bluuebunny/crossref_metadata_2025 huggingface dataset:
Attention for the Inattentive: Positive Effects of Negative Financial Shocks*
Authors: Ouimet Paige , Tate Geoffrey
Published: July 2019

Using unique data on employee ownership plans, we find that negative shocks lead to changes in portfolio choices among previously inattentive investors. Employees within employee ownership plans did not actively select into ownership, but instead received grants upon employment. Many employees remain initially passive within these plans. However, following the 2008 Financial Crisis, they become more likely to exercise options, sell restricted stock, and participate in an Employee Stock Purchase Plan (ESPP). These changes likely improve welfare. For example, nonparticipation in an ESPP leaves money on the table. Our results improve our understanding of how investors’ personal return experiences affect investment choices. Negative shocks can increase attention among previously passive investors, yielding decisions that are closer to the optimum.
Involvement of Populus CLEL peptides in root development
Authors: Tian Dongdong , Liu Yueyuan , Tian Lidan , Wan Mengjie , Zheng Bo , Shi Xueping
Published: July 2019

As one of the major groups of small post-translationally modified peptides, the CLV3/EMBRYO SURROUNDING REGION-RELATED (CLE)-like (CLEL) peptide family has been reported to regulate root growth, lateral root development and plant gravitropic responses in Arabidopsis thaliana. In this study, we identified 12 CLEL genes in Populus trichocarpa and performed a comprehensive bioinformatics analysis on these genes. Among them, five P. trichocarpa CLELs (PtrCLELs) were revised with new gene models. All of these PtrCLEL proteins were structurally similar to the A. thaliana CLELs (AtCLELs), including an N-terminal signal peptide, a conserved C-terminal 13-amino-acid CLEL motif and a variable intermediate region. In silico and quantitative real-time PCR analyses showed that PtrCLELs were widely expressed in various tissues, including roots, leaves, buds and stems. Exogenous application of chemically synthesized PtrCLEL peptides resulted in wavy or curly roots and reduced lateral root formation in A. thaliana. Moreover, germinating Populus deltoides seedlings on a growth medium containing these peptides caused the roots to thicken and to form abnormal lateral roots, in many cases in clusters. Anatomical and histological changes in thickened roots were further investigated by treating Populus 717 cuttings with the PtrCLEL10 peptide. We observed that root thickening was mainly due to an increased number of cells in the epidermis, hypodermis and cortex. The results of our study suggested that PtrCLEL and AtCLEL genes encode proteins with similar protein structures, sequences of peptide motif and peptide activities on developing roots. The activities of PtrCLEL peptides in root development were species-dependent.
Periodontal bacteria and the rheumatoid arthritis-related antigen RA-A47: the cross-reactivity potential
Authors: Lucchese Alberta
Published: July 2019

Purpose of review

The purpose of this review is to evaluate the mechanisms that underlie the association between periodontal pathogens and rheumatoid arthritis (RA).

Recent findings

This review focuses on the cross-reactivity hypothesis as a mechanism that might contribute to explain the pathologic evolution of periodontal infections from periodontitis to RA. The scientific rationale is that immune reactions following infection by periodontal bacteria might cross-react with RA autoantigens, in this way eventually leading to autoimmunity.

Using the rheumatoid antigen associated with RA-A47 arthritis as an antigen model and analyzing five periodontal bacteria (eg, Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Treponema denticola, Tannerella forsythia and Prevotella intermedia), an extremely varied pattern of peptide sharing was found. In the context of the cross-reactivity hypothesis, the data allow us to glimpse the possibility of distinguishing the periodontal bacteria capable of attacking the periodontal tissue from those that are additionally equipped with a rheumatologic potential by virtue of the sharing of peptide sequences with RA antigens.
Early Operative Versus Nonoperative Treatment of Fragility Fractures of the Pelvis: A Propensity-Matched Multicenter Study
Authors: Osterhoff Georg , Noser Jonas , Held Ulrike , Werner Clément M. L. , Pape Hans-Christoph , Dietrich Michael
Published: July 2019

Objective:

To compare early operative treatment with nonoperative treatment of fragility fractures of the pelvis regarding mortality and functional outcome.

Design:

Retrospective.

Setting:

Two trauma centers.

Patients and Methods:

Two hundred thirty consecutive patients 60 years of age or older with an isolated low-energy fracture of the pelvis and with a follow-up of at least 24 months. In center 1, treatment consisted of a nonoperative attempt and early operative fixation if mobilization was not possible. In center 2, all patients were treated nonoperatively.

Main Outcome Measurements:

Primary outcome was mortality. Secondary outcomes were in-hospital complications. Patients who survived were contacted by phone, and a modified Majeed score was obtained to assess functional outcome at the final follow-up.

Results:

At the final follow-up (mean 61 months, SD 24), 105/230 (45.7%) patients had died. One year after the initial hospitalization, 34/148 patients [23%, 95% confidence interval (CI): 17%–31%] of the early operative group and 14/82 patients (17%, 95% CI: 10%–27%) of the nonoperative group had died (P = 0.294). Nonoperative treatment had a protective effect on survival during the first 2 years (hazard ratio of the nonlinear effect: 2.86, 95% CI: 1.38–5.94, P < 0.001). Patients in the early operative treatment group who survived the first 2 years had a better long-term survival. The functional outcome at the end of follow-up as measured by a modified Majeed score was not different between the 2 groups (early operative: 66.1, SD 12.6 vs. nonoperative: 65.7, SD 12.5, P = 0.910).

