bluuebunny/crossref_metadata_2025 huggingface dataset:
Onset, Course, and Prognosis for Borderline Personality Disorder
Authors: Zanarini Mary C. , Conkey Lindsey C.
Published: October 2017

Borderline personality disorder (BPD) is a common psychiatric disorder; the best epidemiological evidence estimating that about 2% of American adults meet DSM-IV criteria for BPD and an estimated 19% of psychiatric inpatients and approximately 11% of psychiatric outpatients meet criteria for BPD. Cross-sectional studies have found that BPD is associated with high levels of mental health service utilization and a serious degree of psychosocial impairment These facts suggest that BPD is a serious public health problem and yet, the course of BPD has received relatively little attention. Most studies have used adult samples (people age 18 or older), and clinicians have been reluctant until very recently to diagnose adolescents or latency-aged children as meeting full-blown criteria for BPD, choosing instead to diagnose disruptive mood dysregulation disorder (DMDD)—a disorder of childhood marked by frequent temper outbursts and chronic anger or irritability.
Neurobiology of Borderline Personality Disorder
Authors: Krause-Utz Annegret , Niedtfeld Inga , Knauber Julia , Schmahl Christian
Published: October 2017

In this chapter, neuroimaging findings in BPD are discussed referring to the three core domains of BPD psychopathology: disturbed emotion processing and emotion dysregulation (including dissociation and altered pain processing), behavioral dysregulation and impulsivity, and interpersonal disturbances. Experimental approaches investigating BPD psychopathology on the subjective, behavioral, and neurobiological levels have become increasingly important for an improved understanding of BPD. Over the past decades, neuroimaging has become one of the most important tools in clinical neurobiology. Neuroimaging includes a broad spectrum of methods such as positron emission tomography (PET), structural and functional magnetic resonance imaging (fMRI), MR spectroscopy, and diffusion tensor imaging (DTI).
Eating Disorders in Borderline Personality Disorder
Authors: Chen Eunice
Published: October 2017

Eating disorders (EDs) often arise from a complex interplay of biological, psychological, and social processes in which there is a dialectical tension between the overabundance of food and an obsession with thinness. The DSM-5 recognizes three specific types of EDs that are common in borderline personality disorder (BPD): anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). The impulsive, self-destructive tendencies of those with BPD may also make them particularly vulnerable to developing an ED. Recent advances in neuroscience have resulted in great understanding of the brain mechanisms and processes that control behavior associated with EDs and BPD. Research has supported the idea that the co-occurrence of both disorders may be caused by an inability to tolerate and skillfully manage negative or unpleasant emotions. Other possible commonalities between EDs and BPD involve shared risk factors, such as a history of childhood trauma.
Aggressive Behavior and Interpersonal Difficulties in Borderline Personality Disorder
Authors: Scott Lori N. , Pilkonis Paul A.
Published: October 2017

Interpersonal problems are among the most severely impairing, difficult-to-manage, and intransigent of borderline personality disorder (BPD) features and therefore require special attention in treatment. Emotion dysregulation and related mood-dependent behaviors among individuals with BPD typically occur in the context of interpersonally relevant events or stressors, signifying the central role of interpersonal and attachment-related concerns for these patients. Two prominent interpersonal themes in those with BPD are discussed: interpersonal hypersensitivity and angry or aggressive behavior. The chapter provides a brief case illustration of how these themes might emerge in psychotherapy and recommends explicit assessment of interpersonal problems and aggression to enhance risk evaluation, case formulation, treatment planning, and monitoring progress in treatment.
Mentalization-Based Treatment
Authors: Choi-Kain Lois W.
Published: October 2017

This chapter reviews the formulation of borderline personality disorder (BPD) as a disorder of mentalization, the mentalization-based treatment (MBT) technique and treatment framework, and the empirical literature that provides the evidentiary basis for MBT’s theories and efficacy. The chapter also discusses some limitations to its application and claims. Mentalization broadly encompasses a wide territory of mental activities by which people understand themselves and their identity, manage their emotions and thoughts meaningfully and effectively, respond to their own experience and others in behavior, and maintain secure and productive relationships. When mentalization dysfunctions, personalities become disordered. Mentalization as a concept integrates ideas from both traditional psychoanalytic theory to modern-day neuroscience. The bridging of theories from the psychoanalytic tradition with current neuroscientific discovery makes mentalization-based treatment (MBT) a broadly appealing intellectual framework with which to relate clinical theory, empirical evidence, and psychotherapeutic technique in the treatment of BPD.
Dialectical Behavior Therapy
Authors: Rizvi Shireen L. , Roman Kristen M.
Published: October 2017

Dialectical behavior therapy (DBT) is an evidence-based, psychosocial treatment originally developed for suicidal individuals with borderline personality disorder (BPD). It is now broadly seen as the treatment of choice for individuals with BPD. DBT is a comprehensive, cognitive-behavioral treatment designed to help a client achieve a “life worth living.” Research on DBT’s effectiveness is compelling and was the first to empirically demonstrate that individuals with BPD and severe emotional dysregulation and/or suicidal behavior could be effectively treated with a psychosocial therapy. As the research literature on DBT continues to grow, it will be important to move beyond randomized clinical trials comparing DBT to control treatments and instead focus on identifying important predictors and mediators of change. This chapter describes the foundation and theoretical underpinnings of DBT, provides details about the structure of DBT in all its components, and summarizes some existing research. A detailed case example is provided.
Cognitive Therapy for Personality Disorders
Authors: Davidson Kate M
Published: October 2017

