bluuebunny/crossref_metadata_2025 huggingface dataset:
Wrestling With the Invincibility Myth: Exploring Physicians’ Resistance to Wellness and Resilience-Building Interventions
Authors: LaDonna Kori A. , Cowley Lindsay , Touchie Claire , LeBlanc Vicki R. , Spilg Edward G.
Published: August 2021

Purpose

Physicians are expected to provide compassionate, error-free care while navigating systemic challenges and organizational demands. Many are burning out. While organizations are scrambling to address the burnout crisis, physicians often resist interventions aimed at enhancing their wellness and building their resilience. The purpose of this research was to empirically study this phenomenon.

Method

Constructivist grounded theory was used to inform the iterative data collection and analysis process. In spring 2018, 22 faculty physicians working in Canada participated in semistructured interviews to discuss their experiences of wellness and burnout, their perceptions of wellness initiatives, and how their experiences and perceptions influence their uptake of the rapidly proliferating strategies aimed at nurturing their resilience. Themes were identified using constant comparative analysis.

Results

Participants suggested that the values of compassion espoused by health care organizations do not extend to physicians, and they described feeling dehumanized by professional values steeped in an invincibility myth in which physicians are expected to be “superhuman” and “sacrifice everything” for medicine. Participants described that professional values and organizational norms impeded work–life balance, hindered personal and professional fulfillment, and discouraged disclosure of struggles. In turn, participants seemed to resist wellness and resilience-building interventions focused on fixing individuals rather than broader systemic, organizational, and professional issues. Participants perceived that efforts aimed at building individual resilience are futile without changes in professional values and sustained organizational support.

Conclusions

Findings suggest that professional and organizational norms and expectations trigger feelings of dehumanization for some physicians. These feelings likely exacerbate burnout and may partly explain physicians’ resistance to resilience-building strategies. Mitigating burnout and developing and sustaining a resilient physician workforce will require both individual resistance to problematic professional values and an institutional commitment to creating a culture of compassion for patients and physicians alike.
Developing the Virtual Resus Room: Fidelity, Usability, Acceptability, and Applicability of a Virtual Simulation for Teaching and Learning
Authors: Foohey Sarah , Nagji Alim , Yilmaz Yusuf , Sibbald Matthew , Monteiro Sandra , Chan Teresa M.
Published: August 2021

Problem

Physical distancing restrictions during the COVID-19 pandemic led to the transition from in-person to online teaching for many medical educators. This report describes the Virtual Resus Room (VRR)—a free, novel, open-access resource for running collaborative online simulations.

Approach

The lead author created the VRR in May 2020 to give learners the opportunity to rehearse their crisis resource management skills by working as a team to complete virtual tasks. The VRR uses Google Slides to link participants to the virtual environment and Zoom to link participants to each other. Students and facilitators in the emergency medicine clerkship at McMaster University used the VRR to run 2 cases between June and August 2020. Students and facilitators completed a postsession survey to assess usability and acceptability, applicability for learning or teaching, and fidelity. In addition, students took a knowledge test pre- and postsession.

Outcomes

Forty-six students and 11 facilitators completed the postsession surveys. Facilitators and students rated the VRR’s usability and acceptability, applicability for learning and teaching, and fidelity highly. Students showed a significant improvement in their postsession (mean = 89.06, standard deviation [SD] = 9.56) compared with their presession knowledge scores (mean = 71.17, SD = 15.77; t(34) = 7.28, P < .001, with a large effect size Cohen’s d = 1.23). Two perceived learning outcomes were identified: content learning and communication skills development. The total time spent (in minutes) facilitating VRR simulations (mean = 119, SD = 36) was significantly lower than time spent leading in-person simulations (mean = 181, SD = 58; U = 20.50, P < .008).

Next Steps

Next steps will include expanding the evaluation of the VRR to include participants from additional learner levels, from varying sites, and from other health professions.
Physician-approved protocols increase naloxone dispensing rates
Authors: Gangal Neha S. , Hincapie Ana L. , Jandarov Roman , Frede Stacey M. , Boone Jill M. , Heaton Pamela C.
Published: August 2021

Objective

To measure the impact of the implementation of a law that allows pharmacists to provide naloxone under a physician-approved protocol on naloxone dispensing rates in an all-payer population across the United States.

Methods

Prescription claims from a national grocery chain for 31 states and Area Heath Resource File were used for this retrospective study. The study sample included all patients who filled at least one naloxone prescription during the study period from July 16, 2014 to January 16, 2017. A stepwise autoregression was performed for 30 consecutive months to evaluate the change in naloxone prescription dispensing rate. The primary independent variable was “implementation of the physician-approved protocol.” The primary outcome measure was the rate of naloxone prescriptions dispensed per month per state. Secondary outcome measures were naloxone dispensing rates by each payer.

Results

Number of patients who received naloxone prescriptions in the states with physician-approved protocol was 423% higher compared to states without the protocol. The overall model showed that the naloxone dispensing rate was 6 times higher in the states with a physician-approved protocol. In the payer-based models, comparing states with and without protocol, the dispensing rate was highest for Medicare (9.0 times) followed by Private (4.6 times), Medicaid (3.2 times), and Cash (3.1 times). The number of prescriptions dispensed in the low-employment states with the protocol was 17.59 times higher compared to states without the protocol.