Conclusion:

Early operative fixation of patients who cannot be mobilized within 3–5 days was associated with a higher mortality rate and complication rate at 1 year but with a better long-term survival after more than 2 years. Hence, patients with a life expectancy of less than 2 years may not benefit from surgery with regard to survival.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Use of hamstring autograft to reconstruct the patellar tendon after endoprosthetic replacement of the proximal tibia for bone sarcomas
Authors: Madi Naji S. , Masrouha Karim Z. , Haidar Rachid K. , Saghieh Said S.
Published: July 2019

The surgical treatment of bone sarcoma involves wide surgical resection and endoprosthetic replacement. Surgical resection for proximal tibia bone sarcoma includes the patellar tendon. The secondary extension lag is a common complication and, although many have been described, the options for reconstruction of the patellar tendon are suboptimal. We propose adding a biological reinforcement, the hamstring tendons, to our extensor mechanism reconstruction technique (polyprolene mesh and gastrocnemius flap). We describe the surgical technique and, using an illustrative case, compare the outcome of this technique with the outcome following reconstruction without reinforcement. Level of evidence: Level III.
Percutaneous Decannulation Instead of Surgical Removal for Weaning After Venoarterial Extracorporeal Membrane Oxygenation—A Crossed Perclose ProGlide Closure Device Technique Using a Hemostasis Valve Y Connector
Authors: Lüsebrink Enzo , Stremmel Christopher , Stark Konstantin , Petzold Tobias , Hein-Rothweiler Ralph , Scherer Clemens , Schüttler Dominik , Massberg Steffen , Orban Martin
Published: July 2019

Objectives:

Improvements in cannula removal techniques, and in particular a standardized decannulation technique with a suitable closure device, are needed to further improve patients’ outcomes after percutaneous cannulation. The decannulation techniques described so far are neither sufficiently standardized nor proven enough to be used in the large group of venoarterial extracorporeal membrane oxygenation patients. To meet this challenge, we have established a highly standardized and safe decannulation technique based on the Perclose ProGlide closure system (Abbott Vascular, Lake Bluff, IL).

Design:

Establishment of a highly standardized and safe decannulation technique based on the Perclose ProGlide closure system, which is described in detail with comprehensive instructions for the executive clinician and first application in the context of a pilot study.

Measurements and Main Results:

So far our technique has already been used successfully in seven patients since January 2019 as a standard procedure on our ICU with only one minor complication occurred after the first procedure, that is, a small pseudoaneurysm likely originating from antegrade perfusion puncture site which was sealed by thrombin injection.

Conclusions:

Our crossed ProGlide technique using a hemostasis valve Y connector ensuring no blood loss seems to be a very promising decannulation technique.
Role of Caspase 1 in Ischemia/Reperfusion Injury of the Myocardium
Authors: Rauf Ali , Shah Mo , Yellon Derek M. , Davidson Sean M.
Published: July 2019

Acute occlusion of a coronary artery can result in myocardial infarction—a leading cause of premature death. Prompt restoration of blood flow to the myocardium can prevent excessive death of cardiomyocytes and improve clinical outcome. Although the major mechanism of cell death after reperfusion is necrosis, it is now recognized that many other cell death pathways may be involved in ischemia–reperfusion (I/R) injury. Pyroptosis is one such cell death pathway that is caspase-1–dependent and induced in response to cellular insult. The activated caspase-1 protease cleaves and activates specific cellular targets including gasdermin D and the proinflammatory cytokines interleukin-1β and interleukin-18. The N-terminal fragment of gasdermin D forms plasma membrane pores resulting in cytosolic leakage and cell rupture, releasing interleukin-1β and interleukin-18. Evidence suggests that inflammation induced by I/R through the pyroptotic pathway contributes to cardiomyocyte death, excessive scar formation, and poor ventricular remodeling. For this reason, there is growing interest in targeting components of the pyroptotic pathway as a means of reducing I/R injury.
Soy Isoflavones Inhibit Endothelial Cell Dysfunction and Prevent Cardiovascular Disease
Authors: Yamagata Kazuo
Published: July 2019

Soybeans are among the most popular foods worldwide, and intake of soy-containing foods has been associated with many health benefits in part because of it structure similar to estrogen. Epidemiologic studies have demonstrated that soy consumption improves serum profiles of hypercholesterolemic patients. Several studies have also indicated an inverse relationship between the consumption of soy isoflavones and the incidence of cardiovascular diseases (CVD). Soy is a rich dietary source of isoflavones. The main soy isoflavones are daidzein and genistein; equol, another isoflavone and a major intestinal bacterial metabolite of daidzein, is generated by enterobacterial effects. Many isoflavones have antioxidative effects and anti-inflammatory actions, as well as induce nitric oxide production to maintain a healthy endothelium and prevent endothelial cell dysfunction. These effects may limit the development of atherosclerosis and CVD and restore healthy endothelial function in altered endothelia. Although the evidence supporting the benefits of soy isoflavones in CVD prevention continues to increase, the association between soy isoflavones and disease is not fully understood. This review summarized recent progress in identifying the preventive mechanisms of action of dietary soybean isoflavones on vascular endothelial cells. Furthermore, it describes the beneficial roles that these isoflavones may have on endothelial dysfunction-related atherosclerosis.
A Novel Mechanism of Sildenafil Improving the Excessive Proliferation and H2S Production in Pulmonary Arterial Smooth Muscle Cells
Authors: Yao Zhenya , Wang Cheng
Published: July 2019