CBT for personality disorders (CBTpd) uses a developmental model that places emphasis on core beliefs concerned with self-identity and other people that have arisen in childhood and behavioral strategies to compensate, avoid, or cope with these core beliefs. The therapy is less intensive than other therapies for personality disorder. A narrative formulation engages individuals in therapy and increases psychological understanding of problems, such as how core beliefs developed through adverse events in childhood led to emotional and behavioral patterns that are negative and often self-destructive and interfere with the development of positive relationships and the enhancement of life skills. CBTpd helps the patient gain control over distress, promotes more adaptive beliefs about self, and increases interpersonal skill and resilience. CBTpd has been evaluated in randomized controlled trials and shown to be effective in treating BPD, including those with suicidal behavior and severe depression.
Supportive Psychotherapy and Case Management
Authors: Hellerstein David J. , Aviram Ron B.
Published: October 2017

Psychotherapy of borderline personality disorder (BPD) has often focused on specialized and putatively more effective treatments such as dialectical behavioral therapy. In recent years, accumulating evidence suggests that many BPD patients benefit equally well from well-structured but less specialized care designed to meet their needs. Supportive psychotherapy (SPT) and various forms of clinical management, such as structured clinical management (SCM) and general psychiatric management (GPM), have been successfully adapted for treatment of BPD. This chapter describes the theoretical backgrounds for these approaches, main treatment techniques, and how they can be implemented to provide good outcomes for individuals diagnosed with BPD.
Biological and Physiological Aspects of Emotion Regulation
Authors: McRae Kateri , Shiota Michelle
Published: October 2017

Chapter 3 highlights the biological and physiological consequences of emotion regulation. Predominantly, researchers manipulate emotion regulation strategy use and measure emotional outcomes. Biological data has enhanced this work, providing relatively objective outcomes which can be usd to compare and contrast the effects of different strategies. Emotion regulation strategies such as cognitive reappraisal impact sympathetic responding, cortisol levels, and neural activation in regions associated with emotion generation. Parasympathetic influences on the heart, measured via respiratory sinus arrhythmia (RSA), high-frequency heart rate variability (HF-HRV), and the ratio of high-frequency to low-frequency heart rate variability, highlight the success of cognitive reappraisal when compared with expressive suppression. Other research has revealed more nuance, inciting new hypotheses about which types of reappraisal work best in varying situations.
Emotion Regulation and Conduct Disorder
Authors: Thomson Nicholas D. , Centifanti Luna C. M. , Lemerise Elizabeth A.
Published: October 2017

The present chapter examines several developmental pathways towards a diagnosis of conduct disorder (CD) in childhood and adolescence. In particular, we discuss the evidence for considering how children with CD manage their emotions since subgroups of children with CD may show a different developmental trajectory based on their emotion regulation abilities. The chapter reviews the prevalence and life-course of CD, the development of emotion regulation, temperament and emotionality, and the development of reactive and proactive aggression. It discusses the biopsychosocial distinction of CD with callous-unemotional (CU) traits and CD with severe anger dysregulation. It also reviews the most recent evidence on effective interventions and treatment for children and adolescents with CD and CU traits. The chapter closes with a discussion of the implications for clinical practice of CD based on the heterogeneity within the disorder.
Emotion Regulation and Eating Disorders
Authors: Baudinet Julian , Dawson Lisa , Madden Sloane , Hay Phillipa
Published: October 2017

Chapter 10 discusses the prevalence and manifestation of childhood and adolescent eating disorders focusing on Anorexia Nervosa (AN), due to its prevalence. Implementation of maladaptive emotion regulation strategies, with a reduced ability to label and describe emotions leads to the development and propagation of AN. Family based treatments have been widely recognized, as the leading intervention for adolescents with AN, with efficacy rates from 20% to 60%. However, this chapter focuses on a novel approach to AN treatment, centered on emotion regulation in its management, as this may improve treatment outcomes. Programs include: Maudsley Model of Anorexia Nervosa Treatment for Adults and Emotion Acceptance Behavior Therapy, in addition to the modification or adaption of existing, evidence based treatments, such as Radically-Open DBT, although many programs require empirical validation in adolescent samples.
Emotion Regulation and Substance Use Disorders in Adolescents
Authors: Wills Thomas A. , Simons Jeffrey S. , Manayan Olivia , Robinson M. Koa
Published: October 2017