Conclusions

Implementation of physician-approved protocol was strongly associated with an increase in naloxone dispensing rates, especially in the low-employment states.
Radiographic pseudosubluxation of the shoulder in pediatric proximal humeral fractures
Authors: Torrez Timothy William , Seidenstein Alexandra , Debell Henry A , Conklin Michael , McGwin Gerald , Gilbert Shawn R.
Published: August 2021

This study was undertaken to determine the incidence, need for intervention, and time to resolution of pseudosubluxation of the shoulder in pediatric proximal humerus fractures. One hundred and ninety-nine radiographs (199 x-rays) were analyzed for pseudosubluxation of the shoulder following pediatric proximal humeral fractures. Pseudosubluxation occurs when the center of the humeral head aligns with the inferior one-fourth of the glenoid. Fourteen patients met the inclusion criteria for pseudosubluxation. The nonoperative cohort consisted of 100 females and 93 males and the operative cohort consisted of 3 males and 3 females. Total 14 children out of 199 had pseudosubluxation. Ten pseudosubluxations were seen 7 days postinjury and four were noted immediately after injury. Pseudosubluxation was seen in nine boys (64%) and five girls (36%) in the nonoperative group. Increased relative risk (RR) was associated with: fall >3 m (RR = 25.7; 95% CI, 2.7–244.0), motorized transport (RR = 11.7; 95% CI, 1.41–96.03) and sports injuries (RR = 11.0, 95% CI, 1.2–100). No statistical analysis was conducted on the operative group given the small sample. This study establishes incidence, risk factors and expected clinical course for pseudosubluxation following proximal humerus fractures. The overall incidence in the nonoperative cohort was 7.3%, radiographic evidence of pseudosubluxation resolution was available for (n = 10) patients with 100% resolution by 6 weeks. There were no readmissions or complications in the 14 patients. Pseudosubluxation occurrence was significantly increased in four mechanisms: falls >3 m, sports trauma and motor transportation. This study provides the natural history and risk factors for pseudosubluxation following proximal humerus fractures. Pseudosubluxation is more likely to occur in higher energy fracture mechanisms and will resolve without treatment. Level of Evidence: Level III, retrospective cohort.
An analysis of treatment outcome following classical Ponseti technique in older children with clubfoot – A concept stretched too far?
Authors: Agarwal Anil , Shanker Mukesh
Published: August 2021

We questioned whether indications of Achilles tenotomy and standards of equinus correction as used for infants/young children hold true for use of the classical Ponseti technique in older children as well. Children aged 2–12 years with previously untreated unilateral/bilateral idiopathic clubfeet were included. For the purpose of this study, the subjects were treated by the classic Ponseti technique and underwent percutaneous tenotomy when talar head was reduced. A successful outcome and braceable feet were considered to be achieved when there was at least 10 degrees of ankle dorsiflexion post-tenotomy. The feet were classified into success and failure groups based on the above outcome and compared statistically. Furthermore, we documented the overall foot abduction and ankle dorsiflexion achieved post-tenotomy in older children. Final evaluations were done in 27 patients (39 feet; bilateral 12). Post-tenotomy, 16 feet (41%) constituted the success group. The average age (3.3 versus 5.8 years), foot abduction (39.4 versus 28.7 degrees) and ankle dorsiflexion (14.7 versus 4.1 degrees) for the success group were statistically different from the failure group. There were several residual foot deformities post-tenotomy, chiefly empty heel, varus, equinus and rotation. The reduction of lateral head of talus was not a reliable indicator for planning Achilles tenotomy in the older child. A 10-degree ankle dorsiflexion postclassical Ponseti method was achievable in only 41% feet for older children. Further, several residual deformities were present in treated feet post-tenotomy.
Lower Neurological Risk with Anterior Operations Compared to Posterior Operations for Thoracic Disc Herniations
Authors: Cummins Daniel , Callahan Matthew , Clark Aaron J. , Theologis Alekos A.
Published: August 2021

Study Design.

Retrospective cohort study.

Objective.

Compare rates of postoperative neural deficits between surgical approaches for thoracic disc herniations (TDHs).

Summary of Background Data.

Anterior and posterior approaches for TDH carry high reported neurological risk, albeit comparative risk is not well defined.

Methods.

Health Care Utilization Project (HCUP) state inpatient databases (NY, FL, CA; 2005–2014) were queried for patients who underwent TDH operation. Demographics, operative details, surgical approach, neural injury, length of stay (LOS), and discharge location were assessed. Multivariate linear regression was used to determine relative risk of neural deficit and skilled nursing facility (SNF) discharge.

Results.

Six hundred ninety-seven patients (mean age 52.0 yrs, 194 institutions) met inclusion. Majority of operations were elective (76.0%) and one to two levels (80.5%). Overall neural injury rate was 9.0%. Anterior operations had significantly lower rates of neural injury compared with posterior operations on univariate analysis (4.6% vs. 11.4%; P < 0.01). All multilevel operations had similarly high rates of neural injury. On multivariate analysis, posterior approaches (RR 1.78; P = 0.12) and combined approaches (RR 2.15; P = 0.17) had higher neural risk compared with anterior approaches after controlling for younger age, higher Charlson Comorbidity Index, and nonelective admissions. Combined approaches had similar neural injury rates (13.8%) to posterior operations (11.4%) and significantly longer LOS and SNF discharges compared with single approaches. Neural deficit was associated with discharge to SNF (With = 87.3%; Without = 23.7%; P < 0.01) and increased LOS (With = 12.5 days; Without = 6.9 days; P < 0.01).

Conclusion.

