bluuebunny/crossref_metadata_2025 huggingface dataset:
Design and Outcomes of a Novel Keratoprosthesis: Addressing Unmet Needs in End-Stage Cicatricial Corneal Blindness
Authors: Bakshi Shaunak K. , Graney John , Paschalis Eleftherios I. , Agarwal Shweta , Basu Sayan , Iyer Geetha , Liu Christopher , Srinivasan Bhaskar , Chodosh James
Published: November 2019

Purpose:

The most commonly applied prosthetic devices for corneal blindness in the setting of severe cicatricial keratoconjunctivitis are the Boston keratoprosthesis type II and the modified osteo-odonto-keratoprosthesis, with these requiring either normal eyelid skin or a healthy cuspid tooth, respectively. For patients with neither attribute, we developed a new keratoprosthesis device combining positive aspects of both Boston keratoprosthesis type II and modified osteo-odonto-keratoprosthesis, which we have named the “Lux.”

Methods:

Short-term postoperative outcomes for the Lux keratoprosthesis, best-corrected visual acuity (BCVA), device retention, and complications, were examined in a retrospective case series of 9 eyes of 9 patients implanted at 4 centers.

Results:

Seven of 9 (77.8%) eyes had cicatricial corneal blindness due to autoimmune disease and 2 (22.2%) from severe burns. Preoperative BCVA was ≤hand motions in all patients. Three (33.3%) had previously received at least 1 keratoprosthesis in the affected eye, and 4 (44.4%) had previously undergone ≥1 therapeutic keratoplasty. One patient had 19 previous eye surgeries. The mean duration of postoperative follow-up was 18.7 months (range 7–28 months). BCVA of ≥20/200 was achieved in all 9 patients, with 2 (22.2%) reaching 20/20 at the last examination, and all 9 (100%) of the devices were retained. One recipient developed a retinal detachment 2 months after implantation. Two (22.2%) patients required placement of a glaucoma drainage device.

Conclusions:

The Lux keratoprosthesis was developed for patients with severe cicatricial keratoconjunctivitis who were otherwise not candidates for existing keratoprosthesis designs. Short-term outcomes after implantation of the Lux keratoprosthesis were encouraging.
Complexities of HIV Disclosure in Patients Newly Entering HIV Care: A Qualitative Analysis
Authors: Chapman Lambert Crystal , Tarver Will L. , Musoke Pamela L. , Stringer Kristi L. , Whitfield Samantha , Turan Bulent , Modi Riddhi , Mugavero Michael J. , Fredericksen Rob J. , Weiser Sheri , Johnson Mallory O. , Turan Janet M.
Published: November 2019

The role of HIV disclosure and its influence on engagement in HIV care after initial linkage to care is not well understood. We conducted 28 in-depth interviews with patients newly entering HIV care. Gaining access to social support was a key reason that many patients disclosed their HIV status. For some, HIV disclosure improved support networks related to engagement in care at the time of care entry, in the form of appointment reminders, emotional support, and confidence to disclose more widely. However, some participants cited anticipated stigma as a barrier to disclosure, as they feared rejection or further disclosure without their permission. Early access to social support and skill building related to stigma reduction and coping can be useful resources to help patients manage HIV, as they initiate care. In addition, incorporating support for smart disclosure decisions into interventions may improve access to social support, ultimately improving engagement in care.
Follow-Up of the Libby, Montana Screening Cohort
Authors: Larson Theodore C. , Williamson Laura , Antao Vinicius C.
Published: November 2019

Objective:

To evaluate mortality patterns among participants in a community-based screening program for asbestos-related disease.

Methods:

We calculated standardized mortality ratios (SMRs) and stratified results by exposure group (three occupational exposure groups, household contacts and residents without occupational asbestos exposure) and by radiographic abnormality presence.

Results:

All-cause mortality (15.8%; 1,429/8,043) was statistically lower than expected. Asbestosis was statistically elevated in all exposure groups. Lung cancer was moderately associated with vermiculite miner/miller employment. Mesothelioma was elevated in that same exposure group and among residents. Systemic autoimmune disease mortality was also elevated. Radiographic parenchymal abnormalities were associated with lung cancer mortality.

Conclusion:

In addition to asbestos-related mortality in occupational exposure groups, this initial follow-up of this cohort also shows elevated mortality for some asbestos-related causes in non-occupational exposure groups.
Nerve Function Impairment After Acute Vibration Exposure
Authors: Löfgren Anton , Vihlborg Per , Fornander Louise , Bryngelsson Ing-Liss , Graff Pål
Published: November 2019

Objective:

This study was to investigate the acute effects of hand-arm vibrations on the nerve functions of the hands, and the impact of the grip force applied to the vibrating tool during exposure.

Methods:

Grip strength and perception of vibration, touch, and temperature were evaluated using quantitative sensory testing (QST) before and after vibration exposure in 21 occupationally unexposed individuals. The procedure was performed twice, with a higher grip force being applied during exposure on the second occasion.

Results:

Vibration perception was significantly impaired after both exposures. Grip strength, perception of touch, and temperature were only significantly affected after the high grip force exposure.

