bluuebunny/crossref_metadata_2025 huggingface dataset:
Rapid Implementation of Telecritical Care Support During a Pandemic: Lessons Learned During the Coronavirus Disease 2020 Surge in New York City
Authors: Krouss Mona , Allison Michael G. , Rios Saul , Bringardner Benjamin D. , Langston Matthew D. , Sokol Seth I. , McCurdy Michael T.
Published: October 2020

Objectives:

We describe the key elements for a New York City health system to rapidly implement telecritical care consultative services to a newly created ICU during the coronavirus disease 2020 patient surge.

Design:

This was a rapid quality-improvement initiative using public health decrees, a HIPAA-compliant and device-agnostic telemedicine patform, and a group of out-of-state intensivist volunteers to enhance critical care support. Telecritical care volunteers initially provided on-demand consults but then shifted to round twice daily with housestaff in a 12-bed newly created ICU.

Setting:

A 457-bed safety net hospital in the Bronx, NY, during the pandemic.

Subjects:

The 12-bed newly created ICU was staffed by a telecritical care attending, a cardiology fellow, and internal medicine residents.

Intervention:

Prior to the intervention, the ad hoc ICU was staffed by a cardiology fellow as the attending of record, with critical care support on demand. The intervention involved twice daily rounding with an out-of-state, volunteer intensivist.

Measurements and Main Results:

Volunteers logged 352 encounters. Data from 26 unique encounters during the initial on-demand consult pilot study of tele-ICU support were recorded. The most common interventions were diagnostic test interpretation, ventilator management, and sedation change. The majority of housestaff felt the new tele-ICU service improved the quality of care of patients and decreased anxiety of taking care of complex patients. Likewise, the majority of volunteers expressed making significant alterations to care, and 100% believed critical care input was needed for these patients. The largest lessons learned centered around mandating the use of the telecritical care volunteers and integration into a structured format of rounding.

Conclusions:

The need for rapid implementation of ICUs during a major public health crisis can be challenging. Our pilot study supports the feasibility of using an out-of-state telecritical care service to support ICUs, particularly in areas where resources are limited.
Multifactor analysis of patients with oral sensory complaints in a case-control study
Authors: Jin Jian-Qiu , Cui Hong-Mei , Han Ying , Su Sha , Liu Hong-Wei
Published: October 2020

Background:

There are an increasing number of patients with oral sensory complaints (OSCs) presenting to our dental clinic. For most dentists, it is difficult to distinguish burning mouth syndrome (BMS) from other oral mucosal diseases that may cause symptoms such as burning mouth. It is beneficial to effectively distinguish OSC patients to reduce misdiagnosis and eliminate burning symptoms as much as possible.

Methods:

Patients with oral burning sensations in the oral mucosal disease clinic were collected from the Peking University Hospital of Stomatology between September 1, 2014 and December 31, 2018. After excluding oral candidiasis, anemic stomatitis, dental material allergy, and other diseases from patients with oral sensory complaints, basic conditions such as gender, age, education level, job status, hyperglycemia, hypertension, hyperlipidemia, history of brain abnormalities, history of cervical spondylitis, history of thyroid disease, history of thyroid disease and insomnia were obtained. The BMS patients were compared with the control group. The t test and Chi-square test were used for statistical analysis to compare the clinical symptoms of these diseases and explore the risk factors for BMS.

Results:

In this case-control study, 395 patients (321 females and 74 males, mean age 55.26 ± 10.51 years) with oral sensory complaints and 391 healthy controls (281 females and 110 males, mean age 47.11 ± 13.10 years) were enrolled, among which, 8.4% (33/395) had oral candidiasis, 1.3% (5/395) had dental material allergy, 0.8% (3/395) had anemic stomatitis and 0.5% (2/395) had lichen planus. A total of 352 patients were eventually diagnosed with BMS. Anxiety and depression were more severe in BMS patients, as were the incidences of sleep disorders and brain abnormalities. Logistic regression analysis showed that age (odds ratio [OR] = 2.79, 95% confidence interval [CI]: 1.61–4.83, P < 0.001), total cholesterol level (OR = 2.92, 95% CI: 1.32–6.50, P = 0.009) and anxiety score (OR = 1.75, 95% CI: 1.01–2.77, P = 0.017) significantly increased the incidence of BMS. Patients with hyperglycemia (OR = 0.46, 95% CI: 0.23–0.89, P = 0.022), low body mass index (BMI: OR = 0.57, 95% CI: 0.34–0.93, P = 0.026) and low education level (OR = 3.43, 95% CI: 1.91–6.15, P < 0.001) were more likely to suffer from BMS.

Conclusions:

Oral candidiasis, anemic stomatitis, and dental material allergy with burning symptoms should be excluded from patients with BMS. It is recommended to conduct a questionnaire survey (including anxiety and depression), blood cell analysis, and salivary fungus culture for all patients with an oral burning sensation. It is necessary to conduct a patch test on patients with oral burning sensations and metal restorations.
Outcome of Locally Advanced Esophageal Cancer Patients Treated With Perioperative Chemotherapy and Chemoradiotherapy Followed by Surgery
Authors: Ahmed Naseer , Owen Justin , Abdalmassih Michael , Khan Junaid , Nugent Zoann , Qing Gefei , Martineau Patrick , Rathod Shrinivas , Dubey Arbind , Bashir Bashir , Chowdhury Amitava , Buduhan Gordon
Published: October 2020

Objectives:

Perioperative chemotherapy (P-CT) or neoadjuvant chemoradiation (C-RT) followed by surgical resection is the standard of care for locally advanced esophageal cancer (LAEC). We present an institutional review and outcome of patients with LAEC treated with neoadjuvant C-RT or P-CT followed by surgery.

