bluuebunny/crossref_metadata_2025 huggingface dataset:
Racial and Ethnic Disparities in the Incidence of Severe Maternal Morbidity in the United States, 2012–2015
Authors: Admon Lindsay K. , Winkelman Tyler N. A. , Zivin Kara , Terplan Mishka , Mhyre Jill M. , Dalton Vanessa K.
Published: October 2018

OBJECTIVE:

To describe racial and ethnic disparities in the incidence of severe maternal morbidity during delivery hospitalizations in the United States.

METHODS:

We conducted a pooled, cross-sectional analysis of 2012–2015 data from the National Inpatient Sample to define the prevalence of chronic conditions and incidence of severe maternal morbidity among deliveries to non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander, and Native American or Alaska Native women. We used weighted multivariable logistic regression and predictive margins to generate prevalence and incidence estimates. Adjusted rate ratios and differences were calculated to quantify disparities across racial and ethnic categories. Subgroup analyses were performed to examine the incidence of severe maternal morbidity among deliveries to women with comorbid physical health conditions, behavioral health conditions, and multiple chronic conditions within each racial and ethnic category.

RESULTS:

The incidence of severe maternal morbidity was significantly higher among deliveries to women in every racial and ethnic minority category compared with deliveries among non-Hispanic white women. Severe maternal morbidity occurred in 231.1 (95% CI 223.6–238.5) and 139.2 (95% CI 136.4–142.0) per 10,000 delivery hospitalizations among non-Hispanic black and non-Hispanic white women, respectively (P<.001). When excluding cases in which blood transfusion was the only indicator of severe maternal morbidity, only deliveries to non-Hispanic black women had a higher incidence of severe maternal morbidity compared with deliveries among non-Hispanic white women: 50.2 (95% CI 47.6–52.9) and 40.9 (95% CI 39.6–42.3) per 10,000 delivery hospitalizations, respectively (risk ratio 1.2 [95% CI 1.2–1.3], risk difference 9.3 [95% CI 6.5–12.2] per 10,000 delivery hospitalizations; P<.001 for each comparison). Among deliveries to women with comorbid physical and behavioral health conditions, significant differences in severe maternal morbidity were identified among racial and ethnic minority compared with non-Hispanic white women and the largest disparities were identified among women with multiple chronic conditions.

CONCLUSION:

Programs for reducing racial and ethnic disparities in severe maternal morbidity may have the greatest effect focusing on women at highest risk for blood transfusion and maternity care management for women with comorbid chronic conditions, particularly multiple chronic conditions.
Ulipristal Acetate for Treatment of Uterine Leiomyomas
Authors: Liu James H. , Soper David , Lukes Andrea , Gee Phyllis , Kimble Thomas , Kroll Robin , Mallick Madhuja , Chan Anna , Gillard Patrick , Harrington Amanda , Sniukiene Vilma , Shulman Lee P.
Published: October 2018

OBJECTIVE:

To assess the efficacy and tolerability of ulipristal acetate, a selective progesterone receptor modulator, for treatment of symptomatic uterine leiomyomas.

METHODS:

This phase 3, double-blind, double-dummy, placebo-controlled trial randomized premenopausal women (18–50 years) with uterine leiomyomas and abnormal uterine bleeding to once-daily 5 mg ulipristal, 10 mg ulipristal, or placebo in two 12-week treatment courses separated by a drug-free interval of two menses. Coprimary end points were rates of and time to amenorrhea during course 1. Change from baseline to end of course 1 in the Revised Activities subscale of the Uterine Fibroid Symptom and Health-Related Quality of Life questionnaire was a secondary end point. A sample size of 400 was planned to compare separately each ulipristal dose with placebo.

RESULTS:

From January 2014 through November 2016, 432 women were randomized. Demographic characteristics were similar across treatment groups. In course 1, 68 of 162 (42.0% [97.5% CI 33.3–51.1]) and 86 of 157 (54.8% [97.5% CI 45.5–63.8]) patients treated with 5 mg and 10 mg ulipristal, respectively, compared with 0 of 113 (0.0% [97.5% CI 0.0–3.8]) patients treated with placebo achieved amenorrhea (P<.001 for each dose); most women who achieved amenorrhea did so within 10 days (time to amenorrhea, P<.001 for each dose). Significantly greater improvements in Uterine Fibroid Symptom and Health-Related Quality of Life Revised Activities subscale scores were reported with 5 mg and 10 mg ulipristal compared with placebo (least squares mean change from baseline: 48.3, 56.7, and 13.0, respectively; P<.001 for each dose). Both ulipristal doses were well tolerated; in course 1, hot flush occurred in 7.5%, 11.6%, and 1.7% of patients treated with 5 mg ulipristal, 10 mg ulipristal, and placebo, respectively.

CONCLUSION:

Treatment with 5 mg or 10 mg ulipristal was superior to placebo in achieving amenorrhea and generally well tolerated for the medical management of symptomatic uterine leiomyomas.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, NCT02147158.
Above the GRADE: Evaluation of Guidelines in Critical Care Medicine*
Authors: Sims Charles R. , Warner Matthew A. , Stelfox Henry Thomas , Hyder Joseph A.
Published: October 2018

Objectives:

We examined recommendations within critical care guidelines to describe the pairing patterns for strength of recommendation and quality of evidence. We further identified recommendations where the reported strength of recommendation was strong while the reported quality of evidence was not high/moderate and then assessed whether such pairings were within five paradigmatic situations offered by Grading of Recommendations Assessment, Development and Evaluation methodology to justify such pairings.