Conclusions:

Exposure to hand-arm vibrations has acute effects on hand nerve function that are sensitive to the grip force applied during exposure.
von Willebrand factor alloantibodies in type 3 von Willebrand disease
Authors: Faganel Kotnik Barbara , Strandberg Karin , Debeljak Maruša , Kitanovski Lidija , Jazbec Janez , Benedik-Dolničar Majda , Trampuš Bakija Alenka
Published: November 2019

The development of neutralizing antibodies is a rare complication of von Willebrand disease treatment. In major surgical procedures for severe forms of the disease, the recognition of ineffective therapy and alternative treatment protocols are lifesaving. We report the case of a 6-year-old girl with type 3 von Willebrand disease in whom inhibitors were sought due to ineffective haemostasis together with lower than expected von Willebrand factor (VWF) recoveries after a surgical procedure. Replacement therapy first with recombinant factor VIIa and then with high doses of recombinant factor VIII in continuous infusion successfully stopped the bleeding. A high level of anti-VWF antibodies was determined by the immunological method. A frameshift mutation associated with premature termination codon (c.2435delC, p.Pro812ArgfsTer31) was determined in our patient. Although the reports on association of this mutation with inhibitor risk are inconsistent, it represents an evidence-based diagnostic and management practice in recognition of high-risk VWF genotype.
Literature Review
Authors: Alfaro-Cruz Ligia , Heitkemper Margaret , Chumpitazi Bruno P. , Shulman Robert J.
Published: November 2019

Dietary management is key in controlling functional gastrointestinal disorders (FGIDs) symptoms. However, the degree to which patients with FGIDs in clinical studies adhere to dietary recommendations is unknown. Our aim was to evaluate adherence, dietary education, and adherence-related factors in FGIDs dietary intervention trials. A literature search was performed using MEDLINE, Google Scholar, and SCOPUS for clinical trials evaluating dietary management of FGIDs. Full manuscripts published from January 2000 through August 2018 were reviewed. Data including definitions of adherence and rates, study design, dietary education, use of a dietitian, provision of study foods, potential adherence barriers, and dropouts were captured. A total of 21 publications were included. Fifteen (67%) focused on the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet, 5 (24%) on fiber supplementation, and 1 (9%) on a low carbohydrate diet. Fifteen (71%) were randomized controlled trials. Meals/supplements were provided to the study participants in 27%, 80%, and 100%, of the low FODMAP, fiber, and low carbohydrate studies, respectively, which appeared to significantly enhance adherence (P<0.03). Eighteen studies (81%) provided either written or oral diet information to study participants. Overall, only 10 publications (48%) provided adherence data. Nine (60%) of the low FODMAP studies provided adherence data (range, 30% to 100%); ranges could not be calculated for the other dietary trials. The most common method to measure adherence was via food diaries. Therefore, adherence is not often measured in FGIDs dietary intervention clinical trials; when reported, rates of adherence range widely. Studies providing food had the highest adherence rates.
Ultrasonographic assessment of right heart intracardiac mass in patients with hepatitis B virus infection
Authors: Su Chunling , Jin Chunna , Han Jing , Hu Xing , Shi Dongli , Meng Fankun
Published: November 2019

Objective:

The characteristics of right heart intracardiac mass in hepatitis B virus infection patients are not well known. Our aim is to describe their ultrasonographic features and nature of such masses.

Methods:

We retrospectively reviewed imaging reports of hepatitis B virus infection patients from January 2014 to December 2018. Patients with a confirmed finding of right heart intracardiac mass were included, whose pathology reports and contrast-enhanced images were analyzed. Various masses were compared to a general control group from a published study.

Results:

Thirty-eight cases were finally included. Different types of masses presented with a variety of echocardiographic manifestations. Thirty-six cases had masses located in the right atrium, including five thrombus and 31 metastatic carcinoma. The later included one metastatic non-Hodgkin lymphoma and 30 metastatic hepatic carcinoma cases (27 of which had inferior vena cava tumor thrombus). Two cases presented with masses in the right ventricle that included one multiple myxoma and one tricuspid valve leaflet vegetation. Compared with the general population, no primary malignant tumor was found in our study (65% vs. 100%, P = 0.001), and hepatic metastasis was the most common type of malignant tumors (P < 0.001).

Conclusion:

The nature and ultrasonographic features of right heart intracardiac masses in hepatitis B virus infection patients are diverse, and the incidence of malignant tumors was similar to that seen in the general population. Hepatic metastasis, possibly extending via the inferior vena cava into the right atrium, was the most common type. Our study may improve understanding of the right heart intracardiac mass in hepatitis B virus infection patients.
Clostridium difficile caused changes in fatty acids profile and resolvin D1 content in plasma of infected patients
Authors: Dróżdż Mirosław , Gdula-Argasińska Joanna , Biesiada Grażyna , Jurczyszyn Artur , Perucki William , Wołkow Paweł , Borys Agnieszka , Sroczyńska Katarzyna , Zając Anna , Librowski Tadeusz , Garlicki Aleksander , Czepiel Jacek
Published: November 2019

Objectives

Clostridium difficile infection (CDI) is an acute gastrointestinal infection caused by anaerobic, toxin-producing bacteria. During the course of CDI, there is a general inflammatory state. In order to gain a deeper understanding of the role of fatty acids (FAs) in the pathogenesis of acute infection we analyzed their plasma content in both patients with CDI and controls.

Methods

The study groups included 40 patients with CDI and 40 healthy volunteers. Plasma FA content was analyzed by gas chromatography, resolvin D1 (RvD1) level using ELISA assay, and we assessed the white blood cell (WBC) count, neutrophil count and C-reactive protein (CRP) level.

Results

Patients with CDI were characterized by significantly higher values of WBC, neutrophils, platelets and CRP compared with the control group. The saturated FA index was statistically higher and total n-3 FA was significantly decreased in the plasma of CDI patients as compared with the control group. RvD1 content was significantly higher in the control group as compared with patients with CDI.