Chapter 11 evaluates how emotion dysregulation enhances vulnerability to substance use disorders in adolescents. In late adolescence (15–18 years of age), recurrent substance users are prone to develop substance use disorder in adulthood. Substance use disorder may be broadly characterized as the inability to regulate substance consumption, deleteriously impacting social functioning, whilst accumulating a myriad of negative consequences and recurring risk to the self. Research suggests emotion dysregulation may be a predisposing factor that presents prior to onset of disorder. Moreover, dysregulation in cognitive, emotional and behavioral domains may be interconnected processes; substance abuse presenting as a product of overall dysregulation. Although theoretical efforts have outlined conceptual models delineating the relationship between emotion regulation and substance abuse, limited evidence has been garnered in adolescent samples. From a treatment perspective, school-based interventions centered on fostering adaptive emotion regulation skills have demonstrated efficacy, and maintained positive findings at long-term follow-up.
Emotion Regulation in Autism Spectrum Disorder
Authors: Weiss Jonathan A. , Riosa Priscilla Burnham , Mazefsky Carla A. , Beaumont Renae
Published: October 2017

Chapter 12 discusses childhood and adolescent autism spectrum disorder (ASD), a pervasive neurodevelopmental disorder characterized by deficits in social communication, and by restricted, repetitive patterns of behavior, interests, or activities. Emotion regulation difficulty, particularly understanding emotion, is common in ASD, as is the use of maladaptive regulatory strategies (i.e., avoidance, expressive suppression). In terms of treatment, robust empirical evidence supports using mindfulness and cognitive behavioral approaches in treating anxiety, a frequent outcome of emotion dysregulation in youth ASD. In addition, two psychopharmacologic medications, risperidone and ariprazole, have well-established evidence supporting their utility in this population. Understanding the underlying dynamics of emotion regulation through ASD from a developmental perspective, whilst considering the stressors unique to this population, is imperative in order to improve treatment outcomes and optimize individualized skill development. The chapter concludes with a description of a novel intervention designed to specifically address emotion regulation difficulties in children with ASD.
Emotion Dysregulation in Adolescents with Borderline Personality Disorder
Authors: Sharp Carla , Trull Timothy J.
Published: October 2017

This chapter discusses adolescent Borderline Personality Disorder, which is characterized by instability in moods, self-image and behavior, often leading to impulsive behavior and unstable interpersonal relationships. Theoretical and clinical research recognizes the critical role emotions play, making it a quintessential emotion regulation disorder. Additionally, theories emphasize that family environment and/or attachment style are influencing factors in the development of poor emotion regulation competencies. Theories align suggesting reciprocal relationships between emotion dysregulation and alternative domains of functioning. A multi-component model of BPD has been posited theorizing emotion sensitivity (inherent from birth) exacerbates experiences of negative stimulus leading to heightened levels of negative affect making it difficult to learn and implement adaptive emotion regulation strategies. Consequently, dysregulation occurs, which reinforces the bias towards negative stimuli. Currently, six BPD interventions exist, three are evidenced in randomized controlled studies; including Dialectical behavior therapy, Helping Young People Early program and Mentalization-based treatment.
Emotion Regulation in Severe Irritability and Disruptive Mood Dysregulation Disorder
Authors: Kircanski Katharina , Leibenluft Ellen , Brotman Melissa A.
Published: October 2017

Chapter 14 discusses emotion dysregulation in pediatric irritability and disruptive mood dysregulation disorder (DMDD). Irritability refers to a low threshold for experiencing negative affect, namely frustration and anger in the context of blocked goal attainment. The central diagnostic feature of DMDD is chronic, severe irritability leading to functional impairment. The precursor to DMDD, severe mood dysregulation (SMD), was operationalized for research purposes as severe irritability concomitant with hyperarousal symptoms (e.g., agitation, distractibility). As relevant to emotion regulation, the pathophysiology of severe irritability has been associated with reduced context-dependent regulation; dysregulated attention-emotion interactions; and the misinterpretation of social cues, including a preferential threat bias. Currently, no gold standard, evidence-based treatments exist exclusively for DMDD or SMD. However, interventions designed for related clinical disorders have demonstrated promising findings, including parent management training, cognitive-behavioral therapy, and psychopharmacological interventions. Novel interventions such as computer-based training have garnered preliminary empirical support.
Children of Abuse and Neglect
Authors: Riley Faye , Bokszczanin Anna , Essau Cecilia A.
Published: October 2017

This chapter gives a brief background to the topic, overviewing the historical context, definitions, prevalence, assessment methods, and risk factors that can contribute to child maltreatment. It then focuses on child abuse and neglect in the context of emotion regulation, reviewing how abuse and neglect can lead to the development of emotion regulation problems, through processes of caregiver socialisation and neurobiological changes, and how these emotion regulation difficulties may manifest in abused children. The chapter goes on to discuss how the psychological and social problems associated with child abuse are associated with maladaptive emotion regulation capacities, and the processes by which emotion regulation can heighten the risk of continued abuse and exacerbate negative outcomes and psychopathology. Finally, this chapter assesses how emotion regulation has become an important target of clinical interventions for maltreated children.
Children of Divorce
Authors: Tarroja Maria Caridad H. , Balajadia-Alcala Ma. Araceli , Catipon Maria Aurora Assumpta D.
Published: October 2017