Methods:

Patients were identified through the Manitoba Cancer Registry. Overall survival (OS), recurrence-free survival (RFS), and time to recurrence (TTR) were compared using proportion hazard regression analysis. Metabolic and pathologic response rates were compared by the Fisher exact test.

Results:

Sixty-seven patients were treated with C-RT and 32 with P-CT. Fifty-two percent of the patients had pretreatment and posttreatment positron emission tomography scans before surgery. Ninety-five percent of the patients in C-RT and 91% in P-CT had a partial metabolic response or stable disease. Sixty-one percent of C-RT and 34% of P-CT patients had tumor regression grade (TRG) 0 to 1; 39% of C-RT and 66% of P-CT had TRG 2 to 3 (P=0.018). Median OS was 37 and 18 months for patients with TRG 0 to 1 and 2 to 3, respectively (P=0.013, hazard ratio [HR]=1.96). Three-year OS was 43% versus 37% (P=0.37, HR=1.30), RFS was 34% versus 26% (P=0.87, HR=0.96), and median TTR was 30 versus 13 months (P=0.07, HR=0.59) for C-RT and P-CT, respectively.

Conclusions:

C-RT was associated with a higher degree of pathologically tumor regression. Patients with major tumor regression had a better outcome than those with minimal to poor response. There was a trend toward improved TTR with C-RT but no difference in OS or RFS.
Fluid loading therapy to prevent spinal hypotension in women undergoing elective caesarean section
Authors: Rijs Koen , Mercier Frédéric J. , Lucas D. Nuala , Rossaint Rolf , Klimek Markus , Heesen Michael
Published: October 2020

BACKGROUND

Fluid loading is one of the recognised measures to prevent hypotension due to spinal anaesthesia in women scheduled for a caesarean section.

OBJECTIVE

We aimed to evaluate the current evidence on fluid loading in the prevention of spinal anaesthesia-induced hypotension.

DESIGN

Systematic review and network meta-analysis with trial sequential analysis and meta-regression.

DATA SOURCES

Medline, Epub, Embase.com (Embase and Medline), Cochrane Central, Web of Science and Google Scholar were used.

ELIGIBILITY CRITERIA

Only randomised controlled trials were used. Patients included women undergoing elective caesarean section who received either crystalloid or colloid fluid therapy as a preload or coload. The comparator was a combination of either a different fluid or time of infusion.

RESULTS

A total of 49 studies (4317 patients) were included. Network meta-analysis concluded that colloid coload and preload offered the highest chance of success (97 and 67%, respectively). Conventional meta-analysis showed that crystalloid preload is associated with a significantly higher incidence of maternal hypotension than colloid preload: risk ratio 1.48 (95% CI 1.29 to 1.69, P < 0.0001, I2 = 60%). However, this result was not supported by Trial Sequential Analysis. There was a significant dose–response effect for crystalloid volume preload (regression coefficient = −0.073), which was not present in the analysis of only double-blind studies. There was no dose–response effect for the other fluid regimes.

CONCLUSION

Unlike previous meta-analysies, we found a lack of data obviating an evidence-based recommendation. In most studies, vasopressors were not given prophylactically as is recommended. Studies on the best fluid regimen in combination with prophylactic vasopressors are needed. Due to official european usage restrictions on the most studied colloid (HES), we recommend crystalloid coload as the most appropriate fluid regimen.

TRIAL REGISTRATION

CRD42018099347.
Preoperative dexamethasone for pain relief after total knee arthroplasty
Authors: Chan Timmy Chi Wing , Cheung Chi Wai , Wong Stanley Sau Ching , Chung Arthur Yu Fai , Irwin Michael G. , Chan Ping Keung , Fu Henry , Yan Chun Hoi , Chiu Kwong Yuen
Published: October 2020

BACKGROUND

Corticosteroids can reduce pain but the optimal dose and safety profiles are still uncertain.

OBJECTIVE

This study aimed to evaluate two different doses of dexamethasone for pain management and their side effects after total knee arthroplasty.

DESIGN

A prospective randomised, controlled trial.

SETTING

A tertiary teaching hospital in Hong Kong.

PATIENTS

One hundred and forty-six patients were randomly allocated to one of three study groups.

INTERVENTIONS

Before operation, patients in group D8, D16 and P received dexamethasone 8 mg, dexamethasone 16 mg and placebo (0.9% saline), respectively.

MAIN OUTCOME MEASURES

The primary outcome was postoperative pain score. Secondary outcomes were opioid consumption, physical parameters of the knees and side effects of dexamethasone.

RESULTS

Compared with placebo, group D16 patients had significantly less pain during maximal active flexion on postoperative day 3 [−1.3 (95% CI, −2.2 to −0.31), P = 0.005]. There was also a significant dose-dependent trend between pain scores and dexamethasone dose (P = 0.002). Compared with placebo, patients in group D16 consumed significantly less opioid [−6.4 mg (95% CI, −11.6 to −1.2), P = 0.025] and had stronger quadriceps power on the first three postoperative days (all P < 0.05). They also had significantly longer walking distance on postoperative day 1 [7.8 m ([95% CI, 0.85 to 14.7), P = 0.023] with less assistance during walking on the first two postoperative days (all P < 0.029) and significantly better quality-of-recovery scores on postoperative day 1 (P = 0.018). There were significant dose-dependent trends between all the above parameters and dexamethasone dose (all P < 0.05). No significant differences were found in the incidence of chronic pain or knee function 3, 6 and 12 months postoperatively.