The dysregulation of pulmonary arterial vasoactive mediators or excessive proliferation of pulmonary arterial smooth muscle cells (PASMCs) might result in contraction or remodeling of pulmonary blood vessels, leading to related lung diseases. Recent studies suggest that hydrogen sulfide (H2S), a gaseous vasodilator generated in the blood vessels by the enzymes cystathionine γ-lyase (CSE) and cystathionine-β-synthase (CBS), could induce the vasodilation, thus improving contraction or remodeling-induced lung diseases. In this study, we hypothesized that PASMCs could produce H2S and relax the pulmonary artery, and its mechanism is related to CSE, CBS, and TRPV4 channels by affecting both the excessive proliferation and pulmonary vasoconstriction in PASMCs. We found that the sildenafil treatment could remarkably promote H2S production and control the proliferation in PASMCs; meanwhile, the protein levels of CSE and CBS and the intracellular concentration of calcium could also be increased by sildenafil. Moreover, the effects of sildenafil could be reversed by a CBS inhibitor or a CSE inhibitor, indicating that sildenafil could affect CSE and CBS to modulate the production of H2S and the proliferation in rat PASMCs. Together, we demonstrated a new mechanism for sildenafil to modulate the synthesis of H2S and cell proliferation in PASMCs by affecting CSE and CBS. TRPV4-dependent Ca2+ events and BMP4 may also be involved.
Reconstruction of Oncologic Sternectomy Defects: Lessons Learned from 60 Cases at a Single Institution
Authors: Banuelos Joseph , Abu-Ghname Amjed , Bite Uldis , Moran Steven L. , Bakri Karim , Blackmon Shanda H. , Shen Robert , Allen Mark S. , Pairolero Peter C. , Arnold Philip G. , Sharaf Basel
Published: July 2019

Background:

Oncologic sternectomy results in complex defects where preoperative planning is paramount to achieve best reconstructive outcomes. Although pectoralis major muscle flap (PMF) is the workhorse for sternal soft tissue coverage, additional flaps can be required. Our purpose is to evaluate defects in which other flaps beside PMF were required to achieve optimal reconstruction.

Methods:

A retrospective review of consecutive patients at our institution who underwent reconstruction after sternal tumor resection was performed. Demographics, surgical characteristics, and outcomes were evaluated. Further analysis was performed to identify defect characteristics where additional flaps to PMF were needed to complete reconstruction.

Results:

In 11 years, 60 consecutive patients were identified. Mean age was 58 (28–81) years old, with a mean follow-up of 40.6 (12–64) months. The majority were primary sternal tumors (67%) and the mean defect size was 148 cm2 (±81). Fourteen (23%) patients presented with postoperative complications, and the 30-day mortality rate was 1.6%. In 19 (32%) cases, additional flaps were required; the most common being the rectus abdominis muscle flaps. Larger thoracic defects (P = 0.011) and resections involving the inferior sternum (P = 0.021) or the skin (P = 0.011) were more likely to require additional flaps.

Conclusions:

Reconstruction of oncologic sternal defects requires a multidisciplinary team approach. Larger thoracic defects, particularly those that involve the skin and the inferior sternum, are more likely to require additional flaps for optimal reconstruction.
Clinical Characteristics and Outcomes of Ocular Cicatricial Pemphigoid: A Cohort Study and Literature Review
Authors: Fremont Félix , Pelissier-Suarez Cyrielle , Fournié Pierre , Porterie Marie , Thevenin Anaïs , Astudillo Léonardo , Paricaud Kim , Gualino Vincent , Soler Vincent , Pugnet Grégory
Published: July 2019

Purpose:

Ocular cicatricial pemphigoid (OCP) is a rare systemic autoimmune disease and a potentially blinding subepithelial blistering disorder. The purpose of this study was to describe the clinical spectrum of the disease and to assess the efficacy and safety of immunosuppressive agents in a cohort of patients with OCP.

Methods:

We conducted a monocentric retrospective cross-sectional cohort study of all unselected consecutive patients diagnosed with progressive OCP. Ocular and extra ophthalmological involvement as well as histological findings were gathered. Other outcomes were exposures to immunosuppressive agents defined by the use of a particular treatment. For each exposure, success in controlling ocular inflammation was graded as a complete response, response, or failure. Relapses and adverse events (AE) were also recorded.

Results:

Seventeen patients (34 affected eyes), 35% of whom were women, were included, with an age at diagnosis of 75 ± 11 years. Corneal involvement was diagnosed in 30 of 34 eyes, and 22 of 34 eyes had progressive fibrosing conjunctival involvement. Sixty-two exposures to immunosuppressive agents or biologics were recorded: dapsone, n = 26; mycophenolate mofetil, n = 6; azathioprine, n = 4; cyclophosphamide, n = 10; rituximab, n = 14; and intravenous immunoglobulin, n = 2. Rates of response and of complete response achievement during the first 3 months were 84% and 45%, respectively. Response rates were 100%, 100%, 86%, 85%, and 80% for intravenous immunoglobulin, mycophenolate mofetil, rituximab, dapsone, and cyclophosphamide, respectively. Thirteen percent of those drugs were discontinued because of an adverse event in 4 patients.