Data Sources and Extraction:

We identified all clinical critical care guidelines published online from 2011 to 2017 by the Society of Critical Care Medicine along with individual guidelines published by Surviving Sepsis Campaign, Kidney Disease Improving Global Outcomes, American Society for Parenteral and Enteral Nutrition, and the Infectious Disease Society of America/American Thoracic Society.

Data Synthesis:

In all, 15 documents specifying 681 eligible recommendations demonstrated variation in strength of recommendation (strong n = 215 [31.6%], weak n = 345 [50.7%], none n = 121 [17.8%]) and in quality of evidence (high n = 41 [6.0%], moderate n = 151 [22.2%], low/very low n = 298 [43.8%], and Expert Consensus/none n = 191 [28.1%]). Strength of recommendation and quality of evidence were positively correlated (ρ = 0.66; p < 0.0001). Of 215 strong recommendations, 69 (32.1%) were discordantly paired with evidence other than high/moderate. Twenty-two of 69 (31.9%) involved Strong/Expert Consensus recommendations, a category discouraged by Grading of Recommendations Assessment, Development and Evaluation methodology. Forty-seven of 69 recommendations (68.1%) were comprised of Strong/Low or Strong/Very Low variation requiring justification within five paradigmatic scenarios. Among distribution in the five paradigmatic scenarios of Strong/Low and Strong/Very Low recommendations, the most common paradigmatic scenario was life threatening situation (n = 20/47; 42.6%). Four Strong/Low or Strong/Very Low recommendations (4/47; 8.5%) were outside Grading of Recommendations Assessment, Development and Evaluation methodology.

Conclusions:

Among a large, diverse assembly of critical care guideline recommendations using Grading of Recommendations Assessment, Development and Evaluation methodology, the strength of evidence of a recommendation was generally associated with the quality of evidence. However, strong recommendations were not infrequently made in the absence of high/moderate quality of evidence. To improve clarity and uptake, future guideline statements may specify why such pairings were made, avoid such pairings when outside of Grading of Recommendations Assessment, Development and Evaluation criteria, and consider separate language for Expert Consensus recommendations (good practice statements).
Estimating ICU Benefit: A Randomized Study of Physicians
Authors: Valley Thomas S. , Admon Andrew J. , Zahuranec Darin B. , Garland Allan , Fagerlin Angela , Iwashyna Theodore J.
Published: October 2018

Objectives:

The distinction between overuse and appropriate use of the ICU hinges on whether a patient would benefit from ICU care. We sought to test 1) whether physicians agree about which types of patients benefit from ICU care and 2) whether estimates of ICU benefit are influenced by factors unrelated to severity of illness.

Design:

Randomized study.

Setting:

Online vignettes.

Subjects:

U.S. critical care physicians.

Interventions:

Physicians were provided with eight vignettes of hypothetical patients. Each vignette had a single patient or hospital factor randomized across participants (four factors related and four unrelated to severity of illness).

Measurements and Main Results:

The primary outcome was the estimate of ICU benefit, assessed with a 4-point Likert-type scale. In total, 1,223 of 8,792 physicians volunteered to participate (14% recruitment rate). Physician agreement of ICU benefit was poor (mean intraclass correlation coefficient for each vignette: 0.06; range: 0–0.18). There were no vignettes in which more than two thirds of physicians agreed about the extent to which a patient would benefit from ICU care. Increasing severity of illness resulted in greater estimated benefit of ICU care. Among factors unrelated to severity of illness, physicians felt ICU care was more beneficial when told one ICU bed was available than if ICU bed availability was unmentioned. Physicians felt ICU care was less beneficial when family was present than when family presence was unmentioned. The patient’s age, but not race/ethnicity, also impacted estimates of ICU benefit.

Conclusions:

Estimates of ICU benefit are widely dissimilar and influenced by factors unrelated to severity of illness, potentially resulting in inconsistent allocation of ICU care.
Prognostic and predictive role of elevated lactate dehydrogenase in patients with melanoma treated with immunotherapy and BRAF inhibitors: a systematic review and meta-analysis
Authors: Petrelli Fausto , Ardito Raffaele , Merelli Barbara , Lonati Veronica , Cabiddu Mary , Seghezzi Silvia , Barni Sandro , Ghidini Antonio
Published: October 2018

Levels of serum lactate dehydrogenase (LDH) are a recognized prognostic factor in malignant melanoma (MM). It is relevant to confirm its prognostic role in patients treated with targeted therapies [BRAF inhibitors (BRAFi) and MEK inhibitors (MEKi)] and immunotherapy (IT). Furthermore, its role as a predictive marker in patients treated with these drugs had still not been investigated. We performed an electronic search for studies reporting information on overall survival (OS) or progression-free survival (PFS) according to LDH levels and on their predictive effect in patients treated with targeted therapies (BRAFi and MEKi) and IT. Data were pooled using hazard ratios (HRs) for OS and HRs for PFS according to a fixed-effect or a random-effect model. For predictive analysys, effect of new agents versus standard therapy was evaluated in LDH high population. A total of 71 publications were retrieved for a total of 16 159 patients. Overall, elevated LDH levels were associated with an HR for OS of 1.72 [95% confidence interval (CI): 1.6–1.85; P<0.0001]. Similarly, HR for PFS was 1.83 (95% CI: 1.53–2.2; P<0.0001). In the LDH elevated subgroup, new agents improved OS significantly (HR: 0.71; 95% CI: 0.62–0.82; P<0.0001) and PFS (HR: 0.63; 95% CI: 0.55–0.72; P<0.0001). In advanced MM treated with IT or BRAFi±MEKi, elevated LDH level at baseline represents a poor prognostic factor. However, patients with increased LDH levels and treated with these drugs gain significant benefits in terms of PFS and OS.
Long-Term Results of Femtosecond Laser–Enabled Keratoplasty With Zig-Zag Trephination
Authors: Wade Matthew , Muniz Castro Hannah , Garg Sumit , Kedhar Sanjay , Aggarwal Sahil , Shumway Caleb , Farid Marjan
Published: October 2018

Purpose:

To report long-term visual and astigmatism outcomes in cases of zig-zag femtosecond laser–enabled penetrating keratoplasty (FLEK).