The chapter describes children of divorce, their experiences, behaviors, and adjustment issues in relation to their parents’ separation. It also examines how the separation impacts the children’s academic achievement, social relationships, emotional expressions, psychological well-being, and coping skills, and how family relationships, interaction, and communication after the separation mediate the impact of the parents’ separation on the children’s adjustment. This chapter likewise highlights the important role of emotion regulation as a protective factor in the adjustment of children of divorce. The different factors that help in the development of emotion regulation of children of divorce have been identified. Auspicious interventions that have been identified in the literature are described. The chapter ends with specific recommendations on how children of divorce can be further facilitated, particularly in enhancing their emotion regulation competencies.
Transdiagnostic Approaches to Emotion Regulation
Authors: Chu Brian C. , Chen Junwen , Mele Christina , Temkin Andrea , Xue Justine
Published: October 2017

This chapter delineates the transdiagnostic approach to emotion regulation in children and adolescents in terms of underlying mechanisms and unifying treatment approaches. Transdiagnostic attempts to explain the high incidence of comorbidity among related disorders, whilst enhancing understanding of the underlying mechanisms inferring commonalities in development, propagation, and impairment. Additionally, it seeks to streamline and enhance the impact of evidence-based interventions for psychological disorders. However, differing research designs, assessment tools, and analytic methodologies have made comparisons challenging. Evidence from cross-sectional and longitudinal research has identified commonalties across disorders related to strategy deployment and neurological involvement (amygdala). Interventions targeting emotional functioning have demonstrated efficacy for both primary and secondary issues. Research is limited in exploring the shift in emotion regulation functioning. Nascent research on DBT and ERT has employed robust treatment evaluations, reporting outcomes. These programs have demonstrated efficacy across numerous presenting problems maintaining effects in both short and long-term follow-ups.
Incidence of Occult Uterine Malignancy Following Vaginal Hysterectomy With Morcellation
Authors: Wasson Megan , Magtibay Paul , Magtibay Paul , Magrina Javier
Published: October 2017

(Abstracted from J Minim Invasive Gynecol 2017;24:665–669)

The availability of electromechanical morcellation has allowed many women to undergo minimally invasive hysterectomy. However, there has been increasing concern over possible inadvertent morcellation of uterine malignancy.
Multidisciplinary Team Learning in the Management of the Morbidly Adherent Placenta: Outcome Improvements Over Time
Authors: Shamshirsaz Alireza A. , Fox Karin A. , Erfani Hadi , Clark Steven L. , Salmanian Bahram , Baker B. Wycke , Coburn Michael , Shamshirsaz Amir A. , Bateni Zhoobin H. , Espinoza Jimmy , Nassr Ahmed A. , Popek Edwina J. , Hui Shiu-Ki , Teruya Jun , Tung Celestine Shauching , Jones Jeffery A. , Rac Martha , Dildy Gary A. , Belfort Michael A.
Published: October 2017

(Abstracted from Am J Obstet Gynecol 2017;216:612.e1–612.e5)

Placenta accreta, increta, and percreta are described as a group as morbidly adherent placentas (MAPs), are increasing in incidence, and contribute to the morbidity and mortality related to pregnancy. The preparation and surgical approach to MAP vary by institution, and specific best practices have not been fully identified.
Effects and Unforeseen Consequences of Accessing References on a Maintenance of Certification Examination: Findings From a National Study
Authors: Feinberg Richard A. , Jurich Daniel P. , Foster Lauren M.
Published: October 2017

Purpose

Increasing criticism of maintenance of certification (MOC) examinations has prompted certifying boards to explore alternative assessment formats. The purpose of this study was to examine the effect of allowing test takers to access reference material while completing their MOC Part III standardized examination.

Method

Item response data were obtained from 546 physicians who completed a medical subspecialty MOC examination between 2013 and 2016. To investigate whether accessing references was related to better performance, an analysis of covariance was conducted on the MOC examination scores with references (access or no access) as the between-groups factor and scores from the physicians’ initial certification examination as a covariate. Descriptive analyses were conducted to investigate how the new feature of accessing references influenced time management within the test day.

Results

Physicians scored significantly higher when references were allowed (mean = 534.44, standard error = 6.83) compared with when they were not (mean = 472.75, standard error = 4.87), F(1, 543) = 60.18, P < .001, ω
2 = 0.09. However, accessing references affected pacing behavior; physicians were 13.47 times more likely to finish with less than a minute of test time remaining per section when reference material was accessible.

Conclusions

Permitting references caused an increase in performance, but also a decrease in the perception that the test has sufficient time limits. Implications for allowing references are discussed, including physician time management, impact on the construct assessed by the test, and the importance of providing validity evidence for all test design decisions.
Psoriatic arthritis: new evidence for old concepts
Authors: Soriano Enrique R. , Marin Josefina , Acosta-Felquer Maria L.
Published: October 2017

Purpose of review

The review gives an updated overview of some of the new concepts in the management of psoriatic arthritis (PsA): early diagnosis, remission as an objective, treat-to-target, and treatment guidelines.

Recent findings

Early diagnosis, targeting remission as part of a treatment strategy, and new guidelines providing evidence-based support to these concepts are main topics in recent publications.