Conclusions:

This study describes the efficacy of immunosuppressants or biologics with an acceptable safety profile for OCP.
Effect of the infusion rate of propofol on the onset time of rocuronium
Authors: Lin Chia-Shiang , Chen Chien-Chuan , Hsu Yung-Wei
Published: July 2019

Background:

Administration of propofol, especially rapid administration, decreases patient cardiac output (CO) to various degrees. CO might influence the buildup of an effective drug level within the neuromuscular junction and affect the onset time of neuromuscular blockers. The present study aimed to investigate the effects of different infusion rates of propofol on patient CO and the onset time of rocuronium.

Methods:

A total of 90 patients were randomly assigned to receive propofol (2.5 mg/kg) at an infusion rate of 480 mg/min (group A), 240 mg/min (group B), or 120 mg/min (group C). After the administration of propofol, rocuronium (0.6 mg/kg) was administered to facilitate tracheal intubation. The Finometer monitor was used to obtain the cardiovascular profile during the induction of general anesthesia. Neuromuscular relaxation was monitored by acceleromyography using the ulnar nerve at the wrist surface and electrodes with repeated single twitches. Onset time was defined as the time from the beginning of rocuronium injection until 95% twitch depression. The onset time of rocuronium in the three groups was compared using analysis of variance with the post-hoc Tukey test. A p-value <0.05 was considered statistically significant.

Results:

After induction, a significant decrease in CO was observed in group A (21.6% ± 4.6%) when compared with the findings in group B (11.6% ± 4.5%) and group C (9.8% ± 4.6%). The onset time of rocuronium was significantly longer in group A (177.7 ± 17.6 seconds) than in group B (121.3 ± 18.3 seconds) and group C (118.3 ± 12.3 seconds).

Conclusion:

Rapid administration of propofol significantly delays the onset time of rocuronium by altering CO as measured with the Finometer monitor.
Outcomes of Primary Pediatric Stapedotomy
Authors: Page Joshua Cody , Gau Victoria L. , Allsopp Tristan , King DeAnne , Jervis-Bardy Joshua , Dornhoffer John L.
Published: July 2019

Objective:

To review a single institution experience with pediatric stapedotomy for juvenile otosclerosis (JO), congenital stapes footplate fixation (CSFF), or tympanosclerosis.

Study Design:

Retrospective chart review.

Setting:

Tertiary referral center.

Patients:

Pediatric patients undergoing surgery for stapes fixation from 2001 to 2017.

Main Outcome Measures:

Hearing result based on preoperative, first postoperative, and final postoperative pure-tone average air-bone gap (PTA-ABG). Age, sex, diagnosis, procedure performed, prosthesis, and ossicular anomalies were considered.

Results:

A total of 59 children (4–16 years of age) underwent surgery for stapes fixation (67 ears), with an average postoperative audiogram out to 2.88 years. Final postoperative ABG for tympanosclerosis (30.4 dB ± 10.9 dB) showed some improvement but the outcome was significantly worse than in CSFF (21.0 dB ± 11.4 dB) (p = 0.020) and JO (22.8 dB ± 14.9 dB).

Conclusion:

Our data suggest, that in our clinic, surgery for stapes fixation is safe to perform in children. While we achieved desirable results for JO and CSFF, patients with tympanosclerosis showed a statistically worse hearing outcome. Tympanosclerosis deserves special consideration and may be better served with a malleovestibulopexy, total ossicular replacement prosthesis (TORP), or amplification in lieu of traditional stapes surgery.
Organoids for replacement therapy: expectations, limitations and reality
Authors: Xinaris Christodoulos
Published: July 2019

Purpose of review

To discuss existing expectations from organoids and how they can affect biomedical research and society, and to analyse the current limitations and how they can potentially be overcome.

Recent findings

Recent success with engineering human organoids has created great enthusiasm and expectations, especially for their potential as tissue substitutes. The most feasible applications for organoid technologies at the moment are: drug testing, disease modelling and studying of human development.

Being able to engineer transplantable tissues in a dish would fundamentally change the way we conduct biomedical research and clinical practice, and impact important aspects of science and society – from animal experimentation to personalized medicine, bioethics, transplantation and gene therapy. However, whether organoids will soon be able to fulfil these expectations is still unclear, because of significant existing limitations. By answering a set of questions, here I will examine the expectations on the future of organoids and how they can affect the field and the society, I will analyse the most important limitations that still prevent the production of transplantable human tissues in a dish, and discuss possible solution strategies.
Clinical Characteristics of Mycoplasma genitalium and the Usefulness of Syndromic Management Among Women Living With Human Immunodeficiency Virus
Authors: Ong Jason J. , Magooa Mahlape Precious , Chikandiwa Admire , Kelly Helen , Didelot Marie-Noelle , Muller Etienne E. , Maseko Venessa , Segondy Michel , Delany-Moretlwe Sinead , Kularatne Ranmini , Mayaud Philippe
Published: July 2019

We report the clinical symptoms and examination findings of Mycoplasma genitalium (MG) in women living with human immunodeficiency virus in South Africa. If we relied on syndromic management alone to treat MG, only 15 of 46 MG-infected women would have received. appropriate treatment: sensitivity of 32.6% (95% confidence interval, 19.5–48.0) and specificity of 67.4% (95% confidence interval, 63.4–71.2).
Death Related to Elective Nasal Polypectomy
Authors: Čurović Ivana , Savić Slobodan , Bogdanović Milenko , Durmić Tijana
Published: July 2019

The investigation of deaths that are suspected to be related to medical therapy present several challenges for a forensic pathologist. We present a case of an otherwise healthy 58-year-old woman with multiple nasal polyps who underwent nasal polypectomy. The operation was initially considered successful. However, the patient had never recovered from general anesthesia and was declared deceased 24 hours after the surgery.

