bluuebunny/crossref_metadata_2025 huggingface dataset:
Encouraging Student Interest in Teaching Through a Medical Student Teaching Competition
Authors: DeSimone Ariadne K. , Haydek John P. , Sudduth Christopher L. , LaBarbera Vincent , Desai Yaanik , Reinertsen Erik , Manning Kimberly D.
Published: December 2016

Problem

Clinician educators have realized the value not only of assigning teaching roles to medical students but also of offering explicit training in how to teach effectively. Despite this interest in the development of medical students’ teaching skills, formal teaching instruction and opportunities for practice are lacking.

Approach

To encourage medical student interest in teaching, the authors developed and implemented a medical student teaching competition (MSTC) at Emory University School of Medicine during the summers of 2014, 2015, and 2016. Each year, eight student finalists were each paired with a physician “teaching coach” and given one month to prepare for the MSTC. During the competition, each finalist delivered an eight-minute presentation to a panel of seven physician and resident judges. The authors describe the development, implementation, and assessment of the MSTC.

Outcomes

Approximately 150 medical students and faculty members attended the MSTC each year. The students in attendance felt that the MSTC made them more likely to seek out opportunities to learn how to teach effectively and to practice teaching. Additionally, some students are now more interested in learning about a career in academic medicine than they were before the MSTC.

Next Steps

Given the need for more formal initiatives dedicated to improving the teaching skills of doctors-in-training, including medical students, innovative solutions such as the MSTC may enhance a medical school’s existing curriculum and encourage student interest in teaching. The MSTC model may be generalizable to other medical schools.
At a Crossroads: Family Medicine Education in China
Authors: Wu Dan , Lam Tai Pong
Published: December 2016

China is engaged in efforts to train 300,000 family doctors by 2020 to meet its population’s health care needs. This Article discusses the family doctor shortage, compares family medicine training programs, examines the distributional challenges faced by these programs, and proposes directions for further experimentation. Despite an increasing number of family doctors, they represented only 5.6% of all doctors in 2013. Currently, three training programs run concurrently—the post-transfer training, residency training, and designated family medicine undergraduate education programs. These programs face several challenges. First, the educational qualifications of primary care practitioners (PCPs) vary greatly between rural and urban regions. From 2005 to 2013, the percentage of PCPs with three or more years of medical training in urban areas was at least 20.0% higher than in rural areas. Second, regional disparities in the number of family doctors for every 10,000 people exist. The richer eastern part of China has a ratio of 1.51 family doctors for every 10,000 people, nearly double that of central (0.70) and western China (0.86). Third, better-educated doctors are most likely going to prefer to work in hospitals, which offer a lucrative career path with higher pay and social status. Intervention packages that combine student selection policies that look at place of origin and career intent with other incentive strategies are worth implementing. Adequate clinical exposure and regular, rigorous evaluations are crucial for enhancing training quality. China should strike a balance in the distribution of family doctors between the richer and poorer areas to ensure equity.
Advancing Nursing Research in the Visual Era
Authors: Evans-Agnew Robin A. , Boutain Doris M. , Rosemberg Marie-Anne S.
Published: December 2016

Photovoice is a powerful research method that employs participant photography for advancing voice, knowledge, and transformative change among groups historically or currently marginalized. Paradoxically, this research method risks exploitation of participant voice because of weak methodology to method congruence. The purposes of this retrospective article are to revisit current interdisciplinary research using photovoice and to suggest how to advance photovoice by improving methodology-method congruence. Novel templates are provided for improving the photovoice process across phenomenological, grounded theory, and critical theory methodologies.
Thinking Upstream
Authors: Butterfield Patricia G.
Published: December 2016

Thinking upstream was first introduced into the nursing vernacular in 1990 with the goal of advancing broad and context-rich perspectives of health. Initially invoked as conceptual framing language, upstream precepts were subsequently adopted and adapted by a generation of thoughtful nursing scholars. Their work reduced health inequities by redirecting actions further up etiologic pathways and by emphasizing economic, political, and environmental health determinants. US health care reform has fostered a much broader adoption of upstream language in policy documents. This article includes a semantic exploration of thinking upstream and a new model, the Butterfield Upstream Model for Population Health (BUMP Health).
Practical Issues of Conducting a Q Methodology Study
Authors: Stone Teresa Elizabeth , Maguire Jane , Kang Sook Jung , Cha Chiyoung
Published: December 2016

This article advances nursing research by presenting the methodological challenges experienced in conducting a multination Q-methodology study. This article critically analyzes the relevance of the methodology for cross-cultural and nursing research and the challenges that led to specific responses by the investigators. The use of focus groups with key stakeholders supplemented the Q-analysis results. The authors discuss practical issues and shared innovative approaches and provide best-practice suggestions on the use of this flexible methodology. Q methodology has the versatility to explore complexities of contemporary nursing practice and cross-cultural health research.
Macroprolactinomas and Nonfunctioning Pituitary Adenomas and Pregnancy Outcomes
Authors: Lambert Kimberley , Rees Kate , Seed Paul T. , Dhanjal Mandish K. , Knight Marian , McCance David R. , Williamson Catherine
Published: December 2016

OBJECTIVE:

To examine the monitoring, management, and outcomes of pituitary tumors in pregnancy.

