bluuebunny/crossref_metadata_2025 huggingface dataset:
Management of Postoperative Issues in Gynecology and Gynecologic Oncology: A New Method for Teaching Residents
Authors: Rolston Aimee , Brackmann Melissa , Mclean Karen , Reynolds R. , Marzano David , Malone Anita
Published: October 2019

PURPOSE:

This project sought to develop and assess a curriculum to improve resident knowledge of and comfort in managing common postoperative issues.

BACKGROUND:

Junior obstetrics/gynecology residents enter training with varied experience in post-operative management. They are often the first contact for surgical patients with little formal education on post-operative issues.

METHODS:

Eleven common post-operative issues were identified based on literature review, resident experience and gynecology/gynecologic oncology faculty input. Topic based curriculum included: example case, pathophysiology, differential diagnosis, next steps, and useful resources. It was presented at two educational sessions, involving lectures and small-group simulations. Residents completed a pre and post-assessment questionnaire assessing comfort level in managing (10-point Likert scale) and baseline knowledge about (content-specific questions) the topics.

RESULTS:

Twenty-three residents participated. Seventeen completed one or both pre-assessment surveys (nine junior residents). Ten completed one or both post-assessment surveys (five junior residents). All post-assessment respondents reported improved knowledge of issues covered. Average self-rated comfort level increased for ten of eleven topics amongst junior residents (average increase 1.6 points (range 0.5–3.2; p = 0.02)). Largest increase in score was for hypoxia and low urine output. Average scores maintained or improved for 80% of the content questions (not significant). Residents had no preference for lecture versus small group format.

DISCUSSION:

As a result of directed teaching, resident knowledge of post-operative issues showed measurable improvement. Resident comfort level in management increased significantly for 90% of topics covered, most noticeably amongst junior residents. A systematic, resident-led curriculum on post-operative management can improve resident knowledge and patient care.
Meet You by the Bayou: A Comparison of Resident and Student Views of Resident Teaching Skills on the OB/GYN Clerkship
Authors: Ratan Bani , Johnson Grace , Williams Amanda , Greely Jocelyn , Rutledge Emily , Kilpatrick Charles
Published: October 2019

PURPOSE:

Compare how OB/GYN residents and medical students view residents as teachers.

BACKGROUND:

The AAMC Medical School Graduation Questionnaire consistently rates OB/GYN residents among the least effective teachers of all the core clerkships. An initial needs-assessment for a resident-as-teacher program was performed to ascertain areas for improvement from both resident and medical student perspectives.

METHODS:

A cross-sectional survey based on the Baker Clinical Educator Self-Assessment using a 1-5 Likert scale was administered to all residents enrolled in an academic OB/GYN Residency in October 2017 and to 37 medical students participating in end-of-clerkship focus groups from October 2017-June 2018. The survey consisted of 13 questions regarding resident teaching skills. Kruskal-Wallis test and two-way ANOVA was used for analysis.

RESULTS:

34 of 48 residents (71% response rate) and all 37 students participating in focus groups completed the survey. Both groups rated residents highest in teaching a skill and lowest in using student learning objectives (p<0.01). Residents’ rating of their own teaching skills was consistently higher than students’ ratings in all except 3 areas: facilitating students’ clinical reasoning, teaching at the bedside, and using questions to teach. Student and resident responses significantly differed only in regards to providing an effective orientation to trainees (2.76 vs 3.71, p<0.01).

DISCUSSION:

A modified Baker Clinical Educator Self-Assessment is useful to evaluate resident and student views of resident teaching. While both agree that OB/GYN residents excel at teaching procedural skills and need improvement in incorporating learning objectives, they significantly differ in views of effectiveness of the student orientation.
The Impact of Interprofessional Education on Attitudes of Medical Students Toward Nurses and Certified Nurse Midwives: A Narrative Review
Authors: Etezadi-Amoli Neda
Published: October 2019

OBJECTIVE:

To identify how interprofessional education (IPE) may influence attitudes of medical students towards nurses or Certified Nurse Midwives (CNMs).

DATA SOURCES:

PubMed and CINAHL were searched using keywords and MeSH terms from 2007 to present.

METHODS OF STUDY SELECTION:

The search included English-language articles published between 2007 and 2018, subsequent to creation of the Institute for Healthcare Improvement’s Triple Aim which linked interprofessional teams to improved healthcare outcomes. Inclusion criteria for articles was whether IPE activities involving medical students improved attitudes of these students towards other healthcare team members, specifically nurses and/or CNMs.