Methods:

Retrospective review. Three hundred thirty-five eyes of 287 patients underwent (FLEK) with a zig-zag incision pattern. Patients were assessed preoperatively and underwent postoperative comprehensive examinations at standard intervals of 1, 3, 6, 9, and 12 months, and 6 months thereafter. Postoperative uncorrected distance visual acuity and spectacle-corrected distance visual acuity and manifest and topographical (Mrx cyl and Topo cyl) astigmatism were compared with preoperative values.

Results:

Three hundred thirty-five eyes received FLEK with zig-zag configuration. Data are presented for the last recorded visit before any refractive procedure. Sutures were removed in 202 of 335 eyes at an average time to removal of 1.3 ± 1.1 years, and a mean follow-up period of 2.9 ± 2.1 years (range 0–10 years). After full suture removal, mean uncorrected distance visual acuity and spectacle-corrected distance visual acuity were logarithm of the minimum angle of resolution 0.84 (Snellen 20/138) ± 0.55 and 0.33 (Snellen 20/42) ± 0.33, respectively. Mean Mrx cyl and Topo cyl of these groups were 3.38 ± 2.22 and 4.77 ± 3.15, respectively. Of the total number of grafts, the rate of graft rejections was 14.0%, and the failure rate was 5.6%.

Conclusions:

The femtosecond laser–generated zig-zag–shaped incision results in lower manifest and topographical astigmatism than the reported average for conventional penetrating keratoplasty. Graft rejection and failure rates are similar to published data for conventional penetrating keratoplasty.
Relationship Between Types of Social Support, Coping Strategies, and Psychological Distress in Individuals Living With Congenital Heart Disease
Authors: Kim Mi-Yeon , Johnson Joy L. , Sawatzky Richard
Published: October 2018

Background:

Many people with congenital heart disease (CHD) experience psychological distress related to medical complications and psychosocial issues related to the disease. Although studies show that social support and coping strategies are closely associated with psychological distress in people struggling with different chronic health challenges, very little is known about whether the same factors hold true for the psychological distress of people living with CHD.

Objective:

The purpose of this study was to examine the relationships between types of social support, coping strategies, and psychological distress for individuals living with CHD.

Design:

A cross-sectional survey design with self-report questionnaires was used.

Method:

A convenience sample of 272 participants was obtained from the Adult Congenital Heart Disease program at a tertiary care hospital in Western Canada. Structural equation modeling was conducted to examine hypothesized relationships among study variables.

Results:

Perceived social support was directly related to both anxiety and depression. Received social support influenced anxiety and depression, but its effect was through perceived social support. Wishful-thinking coping strategies mediated the relationships between perceived social support and both anxiety and depression.

Conclusion:

Individuals with CHD who have low perceived and received social support are vulnerable to experiences of psychological distress. Assessments of social support and facilitation of positive coping strategies are integral to nursing care for adults with CHD.
Development of a Multistep Hypertension Quality Improvement Program in an Academic General Medicine Practice
Authors: Bui-Duy Mai-Khanh , Wong Shirley , Lam Rosemary , Karliner Leah S.
Published: October 2018

Hypertension is a common problem and a major risk factor for cardiovascular disease. It is unclear whether efforts to control blood pressure (BP) known to be effective in integrated healthcare systems can be successfully implemented in an academic setting. We describe our experience implementing a multistep quality improvement program within an academic general medicine practice aimed at improving BP among patients with uncontrolled hypertension. Ensuring medical assistants were correctly measuring BP provided the basis for accurate data entry into the electronic medical record (EMR); our EMR-based registry data allowed us to feedback primary care provider (PCP) level data on BP control for panel management, which resulted in improvements in BP for a substantial proportion of patients, particularly for those with more practice visits. However, due to PCP, patient, and system barriers, our initial attempt to integrate a pharmacist into our team for hypertension management was only successful for a small number of patients who engaged in pharmacist in-person visits. Future improvement efforts will focus on addressing the barriers to more intensive BP management, integrating lessons from this experience. As chronic disease management shifts to a population-based model, team change will be a necessary component for achieving clinical improvement.
Can a Chronic BPPV With a History of Trauma be the Trigger of Symptoms in Vestibular Migraine, Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), and Whiplash Associated Disorders (WAD)? A Retrospective Cohort Study
Authors: Tjell Carsten , Iglebekk Wenche , Borenstein Peter
Published: October 2018

Background:

In patients with chronic benign paroxysmal positional vertigo (BPPV), i.e., chronic vestibular multicanalicular canalithiasis (CVMCC), abnormal signals are transmitted from diseased labyrinths via the healthy vestibular nuclei complex to their end organs. The vestibulo-thalamo-cortical reflex as proposed in vestibular migraine is just one of these reflexes. In a group of patients diagnosed with CVMCC otolith repositioning maneuvers specific for each semicircular canal (SCC) ameliorated pain and other symptoms in 90%. Increased awareness of CVMCC may reduce suffering and continuous medication.