Overall rate of neural deficit after operation for TDH was 9.0%. While anterior approach was associated with a lower neural injury rate, this association was confounded by age, Charlson Comorbidity Index, and admission type. After correcting for these confounders, a nonsignificant trend remained that favored the anterior approach. Neural deficit was associated with increased LOS and discharge to SNF postoperatively.

Level of Evidence: 4
Volumetric Changes in Cervical Disc Herniation
Authors: Fu Su , Zhang Chunlin , Yan Xu , Li Dongzhe , Wang Yongkui , Dong Chao , Cao Zhengming , Ning Yongming , Shao Chenglong , Yang Tengyue
Published: August 2021

Study Design.

Retrospective study on 185 patients with 490 cervical disc herniation (CDH).

Objective.

The aim of this study was to compare the changes in volumes of CDH in patients with degenerative cervical myelopathy (DCM) surgically treated by expansive open-door laminoplasty (EOLP) or cervical microendoscopic laminoplasty (CMEL).

Summary of Background Data.

Spontaneous resorption of CDH was shown in patients with DCM after conservation treatment, but very few in surgically treated patients. Our previous study identified the clinical efficiency of CMEL to treat DCM but how CDH sized postoperatively, as well as comparing to EOLP, was unknown.

Methods.

Consecutive patients with DCM from December 2015 to December 2019, who underwent MRI evaluation, receiving CMEL or EOLP, and repeat MRI in follow-up were included. The volume of CDH were monitored using the picture archiving and communication system, further calculating the incidence of CDH with volume regression and the percentage changes of CDH volume. The correlations of possible determines with CDH volume changes were analyzed by Spearman rank correlation coefficient.

Results.

A total of 89 patients (215 CDHs, EOLP-group) and 96 patients (275 CDHs, CMEL-group) was surveyed, respectively. Resultantly, volume of CDH was decreased postoperatively in both EOLP and CMEL cases. But this CDH volume regression was more profound in CMEL groups (incidence of 81.2% from 223/275, median volume change ratio of −26.7%, occurring from 1 month after CMEL), statistically different from EOLP group (50.2% from 108/215, median volume change ratio of −5.4%, none-appearance within 1 month). Patients information as sex, age, and follow-up time, not CDH significant, was significantly correlated with CDH volume changes.

Conclusion.

Patients who underwent CMEL developed a postoperative reduction of CDH volume, with more popularity, greater degree and earlier-staged than EOLP-patients. Young females with longer follow-up time were more likely occur.

Level of Evidence: 4
Pharmacogenetic study of methadone treatment for heroin addiction: associations between drug-metabolizing gene polymorphisms and treatment efficacy
Authors: Chen Yen-Jung , Lu Ju-Ting , Huang Chun-Wei , Wu Wei-Hsin , Lee Kuei-Fang , Liu Hsin-Tzu , Shih-Hsin Wu Lawrence
Published: August 2021

Objectives

Opioid dependence is currently one of the most serious problems affecting the social norms and public health system. Methadone maintenance therapy (MMT) is being widely used in treating heroin-dependent patients. The mechanism of methadone metabolism and disposition has been shown to involve cytochrome P450 (CYP450) and P-glycoprotein. The aim of this study was to explore the relationships among genetic polymorphisms, BMI and effective dose of methadone used in MMT within a northern Taiwan cohort.

Methods

One hundred heroin-dependent patients were enrolled in the study. The clinical data gathered included methadone dose, sex and BMI. DNA was collected from the oral swab of the participants to analyze the relevant alleles.

Results

An effective methadone dose correlated with sex, BMI and the presence of ABCB1 2677GG (rs2032582) and CYP2B6 516GG (rs374527). Furthermore, the CYP2B6 516GG homozygote was related to a higher average dose of methadone (GG: 68.50 ± 32.43; GT: 52.28 ± 25.75; TT: 44.44 ± 29.64; P < 0.02), whereas the ABCB1 2677GG homozygote was related to a lower dose (GG: 51.09 ± 20.83; GT: 69.65 ± 37.51; TT: 62.52 ± 30.44; P < 0.05). We examined the predictive effect of polymorphisms combined with sex and BMI on methadone dose by conducting multiple linear regressions. Our data predicted the average dose of methadone in approximately 30% of heroin-dependent patients.

Conclusion

The interactions between genetic polymorphisms and clinical features proved useful in identifying the effective dose of MMT for heroin-dependent patients in Taiwan more precisely.
Reinfection With Severe Acute Respiratory Syndrome Coronavirus 2 Without Recurrence of Multisystem Inflammatory Syndrome in Children
Authors: Buddingh Emilie P. , Vossen Ann C. T. M. , Lamb Hildo J. , van der Palen Roel L. F. , Brinkman Danielle M. C.
Published: August 2021

Multisystem inflammatory syndrome in children is a rare, potentially life-threatening postinfectious complication in children after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. It is currently unknown if multisystem inflammatory syndrome in children (MIS-C) can recur upon reinfection with SARS-CoV-2. Here, we report on a former MIS-C patient who was reinfected with SARS-CoV-2 without recurrence of MIS-C.
Kawasaki Disease Hospitalizations in the United States 2016–2020: A Comparison of Before and During the Coronavirus Disease 2019 Era
Authors: Phamduy Timothy T. , Smith Sharon , Herbst Katherine W. , Phamduy Paul T. , Brimacombe Michael , Hogan Alexander H. , Salazar Juan C. , Sturm Jesse
Published: August 2021

Background:

Kawasaki disease (KD) is an acute vasculitis of young children. A comparison of US hospitalization rates and epidemiologic features of KD in 2020 to those of precoronavirus disease years has yet to be reported.