METHODS:

A national, prospective, observational, population-based case series study was conducted in all U.K. consultant-led obstetric units over 3 years using the U.K. Obstetric Surveillance System. To evaluate rates of adverse pregnancy outcomes, women with a macroprolactinoma (10 mm or greater) or nonfunctioning pituitary adenoma, diagnosed before or during pregnancy, were compared with two comparison groups: 1) a U.K. Obstetric Surveillance System cohort with singleton (n=2,205) or twin (n=27) pregnancy; and 2) data from the Office of National Statistics (n=2,703,102). Main outcome measures were the incidence, management, and frequency of adverse maternal and offspring outcomes of pituitary tumors in pregnancy.

RESULTS:

There were 71 confirmed cases of pituitary tumors in pregnancy (49 macrolactinoma, 16 nonfunctioning adenomas, three acromegaly, three Cushing's disease). The women with pituitary tumors were 4 years older than comparison women (P<.001). None of the nine women treated with surgery or radiotherapy before pregnancy had symptomatic tumor expansion. This occurred in 6 of 40 women with macroprolactinomas and one of seven nonfunctioning adenomas diagnosed before conception and in three of five women with nonfunctioning adenomas diagnosed in pregnancy. Two women had pituitary apoplexy, both of whom also had symptoms of expansion of tumor or surrounding pituitary tissue. To within the level of accuracy possible, there was no evidence that pituitary tumors were associated with adverse pregnancy outcomes (pregnancy-induced hypertension, preeclampsia, preterm labor, stillbirth). Women with nonfunctioning adenomas were more likely to have cesarean delivery compared with women in a control group (relative risk 2.06, confidence interval 1.26–3.36,P=.035).

CONCLUSION:

The majority of women with macroprolactinomas and nonfunctioning adenomas have good pregnancy outcomes. Nonfunctioning pituitary adenomas occur more commonly in pregnancy than previously thought and can present de novo with symptoms of pituitary expansion in pregnancy.
Ovarian Conservation and Overall Survival in Young Women With Early-Stage Cervical Cancer
Authors: Matsuo Koji , Machida Hiroko , Shoupe Donna , Melamed Alexander , Muderspach Laila I. , Roman Lynda D. , Wright Jason D.
Published: December 2016

OBJECTIVE:

To identify predictors of ovarian conservation at hysterectomy and to examine the association of ovarian conservation and survival of young women with early-stage cervical cancer.

METHODS:

This is a retrospective cohort study using the Surveillance, Epidemiology, and End Results Program to identify hysterectomy-based surgically treated patients with stage I cervical cancer diagnosed between 1983 and 2012 (N=16,511). Multivariable models were used to identify independent factors associated with ovarian conservation. Among the subgroup of 9,419 women younger than 50 years of age with stage I disease, survival outcomes and causes of death were examined for 3,908 (41.5%) women who underwent ovarian conservation at hysterectomy without radiotherapy.

RESULTS:

On multivariable analysis, age younger than 50 years, stage IA disease, and squamous histology were independent factors associated with ovarian conservation (all, P<.001). Among 5,526 women younger than 50 years of age with stage IA disease who underwent hysterectomy without radiotherapy, overall survival was significantly higher in patients undergoing ovarian conservation than in those undergoing oophorectomy (20-year rate, 93.5% compared with 86.8%, P<.001); cervical cancer–specific survival was similar between the patients who underwent ovarian conservation and those who underwent oophorectomy (98.8% compared with 97.8%, P=.12). On multivariable analysis, ovarian conservation remained an independent prognostic factor for improved overall survival (adjusted hazard ratio 0.63, 95% confidence interval [CI] 0.49–0.82, P=.001) and was independently associated with lower cumulative risks of death resulting from cardiovascular disease (20-year cumulative rate, 1.2% compared with 3.3%, adjusted hazard ratio 0.47, 95% CI 0.26–0.86, P=.014) and other chronic disease (0.5% compared with 1.4%, adjusted hazard ratio 0.24, 95% CI 0.09–0.65, P=.005) compared with oophorectomy. Both cervical cancer–specific survival (20-year rate, 93.1% compared with 92.0%, P=.37) and overall survival (86.7% compared with 84.6%, P=.12) were similar between ovarian conservation and oophorectomy among 3,893 women younger than 50 years of age with stage IB disease who underwent hysterectomy without radiotherapy.

CONCLUSION:

Among young women with stage IA cervical cancer, ovarian conservation at hysterectomy is associated with decreased all-cause mortality including death resulting from cardiovascular disease and other chronic diseases.
Association of Gestational Weight Gain Expectations and Advice on Actual Weight Gain
Authors: Krukowski Rebecca A. , West Delia S. , DiCarlo Marisha , Cleves Mario A. , Saylors Marie E. , Andres Aline
Published: December 2016

OBJECTIVE:

To examine pregnant women's gestational weight gain expectations and advice from various sources (ie, self, family and friends, physician) and the association of these sources of expectations and advice with measured gestational weight gain.

METHODS:

This is a secondary analysis of a cohort study of 230 pregnant women in their second pregnancy. Each woman was queried at 12 weeks of gestation about the amount of weight: 1) she felt was “healthy” to gain, 2) she expected to gain, 3) her friends and family thought she should gain, and 4) the specificity of her physician's advice about gestational weight gain. Gestational weight gain was calculated as the difference in measured weight between 4 and 10 weeks and 36 weeks of gestation. Odds ratios and corresponding 95% confidence intervals were computed for the association between excessive gestational weight gain and each question using logistic regression in this secondary analysis.

RESULTS:

Participants were 87.4% Caucasian. Overweight and obese women were significantly more likely to expect excessive gestational weight gain compared with normal-weight women. Women who reported expecting to gain excessively were significantly more likely to actually gain excessively (52%; odds ratio [OR] 3.19, 95% confidence interval [CI] 1.77–5.77) than those who expected to gain within the guidelines (36%). After adjusting for self-reported gestational weight gain in the first pregnancy and sociodemographic characteristics, women who reported expecting to gain excessively were still significantly more likely to gain excessively (51%; OR 2.22, 95% CI 1.08–4.56) than those who expected to gain within guidelines (37%).

