and have greater pill burdens. Understanding predictors of switching ART regimens and adherence among adolescents on second-line ART may help to prevent poor treatment outcomes.

Methods:

A quantitative survey was administered to 309 ALHIV attending 3 ART clinics in the Copperbelt Province, Zambia. Medical chart data, including pharmacy refill data, were abstracted. Associations between being on second-line ART and sociodemographic, psychosocial and ART adherence characteristics were tested. Cox proportional hazards models were used to estimate the effect of baseline ART variables on time to switching.

Results:

Ten percent of participants were on second-line regimens. Compared with ALHIV on first-line ART, adolescents on second-line regimens were older (P = 0.02), out of school due to completion of secondary studies (P = 0.04) and on ART longer (P = 0.03). Adolescents on second-line regimens were more likely to report missing ≥48 consecutive hours of drugs in the last 3 months (P = 0.01). Multivariable analysis showed that adolescents who initiated ART with efavirenz-based regimens were more likely to switch to second-line than those put on nevirapine-based regimens (hazard ratio = 2.6; 95% confidence interval: 1.1–6.4).

Conclusions:

Greater support is needed for ALHIV who are on second-line regimens. Interventions for older adolescents that bridge the gap between school years and young adulthood would be helpful. More research is needed on why ALHIV who start on efavirenz-based regimens are more likely to switch within this population.
Functional neuroimaging in obesity
Authors: Patriarca Laura , Magerowski Greta , Alonso-Alonso Miguel
Published: January 2017

Purpose of review

The review examines recent advances in the use of functional neuroimaging to study human obesity, a field that is rapidly expanding and continues to be of paramount importance for a better understanding of the pathogenesis of this condition. With rising levels of obesity worldwide and limited therapeutic options, there is a great need for the development of new solutions that can benefit patients.

Recent findings

Studies that utilize functional neuroimaging are beginning to shed light on the nature of behavioral and neurocognitive dysfunctions previously identified in individuals with obesity. Significant progress has occurred in the study of reward-related processes, cognition–reward interactions, mechanisms of weight loss, genetic influences, and the case of obesity in children and adolescents. Research findings confirm that obesity and its related overeating behaviors are strongly associated with the brain, both at a regional level and a large-scale network level.

Functional neuroimaging studies bring unprecedented levels of detail to examine the brain basis of obesity, and show promise for the development of future brain-based biomarkers and interventions in this condition.
The upside down world of diabetes care medical economics and what we might do to improve it
Authors: Harlan David M. , Hirsch Irl B.
Published: January 2017

Purpose of review

Increasingly over the past generation, the American healthcare delivery system has received consistently poor marks with regard to public health outcomes and costs. This review by two seasoned diabetes care providers is intended to shed light on the fundamental flaws we believe to underlie that poor performance, and suggest options for better outcomes and cost efficiencies.

Recent findings

Despite major advances in diabetes management medications and tools, overall public health with regard to diabetes outcomes remains poor. Efforts focused on controlling costs appear to be exacerbating the problem.

For chronic diseases like diabetes, fee-for-service care models are fundamentally flawed and predictably fail. We suggest that a major overhaul of the medical economics underlying diabetes care can improve patient outcomes and decrease costs.
Utilizing a Novel Mobile Health “Selfie” Application to Improve Compliance to Iron Chelation in Pediatric Patients Receiving Chronic Transfusions
Authors: Leonard Sarah , Anderson Lindsay M. , Jonassaint Jude , Jonassaint Charles , Shah Nirmish
Published: January 2017