Methods:

Using a large, inpatient database, we conducted a retrospective cohort study and analyzed data for patients with (1) diagnosis coding for KD, (2) IV immunoglobulin treatment administered during hospitalization and (3) discharge date between January 1, 2016, and December 30, 2020. Severe cases were defined as those requiring adjunctive therapy or IV immunoglobulin–resistant therapy.

Results:

The annual number of KD hospitalizations were stable from 2016 to 2019 (n = 1652, 1796, 1748, 1692, respectively) but decreased in 2020 (n = 1383). KD hospitalizations demonstrated seasonal variation with an annual peak between December and April. A second peak of KD admissions was observed in May 2020. The proportion of KD cases classified as severe increased to 40% in 2020 from 33% during the years 2016–2019 (P < 0.01). Median age in years increased from 2.9 in subjects hospitalized from 2016 to 2019 to 3.2 in 2020 (P = 0.002).

Conclusions:

Compared with the previous 4 years, the annual number of pediatric KD admissions decreased, and children discharged with diagnostic codes for KD in 2020 were generally older and more likely to have severe morbidity possibly reflective of misdiagnosed multisystem inflammatory syndrome in children. Clinicians should be wary of a possible rise in KD rates in the postcoronavirus disease 2019 era as social distancing policies are lifted and other viruses associated with KD return.
Racial and Ethnic Disparities in Multisystem Inflammatory Syndrome in Children in the United States, March 2020 to February 2021
Authors: Stierman Bryan , Abrams Joseph Y. , Godfred-Cato Shana E. , Oster Matthew E. , Meng Lu , Yip Luke , Patel Pragna , Balachandran Neha , Prezzato Emily , Pierce Timmy , Hsu Katherine K. , Burns Meagan , Peterson Pompa Xandy , Lauro Priscilla , Hartley Amanda , Jones Cassandra , Gretsch Stephanie , Reid Heather , Lim Sarah , Campbell Angela P. , Belay Ermias D.
Published: August 2021

Background:

The incidence of multisystem inflammatory syndrome in children (MIS-C) varies by race and ethnicity. This study assessed whether disparities in MIS-C in the United States by race and ethnicity exceed known disparities in coronavirus disease 2019 (COVID-19) incidence.

Methods:

We compared the distribution of race and ethnicity among patients with MIS-C (<21 years of age, termed children) with onset March 2020 to February 2021 to that of children with COVID-19 and in the general population. Analysis was restricted to 369 counties with high completeness of race and ethnicity reporting for MIS-C and COVID-19. For each racial and ethnic group, observed numbers of patients with MIS-C were compared with expected numbers (observed/expected ratio) in children with COVID-19 and in the general population within these counties.

Results:

Compared with children in the general population, MIS-C was more frequent among Hispanic (139% of expected) and non-Hispanic Black children (183%) and less frequent among non-Hispanic White (64%) and non-Hispanic Asian children (48%). Compared with children with COVID-19, MIS-C was more frequent in non-Hispanic Black children (207% of expected) and less frequent in non-Hispanic White children (68%); however, frequency was not different among Hispanic (102%) and non-Hispanic Asian (74%) children.

Conclusions:

Disparities in MIS-C by race and ethnicity exist, even after controlling for COVID-19 disparities and geographic variations. The high proportion of MIS-C among Hispanic children and low proportion among non-Hispanic Asian children align with COVID-19 rates, while the high proportion among non-Hispanic Black children and low proportion among non-Hispanic White children are not explainable by COVID-19 rates.
A role for substance P and acid-sensing ion channel 1a in prolotherapy with dextrose-mediated analgesia in a mouse model of chronic muscle pain
Authors: Han Der-Sheng , Lee Cheng-Han , Shieh Yih-Dar , Chang Chu-Ting , Li Min-Hsuan , Chu Ya-Cherng , Wang Jaw-Lin , Chang Ke-Vin , Lin Shing-Hong , Chen Chih-Cheng
Published: August 2021

Prolotherapy is widely used in pain control and tissue repair in pain medicine. The classical mode is injection with hypertonic dextrose in muscle or perimysium. However, the analgesic mechanism is still not known. Here, we successfully established dextrose-mediated antinociception in a mouse model of fibromyalgia. The antinociceptive effects of dextrose injections were evaluated in a mouse model of fibromyalgia, in which bilateral chronic mechanical hyperalgesia was induced by unilateral intramuscular acid injection. The injectant (dextrose), dose (≥5%), and volume (>10 μL), but not osmolarity, were essential for the prolotherapy. Further studies showed that the activation of acid-sensing ion channel 1a (ASIC1a), neural activation, and the release of substance P from muscle afferents were required in the dextrose-induced reduction of mechanical hypersensitivity. Both pharmacological blockade and genetic deletion of ASIC1a or substance P as well as lidocaine abolished the dextrose-induced antinociception in mice with chronic hyperalgesia. Moreover, intramuscular dextrose injection induced phosphorylated extracellular signal–regulated kinase expression in dorsal root ganglion neurons expressing substance P; the phosphorylated extracellular signal–regulated kinase expression was inhibited by the ASIC1a antagonist PcTx1. The optimal settings for prolotherapy in fibromyalgia-like pain are dextrose dependent and volume dependent, and the peripheral antinociception involves ASIC1a and substance P signaling in muscle afferents. This study suggests a possible mechanism of action of dextrose prolotherapy in noninflammatory muscle pain such as fibromyalgia and provides insights into treating other types of chronic pain.
Ultrasound Measurement of Vascular Distensibility Based on Edge Detection and Speckle Tracking Using Ultrasound DICOM Data
Authors: Funes-Lora Miguel Angel , Thelen Brian J. , Shih Albert J. , Hamilton James , Rajaram Nirmala , Lyu Jingxuan , Zheng Yihao , Morgan Timothy , Weitzel William F.
Published: August 2021