The autopsy revealed a basilar subarachnoid hemorrhage. The examination of the basilar skull showed a perforation of approximately 15 by 7 mm in the right cribriform plate. Above the bone perforation, there was a disruption of the dura and a 20-mm-long penetrating wound within the right frontal lobe parenchyma of the brain, with associated intraventricular hemorrhage. The subsequent sectioning of the formalin-fixed brain revealed extensive parenchymal destruction. The cause of death was certified as complications of nasal/sinus surgery, with a perforation of the skull base with hemorrhagic tissue destruction, whereas the manner of death was considered accidental.

Common nasal surgical procedures and known complications are discussed.
Differences in Opioid Prescribing Practices among Plastic Surgery Trainees in the United States and Canada
Authors: Grant David W. , Power Hollie A. , Vuong Linh N. , McInnes Colin W. , Santosa Katherine B. , Waljee Jennifer F. , Mackinnon Susan E.
Published: July 2019

Background:

Overprescribing following surgery is a known contributor to the opioid epidemic, increasing the risk of opioid abuse and diversion. Trainees are the primary prescribers of these medications at academic institutions, and little is known about the factors that influence their prescribing. The authors hypothesized that differences in health care funding and delivery would lead to disparities in opioid prescribing. Therefore, the authors sought to compare the prescribing practices of plastic surgery trainees in the United States and Canada.

Methods:

A survey was administered to trainees at a sample of U.S. and Canadian institutions. The survey queried opioid-prescriber education, factors contributing to prescribing practices, and analgesic prescriptions written after eight procedures. Oral morphine equivalents were calculated for each procedure and compared between groups.

Results:

One hundred sixty-two trainees completed the survey, yielding a response rate of 32 percent. Opioid-prescriber education was received by 25 percent of U.S. and 53 percent of Canadian trainees (p < 0.0001). Preoperative counseling was performed routinely by only 11 percent of U.S. and 14 percent of Canadian trainees. U.S. trainees prescribed significantly more oral morphine equivalents than Canadians for seven of eight procedures (p < 0.05). Residency training in the United States and junior training level independently predicted higher oral morphine equivalents prescribed (p < 0.05).

Conclusions:

U.S. trainees prescribed significantly more opioids than their Canadian counterparts for seven of eight procedures surveyed. Many trainees are missing a valuable opportunity to provide opioid counseling to patients. Standardizing trainee education may represent an opportunity to reduce overprescribing.
Implant Surface Options and Biofilm Mitigation Strategies
Authors: Jewell Mark L. , Fickas Becky , Jewell Hillary , Jewell Mary Lind
Published: July 2019

Two important topics in breast augmentation and reconstruction relate to device surface texture and practices to mitigate biofilm contamination of implants. Breast augmentation can be considered a manufacturing process where planning concepts of process engineering and quality can be used to produce great outcomes. This article reviews the options available for surgeons with regards to device surface texture selection and practices to mitigate biofilm contamination of implants at the time of surgery.
Newer approaches in diagnosis of diarrhea in immunocompromised patients
Authors: Santoiemma Phillip P. , Ison Michael G. , Angarone Michael P.
Published: July 2019

Purpose of review

This review will focus on the epidemiology and cause of diarrheal illness in solid organ transplant and stem-cell transplant population recipients with a specific focus on the role of advanced multiplex technology in the diagnosis of diarrhea within this patient population.

Recent findings

A wide range of infectious and noninfectious causes of diarrhea have been described in immunocompromised patients. The most common infections noted are Clostridioides difficile, norovirus, and cytomegalovirus, whereas immunosuppressive drugs and mucositis are the most common noninfectious causes of diarrhea. Historically, diagnostic evaluation has been limited to an array of single pathogen assays. Newer multiplex assays have become available that allow rapid, sensitive detection of a wide range of pathogens in a single assay. These assays have improved the number of patients with a diagnosed pathogen but may identify colonizing pathogens that are not pathogenic. Studies are needed to inform the discrimination and optimal use of these newer assays.

Diarrhea is a common complication in immunocompromised patients and is associated with greater morbidity and rare mortality. New diagnostics facilitate detection of recognized pathogens and may allow for improved outcomes through the use of pathogen-targeted therapy.
Using Lean Six Sigma to Reduce Patient Cycle Time in a Nonprofit Community Clinic
Authors: Kovach Jamison V. , Ingle Dhanashri
Published: July 2019

Background and Objectives:

The mission of nonprofit health care clinics is particularly challenging to fulfill given the large number of uninsured and underinsured people they serve. In addition, these clinics feel pressure to provide services in an efficient manner to prevent patient no-shows and encourage the continuation of medical care. These challenges tend to increase further when clinics feel they have exhausted their internal resourcefulness relative to their effort to improve patient care. Without additional guidance, it can be difficult for organizations to achieve additional performance improvements. To address this problem, a case example is presented that demonstrates how one nonprofit health care clinic used the Lean Six Sigma methodology to help them further improve the efficiency of their clinic visit process.