Objective:

To evaluate if CVMCC can be the trigger of symptoms in vestibular migraine, myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), and whiplash associated disorders (WAD).

Study Design:

Retrospective consecutive observational cohort study.

Setting:

Ambulatory at a private Otoneurology Centre.

Patients:

One hundred sixty-three patients with CVMCC and a history of trauma.

Intervention:

Based on the symptoms (structured symptom questionnaire), the patients are post hoc sub grouped according to the criteria of the different diagnoses.

Main Outcome Measure:

Frequency of patients with CVMCC who fulfill the criteria of the different diagnoses.

Results:

98% of all patients with CVMCC fulfill the Barany Society criteria of a probable vestibular migraine; 17% fulfill the International Classification of Headache Disorders defined vestibular migraine criteria; 63% fulfill the Fukuda criteria of ME/CFS; 100% of the patients with WAD suffer from CVMCC.

Conclusion:

This survey supports the hypothesis that CVMCC can be the trigger of symptoms in vestibular migraine, ME/CFS, and WAD. The actual diagnosis the patient receives is often in accordance with the patient's dominant symptom.
A Systematic Review on Factors Associated With Percutaneous Bone Anchored Hearing Implants Loss
Authors: Bezdjian Aren , Smith Rachel Ann , Thomeer Henricus G.X.M. , Willie Bettina M. , Daniel Sam J.
Published: October 2018

Objective:

To investigate factors associated with percutaneous bone anchored hearing implant (BAHI) loss.

Data Sources:

Africa-Wide, Biosis, Cochrane, Embase, Global Health, LILACs, Medline, Pubmed, and Web of Science electronic databases.

Study Selection:

All studies reporting on adult and/or pediatric patients with a BAHI loss were identified. Retrieved articles were screened using predefined inclusion criteria. Eligible studies underwent critical appraisal for directness of evidence and risk of bias. Studies that successfully passed critical appraisal were included for data extraction.

Data Extraction:

Extracted data included study characteristics (study design, number of total implants and implant losses, follow-up), patient characteristics (sex, age, comorbidities, previous therapies), and information regarding BAHI loss (etiology of loss, timing of occurrence).

Data Synthesis:

From the 5,151 articles identified at the initial search, 847 remained after title and abstract screening. After full text review, 96 articles were eligible. Fifty-one articles passed quality assessment, however, due to overlapping study population, 48 articles reporting on 34 separate populations were chosen for data extraction. Three hundred one implant losses occurred out of 4,116 implants placed, resulting in an overall implant loss occurrence rate of 7.3%. Failed osseointegration was responsible for most implant losses (74.2%), followed by fixture trauma (25.7%). Most losses due to failed osseointegration occurred within 6 months of the implantation. BAHI implant loss occurred more frequently in pediatric patients (p < 0.005).

Conclusion:

The current systematic review identified factors associated with BAHI loss. These factors should be considered when assessing patients’ candidacy and when investigating reasons for impeded implant stability and loss.
Optimizing continuous renal replacement therapy in the ICU: a team strategy
Authors: Joannes-Boyau Olivier , Velly Lionel , Ichai Carole
Published: October 2018

Purpose of review

The consideration of acute kidney injury, its incidence and its impact on the outcome of patients has grown continuously in recent years, leading to an increase in the use of renal replacement therapy (RRT) techniques. However, the successful conduct of RRT depends on the effectiveness of the entire team, doctors and nurses. It is therefore important to know the essential elements to be implemented in the ICU to ensure optimal RRT.

Recent findings

Recent studies show that the successful conduct of a RRT session requires a good knowledge of the principles of the technique, regular basic training, identification of experts, drafting clear and well followed protocols and good communication between the various stakeholders. In addition, the use of the latest advances, such as regional citrate anticoagulation, allows further optimization of therapy, only if, again, both physicians and nurses are properly trained and highly involved.

We now have a better understanding of the measures to be deployed to optimize RRT. Organization, training, evaluation and protocols are the key points of the team's efficiency for a safe and effective implementation of RRT.
Novel pathogenic variants in GBE1 causing fetal akinesia deformation sequence and severe neuromuscular form of glycogen storage disease type IV
Authors: Radhakrishnan Periyasamy , Moirangthem Amita , Nayak Shalini S. , Shukla Anju , Mathew Mary , Girisha Katta M.
Published: October 2018

Glycogen storage disease IV (GSD IV), caused by a defect in GBE1, is a clinically heterogeneous disorder. A classical hepatic form and a neuromuscular form have been described. The severe neuromuscular form presents as a fetal akinesia deformation sequence or a congenital subtype. We ascertained three unrelated families with fetuses/neonates who presented with fetal akinesia deformation sequence to our clinic for genetic counseling. We performed a detailed clinical evaluation, exome sequencing, and histopathology examination of two fetuses and two neonates from three unrelated families presenting with these perinatally lethal neuromuscular forms of GSD IV. Exome sequencing in the affected fetuses/neonates identified four novel pathogenic variants (c.1459G>T, c.144-1G>A, c.1680C>G, and c.1843G>C) in GBE1 (NM_000158). Histopathology examination of tissues from the affected fetuses/neonate was consistent with the diagnosis. Here, we add three more families with the severe perinatally lethal neuromuscular forms of GSD IV to the GBE1 mutation spectrum.
Comparison Between an Oral Sulfate Solution and a 2 L of Polyethylene Glycol/Ascorbic Acid as a Split Dose Bowel Preparation for Colonoscopy
Authors: Lee Han Hee , Lim Chul-Hyun , Kim Jin Su , Cho Yu Kyung , Lee Bo-In , Cho Young-Seok , Lee In Seok , Choi Myung-Gyu
Published: October 2018

Background/Aims:

This study aimed to compare the efficacy and tolerability of an oral sulfate solution (OSS) versus 2 L of polyethylene glycol/ascorbic acid (2L-PEG/Asc) for bowel cleansing before colonoscopy.