This study presents an edge detection and speckle tracking (EDST) based algorithm to calculate distensibility as percentage of change of vessel diameter during cardiac cycles. Canny edge detector, Vandermonde matrix representation, Kanade Lucas Tomasi algorithm with pyramidal segmentation, and penalized least squares technique identifies the vessel lumen edge, track the vessel diameter, detrend the signal and find peaks and valleys when the vessel is fully distended or contracted. An upper extremity artery from 10 patients underwent an ultrasound examination as part of preoperative evaluation before arteriovenous fistula surgery. Three studies were performed to evaluate EDST with automatic peak and valley selection versus manual speckle selection of expert users using manual peak and valley selection. Results demonstrate the effectiveness of the proposed methodology, to obtain comparable results as those obtained by expert-users, and considerably reducing the variability associated with external factors such as excessive motion, fluctuations in stroke volume, beat-to-beat blood pressure changes, breathing cycles, and arm-transducer pressure.
Very long-term outcomes of older adults with stable coronary artery disease (from the CORONOR study)
Authors: Abbadi Abou-bakr , Lemesle Gilles , Lamblin Nicolas , Bauters Christophe
Published: August 2021

Background

There are limited data on stable coronary artery disease (CAD) in the very elderly. The present study aimed to investigate incident cardiovascular events and mortality in older adults (≥85 years) included in a multicenter registry on stable CAD.

Methods

A long-term follow-up was performed in 198 patients ≥85 years with stable CAD, free from myocardial infarction (MI) or coronary revascularization within the year. The median age was 87 years. Clinical events during the follow-up period [death, MI, ischemic stroke, coronary revascularization and hospitalization for heart failure (HF)] were centrally adjudicated.

Results

There were 164 deaths during follow-up. The cumulative risk of all-cause death was 9.1% at 1 year, 53.9% at 5 years and 85.5% at 10 years. The cause of death was adjudicated as cardiovascular in 64 patients with death from HF in 36 patients. Male gender, previous hospitalization for HF and an estimated glomerular filtration rate <60 ml/min/1.73 m2 were independently associated with all-cause death. Ten-year cumulative incidences of MI, ischemic stroke and coronary revascularization were low (6.6, 7.7 and 6.6%, respectively). By contrast, the 10-year cumulative incidence of hospitalization for HF was high (27.8%).

Conclusion

The 10-year mortality of elderly patients with stable CAD is very high. While ischemic events are relatively unfrequent, HF events are frequent and represent the most common cause of cardiovascular death in this population. Prevention and management of HF are important goals for physicians in charge of older adults with stable CAD.
Analysis of clinical risk models vs. clinician’s assessment for prediction of coronary artery disease among predominantly female population
Authors: Havistin Ruby , Ivanov Alexander , Patel Pavan , Crenesse-Cozien Natalia , Ho Jean , Khan Saadat , Brener Sorin J. , Sacchi Terrence J. , Heitner John F.
Published: August 2021

Introduction

Multiple risk models are used to predict the presence of obstructive coronary artery disease (CAD) in patients with chest pain. We aimed to compare the performance of these models to an experienced cardiologist’s assessment utilizing coronary angiography (CA) as a reference.

Materials and methods

We prospectively enrolled patients without known CAD referred for elective CA. We assessed pretest probability of CAD using the following risk models: Diamond–Forrester (original and updated), Duke Clinical score, ACC/AHA, CAD consortium (basic and clinical) and PROMISE minimal risk tool. All patients completed self-administrative Rose angina questionnaire. Independently, an experienced cardiologist assessed the patients to provide a binary prediction of obstructive CAD prior to CA. Obstructive CAD was defined as >80% stenosis in epicardial coronary arteries by visual assessment, or fractional flow reserve <0.80 in intermediate lesions (30–80%).

Results

A total of 150 patients were recruited (100 women, 50 men). Mean age was 58 (32–78) years. Obstructive CAD was found in 31 patients (21%). The area under the curve (AUC) for all the clinical risk prediction models (except the Duke Clinical Score, AUC 0.73, P = 0.07) was significantly lower compared with the clinician’s assessment (AUC 0.51–0.65 vs. 0.81, respectively, P < 0.01). The clinician’s assessment had sensitivity comparable to the Duke Clinical score, which was higher than all other clinical models. There was no difference in prediction performance on the basis of sex in this predominantly female population.

Discussion/Conclusion

In stable patients with chest pain and suspected CAD, current clinical risk models which are universally based upon the characteristics of the chest pain, show suboptimal performance in predicting obstructive CAD. These findings have important clinical implications, as current appropriateness criteria for recommending CA are on the basis of these risk models.
Factors Associated With Depression in Breast Cancer Patients in Saudi Arabia
Authors: Dewan Mashael F. , Lyons Karen S. , Song MinKyoung , Hassouneh Dena
Published: August 2021

Background

Depressive symptoms in Arab women with breast cancer (AWBC) in Saudi Arabia can be influenced by spirituality, religiosity, social support, and breast cancer's stigma. Understanding the role of these factors can raise awareness and help create policies to improve care for breast cancer patients. Yet, there is limited research addressing the impact of these factors on depressive symptoms in AWBC.