Methods:

This research focused specifically on the use of process analysis tools/methods to map the clinic visit process, collect and analyze process performance data, analyze the process to identify and prioritize causes of waste, and develop and implement solutions.

Results:

The clinic's use of this structured improvement approach contributed to reducing patient cycle time by more than 20% and increasing patient visit capacity.

Conclusions:

This research provides a rich example from which other health care facilities can learn to enhance their process improvement capabilities.
Combination of National Quality Assurance Data Collection With a Standard Operating Procedure in Community-Acquired Pneumonia: A Win-Win Strategy?
Authors: Schulte Falko C. , Bewig Burkhard , Petzina Rainer , Graf Demian , Balke Lorenz , Wehkamp Ulrike , Jahnke Iris , Wehkamp Kai
Published: July 2019

Purpose:

The primary contact for German physicians with national quality assurance in community-acquired pneumonia (CAP) is frequently experienced as time-consuming obligatory documentation. Since the regular feedback loop stretches up to 18 months, the immediate impact on quality is perceived as rather low. Ultimately, a method leading to increase in the quality of data collection, clarification on expected clinical treatment standards, and improvement in the acceptance and feedback mechanism is needed.

Methods:

We developed a form merging data collection for quality indicators with a standard operating procedure (SOP) in CAP and implemented it in the daily routine of a university's department for internal medicine. Fulfillment of quality indicators before and after the implementation of the new form was measured.

Results:

Critical parameters such as the documentation of breathing rate and clinical parameters at discharge strongly improved after implementation of the intervention. Uncritical parameters showed slight improvement or stable results at a high level.

Conclusion:

The combination of collection of quality data with a clinical SOP and context information may improve the impact of quality measures by increasing acceptance, quality of data capture, short-loop feedback, and possibly quality of care.
Metal Artifact Reduction in Routine Chest and Abdominal Examinations Using Virtual Monoenergetic Images From Spectral Detector Computed Tomography
Authors: Van Hedent Steven , Kessner Rivka , Große Hokamp Nils , Baran Tomer Ziv , Kosmas Christos , Gupta Amit
Published: July 2019

Objective

The objective of this study was to investigate the quantitative and qualitative effects of virtual monoenergetic images (VMIs) by spectral detector computed tomography (SDCT) on metal artifacts in routine examinations.

Methods

Fifty-nine patients with metal artifacts (caused by pacemakers, ports, screws, or prosthetic joints) affecting muscular tissue in the chest and/or abdomen were scanned using SDCT. Attenuation values around the metallic device were compared with contralateral unaffected values, for conventional images and 80 to 200 keV VMIs. In addition, general image quality and artifact intensity were rated by 2 readers.

Results

The VMIs significantly decreased metal artifact intensity in all patients (P < 0.05). In 39 patients (66.1%), the attenuation values of the artifact and the unaffected area on the optimal keV level were very similar (≤5 Hounsfield unit difference). Qualitative analysis showed that high VMIs significantly improved artifact intensity, with best scores at 140 keV.

Conclusions

High monoenergetic images of SDCT significantly reduce metal artifacts, with optimal assessment at 140 keV.
The Experience With Health Care of Patients With Inflammatory Arthritis
Authors: de Toro Javier , Cea-Calvo Luis , García-Vivar María L. , Pantoja Lucía , Lerín-Lozano Cristina , García-Díaz Silvia , Galindo María J. , Marín-Jiménez Ignacio , Fernández Sabela , Mestre Yvonne , Orozco-Beltrán Domingo
Published: July 2019

Background

Patients' experience with health care is becoming a key component for the provision of a patient-centered health care model. The aim of this study was to assess the experience with health care of patients with inflammatory arthritis and patient- and health care–related factors.

Methods

Patients responded to an anonymous survey provided by their treating clinical teams. The survey comprised the validated 12-item IEXPAC (Instrument to Evaluate the EXperience of PAtients with Chronic diseases) tool and demographic variables and health care–related characteristics that may affect patients' experience.

Results

A total of 359 of 625 surveys were returned (response rate, 57.4%). Overall, patient responses were positive (>60% gave “always/mostly” answers) for statements assessing the interaction between patients and health care professionals or patient self-management following health care professional guidance. However, positive patient responses for items regarding patient interaction with the health care system via the internet or with other patients were less than 13%. Only 25.6% of patients who had been hospitalized reported receiving a follow-up call or visit following discharge. In the bivariate analysis, experience scores were higher (better experience) in men, those seen by fewer specialists or by the same physician, and in patients treated with a fewer number of drugs or with subcutaneous/intravenous drugs. Multivariate analyses identified regular follow-up by the same physician and treatment with subcutaneous/intravenous drugs as variables associated with a better patient experience.