Methods:

A prospective, single-center, single-blinded, noninferiority, randomized, controlled trial was performed. The primary outcome was the rate of successful bowel cleansing, evaluated using the Boston Bowel Preparation Scale (BBPS). Secondary outcomes were examination time, polyp, and adenoma detection rate (PDR and ADR), tolerability, and safety. Ease of use, palatability, intention to reuse, and satisfaction were evaluated using a questionnaire.

Results:

A total of 187 participants were randomized to receive either OSS (n=93) or 2L-PEG/Asc (n=94). Successful bowel cleansing was achieved in 86.0% (80/93) of the OSS group, which was noninferior to the 2L-PEG/Asc group (88.3%, 83/94), with a difference of −2.3% by ITT analysis [95% confidence interval (CI) −12.0 to +7.4]. The withdrawal time of the OSS group was significantly shorter than that of the 2L-PEG/Asc group (11.8±5.2 vs. 14.3±8.5; P=0.016). Ease of use, palatability, intention to reuse, and satisfaction were similar between the 2 groups. Adverse events were also similar between the 2 groups. Mucosal erythema (4.3%) and aphthous lesions (2.1%) were found only in the 2L-PEG/Asc group.

Conclusions:

OSS was as effective as 2L-PEG/Asc for successful bowel cleansing and had acceptable tolerability. OSS is a promising and safe low-volume preparation alternative for colonoscopy. (Clinical trial registration number: NCT02761213.)
Association between AGTR1 A1166C polymorphism and the susceptibility to diabetic nephropathy
Authors: Zhuang Yan , Niu Fukun , Liu Defeng , Sun Juanjuan , Zhang Xiaowei , Zhang Jian , Guo Shuxia
Published: October 2018

Background:

Diabetic nephropathy (DN) is a common complication in patients with diabetic mellitus (DM). Growing evidences have demonstrated that the polymorphisms of angiotensin II receptor type 1 (AGTR1) showed significant association with DN onset, but no consensus has been achieved yet. Therefore, we performed this meta-analysis to combine the findings of previous researches for a more comprehensive conclusion.

Methods:

Eligible publications were identified through electronic databases. The intensity of the correlation between AGTR1 A1166C polymorphism and DN susceptibility was evaluated through calculating pooled odds ratios (ORs) with their 95% confidence intervals (95% CIs). Heterogeneity among included studies was examined with Q test. When P-value less than .05, significant heterogeneity presented, random-effects model was used to calculate the pooled ORs, otherwise, the fixed-effects model was used. Stratification analyses were also performed based on ethnicity and the type of DM.

Results:

Seventeen eligible articles were finally included in the present meta-analysis. The analysis results showed that AGTR1 A1166C polymorphism was significantly related to increased risk of DN under CC versus AA (OR = 1.723, 95% CI = 1.123–2.644), CC + AC versus AA (OR = 1.179, 95% CI = 1.004–1.383), CC versus AA + AC (OR = 1.662, 95% CI = 1.112–2.486), and C versus A (OR = 1.208, 95% CI = 1.044–1.397) genetic models. Additionally, a similar result was also found in Asian and T2DM (type 2 diabetic mellitus) groups after subgroup analyses of ethnicity and DM type.

Conclusion:

AGTR1 A1166C polymorphism may increase the susceptibility to DN, especially in Asians and T2DM population.
Risk factors for procedure-related complications after endoscopic resection of colorectal laterally spreading tumors
Authors: Hong Ji-Yun , Kweon Sun-Seog , Lee Jun , Kim Sang-Wook , Seo Geom-Seog , Kim Hyun-Soo , Joo Young-Eun
Published: October 2018

Colorectal laterally spreading tumors (LSTs) are large and flat elevated neoplasms with diameters of at least 10 mm. Endoscopic resection of LSTs, with their large size and broad base, is difficult and dangerous compared with the resection of polypoid neoplasms. This study aimed to determine the risk factors for procedure-related complications including bleeding and perforation after endoscopic resection of LSTs.

Patients with colorectal LST undergoing endoscopic resection at 5 university hospitals in Honam Province of South Korea were enrolled, and their records about patients, lesions, and procedure parameters associated with the occurrence of complications were reviewed retrospectively. Logistic regression analysis was performed to identify risk factors for complications.

The frequency of comorbidities in bleeding group was significantly higher than in the no bleeding group. The frequency of bleeding was significantly higher in lesions with adenocarcinoma than in lesions with low or high-grade dysplasia. The frequency of bleeding was significantly higher in piecemeal resection than in en bloc resection. The frequency of perforation was significantly higher in endoscopic mucosal resection-precutting (EMR-P) than in endoscopic mucosal resection (EMR) or endoscopic submucosal dissection. The mean procedure duration was significantly longer in the perforation group than in the no perforation group. On multivariate analysis, patient comorbidity and histologic grade of the lesion were significant independent risk factors for bleeding, whereas EMR-P was a significant independent risk factor for perforation after endoscopic resection.