TABULATION, INTEGRATION AND RESULTS:

40 articles were identified including seven that met inclusion criteria and were reviewed in detail. All seven measured pre- and post- IPE exposure using either scales developed for individual studies or the Jefferson Scale on Attitudes. Types of IPE activities varied from simulations to direct patient care experiences. Participants ranged in number from 54 to 277 medical students. Two, one, three, and one studies included first, second, third and fourth year students, respectively. Six of seven studies noted improvement post-IPE exposure with respect to medical student attitudes towards nursing. There was one study that involved CNMs in the IPE activity, but only included data from nursing, social work and medical students.

CONCLUSION:

Simulated and workplace IPE activities can improve attitudes of medical students toward nursing and other health care providers. No studies have evaluated the optimal timing of IPE activities for medical students for improving team performance in practice.
An Innovative STI Curriculum for Medical Students
Authors: Wiczulis Alicia , Sishtla Haritha , Javlekar Ashwini
Published: October 2019

PROBLEM:

Student feedback regarding the 50-minute didactic session on sexually transmitted infections (STIs) in the Ob-Gyn Clerkship was poor, and students wanted more interactive instruction methods in our curriculum.

INTERVENTION:

We created a new curriculum for STIs that is more interactive and appropriate for adult learners. Students begin with a self-directed assignment, where they are referred to specific resources and national guidelines to build their fund of knowledge. We replaced the previous didactic lecture with an interactive case-based session that demonstrates clinical application of the material. Small groups of students discuss four clinical vignettes: STI screening, a patient with a genital ulcer, a woman with pelvic inflammatory disease (PID), and a victim of sexual assault. To assess the effectiveness of our method, we will review student feedback on the new curriculum and student performance on the National Board of Medical Examiners subject exam for Obstetrics and Gynecology. We are also conducting a survey for fourth year students that asks how they would manage a patient with PID and a patient requesting STI screening.

CONTEXT:

Screening, diagnosis, and treatment of sexually transmitted infections (STIs) are critical areas of competency for medical students, and interactive teaching methods are increasingly utilized in the modern medical curriculum.

OUTCOME/LESSONS LEARNED:

The current session has been very positively received by students. There has not been a significant change in exam scores. We will conduct our fourth-year survey in the coming academic year to determine whether there is a significant difference in approach to the two vignettes.
Imaging of Traumatic Injuries to the Male Lower Genitourinary Organs and Impact on Surgical Management
Authors: Lee Michael J. , Archer-Arroyo Krystal , Levenson Robin B. , Mazza Michael , Chong Suzanne
Published: October 2019

Genitourinary trauma occurs in 10% of all patients with abdominal trauma, and it is more common in men due to the external location of the male genital organs and longer length of the male urethra, which make them more susceptible to traumatic injuries.1 Concomitant injuries are not uncommon and may distract from or delay the diagnosis of genitourinary injuries, potentially leading to complications, loss of function, and irreversible damage.1 Radiologists play a key role in diagnosing male genitourinary injuries to expedite appropriate surgical management.
Increasing influenza vaccination acceptance in the homeless
Authors: Beers Lorraine , Filter Marilyn , McFarland Marilyn
Published: October 2019

The US homeless population is predisposed to serious complications of influenza with increased likelihood of hospitalization and death. This quality improvement project sought to increase influenza vaccination in the homeless population of a rural area in the Midwest and improve provider knowledge of risks and preventive care responsibilities.
Reflections on Learning to Heal, Time to Heal, and Let Me Heal
Authors: Ludmerer Kenneth M.
Published: October 2019

In this Invited Commentary, the author reflects on the contributions, influence, and continued relevance of his 3 books on American medical education: Learning to Heal, Time to Heal, and Let Me Heal. Collectively, the books provide a panoramic view of U.S. medical education spanning 2 centuries, and they cover virtually every topic and consideration pertinent to the enterprise. They are works of education as well as works of history, and as such, they identify the timeless principles and values—maintaining rigorous academic standards and serving as a public trust—that need to be protected at all costs if medical education in the United States is to retain its tradition of excellence and leadership. Learning to Heal describes the creation and maturation of the U.S. system of medical education, focusing on its cultural as well as its scientific roots; the book also defined the educational meaning and significance of these changes. Time to Heal introduced the term “learning environment” into the lexicon of medical education; it also inspired a number of notable experiments in undergraduate and graduate medical education. Let Me Heal provided the intellectual foundation for the 2017 version of Section VI of the Common Program Requirements of the Accreditation Council for Graduate Medical Education. However, the most notable contribution of these books is their analysis of medical education’s ongoing challenges and opportunities; thus, they provide a framework for improving medical education and health care delivery in the United States today.
Impact of an Opioid Safety Initiative on Patients Undergoing Total Knee Arthroplasty
Authors: Chen Qi , Hsia Hung-Lun , Overman Robert , Bryan William , Pepin Marc , Mariano Edward R. , Mudumbai Seshadri C. , Buchheit Thomas , Krishnamoorthy Vijay , Good Chester B. , Brookhart M. Alan , Raghunathan Karthik
Published: October 2019

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

The Opioid Safety Initiative decreased high-dose prescriptions across the Veterans Health Administration. This study sought to examine the impact of this intervention (i.e., the Opioid Safety Initiative) on pain scores and opioid prescriptions in patients undergoing total knee arthroplasty.