CONCLUSION:

It may be particularly important to develop interventions that positively influence women's own expectations for gestational weight gain.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, https://clinicaltrials.gov, NCT01131117.
Neonatal Abstinence Syndrome and Ethical Approaches to the Identification of Pregnant Women Who Use Drugs
Authors: Terplan Mishka , Minkoff Howard
Published: December 2016

The United States is experiencing an epidemic of opioid use, addiction, and neonatal abstinence syndrome. Consequentially, a great deal of public, and public health, attention has turned toward the timely recognition of pregnant women who use drugs. We explore the clinical efficacy and ethical acceptability of different methods of identification—contrasting drug testing (using biologic samples such as urine) with screening (using an instrument or questionnaire) under both universal and selective approaches within the current legal and social landscape, which is fraught with potential adverse consequences for both the woman and her child. Unlike other medical conditions such as diabetes, the sequelae of drug use in pregnancy can go beyond the clinical, because its assessment may result in child removal as well as maternal arrest, prosecution, and punishment. Although universal voluntary screening using a validated instrument is the most reasonable public health strategy, physicians should advocate for that only as strongly as they advocate for social support and addiction care services for those subsequently identified.
Group B Streptococci Screening Before Repeat Cesarean Delivery
Authors: Albright Catherine M. , MacGregor Caitlin , Sutton Desmond , Theva Meena , Hughes Brenna L. , Werner Erika F.
Published: December 2016

OBJECTIVE:

To estimate the cost-effectiveness of universal group B streptococci (GBS) screening in women with a singleton pregnancy planning a repeat cesarean delivery.

METHODS:

We conducted a decision analysis from a health care perspective to compare the cost-effectiveness of GBS screening for women planning a repeat cesarean delivery. With universal screening, all GBS-positive women who labored before a scheduled cesarean delivery received antibiotic prophylaxis. With no screening, women who presented in labor received antibiotics based on risk-based criteria. Neonates born to women colonized with GBS were at risk for early-onset GBS disease, disability, and death. We assumed a GBS prevalence of 25%, that 26.6% of women labored between 35 weeks of gestation and their scheduled time for cesarean delivery, and that 3.3% who planned a repeat cesarean delivery instead delivered vaginally. The primary outcome was cost per neonatal quality-adjusted life-year gained, with a cost-effectiveness threshold of $100,000 per quality-adjusted life-year. Neonatal quality of life was assessed using five health states (healthy, mild, moderate, or severe disability, and death) with a life expectancy of 79 years for healthy neonates. One-way sensitivity and Monte Carlo analyses were used to evaluate the results.

RESULTS:

In the base case, universal GBS screening in women planning a repeat cesarean delivery was not cost-effective compared with no screening, costing $114,445 per neonatal quality-adjusted life-year gained. The cost to prevent an adverse outcome from GBS exceeded $400,000. If greater than 28% of women were GBS-positive, greater than 29% labored before their scheduled delivery, or greater than 10% delivered vaginally, universal screening became cost effective.

CONCLUSION:

Universal GBS screening in women with a singleton pregnancy planning a repeat cesarean delivery may not be cost-effective in all populations. However, in populations with a high GBS prevalence, women at high risk of laboring before their scheduled cesarean delivery, or women who may ultimately opt for a vaginal delivery, GBS screening may be cost effective.
Cervical Cancer Screening Guideline Adherence Before and After Guideline Changes in Pennsylvania Medicaid
Authors: Parekh Natasha , Donohue Julie M. , Men Aiju , Corbelli Jennifer , Jarlenski Marian
Published: December 2016

OBJECTIVE:

To assess changes in cervical cancer screening after the 2009 American College of Obstetricians and Gynecologists' guideline change and to determine predictors associated with underscreening and overscreening among Medicaid-enrolled women.

METHODS:

We performed an observational cohort study of Pennsylvania Medicaid claims from 2007 to 2013. We evaluated guideline adherence of 18- to 64-year-old continuously enrolled women before and after the 2009 guideline change. To define adherence, we categorized intervals between Pap tests as longer than (underscreening), within (appropriate screening), or shorter than (overscreening) guideline-recommended intervals (±6-month). We stratified results by age and assessed predictors of underscreening and overscreening through logistic regression.

RESULTS:

Among 29,650 women, appropriate cervical cancer screening significantly decreased after the guideline change (from 45% [95% confidence interval (CI) 44–46%] to 11% [95% CI 11–12%] among 17,360 younger than 30 year olds and from 27% [95% CI 26–28%] to 6% [95% CI 6–7%] among 12,290 women 30 years old or older). Overscreening significantly increased (from 6% [95% CI 5–6%] to 67% [95% CI 66–68%] in those younger than 30 years old and from 54% [95% CI 52–55%] to 65% [95% CI 64–67%] in those 30 years old or older), whereas underscreening significantly increased only in those 30 years old or older (from 20% [95% CI 19–21%] to 29% [95% CI 27–30%]). Pap tests after guideline change, pregnancy, Managed Care enrollment (in those younger than 30 years old), and black race (in those younger than 30 years old) were associated with underscreening. Pap tests after guideline change, more visits, more sexually transmitted infection testing, and white race (in those 30 years old or older) were associated with overscreening.