This study demonstrated that patient comorbidity and histologic grade of lesion were significant independent risk factors for bleeding, and EMR-P was a significant independent risk factor for perforation after endoscopic resection of colorectal LSTs.
An electrical scalpel conization versus Shimodaira-Taniguchi conization procedure for cervical intraepithelial neoplasia
Authors: Kigure Keiko , Nakamura Kazuto , Kitahara Yoshikazu , Nakao Kohshiro , Hirakawa Takashi , Rokukawa Shunichi , Ito Masahiro , Nishimura Toshio , Ito Ikuro , Kagami Issei , Itoga Shunichi
Published: October 2018

The incidence of cervical intraepithelial neoplasia(CIN) among reproductive-aged women has increased in Japan. Cervical conization is commonly applied for local cervical treatment to preserve fertility. The Shimodaira-Taniguchi (S-T) conization procedure is widely used in Japan. S-T conization uses a high-frequency current and a triangular probe with a linear excision electrode to remove cervical tissue as a single informative specimen. However, alternative of an electrosurgical scalpel (ES) has the advantage of adjusting the surgical margin to the transformation zone in order to preserve the maximum amount of healthy cervical tissue with good hemostasis. The aim of this study is to retrospectively analyze data regarding surgical margin status, perioperative adverse events, cervical stenosis, and preterm birth between S-T and ES.

Between January 2009 and December 2014, the medical records of 1166 patients who were diagnosed as CIN II, III, or stage 1a1 cervical cancer and who were treated with conization in 7 hospitals in Gunma Prefecture, Japan were enrolled for this retrospective study. The clinicopathological data was analyzed to statistically compare outcome between S-T and ES conization.

There was no difference for age or post-operative follow-up period between ES and S-T treatments. However, positive surgical margins were significantly less frequent in patients who were treated with S-T than in those treated with ES, resulting in a reduced incidence of re-treatment for S-T in comparison with ES patients. In perioperative adverse events, S-T had more patients who were administered antibiotics. The incidence of preterm delivery and cervical stenosis did not differ significantly between the groups.

We demonstrate here that S-T is an alternative procedure for cervical conization with a low risk of recurrence and acceptably low rate of adverse events such as cervical stenosis and preterm delivery. The results of this study can provide useful information for future management of patient with cervical intraepithelial neoplasia.
Impact of diet restriction on bowel preparation for colonoscopy
Authors: Nam Seung-Joo , Kim Young Jin , Keum Bora , Lee Jae Min , Kim Seung Han , Choi Hyuk Soon , Kim Eun Sun , Seo Yeon Seok , Jeen Yoon Tae , Lee Hong Sik , Chun Hoon Jai , Um Soon Ho , Kim Chang Duck
Published: October 2018

Diet restriction is one of the difficult parts of bowel preparation for colonoscopy, and many patients do not follow instructions properly. Few studies have evaluated the impact of dietary restriction in real clinical setting. The aim of this study was to study the effect of diet control on bowel preparation with detailed investigation of unacceptable food list in order to reveal what kind of foods are most problematic in clinical practice.

Prospective observational study was carried out at a university-affiliated hospital. Around 4 L polyethylene glycol solution was used for bowel preparation on the day of colonoscopy. Patients were allowed to have regular diet until lunch the day before colonoscopy and educated to control diet from 3 days before colonoscopy with information regarding an unacceptable foods list. Factors associated with inadequate bowel preparation were analyzed using univariate statistics and multivariate logistic regression analysis.

Of the 245 patients included in the study, 68 patients (27.8%) followed the diet instructions. Fiber-rich vegetables were the most commonly taken unacceptable foods (N = 143, 58.4%). Inadequate bowel preparation (fair and poor by Aronchick scale) was 47.3%. In multivariate analysis, diabetes [odds ratio (OR) 2.878, 95% confidence interval (CI) 1.242–6.671], preparation to colonoscopy interval (OR 1.003, 95% CI 1.000–1.005) and consumption of foods disturbing bowel preparation (OR 2.142, 95% CI 1.108–4.140) were independent predictors of inadequate bowel preparation.

We could identify substantially low compliance to diet instructions in real clinical practice. Consumption of any foods disturbing bowel preparation was significant factor predicting inadequate bowel preparation, even though we could not select specific food list compromising preparation significantly. Favorable bowel preparation was achieved in the subgroup compliant to diet restriction, suggesting that regular diet avoiding specific kinds of foods can be possible option for diet restriction before colonoscopy.
Esmolol does not improve quality of postsurgical recovery after ambulatory hysteroscopy
Authors: De Oliveira Gildasio S. , Kendall Mark C. , McCarthy Robert J.
Published: October 2018

Introduction:

Intraoperative systemic esmolol has been shown to reduce postsurgical pain. Nonetheless, it is unknown whether the use of intraoperative systemic esmolol can improve patient-reported postsurgical quality of recovery. The main objective of the current investigation was to evaluate the effect of intraoperative esmolol on postsurgical quality of recovery. We hypothesized that patients receiving intraoperative esmolol would report better quality of postsurgical recovery than the ones receiving saline.

Methods:

The study was a prospective randomized double-blinded, placebo-controlled, clinical trial. Healthy female subjects undergoing outpatient hysteroscopic surgery under general anesthesia were randomized to receive intravenous esmolol administered at a rate of 0.5 mg/kg bolus followed by an infusion of 5 to 15 μg/kg/min or the same volume of saline. The primary outcome was the Quality of Recovery 40 (QOR-40) questionnaire at 24 hours after surgery. Other data collected included postoperative opioid consumption and pain scores. Data were analyzed using group t tests and the Wilcoxon exact test.