Methods

This was an ecological study of group-level data among 700 to 850 patients per month over 72 consecutive months (January 2010 to December 2015). The authors examined characteristics of cohorts treated before versus after rollout of the Opioid Safety Initiative (October 2013). Each month, the authors aggregated at the group-level the differences between mean postoperative and preoperative pain scores for each patient (averaged over 6-month periods), and measured proportions of patients (per 1,000) with opioid (and nonopioid) prescriptions for more than 3 months in 6-month periods, preoperatively and postoperatively. The authors compared postintervention trends versus trends forecasted based on preintervention measures.

Results

After the Opioid Safety Initiative, patients were slightly older and sicker, but had lower mortality rates (postintervention n = 28,509 vs. preintervention n = 31,547). Postoperative pain scores were slightly higher and the decrease in opioid use was statistically significant, i.e., 871 (95% CI, 474 to 1,268) fewer patients with chronic postoperative prescriptions. In time series analyses, mean postoperative minus preoperative pain scores had increased from 0.65 to 0.81, by 0.16 points (95% CI, 0.05 to 0.27). Proportions of patients with chronic postoperative and chronic preoperative opioid prescriptions had declined by 20% (n = 3,355 vs. expected n = 4,226) and by 13% (n = 5,861 vs. expected n = 6,724), respectively. Nonopioid analgesia had increased. Sensitivity analyses confirmed all findings.

Conclusions

A system-wide initiative combining guideline dissemination with audit and feedback was effective in significantly decreasing opioid prescriptions in populations undergoing total knee arthroplasty, while minimally impacting pain scores.
Deadliest catch: neutrophil extracellular traps in autoimmunity
Authors: Goel Rishi R. , Kaplan Mariana J.
Published: October 2019

Purpose of review

To summarize recent evidence on the pathogenic effects of neutrophils and neutrophil extracellular traps (NETs) in autoimmune diseases, including systemic lupus erythematosus and rheumatoid arthritis.

Recent findings

NETs can orchestrate innate and adaptive immune dysregulation through diverse mechanisms. NETs induce potent inflammatory responses and represent sources of many autoantigens, creating a feed-forward loop that may perpetuate disease and lead to organ damage. NETs are also increasingly relevant in atherosclerosis and could contribute to the increased risk of premature cardiovascular disease in patients with autoimmunity.

NET formation is increased in a variety of autoimmune and autoinflammatory diseases and can have remarkable effects on cell and tissue-specific damage. Novel therapeutics that target NET formation or clearance is a promising strategy for clinical management of autoimmune diseases and may prevent chronic complications associated with these conditions.
A Novel Traction Frame for Femur Fracture Management in Developing Countries: Technique and Outcomes
Authors: Levy David M. , Meadows Molly C. , Gates Dennis J.
Published: October 2019

Fractures of the femur have long been a major cause of morbidity and mortality in developing countries and are most frequently caused by road traffic accidents. Intramedullary nail fixation has become the gold standard of care for diaphyseal fractures of the femur. However, modern techniques require proper implants, access to imaging, and accessible operating room facilities, all of which have limited availability in the developing world. We describe a new technique for assembly of a polyvinyl chloride traction frame for treatment of femur fractures in resource-poor settings. Our report includes a retrospective review of patients treated with polyvinyl chloride traction frames in the Dominican Republic and Haiti.
Clinical Outcome of Magnetically Controlled Growing Rod in Early-onset Scoliosis
Authors: Guan Dawei , Zhang Yuan , Xu Junfang
Published: October 2019

Study Design:

This was a systematic literature review.

Objective:

To evaluate the efficacy and safety of magnetically controlled growing rod (MCGR) in treating early-onset scoliosis.

Summary of Background Data:

Preliminary studies reported the promising potential of MCGR in deformity correction and spine growth preservation with noninvasive distraction. This study was conducted on the basis of data from published literatures.

Materials and Methods:

A systematic search from multimedical database was conducted for studies of MCGR. Involved studies should provide at least one of the followings: deformity correction, spine growth, and complication. During treatment period, improvement or progression of scoliosis/kyphosis, annual T1–S1/T1–T12 extension, incidence of complication, and unplanned surgery were summarized and the correlations with term of follow-up were investigated.