CONCLUSION:

We observed high rates of cervical cancer overscreening and underscreening and low rates of appropriate screening after the guideline change. Interventions should target both underscreening and overscreening to address these separate yet significant issues.
Association Between Sleep-Disordered Breathing and Hypertensive Disorders of Pregnancy and Gestational Diabetes Mellitus
Authors: Facco Francesca L. , Parker Corette B. , Reddy Uma M. , Silver Robert M. , Koch Matthew A. , Louis Judette M. , Basner Robert C. , Chung Judith H. , Nhan-Chang Chia-Ling , Pien Grace W. , Redline Susan , Grobman William A. , Wing Deborah A. , Simhan Hyagriv N. , Haas David M. , Mercer Brian M. , Parry Samuel , Mobley Daniel , Hunter Shannon , Saade George R. , Schubert Frank P. , Zee Phyllis C.
Published: December 2016

OBJECTIVE:

To estimate whether sleep-disordered breathing during pregnancy is a risk factor for the development of hypertensive disorders of pregnancy and gestational diabetes mellitus (GDM).

METHODS:

In this prospective cohort study, nulliparous women underwent in-home sleep-disordered breathing assessments in early (6–15 weeks of gestation) and midpregnancy (22–31 weeks of gestation). Participants and health care providers were blinded to the sleep test results. An apnea–hypopnea index of 5 or greater was used to define sleep-disordered breathing. Exposure–response relationships were examined, grouping participants into four apnea–hypopnea index groups: 0, greater than 0 to less than 5, 5 to less than 15, and 15 or greater. The study was powered to test the primary hypothesis that sleep-disordered breathing occurring in pregnancy is associated with an increased incidence of preeclampsia. Secondary outcomes were rates of hypertensive disorders of pregnancy, defined as preeclampsia and antepartum gestational hypertension, and GDM. Crude and adjusted odds ratios and 95% confidence intervals (CIs) were calculated from univariate and multivariate logistic regression models.

RESULTS:

Three thousand seven hundred five women were enrolled. Apnea–hypopnea index data were available for 3,132 (84.5%) and 2,474 (66.8%) women in early and midpregnancy, respectively. The corresponding prevalence of sleep-disordered breathing was 3.6% and 8.3%. The prevalence of preeclampsia was 6.0%, hypertensive disorders of pregnancy 13.1%, and GDM 4.1%. In early and midpregnancy the adjusted odds ratios for preeclampsia when sleep-disordered breathing was present were 1.94 (95% CI 1.07–3.51) and 1.95 (95% CI 1.18–3.23), respectively; hypertensive disorders of pregnancy 1.46 (95% CI 0.91–2.32) and 1.73 (95% CI 1.19–2.52); and GDM 3.47 (95% CI 1.95–6.19) and 2.79 (95% CI 1.63–4.77). Increasing exposure–response relationships were observed between apnea–hypopnea index and both hypertensive disorders and GDM.

CONCLUSION:

There is an independent association between sleep-disordered breathing and preeclampsia, hypertensive disorders of pregnancy, and GDM.
Anti-programmed cell death protein 1 tolerance and efficacy after ipilimumab immunotherapy: observational study of 39 patients
Authors: Amode Reyhan , Baroudjian Barouyr , Kowal Anita , Jebali Majdi , Allayous Clara , Bagot Martine , Madjlessi Nika , Roux Jennifer , Viguier Manuelle , Basset Seguin Nicole , Porcher Raphaël , Pagès Cécile , Lebbé Céleste
Published: December 2016

In patients with ipilimumab (IPI)-refractory melanoma, the anti-programmed cell death proteins 1 (PD1s) nivolumab (NIV) and pembrolizumab (PEM) are considered to be a new standard of treatment. Few data are available on anti-PD1 safety in patients who develop IPI-related severe adverse events (AEs) (grade≥3). The aim of this study was to compare the anti-PD1 safety and efficacy in patients with previous severe toxicity to IPI versus in those showing moderate and no previous IPI-related AEs. This single institution-based observational study included all patients treated with anti-PD1 (PEM or NIV) and previously treated with IPI for unresectable stage III or IV melanoma. The patients enrolled were classified according to the occurrence of IPI-related AEs: group A: no previous IPI-related AEs; group B: mild to moderate IPI-related AEs; and group C: severe to life-threatening IPI-related AEs. The main outcome measure was safety of the anti-PD1 among the three groups. The secondary endpoints included response parameters. Groups A, B, and C included, respectively, 16, 13, and 10 patients. The incidence of severe anti-PD1-related AEs (grades 3–4) was 12, 23, and 10% in groups A, B, and C, respectively. One-year estimates of survival were 52.2, 73.4, and 66.7% among the patients in groups A, B, and C, respectively. The number of patients was too small to enable a meaningful statistical comparison. We did not observe any difference in anti-PD1 toxicity onset incidence according to the occurrence of previous IPI AEs. These reassuring real-life data should be confirmed in a wider analysis.
Systematic Review and Meta-analysis of Prophylactic Mesh During Primary Stoma Formation to Prevent Parastomal Hernia
Authors: Chapman Stephen J. , Wood Benjamin , Drake Thomas M. , Young Neville , Jayne David G.
Published: December 2016

BACKGROUND:

Implantation of mesh at the time of stoma formation may reduce the rate of parastomal hernia. Until recently, the evidence has been limited to only a few small randomized controlled trials.

OBJECTIVE:

We present an updated systematic review and meta-analysis to assess the effect of mesh prophylaxis on rates of parastomal hernia. We examine ongoing and unpublished trials via online registries and propose recommendations for future research.