Objective

The aim of this study was to investigate factors influencing depressive symptoms in AWBC in Saudi Arabia.

Methods

A cross-sectional design and convenience sampling were used to recruit 59 AWBC from oncology departments in Jeddah, Saudi Arabia, who were receiving active treatment to participate in this study. Participants completed an online survey or paper-based survey including questions on sociodemographics, social support, spirituality, religiosity, depressive symptoms, and breast cancer's stigma. Pearson correlation and multiple regression analysis were used to examine the influence of numerous factors on depressive symptoms in AWBC; Student t test statistic was used to distinguish the depressive symptom scores between online and paper-based survey.

Results

The average age of participants was 49 years (SD = 8.31). The mean (SD) of depressive symptoms was 20.52 (12.36). Pearson correlation analyses indicated that cancer patients with high levels of depressive symptoms were associated with low levels of spiritualty and religiosity, and high levels of breast cancer stigma.

Conclusions

Religiosity and spirituality work as protective factors against depressive symptoms in AWBC.

Implications for Practice

Including religiosity and spirituality in the intervention plan should be considered when caring for AWBC.
Effect of a Nurse-Led Community Health Worker Intervention on Latent Tuberculosis Medication Completion Among Homeless Adults
Authors: Nyamathi Adeline , Salem Benissa E. , Shin Sanghyuk S. , Jones Adrianna A. , Garfin Dana R. , Yadav Kartik , Chang Alicia H. , White Kathryn , Morisky Donald
Published: August 2021

Background

Tuberculosis (TB) disproportionately affects marginalized and impoverished homeless adults. Although active TB can be prevented by treating latent TB infection (LTBI), individual factors, such as high prevalence of depression and anxiety, drug and alcohol use, and unstable housing, lead to poor LTBI treatment adherence and completion among homeless adults.

Objectives

We hypothesized that the delivery of a tailored nurse-led, community health worker (RN/CHW) program across the LTBI continuum of care (e.g., screening, diagnosis, and treatment) that delivers 3HP treatment (3HP: rifapentine plus isoniazid) for homeless adults (e.g., sheltered and unsheltered) and is tailored to their health and social service needs will overcome existing treatment completion barriers. We also hypothesized that mental health symptoms (e.g., depression and anxiety), drug use score, and problematic alcohol use will decline over time among clients receiving this treatment.

Methods

We assessed the effect of delivering a theoretically guided, RN/CHW-based, single-arm study among eligible LTBI-positive homeless adults (N = 50) on completion of a weekly, directly observed, 12-dose 3HP LTBI treatment in Central City East (Skid Row). Completing 3HP treatment was compared to the only known historical, clinic-based control that obtained 65% completion among homeless adults. Secondary outcomes included drug and alcohol use, depression, and anxiety.

Results

The RN/CHW program achieved a 91.8% 3HP treatment completion rate among homeless adults. Younger homeless adults (<50 years old) were less likely to complete 3HP treatment compared to those who were older. Neither drug use, depression, nor anxiety was associated with 3HP treatment completion. Decrease in anxiety was observed at 3 months, but not at 6 months, compared to baseline.

Discussion

To our knowledge, the pilot study is the first to evaluate an effective RN/CHW-delivered, community-based intervention, which can reduce the burden of active TB for homeless adults.
Cystic Ovarian Mucinous Carcinoma With Carcinosarcomatous Mural Nodules: An Uncommon Entity
Authors: Shetty Divya , Bhalekar Surekha , Rao Sudhamani , Mukharji Snigdha , Rao Rajiv
Published: August 2021

Mural nodules in ovarian mucinous cystic tumors are uncommon, with only 80 cases reported over the last 30 yr. The literature describes only 5 cases of carcinosarcomatous mural nodules with mucinous ovarian neoplasm. We compared and summarized the literature related to mural nodules in mucinous ovarian tumors to elaborate on the clinical and histomorphologic features. A 21-yr-old woman presented with 2 mo history of abdominal distension. Physical examination showed a palpable pelvic mass. Radiologic investigation showed a 31×18.6×25 cm large right ovarian cyst. Few nodular solid masses were also seen, the largest mass measured 3.5×3.1 cm. On histomorphology and immunohistochemistry, it was a mucinous ovarian carcinoma with carcinosarcomatous mural nodules. Carcinosarcomatous mural nodules with ovarian mucinous neoplasm affects younger females. It presents at an early stage and does not carry an adverse prognosis.
A “Null” Pattern of p16 Immunostaining in Endometrial Serous Carcinoma: An Under-recognized and Important Aberrant Staining Pattern
Authors: Matson Daniel R. , Accola Molly A. , Henderson Les , Shao Xiangqiang , Frater-Rubsam Leah , Horner Vanessa L. , Rehrauer William M. , Weisman Paul , Xu Jin
Published: August 2021