Results:

In total, 13 studies (n=249) were involved, with an average of 22.2-month follow-up. Scoliosis correction was well maintained, improving from 36.4 degrees at postinitial to 37.1 degrees at last follow-up (P=0.794). Kyphosis progressed from 28.8 degrees at postinitial to 34.4 degrees at last follow-up (P=0.024). Annual T1–S1 and T1–T12 longitudinal extensions were 8.7 and 4.7 mm/year, respectively. As follow-up went on, no significant decline was observed in annual extension of T1–S1 (P=0.4680) or T1–T12 (P=0.8053). The incidences of alignment-related, implant-related, and wound-related complication were 3.5%, 30.1%, and 6.9%, respectively. No significant correlation was observed between occurrence of complication and term of follow-up. The rate of receiving unplanned surgery was 24.3%.

Conclusions:

MCGR is efficient in the maintenance of coronal correction and preservation of spine growth, with loss of sagittal correction and a 24.3% unplanned revision rate.
High cortical delta power correlates with aggravated allodynia by activating anterior cingulate cortex GABAergic neurons in neuropathic pain mice
Authors: Li Ya-Dong , Ge Jing , Luo Yan-Jia , Xu Wei , Wang Juan , Lazarus Michael , Hong Zong-Yuan , Qu Wei-Min , Huang Zhi-Li
Published: October 2019

Patients with chronic pain often report being sensitive to pain at night before falling asleep, a time when the synchronization of cortical activity is initiated. However, how cortical activity relates to pain sensitivity is still unclear. Because sleep is characterized by enhanced cortical delta power, we hypothesized that enhanced cortical delta power may be an indicator of intensified pain. To test this hypothesis, we used pain thresholds tests, EEG/electromyogram recordings, c-Fos staining, and chemogenetic and pharmacological techniques in mice. We found that sleep deprivation or pharmacologic enhancement of EEG delta power by reserpine and scopolamine dramatically decreased mechanical pain thresholds, but not thermal withdrawal latency, in a partial sciatic nerve ligation model of neuropathic pain mice. On the contrary, suppression of EEG delta power using a wake-promoting agent modafinil significantly attenuated mechanical allodynia. Moreover, when EEG delta power was enhanced, c-Fos expression decreased in most regions of the cortex, except the anterior cingulate cortex (ACC), where c-Fos was increased in the somatostatin- and parvalbumin-positive GABAergic neurons. Chemogenetic activation of GABAergic neurons in ACC enhanced EEG delta power and lowered mechanical pain thresholds simultaneously in naive mice. However, chemogenetic inhibition of ACC GABAergic neurons could not block mechanical allodynia. These results provided compelling evidence that elevated EEG delta power is accompanied with aggravated neuropathic pain, whereas decreased delta power attenuated it, suggesting that enhanced delta power can be a specific marker of rising chronic neuropathic pain and that wake-promoting compounds could be used as analgesics in the clinic.
“Shooting pain” in lumbar radiculopathy and trigeminal neuralgia, and ideas concerning its neural substrates
Authors: Defrin Ruth , Brill Silviu , Goor-Arieh Itay , Wood Irene , Devor Marshall
Published: October 2019

Patients with radicular low back pain (radicular LBP, sciatica) frequently describe their pain as “shooting” or “radiating.” The dictionary meaning of these words implies rapid movement, and indeed, many sufferers report feeling pain moving rapidly from the lower back or buttock into the leg. But, others do not. Moreover, the sensation of movement is paradoxical; it is neither predicted nor accounted for by current ideas about the pathophysiology of radicular LBP. We have used a structured questionnaire to evaluate the sensory qualities associated with “shooting” and “radiating” in 155 patients, 98 with radicular LBP and 57 with trigeminal neuralgia, a second chronic pain condition in which shooting/radiating are experienced. Results indicated a spectrum of different sensations in different people. Although many sciatica patients reported rapid downward movement of their pain, even more reported downward expansion of the area of pain, some reported upward movement, and for some, there was no spatial dynamic at all. The velocity of movement or expansion was also variable. By cross-referencing sensations experienced in the sciatica and trigeminal neuralgia cohorts with known signal processing modes in the somatosensory system, we propose testable hypotheses concerning the pathophysiology of the various vectorial sensations reported, their direction and velocity, and the structures in which they are generated. Systematic evaluation of qualitative features of “shooting” and “radiating” pain at the time of diagnosis can shed light on the pain mechanism in the individual patient and perhaps contribute to a better therapeutic outcomes.
Child's food consumption and physical exercise: Results from a Portuguese descriptive study
Authors: Marques Goreti , Festas Constança , Fernandes Carla Sílvia , Simões Daniela , Ferreira Fátima , Pinto Sara , Jorge Áurea , Ferreira Gustavo
Published: October 2019

Aims:

To describe food consumption in Portuguese primary school children, to analyze the influence of food consumption on the body mass index (BMI), and to analyze the relationship between physical exercise and the child's food consumption.

Method:

A quantitative, descriptive, exploratory, and cross-sectional study was conducted in 2 primary schools of the north of Portugal (n = 109 child). The use of a food register for 5 consecutive days and anthropometric evaluation of the children were used.