Conclusion

In patients with good outcomes, we probably observed the effective resolution of inflammation, as reflected in n-3 FA metabolism and their significant decrease in plasma. This may indicate the therapeutic role of n-3 FA in CDI infection.
Parental involvement in the manual reduction of pulled elbow in children
Authors: Cho Wonjin , Lee Seung Chul , Lee Jeong Hun , Seo Jun Seok , Do Han Ho , Kim Yong Won , Lee Sanghun
Published: November 2019

Objective

To investigate the effect of parental involvement in the manual reduction of pulled elbow in children.

Methods

We conducted a prospective case-control study from January to December 2018. The patients were under 6 years old with suspected radial head subluxation and were randomly assigned to two groups (an intervention group with a physician’s and a parent’s finger placed on the patient’s radial head and a control group with the physician’s finger only placed on the patient’s radial head) according to the method of reduction. The results of a questionnaire given to the parent and physician were analyzed.

Results

A total of 150 patients were included in the study: 75 in the intervention group and 75 in the control group. There were no significant differences between the groups. The average number of attempts at manual reduction was 1.29 ± 0.73 in the intervention group and 1.31 ± 0.72 in the control group (P = 0.91) and the success rate of manual reduction was 96.0 and 94.7% (P = 0.70), respectively. The ease of conducting the procedure by the doctors did not show a significant difference between the two groups. However, the parents’ understanding and satisfaction was significantly higher in the intervention group.

Conclusion

Parental involvement did not affect the procedure of physician, but it improved the understanding and satisfaction of the parents.
Diagnostic performance of prehospital ultrasound diagnosis for traumatic pneumothorax by a UK Helicopter Emergency Medical Service
Authors: Oliver Prudence , Bannister Peter , Bootland Duncan , Lyon Richard M.
Published: November 2019

Objective

Up to 20% of major trauma patients may sustain a pneumothorax. Traumatic pneumothoraces can be difficult to diagnose on scene. Although the use of handheld ultrasound (HHUS) is becoming increasingly widespread, there remains uncertainty about its efficacy as a diagnostic tool in the prehospital setting. The aim of this study was to determine the diagnostic performance of prehospital chest HHUS in trauma patients.

Method

Retrospective review of trauma patients who received a prehospital chest HHUS and subsequently conveyed to the Royal Sussex County Hospital (RSCH) between 1 July 2013 and 24 September 2018. Data including patient age, sex, mechanism of injury and clinical interventions were obtained. Prehospital ultrasound findings were compared with the computer tomography (CT) scan performed on arrival at the hospital.

Results

Four hundred eleven patients were conveyed to RSCH, the single largest group being following road traffic collisions. The majority of HHUS (66%) were performed by doctors. Three hundred sixty-one patients (88%) subsequently had a CT scan. Of these, 98 patients (27%) were found to have pneumothoraces. For pneumothorax diagnosis, prehospital HHUS had a sensitivity of 28% [95% confidence interval (CI): 19–37%] and specificity of 98% [95% CI: 97–99%].

Conclusion

In this retrospective study, sensitivity of prehospital HHUS for diagnosing a pneumothorax was lower than is often reported in in-hospital studies. This suggests that caution should be exercised in using HHUS for the exclusion of pneumothorax in the prehospital setting.
In primary lymph nodal staging of patients with high-risk and intermediate-risk prostate cancer, how critical is the role of Gallium-68 prostate-specific membrane antigen positron emission tomography-computed tomography?
Authors: Kulkarni Smita Chinmay , Sundaram Palaniswamy Shanmuga , Padma Subramanyam
Published: November 2019

Objective

To assess the diagnostic performance of Gallium-68 prostate-specific membrane antigen positron emission tomography-computed tomography (68Ga-PSMA PET-CT) in primary lymphnodal staging of patients with intermediate-risk and high-risk prostate cancer and to compare it with multiparametric MRI (mp-MRI) whenever available.

Materials and methods

68Ga-PSMA PET-CT scans of 51 patients (average age 66.0 ± 7.0 years) with biopsy-proven intermediate-risk and high-risk prostatic cancer who were managed by radical prostatectomy and extended pelvic lymph nodal dissection were retrospectively analyzed. Diagnostic performance of 68Ga-PSMA PET-CT in primary lymph nodal staging was analyzed using histopathology as reference. Diagnostic performance of mp-MRI, which was available in 35/51 patients was compared with that of 68Ga-PSMA PET-CT.

Results

Univariate analysis of patient characteristics showed significant influence of the pathological T-stage and maximum standard uptake value (SUV)max of the primary lesion on presence of nodal metastasis. In 51 patients, for patient-based analysis, the sensitivity, specificity and accuracy of 68Ga-PSMA PET-CT in detecting lymphnodal metastases were 80, 90.3 and 86.3%, respectively, and for lesion-based analysis 69.2, 99.6 and 98.4%, respectively. In 35/51 patients (who also had undergone mp-MRI), the patient-based and lesion-based sensitivity, specificity, and accuracy of 68Ga-PSMA PET-CT were 81.3, 84.2, 82.8% and 70.9, 99.5, 98.2%, respectively, and that of mp-MRI were 43.7, 78.9, 62.8% and 32.2, 98.5, 95.5%, respectively. For lesion-based analysis, 68Ga-PSMA PET-CT performed better than mp-MRI (P value = 0.04).