CONCLUSION

Dexamethasone 16 mg given before total knee arthroplasty led to a reduction in postoperative pain, less opioid consumption, stronger quadriceps muscle power, better mobilisation and better overall quality-of-recovery after operation. No long-term improvement in reduction in pain and function of the knee was found.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02767882.
Asymptomatic Papulovesicles Arising in 48 Hours
Authors: Matzek Carmen , Brodell Robert T. , Nahar Vinayak K.
Published: October 2020

While there are a number of skin rashes associated with photosensitivity, only one produces a distinctive rash with fixed urticaria, macular erythema, and papulovesicles forming small papules and plaques. This polymorphous light eruption requires aggressive broad spectrum UV protection, topical steroids for pruritus, and paradoxically sometimes UV light treatment to “harden” the skin making skin more resistant to rashing when exposed to the sun.
Dermatology Assessment
Authors: Maghfour Jalal , Jacob Sharon E.
Published: October 2020

Dermatology Assessment represents a novel readership-based tutorial module. Each question links to the Journal of the Dermatology Nurses' Association articles (for members) and Journal of the American Academy of Dermatology article citations associated with the topic.
Improving Effective Preventative Care Within an Urban Working Population
Authors: Clark Melanie J. , Jefferson Khara’ A.
Published: October 2020

Objective:

To assess whether standardized screening and service navigation improve access to primary care in low wage workers.

Methods:

Four rapid plan-do-study-act cycles were conducted over an 8-week period. Each cycle consisted of four core interventions. Data were collected every 2 to 3 days, then analyzed on run charts and aggregate data tables.

Results:

Effective care was achieved by increasing the percentage of patients with a primary care provider from 52% to 79%. Patients’ perception of health increased from 3.6 to 4.4 and team communication and support score increased from 3.9 to 4.2 on a 5-point Likert scale.

Conclusions:

Patient engagement and a standardized referral process aids in the establishment of routine, effective care. Application of “smart phrases” in electronic health records provides sustainability for use in other occupational medicine practices.
Standardizing nurse practitioner student evaluation during high-stakes clinical examinations
Authors: Keiffer Melanie , Anderson Mindi , Eckhoff Dawn O. , Blackwell Christopher W. , Talbert Steven , Parker Ann Marie
Published: October 2020

Nurse practitioners (NPs) require clinical competence in advanced health assessment skills to differentiate between normal, variations of normal, and abnormal patient findings. High-stakes clinical examinations, using live hands-on simulation scenarios and standardized patients (SPs) or other human role players, are accepted teaching and evaluation tools for NP students. Providing objective, valid, and reliable feedback to students during high-stakes clinical examinations is of considerable value for ongoing skill development. The study examined opportunities to improve the quality of student evaluation in simulation testing modes. A purposive sample of 17 video recordings of health students' comprehensive examination of an SP or physical examination teaching associate (PETA) from a nursing graduate level health assessment course was evaluated. Using a standardized rubric, students were scored live and after a comprehensive examination of a SP/PETA and via a secure web-based video platform by the faculty and an independent reviewer. Evaluator group examination score comparisons revealed that distributions of examination scores within evaluator groups were not similar. Median examination scores were significantly different between groups; faculty median examination scores significantly higher than SPs/PETAs. Efficiency of student evaluation may be increased by improving reviewer training, reducing checklist length, and adopting electronic scoring. Development of an exemplary teaching video providing explanation and detail for expected student skill performance will allow reviewers to practice and improve competence in reliable scoring, reduce time and effort of scorers, and increase accuracy of scoring.
Augmented Fluoroscopy
Authors: Cicenia Joseph , Bhadra Krish , Sethi Sonali , Nader Daniel A. , Whitten Patrick , Hogarth Douglas Kyle
Published: October 2020

Background:

The diagnosis of lung nodules continues to be a challenge. Confirmed diagnosis allows appropriate treatment for cancers and allows avoidance of more invasive procedures for proven noncancers. Currently, available lung biopsy technologies each have their own limitations, which affect the ability to successfully navigate to a suspicious nodule and to collect a diagnostic sample. Additional advancements in endobronchial navigation, localization, and guided biopsy are needed to obtain higher rates of definitive diagnosis for lung nodules.

Methods:

This is a prospective, multicenter study that assessed the localization success rate and diagnostic yield of bronchoscopies guided only by the LungVision platform. Physicians navigated to pulmonary nodules according to a proposed pathway and verified nodule location using radial endobronchial ultrasound before the biopsy.

Results:

Fifty-five patients were enrolled in the study. Two patients had >1 nodule that was evaluated on the day of the procedure. During bronchoscopy, the nodule localization success rate was 93%. The overall diagnostic yield measured the day of the procedure, based on the immediate rapid on-site pathology report, was 75.4%.