Results:

The vast majority of children had a normal weight (65.10%). However, 34.90% of the children presented significant changes in their BMI (14.70% with low weight, 11.90% overweight, and 8.30% with obesity). Children who engage in physical activity drink more water and consume less sugary products. However, they also consume less meat, fish, and eggs than those who do not perform regular physical activity.

Conclusions:

The study highlights the emergence of new problems, such as the increasing prevalence of underweight children. The prevention of these problems, overweight, or underweight children, should be addressed among healthcare providers, local authorities, families, and teachers.
Pharmaceutical Care in NICUs in Australia and Poland
Authors: Krzyżaniak Natalia , Pawłowska Iga , Bajorek Beata
Published: October 2019

A multidisciplinary and collaborative team network is essential in ensuring positive health outcomes for critically ill neonatal patients. The objective of this study was to investigate the perceptions of neonatal intensive care unit (NICU) doctors and nurses in Australia and Poland toward pharmaceutical care services in the NICU. A cross-sectional, anonymous, electronic-based survey was distributed between January and April 2017 among a sample of NICU doctors, nurses, and midwives. A total of 77 participants from Australia and 93 from Poland completed the survey. Overall, from the perspectives of medical and nursing staff, it is apparent that clinical pharmacy practice on the NICU is more established in Australia than in Poland. Only 8.6% of Polish participants reported that a pharmacist worked directly on the NICU in comparison with 87% of Australian participants (P < .001). The main roles performed by pharmacists in Polish NICUs related to the provision of medicines, whereas Australian pharmacists were highly involved in all aspects of pharmacotherapy, particularly in the clinical and education domains. Future efforts should focus on how practice is structured in each country and what support can be implemented from educational, cultural, and legislative levels to enable better pharmacist integration into the NICU therapeutic team.
Multi-frequency Electrocochleography Measurements can be Used to Monitor and Optimize Electrode Placement During Cochlear Implant Surgery
Authors: Saoji Aniket A. , Patel Neil S. , Carlson Matthew L. , Neff Brian A. , Koka Kanthaiah , Tarigoppula Venkata S. Aditya , Driscoll Colin L. W.
Published: October 2019

Objective:

To report the use of multi-frequency intra-cochlear electrocochleography (ECOG) in monitoring and optimizing electrode placement during cochlear implant surgery. An acoustic pure tone complex comprising of 250, 500, 1000, and 2000 Hz was used to elicit ECOG, or more specifically cochlear microphonics (CMs), responses from various locations in the cochlea. The most apical cochlear implant electrode was used as the recording electrode.

Study Design:

Clinical capsule report.

Setting:

Tertiary academic referral center.

Results:

ECOG measurements were performed during cochlear implant surgery in an adult patient with significant residual acoustic hearing. The 500, 1000, and 2000 Hz CM tracings from the most apical electrode showed an amplitude peak at three different instances during the early phase of cochlear implant electrode insertion. These results are consistent with the tonotopic organization of the cochlea. During final electrode placement a slight advancement of the electrode array resulted in a correlated decrease in 250, 500, and/or 1000 Hz CM amplitude. The electrode array was retracted and repositioned which resulted in a recovery of CM amplitude. Intraoperative CM thresholds revealed a correlation of r = 0.87 with preoperative audiometric thresholds.

Conclusion:

We present a report on simultaneous multi-frequency ECOG monitoring during cochlear implant surgery. Multi-frequency ECOG can be used to differentiate between electrode trauma and the advancement of the apical electrode beyond the CM source in the cochlea.
The Role of Body Mass Index on Hearing Outcomes After Stapes Surgery
Authors: Gadkaree Shekhar K. , Weitzman Rachel E. , Yu Phoebe K. , Miller Ashley L. , Ren Yin , Corrales Carleton Eduardo
Published: October 2019

Background:

Increased body mass index (BMI) has been associated with postoperative complications in multiple surgical specialties. In otologic surgery involving the stapes, where appropriate patient positioning and surgical dexterity are necessary for proper prosthesis placement, patients with higher BMI could make surgery more challenging. The purpose of this study is to evaluate the impact of BMI on outcomes after stapes surgery.

Methods:

Medical records were examined from January 2015 to December 2017 in patients undergoing stapedectomy or stapedotomy at two tertiary care facilities. A retrospective cohort analysis comparing hearing outcomes on postoperative audiogram following procedural intervention with BMI was performed. The primary outcome was postoperative air-bone gap (dB) on audiogram.