Conclusion

68Ga-PSMA PET-CT allows accurate detection of lymphnodal metastases in patients with intermediate-risk and high-risk prostate cancer prior to definitive surgical treatment. It performed better than mp-MRI in a subset of patients.
Osgood–Schlatter disease: a 2020 update of a common knee condition in children
Authors: Ladenhauf Hannah N. , Seitlinger Gerd , Green Daniel W.
Published: November 2019

Purpose of review

Osgood–Schlatter disease (OSD) is one of the most common causes for anterior knee pain in children and adolescents resulting from a traction apophysitis of the tibial tubercle. While a peak in boys aged 12–15 years old was well documented, there seems to be no difference in sex distribution nowadays. This may result from increased participation of young females in high-impact sports. This review provides an up-to-date account on contemporary prophylaxis as well as diagnostic and therapeutic approaches.

Recent findings

Numerous studies have examined risk factors for OSD. These include body weight, muscle tightness, muscle weakness during knee extension and flexibility of hamstring muscles. In particular, shortening of the rectus femoris may substantially alter biomechanical functions of the knee. Conservative management remains successful in over 90% of patients. However, if disabling symptoms and pain persistent after physeal closure, operative treatment may be necessary.

OSD is a mostly self-limiting apophysitis of the tibial tubercle and the adjacent patella tendon in young active patients with open physis. Prevention strategies include quadriceps and hamstring stretching and therefore should be implemented in everyday practice routines for children who partake in regular sports activities.
Two Novel TMPRSS6 Variants in a Compound Heterozygous Child With Iron Refractory Iron Deficiency Anemia
Authors: Allison Jenna , Drury Luke , Ford James B.
Published: November 2019

We describe a Caucasian family with asymptomatic, nonconsanguineous parents, and a daughter with unexplained microcytic anemia diagnosed on routine hemoglobin screening at her 12-month well child check. After failed response to oral and parental iron supplementation, iron refractory iron deficiency anemia was suspected. The family underwent genetic testing and the proband was found to be a compound heterozygote for 2 previously unreported TMPRSS6 variants.
A Retrospective Review of the Use of Sirolimus for Pediatric Patients With Epithelioid Hemangioendothelioma
Authors: Engel Elissa R. , Cournoyer Eily , Adams Denise M. , Stapleton Stacie
Published: November 2019

Epithelioid hemangioendothelioma (EHE) is a rare malignant vascular tumor with no standardized treatment. The mammalian target of rapamycin inhibitor, sirolimus, has been used successfully in adult EHE and other vascular tumors in children but has not been studied in pediatric EHE. The aim of this retrospective case series is to discuss the results of sirolimus for treatment in 6 pediatric patients with EHE. Four of 6 patients demonstrated partial response or disease stabilization with sirolimus treatment. No treatment dosing, trough goals, or duration of treatment recommendations can be made. Prospective studies are warranted to further investigate the use of sirolimus in treatment of EHE.
Response to Denosumab in 2 Children With Recurrent Giant Cell Tumor of the Bone With Pulmonary Metastasis
Authors: Reddy Kiranmye , Ramirez Lorimar , Kukreja Kamlesh , Venkatramani Rajkumar
Published: November 2019

Giant cell tumor of the bone (GCTB) is an uncommon bone tumor, usually localized, and rarely presents at <20 years of age. Denosumab, a fully human monoclonal antibody against RANKL (receptor activator of nuclear factor κB ligand), is approved for the treatment of unresectable GCTB in skeletally mature individuals. We present a case series of 2 pediatric patients with recurrent GCTB with pulmonary metastasis, with clinical response to denosumab therapy.
Clinical Laboratory Manifestation and Molecular Diagnosis of β-Thalassemia Patients in Iraq
Authors: AlMosawi Riham H.N. , Al-Rashedi Nihad A.M. , Ayoub Najla I.
Published: November 2019

Many studies determined the demographic and ethnic border of patients with beta (β)-thalassemia mutations and their migration. The effective way to health care policy of β-thalassemia is to prevent homozygote births and reduce the severity of the disease. The objectives of this study contributed to investigating the molecular and serologic characteristics of β-thalassemia patients in Iraq. Peripheral blood samples were collected from 97 β-thalassemia patients and 32 healthy control subjects. Quantitative sandwich enzyme-linked immunosorbent assay was performed to measure serum ferritin, 25-hydroxy vitamin D, and 8-hydroxydeoxyguanosine (8-OHdG) levels. Further, the β-globin mutation detection assay involving an extensive screening of β-globin mutations by direct Sanger DNA sequencing and gap-PCR was performed to detect the Δ619 deletion mutation. The results revealed that compared with the control subjects, the β-thalassemia patients showed significantly decreased vitamin D levels and significantly increased serum ferritin and 8-OHdG levels (all,P<0.001). Molecular analysis detected 9 types of mutations in the β-thalassemia patients, only 2 of which, namely IVS II-1 G>A and IVS 1-5 G>C, have been previously reported in Iraqi studies, whereas the remaining 7, namely IVS-II-666 C>T, CD2 CAT>CAC, IVS-II-850 G>A, IVS-II-16 GT, have never been reported in the Iraqi population. This study showed that the serum ferritin and 8-OHdG levels were significantly higher, and the serum 25-hydroxy vitamin D levels were significantly lower in the β-thalassemia patients than in the control subjects. Moreover, the results revealed seven newly identified mutations among Iraqi β-thalassemia patients and 2 previously reported mutations.
Ruptured Esophageal Varices From Metastatic Tumor in the Liver
Authors: Mathew Suneeth , Kesha Kilak , Stables Simon , Morrow Paul , Glenn Charley , Tse Rexson
Published: November 2019