Iron chelation therapy can prevent iron overload for pediatric patients with sickle cell disease and β-thalassemia major; however, adherence is suboptimal. Therefore, we developed an intensive training program (ITP), to improve medication management and disease knowledge. The objectives were to determine feasibility of the ITP and its preliminary impact on adherence, disease knowledge, and health outcomes. Pediatric patients were recruited to participate in the ITP over a 90-day period and were followed for 6 months. The ITP consisted of 3 components: (1) provider-led education modules; (2) patient recording daily videos of at-home medication administration; and (3) provider feedback through video messages through the ITP app. Eleven patients participated (mean=12.4 y). Initially, patients endorsed high satisfaction and ease of use and tracked their medication usage 81% (24 out of 30) of days. At 90 days, adherence rates remained consistent (80%) and disease knowledge retention was high (96%). At 6 months, participants exhibited a clinically relevant decrease in serum ferritin, which trended toward statistical significance (P=0.068). Medication possession ratio did not significantly increase (0.65 to 0.72; not significant). The mobile ITP was feasibly implemented in a clinical setting; in addition, high levels of compliance, disease knowledge retention, and acceptance encourage larger studies evaluating mobile health technology to improve child health parameters.
Examining the Relationships Between Clinical Judgment, Simulation Performance, and Clinical Performance
Authors: Victor Joyce , Ruppert Wanda , Ballasy Sara
Published: January 2017

Simulation-based learning experiences are designed to prepare the student for clinical practice; however, there is little documentation of a relationship between simulation performance and performance in the clinical setting. When essential aspects of a clinical situation are replicated in simulation, students should readily understand and manage similar situations in clinical practice. This study examined the relationships between clinical nursing judgment development, simulation performance, and clinical performance.
Effect of Sequence of Simulated and Clinical Practicum Learning Experiences on Clinical Competency of Nursing Students
Authors: Hansen Jamie , Bratt Marilyn
Published: January 2017

Two different sequences of blocks of simulated and clinical practicum learning experiences compared the clinical competency development of nursing students using a randomized crossover design. Competency was measured 3 times: after each block of simulated and clinical experiences and after a final simulated experience. No significant differences in competency scores between the 2 groups across the 3 time points were found. Using alternative models of clinical and simulation learning may help address barriers to the delivery of clinical education faced by schools of nursing.
Ultrasound Examination of the Fetal Heart
Authors: Bishop Katherine C. , Kuller Jeffrey A. , Boyd Brita K. , Rhee Eleanor H. , Miller Stephen , Barker Piers
Published: January 2017

Congenital heart disease (CHD) occurs in 4–13 per 1000 births in the United States. While many risk factors for CHD have been identified, more than 90% of cases occur in low-risk patients. Guidelines for fetal cardiac screening during the second trimester anatomy ultrasound have been developed by the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) in order to improve antenatal detection rates and to standardize the fetal cardiac screening examination. Patients found to be at increased risk of CHD because of risk factors or an abnormal screening examination should be referred for second trimester fetal echocardiography. Recently, 3D and 4D ultrasound techniques are being utilized to enhance detection rates and to better characterize cardiac lesions, and several first trimester ultrasound screening markers have been proposed to identify patients at increased risk of CHD. However, detection rates have not improved significantly due to limitations such as cost, access, and training that are associated with new technologies and screening methods. The most cost effective way to improve detection rates of CHD may be to standardize screening protocols across practices according to established guidelines and to have a low threshold for referral for fetal echocardiography.

Target Audience

Obstetricians and gynecologists, family physicians

Learning Objectives

After completing this activity, the learner should be better able to: (1) Implement ISUOG guidelines for the basic fetal cardiac exam into clinical practice; (2) Select patients appropriately for referral for fetal echocardiography; and (3) Understand the most commonly used 3D and 4D ultrasound techniques used to evaluate the structure and function of the fetal heart.
Inter-relationship of Soft Contact Lens Diameter, Base Curve Radius, and Fit
Authors: Young Graeme , Hall Lee , Sulley Anna , Osborn-Lorenz Kathrine , Wolffsohn James S.
Published: January 2017

Purpose

To evaluate the inter-relationship of soft contact lens base curve radius (BC), diameter, and lens fit using a mathematical model.

Methods

A spreadsheet mathematical model was used to evaluate theoretical fitting characteristics for various combinations of soft lens BC and diameter. The designs were evaluated using ocular topography data collected from 163 UK subjects. The model evaluated lens tightness (edge strain) and on-eye diameter (horizontal corneal overlap) and assumed that acceptable values fell within the range 0 to 6% and 0.2 to 1.2 mm, respectively. Analyses were undertaken of various trends relating to soft lens fit, including (1) the effect of BC and diameter on fitting success; (2) the effect of lens asphericity, BC, and sag on lens diameter on the eye; and (3) the effect of lens diameter on lens tightness.