Dermatologists and rheumatologists should work together to reduce the number of patients remaining undiagnosed, and the time to do so.

Remission definition in PsA is still controversial. There is good evidence and convincing arguments for both multidimensional measures, such as minimal disease activity, or unidimensional ones, as disease activity index for PsA. New data on the analysis of tight control of inflammation in early PsA trial showed that the strategy might not be cost-effective on the short term, and that oligoarthritis is less benefited.

The new European League Against Rheumatism and Group for Research and Assessment of Psoriasis and PsA recommendations exhibit differences. Methotrexate and tumor necrosis factor inhibitors are favored in European League Against Rheumatism guidelines, whereas other conventional synthetic disease-modifying antirheumatic drugs and biologics are equally positioned in Group for Research and Assessment of Psoriasis and PsA recommendations.
Which Domains of the ODI Best Predict Change in Physical Function in Patients After Surgery for Degenerative Lumbar Spondylolisthesis?
Authors: Murphy Hamadi A. , Warnick Eugene , McEntee Richard , Nicholson Kristen , Hollern Douglas A. , Stawicki Christie , Tarazona Daniel , Schroeder Gregory D. , Woods Barrett I. , Kurd Mark F. , Rihn Jeffrey A. , Anderson Greg D. , Kepler Christopher K. , Hilibrand Alan S. , Vaccaro Alexander R. , Radcliff Kris E.
Published: October 2017

Study Design.

A retrospective review.

Objective.

The purpose of this study is to determine the differential improvement of the various individual items of the Oswestry Disability Index (ODI) and to determine their relationship to other measures of Health Related Quality of Life (HRQOL).

Summary of Background Data.

The ODI is an easily scored, common, 10-item questionnaire about symptoms relevant to lumbar spine pathology. It is not clear if all of the items can be reliably applied to spine surgery. The purpose of this study is to determine the differential improvement of the various individual items of the ODI and to determine their relationship to other measures of HRQOL.

Methods.

Analysis of a prospective registry of patients treated at an academic medical center was undertaken. At baseline, standardized outcome measures including ODI and SF12 PCS were collected on all patients undergoing elective fusion surgery for degenerative spondylolisthesis. Multiple linear regressions were performed using change in SF12 PCS as the dependent variable and change in ODI components as the independent variables.

Results.

Baseline and 1-year follow-up data were collected on 196 patients (mean age 60.4 years). There were statistically significant differences in improvement among ODI items. Surprisingly, the most improvement after surgery was noted in the standing, sex life, and social life domains. The least improvement was noted in the personal care, sleeping, and sitting domains. Linear regression for change in ODI components versus change in SF-12 PCS revealed a significant correlation (R
2 = 0.353, P ≤ 0.001). The only retained domains in the final model were change in lifting, standing, and traveling as predictors for ΔPCS.

Conclusion.

All domains of the ODI do not improve equally after surgery for degenerative spondylolisthesis. Some of the domains that improve most (e.g., sex life) have no discernible relationship to the known pathophysiology of degenerative spondylolisthesis. Based upon these results, we conclude that the item bank and composite scoring of the ODI are inappropriate for evaluating quality of life in studies of surgically treated degenerative spondylolisthesis patients.

Level of Evidence: 3
Advances in understanding the molecular underpinnings of adrenocortical tumors
Authors: Nicolson Norman G. , Man Jianling , Carling Tobias
Published: October 2017

Purpose of review

Adrenocortical tumors are divided into benign adenomas and malignant carcinomas. The former is relatively common and carries a favorable prognosis, whereas the latter is rare and frequently presents at an advanced stage, with poor outcomes. Advances in next-generation sequencing, genome analysis, and bioinformatics have allowed for high-throughput molecular characterization of adrenal tumorigenesis.

Recent findings

Although recent genomic, epigenomic, and transcriptomic studies in large tumor cohorts have confirmed the central roles of aberrant Wnt/ß-catenin signaling, constitutive protein kinase A pathway activation, cell cycle dysregulation, and ion channelopathies in adrenal tumorigenesis, these studies also revealed novel signature events underlying malignant differentiation of adrenocortical carcinomas.

Recent advances in understanding of the molecular mechanisms underlying adrenocortical tumorigenesis provide new molecular diagnostic and prognostic tools and opportunities for novel therapeutic approaches. These findings are particularly important in adrenocortical carcinoma, for which current treatment options are limited.
Transient pituitary ACTH-dependent Cushing syndrome caused by an immune checkpoint inhibitor combination
Authors: Lupu Jeremy , Pages Cécile , Laly Pauline , Delyon Julie , Laloi Marie , Petit Antoine , Basset-Seguin Nicole , Oueslati Imen , Zagdanski Anne-Marie , Young Jacques , Bouche Clara , Lebbé Céleste , Gautier Jean-François
Published: October 2017