DATA SOURCES:

MEDLINE, EMBASE, and the Cochrane Library were searched up to March 2016 for published randomized controlled trials. Sixteen international trial registries were inspected for ongoing and unpublished trials.

STUDY SELECTION:

Randomized controlled trials comparing mesh versus no mesh on the incidence of parastomal hernia after colostomy or ileostomy formation were selected.

MAIN OUTCOME MEASURES:

The primary outcome measure was rate of parastomal hernia at least 12 months after stoma formation. Secondary outcomes included rates of stoma-related complications.

RESULTS:

Of 3005 studies identified, 7 randomized controlled trials (432 patients) were eligible for inclusion in the final analysis. All were at high risk of bias. Mesh reduced the incidence of clinically detected parastomal hernia (10.8% vs 32.4%; p = 0.001) (risk ratio, 0.34; 95% CI, 0.18–0.65; I
2 = 39%) and the rate of radiologically detected parastomal hernia (34.6% vs 55.3%; p = 0.01) (risk ratio, 0.61; 95% CI, 0.42–0.89; I
2 = 44%). No increase in the incidence of stoma-related complications was observed with the use of prophylactic mesh. Results from ongoing and unpublished randomized controlled trials are expected, but few will report on alternative mesh types or surgical techniques.

LIMITATIONS:

Heterogeneity of interventions, small patient populations, and a high risk of bias seen in all studies implicate cautious interpretation of the results.

CONCLUSION:

Mesh prophylaxis at the time of stoma formation appears safe and effective in preventing parastomal hernia; however, limitations of the primary evidence justify larger, more rigorous randomized controlled trials.
Postoperative Venous Thromboembolism in Patients Undergoing Abdominal Surgery for IBD: A Common but Rarely Addressed Problem
Authors: Brady Matthew T. , Patts Gregory J. , Rosen Amy , Kasotakis George , Siracuse Jeffrey J. , Sachs Teviah , Kuhnen Angela , Kunitake Hiroko
Published: December 2016

BACKGROUND:

Venous thromboembolism after abdominal surgery occurs in 2% to 3% of patients with Crohn’s disease and ulcerative colitis. However, no evidence-based guidelines currently exist to guide postdischarge prophylactic anticoagulation.

OBJECTIVE:

We sought to determine the use of postoperative postdischarge venous thromboembolism chemical prophylaxis, 90-day venous thromboembolism rates, and factors associated with 90-day thromboembolic events in IBD patients following abdominal surgery.

DESIGN:

This was a retrospective evaluation of an administrative database.

DATA SOURCE:

Data were obtained from Optum Labs Data Warehouse, a large administrative database containing claims on privately insured and Medicare Advantage enrollees.

PATIENTS:

Seven thousand seventy-eight patients undergoing surgery for Crohn’s disease or ulcerative colitis were included in the study.

MAIN OUTCOME MEASURES:

Primary outcomes were rates of postdischarge venous thromboembolism prophylaxis and 90-day rates of postdischarge thromboembolic events. In addition, patient clinical characteristics were identified to determine predictors of postdischarge venous thromboembolism.

RESULTS:

Postdischarge chemical prophylaxis was given to only 0.6% of patients in the study. Two hundred thirty-five patients (3.3%) developed a postdischarge thromboembolic complication. Postdischarge thromboembolism was more common in patients with ulcerative colitis than with Crohn’s disease (5.8% vs 2.3%; p < 0.001). Increased rates of venous thromboembolism were seen in patients undergoing colectomy or proctectomy with simultaneous stoma creation compared with colectomy or proctectomy alone (5.8% vs 2.1%; p < 0.001). The strongest predictors of thromboembolic complications were stoma creation (adjusted OR, 1.95; 95% CI, 1.34–2.84), J-pouch reconstruction (adjusted OR, 2.66; 95% CI, 1.65–4.29), preoperative prednisone use (adjusted OR, 1.57; 95% CI, 1.19–2.08), and longer length of stay (adjusted OR, 1.89; 95% CI, 1.41–2.52).

LIMITATIONS:

This study is limited by its retrospective design.

CONCLUSIONS:

The use of postdischarge venous thromboembolism prophylaxis in this patient sample was infrequent. Development of evidence-based guidelines, particularly for high-risk patients, should be considered to improve the outcomes of IBD patients undergoing abdominal surgery.
Using Modified Frailty Index to Predict Safe Discharge Within 48 Hours of Ileostomy Closure
Authors: Wen Yuxiang , Jabir Murad A. , Dosokey Eslam M. G. , Choi Dongjin , Petro Clayton C. , Brady Justin T. , Steele Scott R. , Delaney Conor P.
Published: December 2016

BACKGROUND:

Enhanced recovery pathways allow for safe discharge and optimal outcomes within 48 hours after ileostomy closure. Unfortunately, some patients undergoing ileostomy closure have prolonged hospital stays. We have shown previously that the Modified Frailty Index can help predict patients who will fail early discharge after laparoscopic colorectal surgery.

OBJECTIVE:

The purpose of this study was to use the Modified Frailty Index to identify patients who were safe for early discharge after ileostomy closure.

DESIGN:

This was a retrospective review.

SETTINGS:

The study was conducted at a tertiary referral center.

PATIENTS:

Patients who underwent ileostomy closure (2006–2015) were stratified into early (≤48 hours) and late discharge groups.

MAIN OUTCOME MEASURES:

The Modified Frailty Index, morbidity, and readmission rates were measured.