Results:

Seventy subjects were randomized and 58 completed the study. There was not a clinically significant difference in the global QoR-40 scores between the esmolol and saline groups at 24 hours, median (interquartile range) of 179 (171–190) and 182 (173–189), respectively, P = .82. In addition, immediate post-surgical data in the post-anesthesia care unit did not show a benefit of using esmolol compared to saline in regard to pain scores, morphine consumption, and postoperative nausea and vomiting.

Conclusions:

Despite current evidence in the literature that intraoperative esmolol improves postsurgical pain, we did not detect a beneficial effect of intraoperative esmolol on patient-reported quality of recovery after ambulatory surgery. Our results confirm the concept that the use of patient-centered outcomes rather than commonly used outcomes (e.g., pain scores and opioid consumption) can change the practice of perioperative medicine.
Risk of regorafenib-induced cardiovascular events in patients with solid tumors
Authors: Chen Jianxin , Wang Junhui
Published: October 2018

Background:

The present comparative meta-analysis was conducted to evaluate the cardiovascular events of regorafenib in patients with solid tumors.

Methods:

Eligible studies from MEDLINE, Google Scholar, Cochrane Library, Clinical key, EBSCO publishing and Ovid, which had reported cardiovascular adverse events potentially caused by regorafenib were absorbed. Data of clinical characteristics and cardiovascular events including hypertension, hemorrhage, thrombosis, and heart failure were extracted from selected literatures for the final analysis. Pooled analysis of cardiovascular adverse events was developed by relative risks (RRs) and corresponding 95% confidence intervals (CIs) with software STATA 13.0 and RevMan 5.3.

Results:

Thirty studies including 3813 patients were fit into analysis. The incidences of cardiovascular events of all-grade were: hypertension, 36.8% (95% CI, 29.8%–43.8%), hemorrhage, 8.6% (95% CI, 3.2%–14%), thrombosis, 1.4% (95% CI, 0.1%–2.8%), and heart failure, 2.9% (95% CI, 0.3%–5.6%). The incidences of cardiovascular events of high-grade were: hypertension, 9.9% (95% CI, 7.4%–12.4%), hemorrhage, 1.2% (95% CI, 0.3%–2.2%), thrombosis, 1.6% (95% CI, 0.2%–3.4%), and heart failure, 2.9% (95% CI, 0.3%–5.6%). The RRs and their 95% CIs of all-grade cardiovascular events among patients treated with regorafenib were: hypertension, 4.10 (95% CI, 3.07–5.46; P < .00001), hemorrhage, 2.71 (95% CI, 1.45–5.08; P = .002), thrombosis, 1.27 (95% CI, 0.49–3.27; P = .62), and heart failure, 0.79 (95% CI, 0.16–3.94; P = .77). The RRs and their 95% CIs of high-grade cardiovascular events among patients treated with regorafenib were: hypertension, 5.82 (95% CI, 3.46–9.78; P < .00001), hemorrhage, 0.90 (95% CI, 0.50–1.61; P = .72), thrombosis, 1.28 (95% CI, 0.48–3.41; P = .62), and heart failure, 1.15 (95% CI, 0.23–5.69; P = .86), respectively.

Conclusion:

The present meta-analysis has demonstrated that regorafenib is associated with an increasing risk of hypertension at all-grade and high-grade, as well as hemorrhage at all-grade. Adequate awareness of cardiovascular adverse events of regorafenib should be established for clinicians.
Analysis of the behavior change mechanism of township hospital health workers in Hubei Province, China
Authors: He Zhifei , Feng Zhanchun , Zhou Yan , Wu Tailai , Bishwajit Ghose , Zou Dongsheng , Cheng Zhaohui
Published: October 2018

This study aims to analyze the behavior changes of health workers in township hospitals by exploring their individual service, health information utilization, and health information exchange before and after intervention.

A cross-sectional survey was conducted from September, 2016 to December, 2016 in Qianjiang city, Hubei Province, China. A total of 432 township hospital health workers were investigated from 12 township hospitals. t test and chi-square test were adopted in the difference analysis to compare the behavior changes and factors of the control and intervention groups before and after intervention. t test and U test were used to analyze the behaviors and the key impact factors of health workers in township hospitals. The hypothesis test of the behavior changes in the township hospitals were analyzed using the partial least squares (PLS) method.

No significant difference was observed between the control and intervention groups of health workers in township hospitals. Significant differences were observed in the behavior attitude (BA), perceived behavior control (PBC), behavior intention (BI), and behaviors of information utilization and exchange in the intervention group. A significant difference was observed in the indicators of subjective norm (SN), BI, and behaviors with respect to information exchange. A large increment was observed in the intervention group. Based on results of PLS, the individual service, health information utilization, and health information exchange established relationships with BA, SN, PBC, and BI to a certain degree.

A cause and effect relationship can be observed among BA, SN, PBC, BI, and behaviors of health workers in the township hospitals. BI can promote behavior changes among township hospital health workers. Moreover, different behaviors are demonstrated by different people because of BA, SN, PBC, and BI. The results of this study can contribute to improving the feasibility, pertinence, and effects of health service, and can serve as the guide in understanding health workers’ behaviors.
Thyroplasty in unilateral vocal fold paresis with coexisting hereditary hemorrhagic telenagiectasia
Authors: Jackowska Joanna , Klimza Hanna , Zagozda Natalia , Remacle Marc , Wojnowski Waldemar , Piersiala Krzysztof , Wierzbicka Małgorzata
Published: October 2018

Rationale:

The coincidence of an idiopathic unilateral vocal fold paresis and hereditary hemorrhagic telenagiectasia (HHT) is extremely rare and has not been described in the available literature yet.