Immune checkpoint inhibitors have improved survival in numerous advanced malignancies, but are associated with a number of immune-related adverse events, including endocrinopathies. Endogenous Cushing’s syndrome (CS) is a rare disorder resulting from exposure to high levels of circulating cortisol. CS can be caused either by adrenal cortex tumors or hyperplasia or by pituitary or extra-pituitary tumors over-secreting ACTH (known as ACTH-dependent CS). We report the first case of transient ACTH-dependent CS, which appeared after combined ipilimumab and nivolumab therapy. Our patient presented typical clinical features of CS after three infusions of combined therapy, high serum and daily urinary free cortisol, and high serum ACTH levels. Pituitary MRI showed an enlargement of the pituitary gland suggesting ACTH secretion of pituitary origin, which was confirmed by inferior petrosal sinus sampling. The pituitary findings were preceded by thyroiditis. The evolution was characterized by spontaneous CS regression and subsequent appearance of severe corticotroph deficiency consistent with destructive hypophysitis. Immunotherapy is a novel cause of CS.
The Effect of Music Therapy on Anxiety and Various Physical Findings in Patients With COPD in a Pulmonology Service
Authors: Horuz Dilek , Kurcer Mehmet Ali , Erdoğan Zeynep
Published: October 2017

This interventional study was carried out to determine the effect of music therapy on anxiety and the various physical findings in patients with chronic obstructive pulmonary disease in the pulmonary diseases service. Ninety-six patients (28 females, 68 males) of 114 adult patients who were hospitalized between November 10, 2013, and March 10, 2014, were included in the study. Ninety-six patients were separated in 3 groups. The data for the study were collected from a questionnaire form of sociodemographic and clinical characteristics, a patient follow-up form, and the Beck Anxiety Scale. SPPS 11.5 was used for data analysis. The Kolmogorov-Smirnov Test was used to determine whether the data showed normal distribution. The nonparametric Kruskal-Wallis Test was used to determine the differences between mean anxiety scores on day 0, day 5, and day 15, and the differences in physiological findings on day 0, day 5, and day 15. There was a significant decrease in anxiety level average on day 5 (P ≤ .0001) and day 15 (P ≤ .0001) of the study in both the Western classical music and Turkish classical music groups compared with control group. There was also a significant decrease in systolic blood pressure and diastolic blood pressure averages in both music groups compared with control group (P ≤ .005). There was no significant difference in heart rates and respiration rate average between the Western classical music and Turkish classical music groups compared with the control group (P > .05).
SUPERFICIAL AND DEEP CAPILLARY ISCHEMIA AS A PRESENTING SIGN OF RETINAL VASCULOPATHY WITH CEREBRAL LEUKOENCEPHALOPATHY AND SYSTEMIC MANIFESTATIONS
Authors: Nagiel Aaron , Lalane Robert A. , Jen Joanna C. , Kreiger Allan E.
Published: October 2017

Purpose:

The aim of this study was to investigate the presenting sign of retinal vasculopathy with cerebral leukoencephalopathy and systemic manifestations, a rare autosomal dominant condition caused by mutations in the TREX1 gene, and to explore the potential efficacy of bevacizumab in preventing capillary occlusions.

Methods:

Observational case report with the use of ultra–widefield fluorescein angiography, optical coherence tomography, and optical coherence tomography angiography.

Results:

A 31-year-old man with a family history of retinal vasculopathy with cerebral leukoencephalopathy and systemic manifestations presented with a scotoma in his left eye. The visual acuity was 20/20 in both eyes, and his examination was notable for scattered cotton wool spots in the retina of both eyes as well as an area of paracentral acute middle maculopathy in the left eye. Ultra–widefield fluorescein angiography revealed peripheral capillary nonperfusion and vascular leakage corresponding to the cotton wool spots. Spectral domain optical coherence tomography and optical coherence tomography angiography confirmed the presence and distribution of superficial capillary plexus and deep capillary plexus ischemia. Neurologic examination and imaging were normal. A trial of monthly intravitreal bevacizumab injections to the left eye over 6 months resulted in diminished capillary leakage.

Conclusion:

Retinal vasculopathy with cerebral leukoencephalopathy and systemic manifestations is a rare genetic condition manifested most commonly by cerebral and retinal ischemia. This retinal vasculopathy leads to occlusions of small-caliber retinal vessels in the superficial plexus and deep plexus with resulting cotton wool spots and paracentral acute middle maculopathy, respectively. Recognition of the retinal findings by ophthalmologists and neurologists may avoid unnecessary brain biopsies in diagnosing this rare disorder.
“It Doesn't Make Sense for Us Not to Have One”—Understanding Reasons Why Community Sports Organizations Chose to Participate in a Funded Automated External Defibrillator Program
Authors: Fortington Lauren V. , Bekker Sheree , Morgan Damian , Finch Caroline F.
Published: October 2017

Objective:

Implementation of automated external defibrillators (AEDs) in community sports settings is an important component of emergency medical planning. This study aimed to understand motivations for why sports organizations participated in a government-funded program that provided AEDs and associated first-aid training.

Design:

Face-to-face interviews.

Setting:

Community sports organizations in Victoria, Australia.

Participants:

Representatives from 14 organizations who participated in a government-funded AED program.