Results:

Two hundred sixty three stapedotomy and stapedectomy patients were included in the study. Six percent had BMI less than 18.5 (underweight), 30% had BMI between 18.6 and 24.9 (normal weight), 38% had BMI between 25 and 29.9 (overweight), 24% had BMI above 30 (obese). The mean preoperative and postoperative air-bone gap (ABG) was 27.0 dB (standard deviation [SD] 15) and 10.4 dB (SD 10.6), respectively, with a postoperative ABG less than or equal to 20 dB in 87% of cases. There were no significant differences in postoperative ABG results when comparing the BMI categories (p = 0.11).

Conclusions:

Stapedotomy and stapedectomy are effective surgeries that can be performed by experienced surgeons with successful hearing improvement. While high BMI patients may be a challenge to position appropriately for their surgery, this does not translate to altered otologic outcomes for these patients.
Precision medicine and treatable traits in chronic airway diseases - where do we stand?
Authors: Ulrik Charlotte Suppli , Vijverberg Susanne , Hanania Nicola A. , Diamant Zuzana
Published: October 2019

Purpose of review

To provide an update on the implementation of precision medicine, based on treatable traits and mechanisms, in the daily clinical management of chronic airways diseases.

Recent findings

Recent insights into the complex and heterogeneous nature of chronic airway diseases including chronic obstructive pulmonary disease (COPD) and asthma identified several clinical and inflammatory phenotypes. This shifted the management focus of these diseases away from the prototypic disease labels and paved the way for developing novel targeted therapies.

The concept of precision medicine aims to link the right patient to the right treatment, while minimizing the risk of adverse effects. Several treatable features (’treatable traits’) have now been identified for these chronic airway diseases, including pulmonary, extra-pulmonary, and psychological/lifestyle/environmental traits. As the next step, innovative detection techniques should clarify underlying mechanisms and molecular pathways of these treatable traits and novel reliable point-of-care (composite) biomarkers to help predict responders to targeted therapies must be developed.

Precision medicine links the right patient to the right treatment. Identification of treatable traits in asthma and COPD will help optimize the treatment approach in these heterogeneous diseases. Furthermore, in-depth identification of underlying molecular pathways and reliable biomarkers in chronic airways diseases to guide targeted treatment in individual patients is in progress.
Association between ADAMTS7 polymorphism and carotid artery plaque vulnerability
Authors: Li Hao-wen , Shen Mi , Gao Pei-yi , Li Zi-rui , Cao Jing-li , Zhang Wen-li , Sui Bin-bin , Wang Yu-xin , Wang Ya-jie
Published: October 2019

Recent genome-wide association studies (GWAS) indicated that polymorphisms in ADAMTS7 were associated with artery disease caused by atherosclerosis. However, the correlation between the ADAMTS7 polymorphism and plaque stability remains unclear. The objective of this study was to evaluate the association between 2 ADAMTS7 variants rs3825807 and rs7173743 and ischemic stroke or atherosclerotic plaque vulnerability.

This research is an observational study. Patients with ischemic stroke and normal control individuals admitted to Beijing Tiantan Hospital from May 2014 to October 2017 were enrolled. High-resolution magnetic resonance imaging was used to distinguish vulnerable and stable carotid plaques. The ADAMTS7 SNPs were genotyped using TaqMan assays on real-time PCR system. The multivariate logistic regression analyses were used to adjust for multiple risk factors between groups.

Three hundred twenty-six patients with ischemic stroke (189 patients with vulnerable plaque and 81 patients with stable plaque) and 432 normal controls were included. ADAMTS7 polymorphisms of both rs7173743 and rs3825807 were associated with carotid plaque vulnerability but not the prevalence of ischemic stroke. The T/T genotype of rs7173743 [odds ratio (OR) = 1.885, 95% confidence interval (CI) = 1.067–3.328, P = .028] and A/A genotype of rs3825807 (OR = 2.146, 95% CI = 1.163–3.961, P = .013) were considered as risk genotypes for vulnerable plaque susceptibility.

In conclusion, ADAMTS7 variants rs3825807 and rs7173743 are associated with the risk for carotid plaque vulnerability.
Assessing the efficacy of mammalian target of rapamycin inhibitors by phosphorylation of p70S6K in CD4-positive cells of liver transplant patients
Authors: Wang Jun-Yu , Fan Hua
Published: October 2019

The activity of p70S6 kinase located downstream of the mammalian target of rapamycin (mTOR) pathway is sensitive to mTOR inhibitors. However, the methods of assessing p70S6 kinase activity are still unclear. This study aimed to investigate p70S6 kinase activity in CD4-positive cells of liver transplant patients.

Liver transplant patients treated with mTOR inhibitors were recruited from Beijing Chaoyang Hospital between October 2014 and October 2016. The influence of mycophenolic acid (MPA) derivatives and prednisone on p70S6 kinase phosphorylation in CD4-positive cells was examined in liver transplant patients and healthy controls (HCs). The phosphorylation of p70S6K in CD4 + CD25hi regulatory T cells (Treg cells) and CD4 + CD25- T effector cells was analyzed by phospho-flow cytometry.