RESULTS:

A total of 272 patients undergoing ileostomy closure were evaluated. Overall length of stay was 3.64 days (±3.23 days), with 114 patients (42%) discharged within 48 hours. Sex, age, and ASA scores were similar between early and later discharge groups (p > 0.2). Univariate logistic regression demonstrated that a Modified Frailty Index score of 0 was associated with early discharge (p = 0.03), whereas a Modified Frailty Index score ≤1 and ≤2 were not. There was no significant association between the Modified Frailty Index and complication or readmission rates. Postoperative complications occurred in 39 patients (14.3%), and 1 patient died secondary to an anastomotic leak. Fifteen patients (5.5%) were readmitted within 30 days. Readmission rate within 30 days was 3.2%, with a Modified Frailty Index score of 0, 6.1% for a Modified Frailty Index score of <1, and 5.9% for a Modified Frailty Index score of <2, for which there was not an association based on univariate logistic regression (Modified Frailty Index = 0, p = 0.13; <1, p = 0.55; <2, p = 0.53).

LIMITATIONS:

The study was limited by nature of being a retrospective review.

CONCLUSIONS:

Patients undergoing ileostomy closure with a Modified Frailty Index score of 0 are associated with higher rates of discharge within 48 hours of ileostomy closure surgery than those with a higher Modified Frailty Index, without higher readmission rates. This information can be helpful to better manage patient and resource use expectations for the duration of inpatient recovery.
Natural Orifice Specimen Extraction With Single Stapling Colorectal Anastomosis for Laparoscopic Anterior Resection: Feasibility, Outcomes, and Technical Considerations
Authors: Saurabh Bansal , Chang Sheng-Chi , Ke Tao-Wei , Huang Yu-Chun , Kato Takashi , Wang Hwei-Ming , Tzu-Liang Chen William , Fingerhut Abe
Published: December 2016

BACKGROUND:

Double and triple stapling techniques to close the rectal stump in laparoscopic anterior resection are fraught with technical drawbacks that could possibly be avoided with the use of the single stapling technique. However, little is known of its safety in laparoscopic surgery or outcomes when combined with natural orifice specimen extraction.

OBJECTIVE:

This study aims to analyze the feasibility and the operative and immediate postoperative outcomes of single-stapled anastomosis and natural orifice specimen extraction with conventional techniques. It intends to evaluate technical variations related to colon, mesentery, and pelvic anatomy characteristics.

DESIGN AND PATIENTS:

A consecutive series of 188 patients underwent elective surgery for benign or malignant lesions between 10 and 40 cm from the anal verge, 5 cm or less in diameter on radiological examination, stage T1 to T3, Nx, M0, with 2 different methods of rectal stump closure (pursestring vs linear-stapled closure) associated with single or double stapling and per anus vs conventional specimen extraction.

SETTING:

This study was conducted at China Medical University Hospital, Taiwan, a tertiary referral center, between January 2012 and April 2015.

MAIN OUTCOME MEASURES:

The main outcomes measured are feasibility and operative and immediate postoperative outcomes.

RESULTS:

Single-stapled resection with natural orifice specimen extraction was feasible in 94% patients with an 11% perioperative morbidity rate. The patients required statistically significantly less analgesia, had earlier return of bowel movements, and shorter hospital stay, whereas there was no statistically significant difference in the overall readmission rate and overall morbidity, including anastomotic leakage.

LIMITATIONS:

This was a single-center, retrospective case-matched study.

CONCLUSION:

Anatomic variations (short colon and short mesentery) can be managed adequately with intracorporeal anvil head fixation. The single stapling technique is feasible and as safe as conventional double stapling techniques, although it is technically more demanding. The transanal endoscopic operation platform can be useful when the rectal stump is long.
Excimer Light Treatment for Idiopathic Guttate Hypomelanosis: A Pilot Study
Authors: Gordon Jennifer R.S. , Reed Kellie E. , Sebastian Katherine R. , Ahmed Ammar M.
Published: December 2016

BACKGROUND

Idiopathic guttate hypomelanosis (IGH) is a commonly acquired benign leukoderma characterized by multiple discrete, hypo- or depigmented macules often on extremities that can be aesthetically undesirable for patients. This is the first study using excimer laser for treatment.

OBJECTIVE

To determine the effectiveness of excimer laser for repigmentation of idiopathic guttate hypomelanosis.

METHODS AND MATERIALS

In this longitudinal, split-body controlled, single-blinded pilot study, 6 patients were treated with excimer laser for 12 weeks using the vitiligo protocol. Effectiveness was graded by the blinded observer scale through photographic comparisons at the end of the study. Participants also graded their progress at intervals during the study. A descriptive trend analysis and an ANOVA model were used to determine outcomes.

RESULTS

Lesions that received the excimer treatment had significantly higher repigmentation by the end of the study compared with baseline and untreated lesions.

CONCLUSION

Excimer laser treatments are already considered to be a safe modality for a variety of skin conditions. This study suggests that excimer is an effective treatment option with acceptable cosmetic outcomes for IGH.
Neural activity, memory, and dementias: serotonergic markers
Authors: Meneses Alfredo
Published: December 2016