Main Outcome Measures:

Motivations to participate in the AED program were explored using a qualitative descriptive approach.

Results:

Two overarching themes emerged: awareness of the program and decision to apply. Awareness was gained indirectly through grant advertising in newsletters/emails/web sites and directly through their sporting associations. For most organizations, there was no decision process per se, rather, the opportunity to apply was the key determinant for participating in the program. A duty of care also emerged as a key driving factor, with recognition of AEDs as a valuable asset to communities broadly, not just the participants' immediate sports setting. Reflecting on participation in the program, these participants identified that it was important to increase awareness about AED ownership and use. The program benefits were clearly summed up as being best prepared for a worst-case scenario.

Discussion:

This study provides new understanding of why community sports organizations apply for an AED and training. The strongest reason was simply the opportunity to acquire this at no cost. Therefore, for wider implementation of AEDs, additional funding opportunities, targeted awareness of these opportunities, and continued promotion of AED importance are recommended.
Effect of a Commercially Available Footwear Insole on Biomechanical Variables Associated With Common Running Injuries
Authors: Lewinson Ryan T. , Stefanyshyn Darren J.
Published: October 2017

Objective:

To determine whether Dr. Scholl's Active Series (DSAS) footwear insoles alter biomechanical variables associated with running injuries.

Design:

Randomized, controlled experiment.

Setting:

Sport medicine and biomechanics gait analysis laboratory.

Participants:

Fifteen healthy adults.

Interventions:

The control condition was the participant's own athletic footwear. The experimental condition was the participant's own athletic footwear plus a DSAS insole. Participants completed running gait analysis trials with each condition.

Main Outcome Measures:

Peak vertical loading rates (VLRs), peak ankle eversion velocities (AEVs), peak ankle eversion angles (AEAs), and knee abduction angular impulses (KAAIs) were calculated and compared between the control and DSAS conditions because these variables have been associated with plantar fasciitis (VLRs), tibial stress syndrome (AEVs, AEAs), and patellofemoral pain syndrome (KAAIs).

Results:

Dr. Scholl's Active Series insoles reduced VLRs across participants by 16% (P < 0.001) but had no consistent influence on AEVs, AEAs, or KAAIs. Participant-specific responses showed that most runners either experienced AEA and KAAI reductions or no change with the DSAS insole, whereas AEVs commonly increased with the DSAS insole.

Conclusions:

Dr. Scholl's Active Series insoles demonstrate efficacy in reducing VLRs, which are associated with plantar fasciitis. Biomechanical changes to variables associated with tibial stress syndrome (AEVs, AEAs) and patellofemoral pain syndrome (KAAIs) were inconsistent.
Individualized Biventricular Epicardial Augmentation Technology in a Drug-Induced Porcine Failing Heart Model
Authors: Jagschies Lasse , Hirschvogel Marc , Matallo Jose , Maier Andreas , Mild Karin , Brunner Horst , Hinkel Rabea , Gee Michael W. , Radermacher Peter , Wildhirt Stephen M. , Hafner Sebastian
Published: October 2017

For treatment of advanced heart failure, current strategies include cardiac transplantation or blood-contacting pump technology associated with complications, including stroke and bleeding. This study investigated an individualized biventricular epicardial augmentation technology in a drug-induced porcine failing heart model. A total of 11 pigs were used, for the assessment of hemodynamics and cardiac function under various conditions of support pressures and support durations (n = 4), to assess device positioning and function by in vivo computer tomographic imaging (n = 3) and to investigate a minimally invasive implantation on the beating heart (n = 4). Support pressures of 20–80 mm Hg gradually augmented cardiac function parameters in this animal model as indicated by increased left ventricular stroke volume, end-systolic pressures, and decreased end-diastolic pressures. Strong evidence was found regarding the necessity of mechanical synchronization of support end with the isovolumetric relaxation phase of the heart. In addition, the customized, self-expandable implant enabled a marker-guided minimally invasive implantation through a 4 cm skin incision using fluoroscopy. Correct positioning was confirmed in computer tomographic images. Continued long-term survival investigations will deliver preclinical evidence for further development of this concept.
The Impact of Obesity on Mortality and Other Outcomes in Patients With Nonvariceal Upper Gastrointestinal Hemorrhage in the United States
Authors: Abougergi Marwan S. , Peluso Heather , Mrad Chebli , Saltzman John R.
Published: October 2017

Goals:

To quantify in patients with nonvariceal upper gastrointestinal hemorrhage (NVUGIH) the relationship between obesity and mortality, disease severity, treatment modalities, and resource utilization.

Background:

NVUGIH is the most common gastrointestinal emergency.

Study:

Adults with a principal diagnosis of NVUGIH were selected from the 2014 National Inpatient Sample. The primary outcome was in-hospital mortality. Secondary outcomes were hemorrhagic shock, prolonged mechanical ventilation (PMV), upper endoscopy [esophagogastroduodenoscopy (EGD)], radiologic treatment, surgery, length of hospital stay (LOS), and total hospitalization costs and charges. Confounders were adjusted for using multivariable regression analyses.