Conclusion:

LungVision provides reliable navigation and ability to biopsy pulmonary nodules with an acceptable success rate. The platform demonstrates a high localization rate of pulmonary nodules.
Performance of Xpert HPV on Self-collected Vaginal Samples for Cervical Cancer Screening Among Women in South Africa
Authors: Saidu Rakiya , Kuhn Louise , Tergas Ana , Boa Rosalind , Moodley Jennifer , Svanholm-Barrie Cecilia , Persing David , Campbell Scott , Tsai Wei-Yann , Wright Thomas C. , Denny Lynette
Published: October 2020

Objectives

Self-sampling may increase access to cervical cancer screening in low-resource settings. Using Xpert HPV, we compared test performance of self- and clinician-collected samples in HIV-positive and HIV-negative women in South Africa.

Materials and Methods

Three hundred thirty HIV-positive and 375 HIV-negative women in the screening group and 202 HIV-negative and 200 HIV-positive women in the referral group, aged 30–65 years, participated in the study. All women self-collected a vaginal sample, and then, a cervical sample was collected by a clinician (both tested using Xpert HPV), followed by colposcopic examination and collection of histologic specimens.

Results

There was good agreement between self- and clinician-collected samples for detection of any high-risk human papillomavirus (HPV, κ = 0.72 [95% CI = 0.669–0.771]). Prevalence of HPV and sensitivity of the test to detect cervical intraepithelial neoplasia 2+ was similar in self- and clinician-collected samples. Specificity was lower in self-collected than in clinician-collected samples in both HIV-negative (self: 77.5% [95% CI = 72.8–81.8] vs clinician: 86.9% [95% CI = 82.9–90.2]) and HIV-positive (self: 44.0% [95% CI = 38.0–50.1] vs clinician: 59.7% [95% CI = 53.6–65.6]) women. Restricting the definition of screen-positive to 3 of 5 channels on HPV Xpert improved specificity in both HIV-negative (self: 83.2% [95% CI = 78.8–87.0] vs clinician: 89.7% [95% CI = 86.1–92.7]) and HIV-positive (self: 54.2% [95% CI = 48.1–60.2] vs clinician: 67.4% [95% CI = 61.5–72.9]) women.

Conclusions

The self-collected sample had good agreement with the clinician-collected sample for the detection of HPV, and restricting the HPV types may improve the specificity in HIV-positive women.
Approach to the patient with infectious colitis: clinical features, work-up and treatment
Authors: Iqbal Tehseen , DuPont Herbert L.
Published: October 2020

Purpose of review

To provide the definition, causes, and current recommendations for workup and treatment of acute infectious colitis in adults, a common medical problem of diverse cause.

Recent findings

The management of acute colitis in adults depend upon establishment of cause. Most forms of infectious colitis are treatable with antimicrobials. Multiplex polymerase chain reaction (PCR) followed by guided culture on PCR-positive pathogens can often confirm active infection while standard culture methods provide isolates for antibiotic susceptibility testing, subtyping, and Whole Genome Sequencing.

Patients with colitis may be suffering from a range of etiologies including infectious colitis, neutropenic colitis, drug-induced colitis, and inflammatory bowel disease. The present review was prepared to provide an approach to prompt diagnosis and management of acute colitis to prevent severe complications (e.g. dehydration and malnutrition, or toxic megacolon) and provide recommendations for antimicrobial therapy.
Is there a causal relationship between trehalose consumption and Clostridioides difficile infection?
Authors: Buckley Anthony M. , Moura Ines B. , Wilcox Mark H.
Published: October 2020

Purpose of review

Trehalose metabolism appears to play a role in the pathogenicity of some microbes. It has been claimed that trehalose consumption may be a risk factor for Clostridioides difficile infection (CDI), but the evidence for a causal link is contentious.

Recent findings

Epidemic ribotypes of C. difficile harbour mutations or have acquired extra genes that mean these strains can utilize lower concentrations of bioavailable trehalose, providing a competitive metabolic advantage in some CDI animal models. By contrast, evidence has emerged to show that trehalose-induced microbiota changes can help protect/reduce CDI in other models. In addition, C. difficile trehalose metabolic variants are widespread among epidemic and nonepidemic ribotypes alike, and the occurrence of these trehalose variants was not associated with increase disease severity or mortality.

Currently, there is no proven causal association between the incidence or severity of human CDI and the presence of trehalose metabolism variants. Furthermore, microbial metabolism reduces trehalose bioavailability, potentially removing this competitive advantage for C. difficile trehalose metabolism variants. Taken together, trehalose consumed as part of a normal diet has no increased risk of CDI.
Learning from Each Other: A Multisite Collaborative to Reduce Electrolyte Testing
Authors: Coe Megan , Gruhler Heidi , Schefft Matthew , Williford Dustin , Burger Barrett , Crain Emily , Mihalek Alexandra J. , Santos Maria , Cotter Jillian M. , Trowbridge Gregory , Kessenich Jeri , Nolan Mark , Tchou Michael J.
Published: October 2020

Introduction:

Inpatient electrolyte testing rates vary significantly across pediatric hospitals. Despite evidence that unnecessary testing exists, providers still struggle with reducing electrolyte laboratory testing. We aimed to reduce serum electrolyte testing among pediatric inpatients by 20% across 5 sites within 6 months.

Methods:

A national quality improvement collaborative evaluated standardized interventions for reducing inpatient serum electrolyte testing at 5 large tertiary and quaternary children’s hospitals. The outcome measure was the rate of electrolyte laboratory tests per 10 patient-days. The interventions were adapted from a previous single-site improvement project and included cost card reminders, automated laboratory plans via electronic medical record, structured rounds discussions, and continued education. The collaborative utilized weekly conference calls to discuss Plan, Do, Study, Act cycles, and barriers to implementation efforts.