Conclusions

This study identifies areas of care for patients with inflammatory arthritis with the potential to improve patients' experience and highlights the importance of patient-physician relationships and comprehensive patient care.
Left-sided Portal Hypertension After Pancreaticoduodenectomy With Resection of the Portal Vein/Superior Mesenteric Vein Confluence in Patients With Pancreatic Cancer
Authors: Mizuno Shugo , Kato Hiroyuki , Yamaue Hiroki , Fujii Tsutomu , Satoi Sohei , Saiura Akio , Murakami Yoshiaki , Sho Masayuki , Yamamoto Masakazu , Isaji Shuji
Published: July 2019

Objective:

The aim of this study was to evaluate how often left-sided portal hypertension (LPH) develops and how LPH affects the long-term outcomes of patients with pancreatic cancer treated with pancreaticoduodenectomy (PD) and resection of the portal vein (PV)/superior mesenteric vein (SMV) confluence.

Summary Background Data:

Little is known about LPH after PD with resection of the PV/SMV confluence.

Methods:

Overall, 536 patients who underwent PD with PV/SMV resection were enrolled. Among them, we mainly compared the SVp group [n=285; the splenic vein (SV) was preserved] and the SVr group (n = 227; the SV was divided and not reconstructed).

Results:

The incidence of variceal formation in the SVr group increased until 3 years after PD compared with that in the SVp group (38.7% vs 8.3%, P < 0.001). Variceal bleeding occurred in the SVr group (n = 9: 4.0%) but not in the SVp group (P < 0.001). In the multivariate analysis, the risk factors for variceal formation were liver disease, N factor, conventional PD, middle colic artery resection, and SV division. The only risk factor for variceal bleeding was SV division. The platelet count ratio at 6 months after PD was significantly lower in the SVr group than in the SVp group (0.97 vs 0.82, P < 0.001), and the spleen–volume ratios at 6 and 12 months were significantly higher in the SVr group than in the SVp group (1.38 vs 1.00 and 1.54 vs 1.09; P < 0.001 and P < 0.001, respectively).

Conclusions:

PD with SV division causes variceal formation, bleeding, and thrombocytopenia.
Surgical Data Recording Technology
Authors: Shah Neal A. , Jue Jessica , Mackey Tim K.
Published: July 2019

Reducing preventable medical errors remains a universal goal, yet implementing effective solutions remains a challenge. The development of surgical data recording technology shows promise to generate robust qualitative and quantitative data in the surgical theater. These data can allow physicians and their teams to capture specific sources of error and implement corrective interventions. Surgical data recording technology encompasses rudimentary data tabulation on notecards, to integrated audio-video systems containing cameras, microphones, and sensors, capturing and synthesizing intraoperative, environmental, and instrumentation information, along with devices tailored to robotic surgical systems. There is growing interest in the implementation of such technology in medical centers, particularly in the United States, Canada, and Europe, but existing medicolegal and regulatory challenges necessitate further research and clinical assessment in order for this technology to facilitate improved surgical patient safety.
Mallet Finger
Authors: Ramponi Denise R. , Hellier Susan D.
Published: July 2019

This article provides an overview of issues associated with traumatic injury to the distal finger that results in extensor tendon disruption or bony avulsion at the base of the distal phalanx. Commonly referred to as mallet finger, drop finger, or baseball finger, terminal extensor tendon injuries are a common presentation to the emergency department. Providers need to be advised of evidence-based management of these extensor tendon injuries in order to prevent decreased function and permanent deformity. Current evidence supports nonoperative interventions, but injuries need to be addressed in a timely manner in order to avoid poor outcomes.
Low-dose Rituximab and Thymoglobulin Induction With Steroid-free Maintenance Immunosuppression and Protocol Biopsies Improves Long-term Patient and Graft Survival After Kidney Transplantation: Survival and Safety Outcomes in More Than 1100 Patients From a Single Center
Authors: Pathak Vivek , Madhavan Devdas , Narayanasamy Kuppurajan , Kumar Sampath , Ramalingam Vasanthan , Sengodagounder Balasundaram , Bodonyi-Kovacs Gabor
Published: July 2019

Background.

Steroid-free maintenance immunosuppression after kidney transplantation provides acceptable patient and graft survival and minimizes steroid-associated side effects among recipients with a low immunological risk. However, the long-term outcomes of such protocols, incorporating low-dose rituximab and thymoglobulin induction along with protocol biopsies, in non-European populations remains underreported.

Methods.

We retrospectively analyzed 1142 consecutive kidney transplantations conducted at our center from July 2005 to October 2017. Immunosuppression protocol included induction with thymoglobulin and low-dose preoperative rituximab. Maintenance immunosuppression consisted of tacrolimus and mycophenolate mofetil; prednisolone was discontinued on postoperative day 5. Protocol biopsies were carried out at 3 months and at 1, 5, and 10 years after transplantation—in addition to the indicated biopsies. The 12-year patient and graft survival and posttransplantation complications were studied.

Results.

The analysis of outcomes was conducted for 1111 transplant recipients. Patients (70.59%) remained steroid-free at 12 years after transplantation. The patient survival rates at 1, 5, and 12 years were 97.7%, 94.8%, and 92.4%, respectively. The corresponding graft survival rates were 97.2%, 90.9%, and 86.1%, respectively. Biopsy-proven acute rejection occurred in 12.7% of recipients, including 3.5% subclinical rejections. The cumulative incidence of graft loss was 6.56% at 12.3 years. The overall incidence of death was 5.3%.

Conclusions.