The phospho-flow technique detected a significant loss of p70S6 kinase phosphorylation in CD4-positive cells of patients treated with mTOR inhibitors compared with HCs. MPA derivatives and prednisone did not affect p70S6 kinase phosphorylation significantly. No significant difference in p70S6 kinase phosphorylation was observed when the whole blood was stored within 3 hours at room temperature. The phosphorylation of p70S6K was significantly lower in CD4 + CD25hi Treg cells than in CD4 + CD25-T effector cells in HCs. After liver transplant patients were treated with mTOR inhibitors, p70S6K phosphorylation was more reduced in CD4 + CD25-T effector cells than in CD4 + CD25hi Treg cells.

The presence of phosphorylation of p70S6 kinase in CD4-positive cells was reduced in liver transplant patients who were treated by mTOR inhibitors.
Expression of estrogen receptor beta and overall survival in non-small cell lung cancer patients
Authors: Chen Haisheng , Yan Mi , Shi Wenna , Shi Jing , Duan Cunxian , Fan Qing , Wang Yanhong , Li Hui
Published: October 2019

Background:

Lung cancer is the leading cause of cancer-related deaths among males and the second leading cause among females worldwide. Numerous studies have linked estrogen status to lung cancer outcome. However, there are studies with conflicting results about the effect of ERβ on survival of lung cancer. The aim of this meta-analysis is to evaluate the prognostic impact of estrogen receptor beta expression on survival among NSCLC patients.

Methods:

We will search 15 electronic databases, including PubMed, Web of Science, EMBASE, Cochrane Library, and CNKI from inception to June 1, 2019. We will include all cohort studies comparing overall survival of NSCLC patients with high or low estrogen receptor beta expression. The database searches will be supplemented by searching through citations and references. Two reviewers will independently screen search results to identify eligible articles, complete data collection, and conduct quality assessment. All disagreements will be resolved by an independent third reviewer. Methodological quality of the included studies will be assessed using the Newcastle- Ottawa scale. Discrepancies will be resolved by consensus or by consulting a third author. Meta-analyses will be performed, and findings will be reported according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) and the meta-analysis of observational studies in epidemiology (MOOSE) guidelines.

Results:

The results will be submitted to a peer-reviewed journal for publication.

Conclusion:

This review will provide a comprehensive evaluation of the evidence on the prognostic impact of ERβ expression among NSCLC patients and will help clinicians find potential treatments based on estrogen signaling.
A new method of intermittent lower dose of tolvaptan combined with fluid restriction to treat the syndrome of inappropriate antidiuresis
Authors: Yuan Xianxian , Pan Hui , Zhu Huijuan , Li Jiapei , Miao Hui , Ke Xiaoan , Chen Shi
Published: October 2019

Rationale:

Tolvaptan, an oral vasopressin V2 receptor antagonist, is a new approach for the treatment of adult patients with the syndrome of inappropriate antidiuresis (SIADH). However, dose-dependent side effect including rapid increase in serum sodium levels and liver injury, and the expensive price limit the long-term use of tolvaptan. We report a case of SIADH patient treated with intermittent lower dose of tolvaptan combined with fluid restriction.

Patient concerns:

A 60-year-old woman presented of nausea and vomiting, dizzy and amaurosis, and transient disturbance, after a week of persistent diarrhea.

Diagnosis:

Diagnosis of SIADH was based on severe persistent hyponatremia, decreased plasma osmolality, raised urinary sodium excretion, and the absence of other causes.

Interventions:

She was given the treatment of tolvaptan 15 mg once daily, and experienced tolvaptan-related side effects including thirst and dry mouth, polyuria, and dizziness. Then, single dose of tolvaptan was reduced from 15 to 7.5 mg, and the interval between medication was gradually prolonged from 24 to 72 hours. Meanwhile, serum sodium was negatively correlated with the amount of daily water intake in interval days, so daily water intake of the patient was restricted to 1500 mL in interval days.

Outcomes:

Serum sodium was maintained within the normal range, 137 to 141 mmol/L without liver damage.

Lessons:

For patients with chronic SIADH, the tolvaptan dose should be individualized, and the regimen of intermittent lower dose of tolvaptan combined with fluid restriction maybe an effective choice.
PD-1/PD-L1 pathway activation restores the imbalance of Th1/Th2 and treg/Th17 cells subtypes in immune thrombocytopenic purpura patients
Authors: Wu Die , Liu Ying , Pang Nannan , Sun Mingling , Wang Xiujuan , Haridia Yasen , Zhao Fang , Qin Yuting , Fan Wenxia , Guo Xinhong , Ding Jianbing
Published: October 2019

This study aims to investigate the changes of cytokines and the effect of programmed death ligand 1 (PD-L1) signaling pathway on T cell function in patients with immune thrombocytopenic purpura (ITP).