Ruptured esophageal varices can present as sudden death from gastrointestinal hemorrhage. The most common underlying pathology causing esophageal varices is cirrhosis leading to portal hypertension. However, not all esophageal varices arise from portal hypertension, and not all portal hypertensions are caused by cirrhosis. We present a rare case of ruptured esophageal varices casing death in an individual with metastatic tumor (high-grade) neuroendocrine tumor in the liver causing portal hypertension. This is, to the best of our knowledge, the first case report in the literature reporting a neuroendocrine tumor causing esophageal varices. This case report aims to document this rather rare entity, highlight another mechanism on how metastatic disease can result in sudden death, and give a brief review of literature on metastatic tumor in the liver causing esophageal varices.
c-KIT Analysis and Targeted Molecular Sequencing of Mesonephric Carcinomas of the Female Genital Tract
Authors: Pors Jennifer , Ho Julie , Prentice Leah , Thompson Emily , Cochrane Dawn , Gibbard Evan , Huntsman David , Gilks Blake , Hoang Lynn N.
Published: November 2019

Mesonephric carcinoma is a rare malignancy, thought to derive from Wolffian remnants. To date, no targeted molecular therapeutic options have been identified. On the basis of limited case reports, c-KIT immunohistochemical expression has been reported in female adnexal tumors of Wolffian origin, and targeted therapy with Imatinib has been attempted with mixed success. Currently, it is unclear whether c-KIT immunohistochemical expression is seen in mesonephric carcinoma, a tumor that is thought to be related to female adnexal tumors of Wolffian origin, and how this correlates with KIT mutational status. In this study, we assessed the immunohistochemical expression of c-KIT and KIT mutational status, in a series of 13 mesonephric neoplasms (5 cervical [including 2 cervical carcinosarcomas], 3 uterine corpora, 4 ovarian, and 1 vaginal/pelvic). The intensity of staining and proportion of cells showing cytoplasmic/membranous staining for c-KIT were recorded. KIT was sequenced using a next-generation sequencing panel that targeted 120 hotspots and 17 exons in 33 known actionable cancer genes. This panel included KIT exons 9, 11, and 13, and 6 hotspots (T670, D816, D820, N822, Y823, A829). Although c-KIT immunohistochemical expression was observed in the majority of mesonephric carcinomas (10/12 cases; 83%), no KIT mutations were detected. This cautions pathologists against the use of c-KIT immunohistochemistry as a surrogate marker for KIT-activating mutations in this setting. Consistent with previous studies, the majority of mesonephric neoplasms (10/13; 77%) harbored KRAS mutations. Additional mutations were found in CTNNB1 (2/13, 15%), TP53 (2/13, 15%), and PIK3CA (1/13, 8%).
Validity and Reliability of the Brazilian Portuguese Version of the Pediatric Confusion Assessment Method for the ICU
Authors: de Castro Roberta Esteves Vieira , Prata-Barbosa Arnaldo , de Magalhães-Barbosa Maria Clara , Cunha Antônio J. L. A. da , Cheniaux Elie , Smith Heidi A. B.
Published: November 2019

Objectives:

To determine the validity and reliability of the Brazilian Portuguese version of the Pediatric Confusion Assessment Method for the ICU for diagnosing delirium in patients with chronological and developmental ages from 5 to 17 years in Brazilian PICUs.

Design:

Prospective, cross-sectional study.

Settings:

Eight Brazilian PICUs (seven in Rio de Janeiro and one in São Paulo).

Patients:

One-hundred sixteen patients, 5–17 years old, without developmental delay, submitted to mechanical ventilation or not.

Interventions:

To assess the inter-observer reliability, two previously trained researchers concomitantly applied the Brazilian Portuguese version of the Pediatric Confusion Assessment Method for the ICU and independently rated the same patient. To assess the criterion validity, a pediatric neurologist or psychiatrist, blinded to the Brazilian Portuguese version of the Pediatric Confusion Assessment Method for the ICU assessments, evaluated the same patient within 30 minutes, using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, considered the reference standard.

Measurements and Main Results:

One-hundred forty-nine paired assessments were included (some patients had more than one). Delirium was diagnosed in 11 of 149 assessments (7%), or eight of 116 patients (7%), using both the Brazilian Portuguese version of the Pediatric Confusion Assessment Method for the ICU and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. There was one false positive and one false negative diagnosis, which resulted in 90.9% sensitivity (95% CI, 58.7–99.8%) and 99.3% specificity (95% CI, 96–100%) for the Brazilian Portuguese version of the Pediatric Confusion Assessment Method for the ICU. The inter-rater reliability was considered almost perfect (κ = 1.0).

Conclusions:

The Brazilian Portuguese version of the Pediatric Confusion Assessment Method for the ICU is a valid and reliable tool for diagnosing delirium in pediatric patients 5–17 years old who are spontaneously breathing and not pharmacologically sedated in Brazilian PICUs. The implementation of this tool may be useful to reduce underdiagnosis, ensure monitoring and earlier intervention, provide a better prognosis, and improve research on delirium in this age group in Brazil. Further studies are necessary to test the psychometric properties of the Brazilian Portuguese version of the Pediatric Confusion Assessment Method for the ICU in sedated and mechanically ventilated children.
Diverging trends in incidence of HIV versus other sexually transmitted infections in HIV-negative MSM in Amsterdam
Authors: van Bilsen Ward P.H. , Boyd Anders , van der Loeff Maarten F.S. , Davidovich Udi , Hogewoning Arjan , van der Hoek Lia , Prins Maria , Matser Amy
Published: November 2019

Objectives:

We investigated changes in incidence rates of HIV and sexually transmitted infections (STIs) and trends in sexual behavior in MSM from 2009 to 2017.