Results:

The study included 17,149 patient-days across 5 hospitals. The baseline preintervention electrolyte laboratory testing rate mean was 4.82 laboratory tests per 10 patient-days. Postimplementation, special cause variation in testing rates shifted the mean to 4.19 laboratory tests per 10 patient-days, a 13% reduction. There was a wide variation in preintervention electrolyte testing rates and the effectiveness of interventions between the hospitals participating in the collaborative.

Conclusions:

This multisite improvement collaborative was able to rapidly disseminate and implement value improvement interventions leading to a reduction in electrolyte testing; however, we did not meet our goal of 20% testing reduction across all sites. Quality improvement collaboratives must consider variation in context when adapting previously successful single-center interventions to a wide variety of sites.
Improving the Resident Educational Experience in a Level IV Neonatal/Infant Intensive Care Unit
Authors: Handley Sara C. , Pouppirt Nicole , Zucker Eric , Coughlin Katherine A. , Ades Anne
Published: October 2020

Introduction:

The neonatal/infant intensive care unit (N/IICU) at the Children’s Hospital of Philadelphia is a 98-bed, level IV unit through which second-year pediatric residents rotate monthly. We developed a quality improvement project to improve the resident educational experience using goal setting. Primary objectives were to increase resident educational goal identification to 65% and goal achievement to 85% by June 2017. Secondary objectives were to (1) increase in-person feedback from fellows and/or attendings to 90% by June 2017 and (2) sustain improvements through June 2018.

Methods:

The quality improvement team developed a driver diagram and administered a baseline survey to 48 residents who had rotated through the N/IICU in the 18 months before the project. Plan-Do-Study-Act cycles targeted project awareness and trialing of 3 different methods to elicit goals and track feedback, from July 2016 through June 2018.

Results:

The baseline survey response rate was 52% (n = 25). Among 60 rotating residents, the median resident-reported rate of goal achievement increased from 37.5% to 50%, and residents receiving in-person feedback increased from 25% to 50%. Of the 63% (n = 38) of residents who participated in data collection, goal identification and achievement increased from 38% to 100% between academic year 2016 and academic year 2017, and in-person feedback increased from 24% to 82%.

Conclusions:

Instituting a goal-setting framework for residents during their N/IICU rotation increased goal achievement and in-person feedback. Consistent resident participation in postrotation data collection made measuring project outcomes challenging. These data support goal-oriented learning as an approach to enhance learner engagement and improve goal achievement.
Long-term Effects of an Evidence-based Guideline for Emergency Management of Pediatric Syncope
Authors: Shanahan Kristen H. , Monuteaux Michael C. , Brunson Dalton , Guse Sabrina E. , Alexander Mark E. , Porter John J. , Neuman Mark I. , Fine Andrew M.
Published: October 2020

Introduction:

Variability exists in the management of childhood syncope as clinicians balance resource utilization with the need to identify serious diseases. Limited evidence exists regarding the long-term impact of evidence-based guidelines (EBGs) on clinical practices. This study’s objective was to measure long-term changes in the management of syncope after implementing a syncope EBG in a single pediatric emergency department following the redistribution of resources to facilitate compliance over time.

Methods:

We included healthy patients aged 8–22 years, presenting to the pediatric emergency department with syncope between 2009 and 2017. Interrupted time series analysis compared testing rates and length of stay among the pre-EBG, short-term follow-up, and long-term follow-up periods.

Results:

The study included 1,294 subjects. From the pre-EBG period to the long-term follow-up period, recommended electrocardiogram and urine pregnancy test rose significantly [level change odds ratio (95% confidence interval) 5.56 (1.73–17.91) and 3.15 (1.07–9.32), respectively]. Testing and management not recommended by the EBG decreased significantly, including complete blood count, electrolytes, point-of-care glucose, chest radiograph, and intravenous fluids [level change odds ratio (95% confidence interval) 0.19 (0.09–0.40), 0.15 (0.07–0.32), 0.38 (0.18–0.81), 0.17 (0.06–0.49), and 0.18 (0.08–0.39), respectively]. Length of stay declined significantly. No delayed diagnoses occurred.

Conclusions:

Sustained improvements in syncope management persisted during long-term follow-up of the EBG despite minimal resources. The EBG was associated with increased focused evaluation and decreased low yield testing. EBGs may be useful tools to influence sustained clinical practices to promote safe, cost-effective, and high-quality care.
Mathematical Model Impact Analysis of a Real-Life Pre-exposure Prophylaxis and Treatment-As-Prevention Study Among Female Sex Workers in Cotonou, Benin
Authors: Geidelberg Lily , Mitchell Kate M. , Alary Michel , Mboup Aminata , Béhanzin Luc , Guédou Fernand , Geraldo Nassirou , Goma-Matsétsé Ella , Giguère Katia , Aza-Gnandji Marlène , Kessou Léon , Diallo Mamadou , Kêkê René K. , Bachabi Moussa , Dramane Kania , Lafrance Christian , Affolabi Dissou , Diabaté Souleymane , Gagnon Marie-Pierre , Zannou Djimon M. , Gangbo Flore , Silhol Romain , Cianci Fiona , Vickerman Peter , Boily Marie-Claude
Published: October 2020

Background:

Daily pre-exposure prophylaxis (PrEP) and treatment-as-prevention (TasP) reduce HIV acquisition and transmission risk, respectively. A demonstration study (2015–2017) assessed TasP and PrEP feasibility among female sex workers (FSW) in Cotonou, Benin.