Dysfunctional memory seems to be a key component of diverse dementias and other neuropsychiatric disorders; unfortunately, no effective treatment exists for this, probably because of the absence of neural biomarkers accompanying it. Diverse neurotransmission systems have been implicated in memory, including serotonin or 5-hydroxytryptamine (5-HT). There are multiple serotonergic pharmacological tools, well-characterized downstream signaling in mammals' species and neural markers providing new insights into memory functions and dysfunctions. Serotonin in mammal species has multiple neural markers, including receptors (5-HT1–7), serotonin transporter, and volume transmission, which are present in brain areas involved in memory. Memory, amnesia, and forgetting modify serotonergic markers; this influence is bidirectional. Evidence shows insights and therapeutic targets and diverse approaches support the translatability of using neural markers and cerebral functions and dysfunctions, including memory formation and amnesia. For instance, 5-HT2A/2B/2C, 5-HT4, and 5-HT6 receptors are involved in tau protein hyperphosphorylation in Alzheimer’s disease. In addition, at least, 5-HT1A, 5-HT4, 5-HT6, and 5-HT7 receptors as well as serotonin transporter seem to be useful neural markers and therapeutic targets. Hence, available evidence supports the notion that several mechanisms cooperate to achieve synaptic plasticity or memory, including changes in the number of neurotransmitter receptors and transporters. Considering that memory is a key component of dementias, hence reversing or reducing memory deficits might positively affect them?
Unaltered Dopamine Transporter Availability in Drug-Naive Patients With Schizophrenia After 6 Months of Antipsychotics Treatment
Authors: Chang Wei Hung , Chen Kao Chin , Lee I Hui , Chi Mei Hung , Chen Po See , Yao Wei Jen , Chiu Nan Tsing , Yang Yen Kuang
Published: December 2016

Background

Dopaminergic dysfunction, namely, dopamine transporter (DAT) availability variations in patients with drug-naive schizophrenia after long-term treatment, is still not well understood. The aims of the study were to explore (i) whether the DAT availability in patients with drug-naive schizophrenia differed after antipsychotic treatment and (ii) whether treatment with different generations of antipsychotics influenced the DAT availability after follow-up for 6 months.

Methods

Twenty-four first-episode, drug-naive patients with schizophrenia were divided into first- and second-generation antipsychotic groups naturalistically. After 6 months of follow-up, 7 patients who received first-generation antipsychotic treatment and 17 patients who received second-generation antipsychotic treatment completed the study. The patients underwent premedication and 6-month follow-up measurements using single-photon emission computed tomography with technetium Tc 99m (99mTc) TRODAT-1. Psychopathological evaluations and adverse effects were recorded using appropriate scales.

Results

Both of the treatment groups significantly improved according to Positive and Negative Symptoms Scale evaluation. However, no significant difference was noticed between the premedication and 6-month follow-up DAT scans. Nonsignificant differences existed even in the groups of different generations of antipsychotics.

Conclusions

Improvements in psychotic symptoms in patients with schizophrenia may not be influenced by DAT availability, even under treatment with different antipsychotics for a sufficient treatment period.
Chelation Therapy for Nickel Allergy
Authors: Rundle Chandler , Jacob Sharon E.
Published: December 2016

By definition, a drug is a medicine or substance that exerts a physiologic effect on an organism. In dermatology, medications and substances are utilized on a daily basis from topical treatments to anesthetics in micrographic surgery. The purpose of this column is to focus on some of the more common drugs used in dermatology, specifically their mechanism of action, how they are utilized, and routine alternatives (if available). This article revisits the history of chelation therapy for nickel allergy; discusses its role in dermatology with an emphasis on the mechanism of action, adverse effects, and how it compares with alternative treatment options; and highlights the future implications in medical therapy.
Compensatory Saccades Are Associated With Physical Performance in Older Adults: Data From the Baltimore Longitudinal Study of Aging
Authors: Xie Yanjun , Anson Eric R. , Simonsick Eleanor M. , Studenski Stephanie A. , Agrawal Yuri
Published: December 2016

Objective:

To determine whether compensatory saccade metrics observed in the video head impulse test, specifically saccade amplitude and latency, predict physical performance.

Study Design:

Cross-sectional analysis of the Baltimore Longitudinal Study of Aging, a prospective cohort study.

Setting:

National Institute on Aging Intramural Research Program Clinical Research Unit in Baltimore, Maryland.

Patients:

Community-dwelling older adults.

Intervention(s):

Video head impulse testing was performed, and compensatory saccades and horizontal vestibulo-ocular reflex (VOR) gain were measured. Physical performance was assessed using the Short Physical Performance Battery (SPPB), which included the feet side-by-side, semitandem, tandem, and single-leg stance; repeated chair stands; and usual gait speed measurements.

Main Outcome Measure(s):

Compensatory saccade amplitude and latency, VOR gain, and SPPB performance.

Results:

In 183 participants who underwent vestibular and SPPB testing (mean age 71.8 yr; 53% females), both higher mean saccade amplitude (odds ratio [OR] =1.62, p = 0.010) and shorter mean saccade latency (OR = 0.88, p = 0.004) were associated with a higher odds of failing the tandem stand task. In contrast, VOR gain was not associated with any physical performance measure.

Conclusion:

We observed in a cohort of healthy older adults that compensatory saccade amplitude and latency were associated with tandem stance performance. Compensatory saccade metrics may provide insights into capturing the impact of vestibular loss on physical function in older adults.
The effect of intraoperative and 6-h postoperative intravenous administration of low-dose prostacyclin on the endothelium, hemostasis, and hemodynamics in patients undergoing a pancreaticoduodenoctemy: a randomized-controlled pilot study
Authors: Johansson Pär I. , Mortensen Christian R. , Nielsen Tatiana , Tollund Carsten , Stensballe Jakob , Hansen Carsten P. , Frederiksen Hans J. , Ostrowski Sisse R.
Published: December 2016

Background

Capillary leakage, secondary to endothelial breakdown, is common in patients undergoing major surgical procedures with extensive tissue injury and this is associated with increased morbidity and mortality. Prostacyclin has been ascribed cytoprotective properties together with its vasodilatory and antiplatelet effects. The present pilot study investigated the safety and endothelial protective effects of low-dose prostacyclin infusion.