Results

The highest overall success rate (90.2%) was achieved with an 8.60/14.2 mm (BC/diameter) design. Using this design on the sample population, the median edge strain value was 3.2% (IQR: 2.1%) whereas median corneal overlap was 0.62 mm (IQR: 0.35). There was a positive correlation (r= 0.37,P< .0001) between edge strain and corneal overlap. Edge strain showed significant correlations with each of the ocular topography variables, most notably corneal asphericity (−0.62,P< .0001). Corneal overlap showed significant correlations with corneal asphericity (r= −0.42,P< .0001) and corneal diameter (r = 0.92,P< .0001). For a 0.4 mm change in BC, it is necessary to change diameter by 0.2 mm to maintain similar on-eye diameter (arclength). When changing lens diameter, a change in BC of 0.2 mm is required to maintain similar tightness of fit.

Conclusions

Mathematical modeling is a useful technique for large-scale evaluation of the interactions of soft contact lens design and fit. The study has given useful insights into the general performance of soft lens designs.
Discordance Rate in Estrogen Receptor, Progesterone Receptor, HER2 Status, and Ki67 Index Between Primary Unifocal and Multiple Homogenous Breast Carcinomas and Synchronous Axillary Lymph Node Metastases Have an Impact on Therapeutic Decision
Authors: Georgescu Rares , Boros Monica , Moncea Denisa , Bauer Orsolya , Coros Marius-Florin , Oprea Adela , Moldovan Cosmin , Podoleanu Cristian , Stolnicu Simona
Published: January 2017

Background:

We aimed to demonstrate that in breast carcinomas the tumor profile is not stable during the metastatic process, with impact on therapeutic decisions.

Materials and Methods:

We analyzed the estrogen receptor (ER), progesterone receptor (PR), and HER2 status and Ki67 index in 41 primary unifocal (PU) and 37 primary multiple (PM) breast carcinomas with identical immunohistochemical profiles among multiple tumor foci and the matched axillary lymph node metastases. We defined as concordant cases in which the primary tumor (PU or PM) and lymph node metastases displayed identical positivity or negativity for ER, PR, HER2, Ki67 and as discordant cases in which there was a mismatch in at least 1 biological parameter among PU and PM tumor and lymph node metastases. Moreover, we defined as concordant cases in which the molecular profile (based on the immunohistochemical evaluation of ER, PR, HER2, and Ki67) was concordant among PU and PM tumors and lymph node metastases and mismatch cases as those in which the molecular profile of the primary tumor differs from one of the lymph node metastases in at least 1 lymph node.

Results:

The positivity for the biological markers is not stable during the metastatic process. In this study the total rate of discordant cases was 92.7% in PU tumors and 75.7% in PM homogenous tumors (P=0.058, odds ratio=0.245, 95% confidence interval, 0.06-0.991). The total rate of shifted cases was 64.9% in PM tumors and 82.9% in PU tumors. The highest rate of shifting was encountered from Luminal B-like to Luminal A-like. In 11 out of 37 (29.7%) PM and in 17 out of 41 (41.5%) PU cases the subtype shifted to a poorer one with respect to prognosis.

Conclusions:

The patients in whom the primary tumor is hormone receptor and/or HER2 negative but is positive for these markers in the axillary lymph nodes could become eligible for hormonal treatment and/or trastuzumab treatment, which may significantly improve the patient’s outcome.
A Reexamination of the Accuracy of the Broselow Tape as an Instrument for Weight Estimation
Authors: Waseem Muhammad , Chen Justin , Leber Mark , Giambrone Ashley E. , Gerber Linda M.
Published: January 2017

Background

Accurate weight estimation is important for calculating appropriate medication dosages, determining rates of fluid replacement, and selecting correct equipment sizes in critically ill children requiring resuscitation. The actual measurement of the weight of a critically ill or injured child is often not possible. The Broselow Pediatric Emergency Tape (BT) is an important tool for predicting a child’s weight based on his/her height. Although BT has previously been validated, given the increasing prevalence of obesity in today’s society, it behooves clinicians relying on this resuscitation aid to revisit the issue.