The ability to distinguish endometrial serous carcinoma (SC) from high-grade endometrioid adenocarcinoma is of great importance given their differences in prognosis and management. In practice, this distinction typically relies upon the use of a focused immunohistochemical panel including p53, p16, and mismatch repair proteins. The expression of p16 is characteristically strong and diffuse in SCs, and weak and/or patchy in many high-grade endometrioid adenocarcinomas. Here, we report a subset of SCs that are entirely negative for p16 immunostaining, a pattern we refer to as “p16 null.” This pattern was identified in 2 of 63 cases of SC diagnosed at our institution—1 with histologically classic features and 1 with ambiguous high-grade histologic features. These tumors otherwise showed a SC signature by immunohistochemical and demonstrated an SC pattern of genetic mutations. No mutation in the gene for p16, cyclin-dependent kinase inhibitor 2A (CDKN2A), was identified in either case. However, molecular correlates for the absent p16 expression were present, including homozygous deletion of CDKN2A in one case and hemizygous deletion of CDKN2A with promotor hypermethylation of the remaining allele in the other case. To our knowledge, this constitutes the first report conclusively demonstrating the existence of a small subset of SCs that are completely negative by p16 immunohistochemistry, and the molecular lesions responsible for this pattern. In the context of an otherwise clinically and histologically classic example of SC, we endorse this “null” p16 staining pattern as an alternative aberrant staining pattern that should not deter one from committing to this diagnosis.
An Unusual Enteric Yolk Sac Tumor: First Report of an Ovarian Germ Cell Tumor Associated With a Germline Pathogenic Variant in DICER1
Authors: McCluggage W. Glenn , Fu Lili , Mohler Kristen , de Kock Leanne , Sabbaghian Nelly , Mindlin Allison , Stewart Colin J.R. , Gilks C. Blake , Foulkes William D.
Published: August 2021

A variety of unusual tumors are associated with both germline and somatic DICER1 pathogenic variants (PVs), including, in the female genital tract, embryonal rhabdomyosarcoma at various sites and ovarian Sertoli-Leydig cell tumor. There have been occasional reported cases of ovarian germ cell tumors [mainly yolk sac tumor (YST)] harboring DICER1 PVs but, as far as we are aware, none of these has been proven to have a germline provenance. We report an unusual enteric variant of ovarian YST in a 28-yr-old woman associated with a germline PV c.901C>T (p.Gln301Ter) in exon 7 of DICER1, accompanied by a somatic (YST-only) hotspot mutation: c.5437G>A, p.E1813K. To our knowledge, this is the first report of an ovarian germ cell tumor associated with a germline DICER1 PV. We review other reported cases of ovarian germ cell tumor with DICER1 PVs and discuss the differential diagnosis of this unusual variant of YST which was originally diagnosed as a mucinous adenocarcinoma.
Noninvasive Detection of Intracranial Hypertension by Novel Ultrasound Time-Harmonic Elastography
Authors: Kreft Bernhard , Tzschätzsch Heiko , Shahryari Mehrgan , Haffner Paula , Braun Jürgen , Sack Ingolf , Streitberger Kaspar-Josche
Published: August 2021

Objective

A method for measuring intracranial pressure (ICP) noninvasively has long been sought after in neurology and neurosurgery. Treatment failure in individuals presenting with unspecific symptoms such as headache, gait disturbance, or visual impairment occurring in response to increased ICP can lead to irreversible brain injury, progressive disability, and death. Guidelines for diagnostic ICP measurement recommend intracranial placement of pressure tip catheters or lumbar puncture (LP) despite their invasiveness and possible complications. As ICP fluctuations are closely associated with changes in brain stiffness, ultrasound elastography could be a valid method to detect ICP noninvasively and with short examination times.

Materials and Methods

In this pilot study, we have investigated the use of time-harmonic shear waves, introduced into the brain by an external shaker, and measured in real-time by transtemporal ultrasound, for deducing a noninvasive imaging marker sensitive to elevated ICP. To this end, we developed cerebral ultrasound time-harmonic elastography for the noninvasive quantification of shear wave speed (SWS) as a surrogate marker of cerebral stiffness in a short examination time of a few minutes.

Results

We found that SWS in patients enrolled for LP with confirmed intracranial hypertension was 1.81 ± 0.10 m/s, distinguishing them from healthy volunteers with excellent diagnostic accuracy (1.55 ± 0.08 m/s; P < 0.001; area under the curve, 0.99). Interestingly, values in symptomatic patients decreased to normal stiffness immediately after LP (1.56 ± 0.06 m/s, P < 0.001). Moreover, invasively measured opening pressure correlated with SWS measured before LP and liquid volume drained through the spinal tap with the SWS difference between the 2 measurements.

Conclusions

Collectively, our results suggest a tight link between cerebral stiffness and ICP and demonstrate that intracranial hypertension can be detected noninvasively within short examination times, opening avenues for diagnostic applications of cerebral ultrasound time-harmonic elastography in neurology and emergency medicine.
Maintaining Social Distancing
Authors: Han Peggy K. , Fayazi Azadeh R. , Wiryawan Budi , Berg Marc D.
Published: August 2021

Summary Statement

Respiratory failure and cardiopulmonary arrest in patients with SARS-CoV-2 infection require life-saving procedures that aerosolize virus and increase risk of transmission. To educate faculty, trainees, and staff on safe practices, a video with embedded questions was created demonstrating intubation and cardiopulmonary resuscitation in pediatric SARS-CoV-2+ patients. Just-in-time in situ simulations of these scenarios were also carried out while adhering to isolation and social distancing protocols. We demonstrated that use of simulation to train physicians and staff during the COVID-19 pandemic is possible and effective in improving confidence in performance of the procedures.
Robotic Ventral Hernia Repair
Authors: Kudsi Omar Yusef , Gokcal Fahri , Bou-Ayash Naseem , Crawford Allison S. , Chang Karen , Chudner Alexandra , La Grange Sara
Published: August 2021

Objective:

To describe the outcomes of RVHR with varying prosthetic reinforcement techniques.