Design:

Open prospective cohort study.

Methods:

HIV-negative MSM enrolled in the Amsterdam Cohort Studies were included. Participants semiannually completed a questionnaire on sexual behavior and were tested for HIV-1, syphilis, and urethral, anal and pharyngeal chlamydia and gonorrhea. Time trends in incidence rates were analyzed using exponential survival models.

Results:

During follow-up, 42 of 905 MSM acquired HIV. The HIV incidence rate was 1.9/100 person-years [95% confidence interval (CI) 1.0–3.7] in 2009 and decreased to 0.5/100 person-years (95% CI 0.2–1.4) in 2017 (P = 0.03). The largest decrease was observed in participants aged at least 35 years (P = 0.005), while the trend remained stable in 18–34 year olds (P = 0.4). The incidence rate for any bacterial STI was 16.8/100 person-years (95% CI 13.4–21.0) in 2010, and increased to 33.1/100 person-years (95% CI 29.0–37.9) in 2017 (P < 0.001). Between 2009 and 2017, the percentage reporting condomless anal sex with casual partners increased from 26.9 to 39.4% (P < 0.001), and the mean number of casual partners from eight (95% CI 8–8) to 11 (95% CI 10–11) (P = 0.05). Condomless anal sex with steady partner(s) remained stable over time (P = 0.5).

Conclusion:

Among MSM in Amsterdam, incidence rates of HIV versus other STI show diverging trends. The increase in STI incidence coincides with a decrease in condom use with casual partners. The decrease in HIV incidence, despite increased sexual risk behavior, suggests that other HIV prevention methods have been successful in reducing HIV transmission among MSM.
Association between quality-of-care indicators for HIV infection and healthcare resource utilization and costs
Authors: Nduaguba Sabina O. , Barner Jamie C. , Ford Kentya H. , Lawson Kenneth A. , Barnes James N. , Wilson James P.
Published: November 2019

Objectives:

Multiple care quality indicators for HIV infection exist but few studies examine their impact on health outcomes. This study assessed which HIV care quality indicators were associated with healthcare resource utilization and costs.

Design:

Retrospective analysis of Texas Medicaid claims data (01 January 2012 to 31 September 2016).

Methods:

Included patients had at least two HIV-related medical claims during the identification period (01 July 2012 to 31 August 2014) (index = date of first HIV claim), were 18–62 years at index, and were continuously enrolled in the 6-month pre-index and 1-year post-index periods. Dependent variables included emergency department (ED) visits, inpatient hospitalizations, prescription count, and all-cause healthcare costs. Independent variables included CD4+ cell count monitoring, syphilis, chlamydia, gonorrhea, hepatitis B, hepatitis C, and tuberculosis screenings, influenza and pneumococcal vaccinations, retention in care, and HAART initiation. Covariates included age, chronic hepatitis C virus infection, AIDS diagnosis, sex, and baseline healthcare cost. The study objective was addressed using generalized linear modeling.

Results:

CD4+ cell count monitoring and HAART initiation were significantly associated with reduced emergency department visits (P < 0.0001 for each). Influenza vaccination was significantly associated with reduced inpatient hospitalization (P < 0.0001). CD4+ cell count monitoring (P < 0.0001), TB screening (P = 0.0006), influenza vaccination (P < 0.0001), and HAART initiation (P < 0.0001) were significantly associated with increase prescription claims. CD4+ cell count monitoring, TB screening, and HAART initiation (P < 0.0001 for each) were significantly associated with all-cause healthcare costs.

Conclusion:

HAART may reduce use of emergency care services as early as 1 year following initiation.
Potential health gains in West and Central Africa through savings from lower cost HIV treatment
Authors: Stuart Robyn M. , Kelly Sherrie L. , Martin-Hughes Rowan , Wilson David P.
Published: November 2019

Objective: :

Prices of antiretroviral (ARV) drugs in lower income countries have decreased substantially over the past two decades, helping to facilitate greatly expanded access to antiretroviral therapy (ART). However, ART coverage in many parts of the world remains low. We investigate the extent of epidemiological benefits that might be expected if ARV drug prices decline further.

Design:

A modeling study using data from seven countries in West and Central Africa (Cameroon, Democratic Republic of the Congo, Côte d’Ivoire, Niger, Nigeria, Senegal, and Togo).

Methods:

We investigated how the timing of ARV cost reductions could affect the impact and compared three different possible investment strategies: reinvesting in ART, reinvesting in the HIV response according to historical allocations, and reinvesting with the aim of minimizing HIV incidence and mortality.

Results:

If ARV drug prices fell by 37% relative to 2018 levels (i.e. following continued trend declines), we calculate ART unit costs could decrease by ∼20% (holding other cost components constant). If this could be achieved by 2020 and the savings were reinvested into ART, we estimate that an additional 8% of HIV infections and 11% of HIV-related deaths could be averted over 2020–2030 across the seven countries. Slightly greater gains could be attained if funds were reinvested in ART in combination with primary prevention. Delays in the year of introduction of ARV price reductions would reduce the impact by about 1% per year.