Results:

In total, 227,480 admissions with NVUGIH were included, 11.70% of whom were obese. Obese and nonobese patients had similar odds of mortality (aOR: 0.88; 95% confidence interval [CI]: 0.69-1.12; P=0.30), EGD within 24 hours of admission (aOR: 0.95; CI: 0.89-1.01; P=0.10), radiologic treatment (aOR: 1.06; CI: 0.82-1.35; P=0.66), and surgery (aOR: 1.27; CI: 0.94-1.70; P=0.11). However, obese patients had higher odds of shock (aOR: 1.30; CI: 1.14-1.49; P<0.01), PMV (aOR: 1.39; CI: 1.18-1.62; P<0.01), undergoing an EGD (aOR: 1.27; CI: 1.16-1.40; P<0.01), needing endoscopic therapy (aOR: 1.18; CI: 1.09-1.27; P<0.01), a longer LOS (0.31 d; CI: 0.16-0.46 d; P<0.01), higher costs ($1075; CI: $636-$1514; P<0.01), and higher charges ($4084; CI: $2060-$6110; P<0.01) compared with nonobese patients.

Conclusions:

Obesity is not an independent predictor of NVUGIH mortality. However, obesity is associated with a more severe disease course (shock and PMV), higher rates of EGD and endoscopic therapy use, and significant increases in resource utilization (hospital LOS, total hospitalization costs, and charges).
Dysregulated myelopoiesis and hematopoietic function following acute physiologic insult
Authors: Loftus Tyler J. , Mohr Alicia M. , Moldawer Lyle L.
Published: October 2017

Purpose of review

The purpose of this review is to describe recent findings in the context of previous work regarding dysregulated myelopoiesis and hematopoietic function following an acute physiologic insult, focusing on the expansion and persistence of myeloid-deriver suppressor cells, the deterioration of lymphocyte number and function, and the inadequacy of stress erythropoiesis.

Recent findings

Persistent myeloid-derived suppressor cell (MDSC) expansion among critically ill septic patients is associated with T-cell suppression, vulnerability to nosocomial infection, chronic critical illness, and poor long-term functional status. Multiple approaches targeting MDSC expansion and suppressor cell activity may serve as a primary or adjunctive therapeutic intervention. Traumatic injury and the neuroendocrine stress response suppress bone marrow erythropoietin receptor expression in a process that may be reversed by nonselective beta-adrenergic receptor blockade. Hepcidin-mediated iron-restricted anemia of critical illness requires further investigation of novel approaches involving erythropoiesis-stimulating agents, iron administration, and hepcidin modulation.

Emergency myelopoiesis is a dynamic process with unique phenotypes for different physiologic insults and host factors. Following an acute physiologic insult, critically ill patients are subject to persistent MDSC expansion, deterioration of lymphocyte number and function, and inadequate stress erythropoiesis. Better strategies are required to identify patients who are most likely to benefit from targeted therapies.
First-Trimester Crown-Rump Length and Risk of Chromosomal Aberrations—A Systematic Review and Meta-analysis
Authors: Sagi-Dain Lena , Peleg Amir , Sagi Shlomi
Published: October 2017

Importance

Lower than expected first-trimester crown-rump length (CRL) is a common sonographic finding, usually leading to reassessment of gestational age.

Objective

The aim of this study was to perform a meta-analysis defining the risk of chromosomal aberrations in pregnancies with decreased first-trimester CRL.

Evidence Acquisition

A search was conducted by a research librarian in 5 databases, with no time or language restrictions. Original researches examining the risk of chromosomal aberrations in pregnancies with low CRL were selected. The effect estimates were presented as odds ratios with 95% confidence intervals).

Results

Following screening of 3894 references, 12 articles were selected. Only 2 articles directly fulfilled the review goals, comparing the rates of chromosomal aberrations in small-CRL versus normal-CRL fetuses. Combined analysis of these 2 studies, encompassing a total of 403 fetuses with small CRL and 4047 control pregnancies, yielded an odds ratio of 5.54 (95% confidence interval, 1.2–26.1) for abnormal karyotype in small-CRL fetuses. Ten studies compared CRL in fetuses with specific chromosomal aberrations to pregnancies with normal karyotype, yielding a significant growth delay in fetuses with trisomy 18 (6 of 7 articles) and triploidy, but not in fetuses with trisomy 21. Overall quality of evidence was rated as “very low” using Grading of Recommendations Assessment, Development and Evaluation criteria.

Conclusions and Relevance

Our review results indicate that low first-trimester CRL might be associated with a significantly increased risk of chromosomal anomalies. Thus, invasive prenatal testing or cell-free DNA screening might be offered in such pregnancies, particularly if dating is certain.

Target Audience

Obstetricians and gynecologists, family physicians.

Learning Objectives

After completing this activity, the learner should be better able to describe the paucity of existing literature examining the risk of chromosomal aberrations in pregnancies with decreased first-trimester CRL, discuss the questionability of routine recommendation for gestational age correction in such pregnancies, and recall the appropriate management of such cases, including frequent sonographic fetal growth follow-up and detailed scan for sonographic anomalies, with possible consideration of invasive prenatal testing.