Setting:

Cotonou, Benin.

Methods:

We developed a compartmental HIV transmission model featuring PrEP and antiretroviral therapy (ART) among the high-risk (FSW and clients) and low-risk populations, calibrated to historical epidemiological and demonstration study data, reflecting observed lower PrEP uptake, adherence and retention compared with TasP. We estimated the population-level impact of the 2-year study and several 20-year intervention scenarios, varying coverage and adherence independently and together. We report the percentage [median, 2.5th–97.5th percentile uncertainty interval (95% UI)] of HIV infections prevented comparing the intervention and counterfactual (2017 coverages: 0% PrEP and 49% ART) scenarios.

Results:

The 2-year study (2017 coverages: 9% PrEP and 83% ART) prevented an estimated 8% (95% UI 6–12) and 6% (3–10) infections among FSW over 2 and 20 years, respectively, compared with 7% (3–11) and 5% (2–9) overall. The PrEP and TasP arms prevented 0.4% (0.2–0.8) and 4.6% (2.2–8.7) infections overall over 20 years, respectively. Twenty-year PrEP and TasP scale-ups (2035 coverages: 47% PrEP and 88% ART) prevented 21% (17–26) and 17% (10–27) infections among FSW, respectively, and 5% (3–10) and 17% (10–27) overall. Compared with TasP scale-up alone, PrEP and TasP combined scale-up prevented 1.9× and 1.2× more infections among FSW and overall, respectively.

Conclusions:

The demonstration study impact was modest, and mostly from TasP. Increasing PrEP adherence and coverage improves impact substantially among FSW, but little overall. We recommend TasP in prevention packages.
Computed tomography-derived body composition analysis in patients with advanced cancer: clinical utility and future research
Authors: Abbass Tanvir , Dolan Ross D. , McMillan Donald C.
Published: October 2020

Purpose of review

With weight loss increasingly occurring against a background of obesity across a variety of advanced cancers, there has been increasing interest in computed tomography (CT)-derived body composition analysis. Various imaging software packages and thresholds are commonly in use in CT-derived body composition analysis. This review discusses the current research in field of body composition with emphasis on the information required for such measurements to be taken into routine clinical practice.

Recent findings

CT is widely used for tumour staging in patients with cancer. Over the last decade, this imaging modality has been exploited to make measurements of body composition. Using a common landmark (L3) several different thresholds have been developed to stratify adipose and muscle tissue areas according to age, sex and BMI and their relationship with survival. A significant relationship between CT-derived body composition and clinical outcomes has been shown in different tumour types and geographical locations. However, there is considerable variation with methods, thresholds and muscle groups used for analysis. Therefore, there would appear to be a need to develop reliable methodology and population-specific reference ranges to guide clinical interpretation and enable routine clinical use.

There has been an explosion of clinical research interest in CT-derived body composition analysis. Such body composition analysis provides important host phenotype information which has prognostic value. For CT-derived body composition to be fit for use in routine clinical practice, there is need for universally accepted terminology, software, muscle group selection, prognostic thresholds to standardize such body composition analysis.
Barriers to Care Affecting Presentation to Urogynecologists in a Community Setting
Authors: Smith Fiona K. , Agu Ijeoma , Murarka Shivani , Siddiqui Gazala , Orejuela Francisco J. , Muir Tristi W. , Antosh Danielle D.
Published: October 2020

Objective

To evaluate barriers to care for patients presenting to urogynecologists and determine how these barriers differ in private and public/county health care settings.

Methods

Standardized anonymous questionnaires were distributed from May 2018 to July 2018 to new patients presenting to a urogynecologist at three institutions: two private health care clinics (sites A and B) and one public/county hospital clinic (site C). Patients identified symptom duration, symptom severity, and factors inhibiting presentation to care from a list of barriers. Patients then identified the primary barrier to care.

Results

One hundred nine questionnaires were distributed, and 88 were submitted, resulting in an 81% response rate (31 from site A, 30 from site B, 27 from site C). In analysis of the private versus public setting, there was no statistical difference between age (58 years vs 57 years, P = 0.69), body mass index (28 vs 30, P = 0.301), symptom duration (24 months vs 16 months, P = 0.28), or severity respectively. When asked to identify the primary barrier to presentation, patients in the private setting stated they did not know to see a specialist (26.2%, P = 0.002), while patients in the public setting could not obtain a closer appointment time (22.2% vs 13.1%, P = 0.35. Additionally, patients in the public setting were more likely to cite lack of health care coverage as a barrier to care (18.5% vs 1.6%, P = 0.01).

Conclusion

This study highlights barriers that can contribute to the disparity of care seen in our patient population. Efforts should be made to acknowledge and mitigate hindrances impacting access to care.
Polycarbonate Urethane Mesh: A New Material for Pelvic Reconstruction
Authors: Bickhaus Jennifer A. , Fraser Matthew O. , Weidner Alison C. , Jayes Friederike L. , Amundsen Cindy L. , Gall Ken , Miller Andrew T. , Marini Frank C. , Robboy Stanley J. , Siddiqui Nazema Y.
Published: October 2020

Objective

Polycarbonate urethane (PCU) is a new biomaterial, and its mechanical properties can be tailored to match that of vaginal tissue. We aimed to determine whether vaginal host immune and extracellular matrix responses differ after PCU versus lightweight polypropylene (PP) mesh implantation.