Conclusion:

ARV price reductions could free up funds that – if strategically invested – would help countries move closer toward the elimination of HIV.
Immune effects of Lactobacillus casei Shirota in treated HIV-infected patients with poor CD4+ T-cell recovery
Authors: Tenore Simone de Barros , Avelino-Silva Vivian Iida , Costa Priscilla Ramos , Franco Lucas M. , Sabino Ester Cerdeira , Kalil Jorge , Cerqueira Natalia Barros , Nakagawa Zelinda , Kallas Esper Georges
Published: November 2019

Background:

HIV infection leads to depletion of intestinal CD4+ T cells, mucosal barrier dysfunction, increased gut permeability and microbial translocation even among patients on suppressive ART. Previous studies suggest probiotics may help restore intestinal function.

Methods:

In this double-blind, placebo-controlled pilot study, we enrolled HIV-infected patients on suppressive ART with poor CD4+ recovery to address the effect of daily oral use of Lactobacillus casei Shirota (LcS) on CD4+ T-cell count and CD4+/CD8+ ratio at 6 and 12 weeks after treatment initiation; immune activation and intestinal microbiome composition were addressed as secondary outcomes.

Results:

From January 2015 to July 2016, 48 patients were randomized (1 : 1) to active intervention or placebo. Groups had comparable demographic and clinical characteristics; only CD4+ T-cell nadir was statistically different between groups. All participants were virologically suppressed under ART. At week 6, the increment in CD4+ T-cell count was 17 cells/μl [interquartile range (IQR) −33 to 74] in the active intervention arm and 4 cells/μl (IQR −43 to 51) in the placebo arm (P = 0.291); at week 12, the change in CD4+ T-cell count was 8 cells//μl (IQR −30 to 70) in the active arm and 10 cells//μl (IQR −50 to 33) among participants allocated to placebo (P = 0.495). Median change in CD4+/CD8+ ratio at week 6 compared with baseline was 0 (IQR −0.04 to 0.05) in the active intervention arm and −0.01 in the placebo arm (IQR −0.06 to 0.03; P = 0.671). At week 12, the change in CD4+/CD8+ ratio was higher in the active product group compared with placebo (respectively 0.07 and 0.01), but this difference failed to reach statistical significance (P = 0.171). We found no significant effects of LcS on immune activation markers, CD4+ and CD8+ subpopulations, sCD14 levels or NK cells at week 12. Finally, we found no statistically significant differences between groups in the change of enteric microbiome at week 12.

Conclusion:

In this pilot study, we found no statistically significant effect of LcS probiotic on CD4+ T-cell counts, CD4+/CD8+ ratio, immune activation or intestinal microbiome among HIV-infected patients on suppressive ART with poor CD4+ recovery.
Benzodiazepine Use Is Associated With an Increased Risk of Neurocognitive Impairment in People Living With HIV
Authors: Saloner Rowan , Grelotti David J. , Tyree Griffin , Sundermann Erin E. , Ma Qing , Letendre Scott , Heaton Robert K. , Cherner Mariana
Published: November 2019

Objective:

Despite potential for dependence and adverse neurological effects, long-term benzodiazepine (BZD) use is common among people living with HIV (PLWH). As PLWH are at risk for central nervous system dysfunction, we retrospectively examined the association between BZD use and HIV-associated neurocognitive impairment (NCI).

Methods:

Three hundred six PLWH underwent comprehensive neurobehavioral evaluations. Current BZD use (BZD+) was determined through self-report. Using propensity scores, 153 BZD− individuals were matched to 153 BZD+ participants on demographics and medical comorbidities. Multiple regression models examined NCI and demographically adjusted neurocognitive T-scores as a function of BZD status, adjusting for estimated premorbid ability, current affective symptoms, and nadir CD4 count. Secondary analyses explored neurocognitive correlates of positive BZD urine toxicology screens (TOX+) and specific BZD agents.

Results:

Median duration of BZD use was 24 months. Current BZD use related to higher likelihood of NCI (odds ratio = 2.13, P = 0.003) and poorer global (d = −0.28, P = 0.020), processing speed (d = −0.23, P = 0.047), and motor T-scores (d = −0.32, P = 0.008). Compared with BZD−/TOX−, BZD+/TOX+ exhibited additional decrements in executive function (d = −0.48, P = 0.013), working memory (d = −0.49, P = 0.011), and delayed recall (d = −0.41, P = 0.032). For individual agents, diazepam, lorazepam, and alprazolam were most strongly associated with NCI (odds ratios >2.31).

Discussion:

BZD use may elevate risk for NCI in PLWH, potentially through diffuse neurocognitive slowing and acute compromise of recall and higher-order capacities. These effects are robust to psychosocial and HIV-specific factors and occur in comparison with a tightly matched BZD− group. Prospective and interventional studies should evaluate causal associations between NCI and BZD use and explore treatment alternatives to BZDs in PLWH.
Brief Report: Incidence of HIV in a Nationwide Cohort Receiving Pre-exposure Prophylaxis for HIV Prevention
Authors: Van Epps Puja , Wilson Brigid M. , Garner Will , Beste Lauren A. , Maier Marissa M. , Ohl Michael E.
Published: November 2019

Background:

Cases of HIV, while infrequent, have been reported during tenofovir disoproxil fumarate/emtricitabine use as pre-exposure prophylaxis (PrEP). We describe the incidence of HIV and patterns of PrEP use within the Veterans Health Administration (VHA).

Methods:

We conducted a retrospective cohort study among persons initiating PrEP in the VHA between July 2012 and April 2016 using national VHA data. We defined time on PrEP and time at risk of HIV exposure as the total time from the first PrEP fill to exhaustion of supply of the final PrEP prescription. We identified incident cases of HIV infection after PrEP initiation based on laboratory data. Medication adherence measures and days without pills were calculated using pharmacy fill data. We used a chart review to determine patient-reported PrEP use around the time of diagnosis.