Summary of Background Data:

As a recent addition to minimally invasive hernia repair, more data is needed to establish the long-term benefits of RVHR and to identify potential predictors of adverse outcomes.

Methods:

Patients who underwent RVHR over a 7-year period were evaluated. Robotic intraperitoneal onlay mesh (rIPOM), transabdominal preperitoneal (rTAPP), Rives-Stoppa (rRS), and transversus abdominis release (rTAR) techniques were compared. The main outcomes were 90-day FFC, and 5-year FFR, depicted through Kaplan-Meier curves stratified by repair type and date.

Results:

A total of 644 RVHRs were analyzed; 197 rIPOM, 156 rTAPP, 153 rRS, and 138 rTAR. There was a gradual transition from intraperitoneal to extraperitoneal mesh placement across the study period. Although rTAPP had the highest 90-day FFC (89.5%) it also had the lowest 5-year FFR (93.3%). Conversely, although rTAR demonstrated the lowest FFC (71%), it had the highest FFR (100%). Coronary artery disease, lysis of adhesions, incisional hernia, and skin-to-skin time (10 minutes. increment) were significant predictors of 90-day complications. Incisional hernia was the sole predictor of 5-year recurrence.

Conclusions:

This study provides an in-depth perspective of the largest series of RVHR. Based on this experience, rTAPP is no longer recommended due to its limited applicability and high recurrence rate. Both rIPOM and rRS offer encouraging short- and long-term outcomes, while rTAR is associated with the highest perioperative morbidity. Longer follow-up is needed to assess rTAR durability, despite a promising recurrence profile.
Serological Response to the BNT162b2 COVID-19 mRNA Vaccine in Adolescent and Young Adult Kidney Transplant Recipients
Authors: Haskin Orly , Ashkenazi-Hoffnung Liat , Ziv Noa , Borovitz Yael , Dagan Amit , Levi Shelly , Koren Gili , Hamdani Gilad , Levi-Erez Daniella , Landau Daniel , Alfandary Hadas
Published: August 2021

Background.

Initial reports in adult kidney transplant recipients (KTR) indicate low immunogenicity after 2 doses of the BNT162b2 COVID-19 mRNA vaccine. We describe the immunogenicity of this vaccine compared to the serologic response in naturally infected COVID-19 positive adolescent and young adult KTR.

Methods.

For this prospective observational study, the study group included 38 KTR who received 2 doses of the tested vaccine, and the control group included 14 KTR who had a previous polymerase chain reaction–confirmed COVID-19 infection.

Results.

The mean age was 18 ± 3 y. Positive serologic responses were observed in 63% and 100% of the study and control groups, respectively (P = 0.01). Antibody titers were almost 30-fold higher in the control than the study group (median [interquartile range (IQR)]: 2782 [1908–11 000] versus 100.3 [4.7–1744] AU/mL, P < 0.001), despite the longer time from the COVID-19 infection to serologic testing compared to time from vaccination (median [IQR]: 157.5 [60–216] versus 37 [20.5–53] d, P = 0.011). Among vaccinated patients, higher proportions of those seronegative than seropositive were previously treated with rituximab (50% versus 8%, P = 0.01). Time from the second vaccine dose to serologic testing was longer in seropositive than seronegative patients (median [IQR]: 24.5 [15–40] versus 46 [27–56] d, P = 0.05). No patient developed symptomatic COVID-19 disease postvaccination.

Conclusions.

The BNT162b2 COVID-19 mRNA vaccine yielded higher positive antibody response in adolescent and young adult KTR than previously reported for adult KTR. Antibody titers after vaccination were significantly lower than following COVID-19 infection. Longer time may be required to mount appropriate humoral immunity to vaccination in KTR.
Faecalibacter rhinopitheci sp. nov., a bacterium isolated from the faeces of Rhinopithecus bieti
Authors: Wang Qiong , Han Xiu-Lin , Huang Zhi-Pang , Huang Song , An De-Feng , Shen Jian-Qiang , Lai Jian-Dong , He Xin-Ming , Ba Sang , Li Chun , Li Yan-Peng , Zhang Chen-Lu , Fang Zhi-Qin , Jiang Yi , Jiang Cheng-Lin , Lu Tao
Published: August 2021

A novel Gram-stain-negative strain, WQ 117T, isolated from the faeces of Rhinopithecus bieti collected at Yunnan Snub-nosed Monkey National Park, Yunnan province, PR China, was subjected to a polyphasic taxonomic study. The results of phylogenetic analysis based on 16S rRNA gene sequences indicated that the isolate represented a member of the genus

Faecalibacter

, sharing 97.64 % sequence similarity with the type strain

Faecalibacter macacae

YIM 102668T. The G+C content of the genomic DNA of WQ117T was 30.5 mol%. The predominant isoprenoid quinone was MK-6. The major cellular fatty acids was iso-C15 : 0. The whole genome average nucleotide identity (gANI) values and the digital DNA–DNA hybridization values between WQ 117T and YIM 102668T were 79.66 % and 22.20 %, respectively. Growth occurred at 0–50 °C (optimally at 28–35 °C), pH 7.0–9.0 (optimally at pH 8.0) and with 0–2 % (w/v) NaCl (optimally without NaCl). On the basis of the taxonomic evidence, a novel species, Faecalibacter rhinopitheci sp. nov., is proposed. The type strain is WQ 117T (=KCTC 82394T=CCTCC AA 2020027T).