Methods

Hysterectomy and ovariectomy were performed on 24 Sprague-Dawley rats. Animals were divided into 3 groups: (1) PCU vaginal mesh, (2) PP vaginal mesh, and (3) sham controls. Vagina-mesh complexes or vaginas (controls) were excised 90 days after surgery. We quantified responses by comparing: (1) histomorphologic scoring of hematoxylin and eosin– and Masson trichrome–stained slides, (2) macrophage subsets (immunolabeling), (3) pro-inflammatory and anti-inflammatory cytokines (Luminex panel), (4) matrix metalloproteinase (MMP)-2 and -9 using an enzyme-linked immunosorbent assay, and (5) type I/III collagen using picrosirius red staining.

Results

There was no difference in histomorphologic score between PCU and PP (P = 0.211). Although the histomorphologic response was low surrounding all mesh fibers, groups with PCU and PP mesh had a higher histomorphologic score than the control group (P < 0.005 and P < 0.002, respectively). There were no differences between groups in terms of macrophage subsets, pro-inflammatory cytokines, anti-inflammatory cytokines, MMP-2 and MMP-9, or collagen ratio.

Conclusions

Polycarbonate urethane, an elastomer with material properties similar to those of vaginal tissue, elicits minimal host inflammatory responses in a rat model. Because its implantation does not elicit more inflammation than currently used lightweight PP, using PCU for prolapse mesh warrants further investigation with larger animal models.
The Association of Preoperative Medication Administration and Preoperative and Intraoperative Factors With Postoperative Urinary Retention After Urogynecologic Surgery
Authors: Schmidt Payton , Kobernik Emily K. , Fairchild Pamela S. , Anderson Alec , Lanham Michael , Berger Mitchell B.
Published: October 2020

Objectives

The aim of this study was to determine if preoperative medication administration is associated with postoperative urinary retention (PUR) after urogynecologic procedures and identify preoperative and intraoperative factors that are predictive of PUR.

Methods

A retrospective review of patients who underwent prolapse and/or incontinence surgery was performed. The primary outcome was PUR, defined as postoperative retrograde void trial with postvoid residuals of greater than 100 mL. Bivariate analysis was performed to compare demographics and preoperative and intraoperative characteristics of women with and without PUR, and multivariable logistic regression modeling was used to identify independent predictors of PUR.

Results

Of women in this cohort, 44.8% (364/813) had PUR. There were no significant differences in preoperative medication administration in women with and without PUR. Age older than 60 years (adjusted odds ratio [aOR], 1.48; 95% confidence interval [CI], 1.09–2.02), combined prolapse and incontinence surgery (aOR, 1.84; 95% CI, 1.29–2.62), vaginal hysterectomy (aOR, 1.66; 95% CI, 1.66–2.38), and procedure time (aOR, 1.01; 95% CI, 1.00–1.01) were associated with increased odds of PUR, whereas laparoscopic sacrocolpopexy was associated with lower odds (aOR, 0.22; 95% CI, 0.10–0.46).

Discussion

Although preoperative medication administration was not associated with PUR, other clinically important variables were age older than 60 years, vaginal hysterectomy, incontinence and prolapse surgery, or longer procedure time. Sacrocolpopexy reduced the odds of PUR by approximately 80%. These factors may be useful in preoperative and postoperative counseling regarding PUR after urogynecologic surgery.
Correlation Between Hypertrophic Cervical Elongation and Pelvic Organ Prolapse
Authors: Yang Zhiqi , Xia Zhijun , Cheng Yue
Published: October 2020

Objectives

The association between hypertrophic cervical elongation and pelvic organ prolapse (POP) has been observed, but causation has not been determined. This study assessed the relationship of POP with hypertrophic cervical elongation according to menopausal status and the pelvic compartment involved in prolapse.

Methods

This retrospective single-center case-control study was conducted at Shengjing Hospital of China Medical University between January 2017 and May 2019. Transverse and anteroposterior diameter of the cervix and cervical length were obtained by manual intravaginal measurement for 508 patients with POP and 510 patients without POP. Data were analyzed based on POP compartment and menopausal status.

Results

In the premenopausal group, there was a statistically significant difference in the proportion of patients with hypertrophic cervical elongation in the non-POP and POP groups (P < 0.05); However, among postmenopausal patients, there was no statistical significance between these groups (P > 0.05). Patients with apical compartment POP had a higher proportion of occurrence of hypertrophic cervical elongation than those with nonapical compartment POP (P < 0.05).

Conclusions

Hypertrophic cervical elongation in premenopausal patients is significantly associated with POP; in particular, there is a significant correlation between apical compartment POP and hypertrophic cervical elongation.
Ocular Motor and Vestibular Characteristics of Antiglutamic Acid Decarboxylase–Associated Neurologic Disorders
Authors: Wang Yujie , Tourkevich Roksolyana , Bosley Justin , Gold Daniel R. , Newsome Scott D.
Published: October 2020

Background:

Antiglutamic acid decarboxylase (GAD)-associated neurologic disorders are rare, with varied presentations, including stiff-person syndrome (SPS) and cerebellar ataxia (CA). Vestibular and ocular motor (VOM) dysfunction can be the main presentation in a subset of patients.