Patients concerns:

A 55-year-old female was admitted to hospital due to acute onset of hoarseness, voice fatigue, and effort dyspnea. In the past, the patient was diagnosed with HHT and on admission presented characteristic vascular lesions in the oral cavity. She reported also experiencing a moderate epistaxis at least once per month.

Diagnoses:

The otolaryngological examination (fiberolaryngoscopy, phoniatric examination) revealed unchanged mobility and morphology of the right vocal fold and paresis of the left vocal fold in intermediate position. Computed tomography and magnetic resonance imaging of head, neck, and chest were inconclusive and showed no pathologic findings.

Interventions:

The unilateral paresis was treated for 12 months as idiopathic, with extensive rehabilitation. However, no improvement was observed. As a patient suffering from HHT is a challenge for anesthesiologists in terms of general anesthesia, the decision to perform type I thyroplasty (medialization) in local anesthesia was made.

Outcomes:

There were no complications intraoperatively or in postoperative period. The implemented treatment was successful, as the voice quality improved both in perceptual evaluation (GRBAS scale) and acoustic analysis (F0, jitter, shimmer, NHR).

Lessons:

A routine surgical treatment in patients with HHT is a challenge. However, in this case, it was uneventful and successful, thus it can be recommended in other patients with similar background.
Gross motor proficiency and intellectual functioning
Authors: Alesi Marianna , Battaglia Giusppe , Pepi Annamaria , Bianco Antonino , Palma Antonio
Published: October 2018

This cross-sectional study examines differences in gross motor proficiency as a function of different intellectual functioning profiles. Two motor areas have been investigated as being equally essential to gross motor functions in every-day life: locomotion and object control.

It aims to compare gross motor skills endorsed by children with Down syndrome (DS), children with borderline intellectual functioning (BIF), and typically developing children (TDC).

Group 1 was composed of 18 children with DS (chronological age = 8.22), group 2 was composed of 18 children with BIF (chronological age = 9.32), and group 3 was composed of 18 children with typical development (TD) (chronological age = 9.28).

Gross motor skills were measured through the test of gross motor development (TGMD-Test) composed of locomotion and object control tasks.

Children with DS showed worse gross motor skills compared with children with BIF and typically developing children by underscoring both on all locomotion (e.g., walking, running, hopping, galloping, jumping, sliding, and leaping) and all object control tasks (e.g., throwing, catching, striking, bouncing, kicking, pulling, and pushing).

In DS group strengths were found on run and slide skills, in BIF group strengths were on run, long jump and slide skills and in TDC group strengths were on run and slide skills. For all of the 3 groups the locomotor worst performed task was jump forward with arm swing.

Findings suggest implications for further practice to develop evidence-based exercise programs aimed to rehabilitate gross motor skills through the regular participation in structured exercise activities.
Comparison of the effects of desflurane and total intravenous anesthesia on the optic nerve sheath diameter in robot assisted laparoscopic radical prostatectomy
Authors: Choi Eun-Su , Jeon Young-Tae , Sohn Hye-Min , Kim Dong-Woo , Choi Seok-Jun , In Chi-Bum
Published: October 2018

Background:

Optic nerve sheath diameter (ONSD) is a well-known surrogate marker for intracranial pressure during robot-assisted laparoscopic radical prostatectomies (RALP). ONSD during RALP is known to increase due to elevated intracranial pressure as a result of the steep Trendelenburg position and carbon dioxide pneumoperitoneum. We aimed to compare the effects of total intravenous anesthesia (TIVA) and desflurane anesthesia (DES) on ONSD during RALP.

Methods:

Patients scheduled for RALP were enrolled and randomly assigned to the TIVA (propofol and remifentanil) or DES (desflurane and remifentanil) group in this randomized trial. Ultrasonographic measurements of ONSD were conducted before administration of anesthesia (T0), 10 minutes after the Trendelenburg position (T1), 1 hour after the Trendelenburg position (T2), 2 hours after the Trendelenburg position (T3), 10 minutes after resuming the supine position (T4), and at the time of arrival in the post-anaesthetic care unit (T5). The primary outcome measure was the mean ONSD at T2 of the TIVA and DES group during RALP.

Results:

A total of 56 patients were analysed in this study. The mean ONSD at T1, T2, T3, and T4 were significantly lower for patients in the TIVA group compared with those in the DES group (P = .023, .000, .000, and .003, respectively).

Conclusion:

The mean ONSD for patients in the TIVA group was significantly lower than that in the DES group during the RALP procedure. Our findings suggest that TIVA may be a more suitable anesthetic option for patients at risk of cerebral hypoperfusion.
Intravascular large B-cell lymphoma presenting as multiple stroke
Authors: Yunce Muharrem , Muganlinskaya Nargiz , Selinger Stephen
Published: October 2018

Introduction:

Intravascular large B-cell lymphoma (IVLBCL) is an uncommon disease with a poor prognosis if not diagnosed early. It can present with central nervous system (CNS) manifestations. The diagnosis of IVCBCL is difficult to make given its varied clinical manifestations and the lack of a specific diagnostic modality.

Case presentation:

We report an interesting case of IVLBCL presenting as bilateral strokes. The diagnosis was made by a random skin biopsy, which confirmed IVLBCL. The patient was treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP).

Neurological symptoms improved with R-CHOP. Repeat magnetic resonance imaging (MRI) of the brain showed improvement of the prior lesions.

Conclusion:

IVLBCL is an aggressive disease with high mortality. Timely diagnosis and treatment can be lifesaving.