Results:

We identified 825 unique patients initiating PrEP; they were 97% men and 67% white, with a mean age of 41 years. Six HIV infections were observed during the study period, yielding an HIV incidence of 0.8 (Poisson exact 95% confidence interval: 0.3 to 1.8) cases per 100 person-years. Two cases occurred during active PrEP use by self-report and perfect adherence based on fill data. Both were infected with viruses containing the M184V mutation. Four additional cases were diagnosed after self-reported discontinuation.

Conclusions:

HIV infection was rare in a nationwide cohort of PrEP users. Although most of the infections occurred during inconsistent PrEP use, infections during periods of high measured adherence were also observed. These findings highlight the importance of PrEP persistence during periods of risk.
Isolated Nasal Metastasis From Renal Cell Carcinoma 9 Years After Nephrectomy Seen on FDG PET
Authors: Yao Yutang , Zuo Zhuo , Cheng Zhuzhong
Published: November 2019

A 56-year-old man presented with intermittent epistaxis. Nasopharyngoscope revealed a hemorrhagic mass occupying the left nasal cavity. The patient had a history of renal clear cell carcinoma. 18F-FDG PET/CT was performed to evaluate the potential lesions systematically. PET/CT images showed low to moderate activity in the region of nasal cavity and paranasal sinuses. No abnormal uptake of 18F-FDG was observed in the rest of the body. Eventually, the mass was pathologically proved to be metastatic renal clear cell carcinoma.
Assessment of Response to Neoadjuvant Chemoradiotherapy by 18F-FDG PET/CT in Patients With Locally Advanced Esophagogastric Junction Adenocarcinoma
Authors: Sánchez-Izquierdo Nuria , Perlaza Pilar , Pagès Mario , Buxó Elvira , Rios José , Rubello Domenico , Colletti Patrick M. , Mayoral Maria , Casanueva Sebastian , Fernández-Esparrach Gloria , Ginés Angels , Fuster David
Published: November 2019

Purpose

The outcome of locally advanced adenocarcinoma of the esophagogastric junction (AEG) treated with preoperative chemoradiotherapy is heterogeneous, and favorable response to this treatment is a key factor in the patient's prognosis. The aim of this study was to evaluate 18F-FDG PET/CT in assessing metabolic response in patients with AEG.

Materials and Methods

This prospective study evaluated all consecutive patients with potentially operable locally advanced AEG who were candidates for neoadjuvant chemoradiotherapy. PET/CT and contrast-enhanced thoracoabdominal CT were performed at baseline and 2 weeks after completion of chemoradiotherapy for response evaluation. The response rate was assessed using Response Evaluation Criteria in Solid Tumors criteria for contrast-enhanced thoracoabdominal CT and Positron Emission Tomography Response Criteria in Solid Tumors criteria for PET/CT. The regression rate was assessed using a 5-grade histopathology scoring system of the surgically resected tumor. Metastatic lesions were confirmed by histopathology examination or imaging and clinical follow-up at 6 months.

Results

A total of 40 cases were finally included in the study. Distant metastases were found in the baseline PET/CT in 6 of 40 cases (retroperitoneal [2] or mediastinal/hiliar [1] lymph nodes and liver [2] or bone [1] metastases) and were therefore excluded from surgery. Pathologic response correlated with the ΛSUVmax threshold of ≤45% (P = 0.033). CT response correlated well with both the baseline SUVmax (P = 0.039) and the ΛSUVmax (P = 0.001). Five-year survival curves for AEG correlated with the ΛSUVmax using a threshold of ≤45% for both progression-free and overall survival.

Conclusions

18F-FDG PET/CT is useful for diagnosing nonsuspected metastasis before neoadjuvancy in potentially operable AEG. The ΛSUV correlates with pathologic response and is a long-term independent prognostic factor of survival.
Severe Contralateral Striatal Hypometabolism in a Case of Diabetic Nonketotic Hyperglycemic Hemichorea on 18F-FDG PET/CT Brain
Authors: Kumar Vadi Shelvin , Mehta Sahil , Kumar Rajender , Tandyala Naresh , Singh Harmandeep , Mittal Bhagwant Rai
Published: November 2019

Chorea induced by diabetic nonketotic hyperglycemia is a rare and poorly understood entity with a favorable prognosis after correction of the hyperglycemia. We present a case of elderly diabetic woman with poorly controlled blood glucose levels, presenting with choreiform movements limited to the right side. 18F-FDG PET/CT showed marked hypometabolism in the basal ganglia contralateral to the side with hemichorea. The metabolic dysfunctions lead to nonketotic hyperglycemic chorea, although poorly understood; the index case demonstrated severe glucose hypometabolism in the striatum and adds to the other reported differential diagnoses for striatal hypometabolism.
Reconstruction With Fibula Musculocutaneous Flap in a Patient With Extensive Maxillary Osteoradionecrosis
Authors: Zhu Fengshuo , Li Xiaoguang , Liu Zhonglong , He Yue
Published: November 2019

The authors reported a case of extensive maxillary osteoradionecrosis. The maxilla was resected and reconstructed with fibula musculocutaneous flap. It was the first reported that the osteoradionecrotic maxilla was reconstructed with free vascularized bone. The musculocutaneous flap might be a better choice of maxillary osteoradionecrosis reconstruction instead of the simple soft-tissue flap.