Methods:

Retrospective review of the Johns Hopkins Hospital medical records from 1997 to 2018 identified a total of 22 patients with a diagnosis of anti-GAD–associated SPS or CA who had detailed VOM assessments. Eight had prominent VOM dysfunction at the initial symptom onset and were referred to neurology from ophthalmology or otolaryngology (“early dominant”). Fourteen patients had VOM dysfunction that was not their dominant presentation and were referred later in their disease course from neurology to neuro-ophthalmology (“nondominant”). We reviewed clinical history, immunological profiles, and VOM findings, including available video-oculography.

Results:

In the 8 patients with early dominant VOM dysfunction, the average age of symptom onset was 53 years, and 5 were men. The most common symptom was dizziness, followed by diplopia. Seven had features of CA, and 4 had additional features of SPS. None had a structural lesion on brain MRI accounting for their symptoms. The most common VOM abnormalities were downbeating and gaze-evoked nystagmus and saccadic pursuit. All received immune therapy and most received symptomatic therapy. Most experienced improvement in clinical outcome measures (modified Rankin scale and/or timed 25-foot walk test) or VOM function. By contrast, in the 14 patients in whom VOM dysfunction was nondominant, most had an SPS phenotype and were women. VOM abnormalities, when present, were more subtle, although mostly still consistent with cerebellar and/or brainstem dysfunction.

Conclusions:

Individuals with anti-GAD–associated neurologic disorders may present with prominent VOM abnormalities at the initial symptom onset that localize to the cerebellum and/or brainstem. In our cohort, immune and symptomatic therapies improved clinical outcomes and symptomatology.
Probing plasmonic excitation mechanisms and far-field radiation of single-crystalline gold tapers with electrons
Authors: Lingstädt Robin , Talebi Nahid , Guo Surong , Sigle Wilfried , Campos Alfredo , Kociak Mathieu , Esmann Martin , Becker Simon F. , Okunishi Eiji , Mukai Masaki , Lienau Christoph , van Aken Peter A.
Published: October 2020

Conical metallic tapers represent an intriguing subclass of metallic nanostructures, as their plasmonic properties show interesting characteristics in strong correlation to their geometrical properties. This is important for possible applications such as in the field of scanning optical microscopy, as favourable plasmonic resonance behaviour can be tailored by optimizing structural parameters like surface roughness or opening angle. Here, we review our recent studies, where single-crystalline gold tapers were investigated experimentally by means of electron energy-loss and cathodoluminescence spectroscopy techniques inside electron microscopes, supported by theoretical finite-difference time-domain calculations. Through the study of tapers with various opening angles, the underlying resonance mechanisms are discussed.

This article is part of a discussion meeting issue ‘Dynamic
in situ
microscopy relating structure and function’.
Common and rare variants in HFE are not associated with Parkinson’s disease in Europeans
Authors: Saini Prabhjyot , Bandres-Ciga Sara , Alcantud Jose Luis , Ruz Clara , Gan-Or Ziv ,   for the International Parkinson’s disease Genomics Consortium
Published: October 2020

A recent study suggested that the p.H63D variant in HFE, a gene involved in iron homeostasis, may modify α-synuclein pathology, the pathological hallmark of Parkinson’s disease (PD). If indeed this gene and specific variant are involved in PD, we expect to find differential distribution of HFE variants when comparing PD patients and controls. We analyzed genome-wide association study (GWAS) data from 14,671 PD patients and 17,667 controls and full sequencing data from additional 1,647 PD patients and 1,050 controls, using logistic regression models, and burden and Kernel tests. The HFE p.H63D variant was not associated with PD, nor did all the other common variants in the HFE locus. We did not find association of rare HFE variants with PD as well in all types of burden and Kernel tests. Our results do not support a role for HFE in PD.
Measuring the Impact of Exposure to COVID-19 Vaccine Misinformation on Vaccine Intent in the UK and US
Authors: Loomba S. , de Figueiredo A. , Piatek S. J. , de Graaf K. , Larson H. J.
Published: October 2020

The successful development and widespread acceptance of a SARS-CoV-2 vaccine will be a major step in fighting the pandemic, yet obtaining high uptake will be a challenging task, worsened by online misinformation. To help inform successful COVID-19 vaccination campaigns in the UK and US, we conducted a survey to quantify how online misinformation impacts COVID-19 vaccine uptake intent and identify socio-economic groups that are most at-risk of non-vaccination and most susceptible to online misinformation. Here, we report findings from nationally representative surveys in the UK and the US conducted in September 2020. We show that recent misinformation around a COVID-19 vaccine induces a fall in vaccination intent among those who would otherwise “definitely” vaccinate by 6.4 (3.8, 9.0) percentages points in the UK and 2.4 (0.1, 5.0) in the US, with larger decreases found in intent to vaccinate to protect others. We find evidence that socio-econo-demographic, political, and trust factors are associated with low intent to vaccinateandsusceptibility to misinformation: notably, older age groups in the US are more susceptible to misinformation. We find evidence that scientific-sounding misinformation relating to COVID-19 and vaccines COVID-19 vaccine misinformation lowers vaccination intent, while corresponding factual information does not. These findings reveal how recent COVID-19 misinformation can impact vaccination rates and suggest pathways to robust messaging campaigns.