Patients and methods

A randomized placebo-controlled pilot study evaluating the effect of prostacyclin (iloprost) infusion (1.0 ng/kg/min) versus placebo (saline infusion) intraoperatively and 6 h postoperatively in patients undergoing a pancreaticoduodenoctemy was carried out. Hemodynamics were evaluated by Nexfin, hemostasis was evaluated by thrombelastography, and transfusion requirements were registered. Endothelial damage was evaluated by circulating sE-selectin, soluble thrombomodulin, and nucleosomes.

Results

Comparable baseline demography and surgical time were found. Hemodynamics were comparable between groups. The placebo group received more red blood cells, median 115 ml [interquartile range (IQR): 0–296 ml] versus 0 ml (IQR: 0–0 ml), P=0.027, at the postoperative ward and after 6 h. Thrombelastography maximum clot firmness decreased intraoperatively only in the placebo group (P=0.034)). Soluble thrombomodulin increased more in the placebo group postoperatively [1.63 ng/ml (IQR: 0.65–2.55 ng/ml) versus 0.40 ng/ml (IQR: 0.21–0.63 ng/ml), P=0.027] and 6 h postoperatively [1.83 (1.1–2.36) versus 0.67 (0.42–0.91), P=0.027]. Nucleosomes increased intraoperatively and postoperatively only in the placebo group; thus, the overall level of nucleosomes was higher in the placebo group (P=0.019).

Conclusion

Intraoperative and postoperative low-dose prostacyclin infusion is safe and associated with reduced endothelial cell damage in patients undergoing a pancreaticoduodenoctemy compared with those receiving placebo.
Short article: Absence of serological rheumatoid arthritis biomarkers in inflammatory bowel disease patients with arthropathies
Authors: Van Erp Sanne J.H. , Verheul Marije K. , Levarht E.W. Nivine , van der Reijden Johan J. , van der Heijde Désirée , van Gaalen Floris A. , Hommes Daniel W. , Norman Gary L. , Shums Zakera , Mahler Michael , Verspaget Hein W. , Trouw Leendert A. , van der Meulen-de Jong Andrea E.
Published: December 2016

Objective

Biomarkers that are associated with future progression to rheumatoid arthritis (RA) and joint destruction have been discovered previously in patients with arthralgia. The present study examined these RA biomarkers in inflammatory bowel disease (IBD) patients with arthropathies.

Patients and methods

Sera from 155 IBD patients with and 99 IBD patients without arthropathies were analyzed for immunoglobulin (Ig) M rheumatoid factor (RF), IgA-RF, anti-cyclic citrullinated peptide 2, anti-cyclic citrullinated peptide 3.1, and anti-carbamylated protein antibody positivity using enzyme-linked immunosorbent assays. The prevalence of the autoantibodies in the IBD patients was compared with the prevalence in RA patients.

Results

No differences were found in biomarker positivity between IBD patients with and without arthropathies. Significantly more biomarker positivity (P<0.001) was observed in RA patients compared with IBD patients with arthropathies. Also, smoking turned out to be significantly associated with positivity for IgM-RF or IgA-RF.

Conclusion

Our findings suggest that there is no apparent clinical value in the detection of RA biomarkers in serum of IBD patients to help identify arthropathies.
Clinicopathological analysis and risk factors of advanced colorectal neoplasms incidentally detected by 18F-FDG PET-CT
Authors: Chung Seung Min , Kim Kyeong Ok , Cho Ihn Ho , Kim Tae Nyeun
Published: December 2016

Background

As the clinical use of fluorine-18-fluorodeoxyglucose PET-computed tomography (18F-FDG PET-CT) has increased, the incidental finding of 18F-FDG uptake with subsequent diagnosis of advanced neoplasm at colorectum has increased. The aim of this study is to analyze the characteristics and risk factors of advanced colorectal neoplasm incidentally detected by 18F-FDG PET-CT.

Patients and methods

Patients who underwent colonoscopy because of an incidental finding of 18F-FDG uptake at the colorectum from January 2006 to January 2015 at Yeungnam University Hospital were reviewed retrospectively. Advanced neoplasm was defined as adenoma of at least 10 mm, adenoma with serrated or villous component, high-grade dysplasia, and adenocarcinoma.

Results

Of the 19 798 candidates, 180 patients with incidental colorectal 18F-FDG uptake were included in this study. The indications of PET-CT were metastasis work-up, health screening, and others. The male to female ratio was 1.6 : 1 and the mean age was 62.7±11.4 years. A total of 156 lesions were detected in the colorectum and 86 (47.8%) were diagnosed as advanced neoplasms. Of the 86 patients with advanced neoplasms, 34 (39.5%) underwent an operation, 34 (39.5%) underwent endoscopic resection, and 18 (20.9%) underwent chemotherapy or conservative treatments. In univariate analysis, age of 62.5 years or older, carcinoembryonic antigen (CEA) of at least 3.4 ng/ml, maximum standardized uptake value (SUVmax) of at least 8.0, hypertension, 18F-FDG uptake on the rectosigmoid, and PET-CT for metastasis work-up showed a significant association with advanced neoplasm. In multivariate analysis, CEA (P=0.028), SUVmax (P<0.001) and an indication of PET-CT for metastasis work-up (P=0.008) were independent predictors of advanced neoplasm.

Conclusion

Colonoscopy should be recommended in case of 18F-FDG uptake at the colorectum, particularly in patients with CEA of at least 3.4 ng/ml, SUVmax of at least 8.0, or metastasis work-up of malignancy.