Objective

The aim of this study was to evaluate the accuracy of the color-coded BT in weight estimation and the influence of obesity on its accuracy.

Methods

This is a retrospective study conducted in a pediatric clinic of urban hospital. This study reviewed the medical records of children up to 96 months of age, who presented during 2008–2010. We recorded the child’s age (in months), actual (measured) weight (in kilograms), and height (in centimeters). Based on the height, weight estimation was obtained using the color-coded BT. The actual weight was compared with the predicted weight obtained by the height-based BT. Patients presenting with any medical condition that would substantially affect growth of the child were excluded. A univariate logistic regression model was utilized to predict any underestimation based on age, sex, and body mass index (BMI) percentile.

Results

The medical records of 538 children were reviewed. There was a discrepancy in 226 children (42%). Broselow Pediatric Emergency Tape underestimated weight (measured weight was higher than predicted weight) in 158 children (29.4%) and overestimated (measured weight was lower than predicted weight) in 68 children (12.6%). Of the 158 underestimated children, 138 were off by 1 color zone, 16 by 2 color zones, and 4 by more than 2 color zones. When characterized by BMI, 46 children (13.6%) had normal BMI, 27 (45.8%) were overweight, and 84 (80.8%) were obese, whereas one child (2.8%) was underweight.

Conclusions

In our population, BT was inaccurate in predicting weight in 42% of children (underestimation in 158 children [29.4%] and overestimation weight in 68 children [12.6%]). However, the majority of discrepancies involved only 1 BT color zone. Emergency physicians should be aware of this discrepancy until more accurate methods become available.
Regional Gray Matter Volumes as Related to Psychomotor Slowing in Adults with Type 1 Diabetes
Authors: Nunley Karen A. , Ryan Christopher M. , Aizenstein Howard J. , Jennings J. Richard , MacCloud Rebecca L. , Orchard Trevor J. , Rosano Caterina
Published: January 2017

Objective

Psychomotor slowing is a common cognitive complication in type 1 diabetes (T1D), but its neuroanatomical correlates and risk factors are unclear. In nondiabetic adults, smaller gray matter volume (GMV) and presence of white matter hyperintensities are associated with psychomotor slowing. We hypothesize that smaller GMV in prefronto-parietal regions explains T1D-related psychomotor slowing. We also inspect the contribution of microvascular disease and hyperglycemia.

Methods

GMV, white matter hyperintensities (WMH), and glucose levels were measured concurrently with a test of psychomotor speed (Digit Symbol Substitution Test [DSST]) in 95 adults with childhood-onset T1D (mean age/duration = 49/41 years) and 135 similarly aged non-T1D adults. Linear regression models tested associations between DSST and regional GMV, controlling for T1D, sex, and education; a bootstrapping method tested whether regional GMV explained between-group differences in DSST. For the T1D cohort, voxel-based and a priori regions-of-interest methods further tested associations between GMV and DSST, adjusting for WMH, hyperglycemia, and age.

Results

Bilateral putamen, but no other regions examined, significantly attenuated DSST differences between the cohorts (bootstrapped unstandardized indirect effects: −3.49, −3.26; 95% confidence interval = −5.49 to −1.80, −5.29 to −1.44, left and right putamen, respectively). Among T1D, DSST was positively associated with GMV of bilateral putamen and left thalamus. Neither WMH, hyperglycemia, age, nor other factors substantially modified these relationships.

Conclusions

For middle-aged adults with T1D and cerebral microvascular disease, GMV of basal ganglia may play a critical role in regulating psychomotor speed, as measured via DSST. Studies to quantify the impact of basal ganglia atrophy concurrent with WMH progression on psychomotor slowing are warranted.