Steroid-free maintenance immunosuppression was associated with excellent long-term patient and graft survival rates and reduced incidence of prednisolone-related side effects, despite acceptable rejection rates. Low-dose rituximab with thymoglobulin induction with immediate steroid withdrawal and surveillance biopsies resulted in excellent long-term outcomes in our single-center experience.
A single-blinded randomized crossover trial comparing peer-to-peer and standard instruction on airway management skill training
Authors: Surabenjawong Usapan , Phrampus Paul Edward , Lutz John , Farkas Deborah , Gopalakrishna Apoorva , Monsomboon Apichaya , Limsuwat Chok , O’Donnell John Marc
Published: July 2019

Background

Peer-to-peer teaching, which is an alternative to standard teaching (by expert instructors), has the potential to emphasize student self-learning and reduce the cost and workload of the instructor. Self-instruction videos with peer feedback are highlighted in many medical and nursing school curricula.

Objective

To evaluate whether peer to peer instruction supported by a structured curriculum and video exemplars is not inferior to standard instructor-led teaching in basic airway management skill, knowledge, and confidence attainment.

Method

This single blinded randomized crossover trial was conducted with a sample of novice nursing students. Data was collected through the pre-to post-knowledge and confidence assessments. The students were randomly assigned to two crossover groups. Each student learned basic airway management skills through both methods. The students’ performances were recorded in every session with recordings reviewed by blinded expert instructors.

Results

The study included 48 participants, who were assigned into both the expert instruction group and peer-to-peer group through computer generated randomization. The skill rating scores of the peer-to-peer group were not inferior to the standard teaching. With further analysis, we noted that the peer-to-peer group scores had significantly higher scores demonstrating a large effect size (Cohen’s d of 1.07 (p-value 0.002) for oropharyngeal airway insertion, 1.14 (p-value <0.001) for nasopharyngeal airway insertion and 0.81 (p-value 0.003) for bag mask ventilation). There was no significant difference between pre- and post-knowledge scores across groups (p-value of 0.13 and 0.22 respectively). Participants in both groups reported higher confidence after learning. However, the difference was not statistically significant.

Conclusions

Undergraduate nursing students trained in basic airway management skills by peer-to-peer instruction and a structured curriculum did not show inferior scores compared to the students who were trained by expert instructors. There was no significant difference in the knowledge and confidence levels between the groups.
Alcohol causes an increased risk of head and neck but not breast cancer in individuals from the UK Biobank study: A Mendelian randomisation analysis
Authors: Ingold Nathan , Amin Hasnat A , Drenos Fotios
Published: July 2019

ABSTACT

Alcohol intake and the risk of various types of cancers have been previously correlated. Correlation though does not always mean that a causal relationship between the two is present. Excessive alcohol consumption is also correlated with other lifestyle factors and behaviours, such as smoking and increased adiposity, that also affect the risk of cancer and make the identification and estimation of the causal effect of alcohol on cancer difficult. Here, using individual level data for 322,193 individuals from the UK Biobank, we report the observational and causal effects of alcohol consumption on types of cancer previously suggested as correlated to alcohol. Alcohol was observationally associated with cancers of the lower digestive system, head and neck and breast cancer. No associations were observed when we considered those keeping alcohol consumption below the recommended threshold of 14 units/week. When Mendelian randomisation was used to assess the causal effect of alcohol on cancer, we found that increasing alcohol consumption, especially above the recommended level, was causal to head and neck cancers but not breast cancer. Our results where replicated using a two sample MR method and data from the much larger COGS genome wide analysis of breast cancer. We conclude that alcohol is causally related to head and neck cancers, especially cancer of larynx, but the observed association with breast cancer are likely due to confounding. The suggested threshold of 14 units/week appears suitable to manage the risk of cancer due to alcohol.
The Human Leukocyte Antigen Locus and Susceptibility to Rheumatic Heart Disease in South Asians and Europeans
Authors: Auckland Kathryn , Mittal Balraj , Cairns Benjamin J , Garg Naveen , Kumar Surendra , Mentzer Alexander J , Kado Joseph , Perman Mai Ling , Steer Andrew C , Hill Adrian V S , Parks Tom
Published: July 2019

Background

Rheumatic heart disease (RHD) remains an important cause of morbidity and mortality globally. Several reports have linked the disease to the human leukocyte antigen (HLA) locus but with negligible consistency.

Methods

We undertook a genome-wide association study (GWAS) of susceptibility to RHD in 1163 South Asians (672 cases; 491 controls) recruited in India and Fiji. We analysed directly obtained and imputed genotypes, and followed-up associated loci in 1459 Europeans (150 cases; 1309 controls) from the UK Biobank study. For fine-mapping, we used HLA imputation to define classical alleles and amino acid polymorphisms.

Results

A single signal situated in the HLA class III region reached genome-wide significance in the South Asians, and replicated in the Europeans (rs201026476; combined odds ratio 1.81, 95% confidence intervals 1.51-2.18, P=3.48×10−10). While the signal fine-mapped to specific amino acid polymorphisms within HLA-DQB1 and HLA-B, with conditioning, the lead class III variant remained associated with susceptibility (P=3.34×10−4), suggesting an independent effect.

Conclusions

A complex HLA signal, likely comprising at least two underlying causal variants, strongly associates with susceptibility to RHD in South Asians and Europeans. Crucially, the involvement of the class III region may partly explain the previous inconsistency, while offering important new insight into pathogenesis.