Totally, 40 untreated ITP patients were recruited and 30 healthy people were recruited as the healthy control. Then whole blood of ITP patients and healthy control was collected, respectively. The sPD-L1/anti-PD-1 was used to activate or block the programmed death (PD-1)/PD-L1 signaling pathway. The expression of PD-1 and PD-L1 on peripheral blood mononuclear cells (PBMCs) were detected by flow cytometry. PBMCs were treated with cluster of differentiation (CD3), cluster of differentiation 28 (CD28), and phytohaemagglutinin (PHA) for 48 hours. Serum levels of sPD-1, sPD-L1, and cytokines were measured by enzyme-linked immunosorbent assay (ELISA).

Compared with the healthy control group, the percentages of PD-1+CD3+CD4+ T cells and PD-L1+HLA-DR+CD11c+ DC cells were increased in ITP patients. The levels of interferon-gamma (IFN-γ), interleukin-17 (IL-17), and sPD-1 in the serum of ITP patients were increased, while IL-4 and transforming growth factor-β (TGF-β) were decreased. Additionally, the level of sPD-1 was negatively correlated with the platelet count. Consistently, after treatment with CD3, CD28, and PHA, IFN-γ and IL-17 levels in culture supernatant of PBMCs from ITP patients were significantly higher than those from healthy controls whereas IL-4 and TGF-β levels were significantly lower. Furthermore, IFN-γ and IL-17 levels secreted by PBMCs from ITP patients decreased after sPD-L1 administration, however, IL-4 and TGF-β levels were increased. The level of IFN-γ in ITP group remained higher after anti-PD-1 blockage, but the levels of IL-4, TGF-β, and IL-17 were not significantly influenced.

sPD-1 may cause the dysfunction of PD-1/PD-L1 signaling pathway, and its level is related to the severity of ITP patients. Activation of PD-1/PD-L1 with sPD-L1 may restore the imbalance of Th1/Th2 and Treg/Th17 cell subtypes in ITP patients but anti-PD-1 may exacerbate disease by enhancing IFN-γ production.
Bacillus cereus isolated from a positive bone tissue culture in a patient with osteolysis and high-titer anti-interferon-γ autoantibodies
Authors: Qiu Ye , Zhang Jianquan , Li Bixun , Shu Hong
Published: October 2019

Rationale:

Bacillus cereus (B cereus) is an aerobic or facultative anaerobic gram-positive, spore-forming bacterium. It can cause fatal disease and generally manifests as 3 distinct syndromes: food intoxication, localized infection, and systemic infection. It is a rare infection that can occur in immunocompetent persons with osteolytic and high-titer anti-IFN-γ autoantibodies.

Patient concerns:

We reported a case of an HIV-negative 24-year old man with an interrupted fever and a 20-day history of progressive ache in the right thigh and high-titer anti-IFN-γ autoantibodies. Magnetic resonance imaging, X-radiography, high-resolution computed tomography, and 3-dimensional reconstruction of the bone showed multiple lucent defects with moth-eaten destruction of the bone and cortical substance of bone in the right femur. Emission CT showed significantly increased uptake in the femur.

Diagnosis and Interventions:

The patient was originally misdiagnosed with osteosarcoma; acute osteomyelitis was also considered. He received intravenous piperacillin, sulbactam, and levofloxacin during hospitalization; however, he did not respond to the 3-week antibiotic course and his condition worsened. After cultures from incisional biopsy specimens were obtained from the femoral cavity, B cereus-induced osteomyelitis was diagnosed. He received intravenous injections of moxifloxacin 400 mg qd for 4 weeks and oral moxifloxacin 400 mg qd for 8 weeks.

Outcomes:

The patient's symptoms and signs improved. His X-radiography, HRCT, MRI, and 3-dimensional reconstruction of the bone showed absolute absorption in the right femur. However, the anti-IFN-γ autoantibody titer was still high. No recurrence was observed after 24 months of follow-up. He is still undergoing follow-up at this time.

Lessons:

This is the first case involving a patient with B cereus infection showing a high titer of anti-IFN-γ autoantibodies. B cereus infection can involve the bone, leading to osteolysis in HIV-negative individuals. Although this patient was HIV-negative and had no other comorbidities, the presence of high titer anti-IFN-γ autoantibodies may be the primary reason for B cereus infection. Clinicians should pay more attention to the identification of osteolytic destruction caused by tumor and infection.
Simpson−Golabi−Behmel syndrome type 1 with subclinical hypothyroidism
Authors: Zhang Jing , Mu Kai , Xu Haiyan , Guo Yuehua , Liu Zhijie , Wang Liling , Li Jiahui , Zhang Fengjuan , Kou Yan , Yuan Xin
Published: October 2019

Rationale:

Simpson−Golabi−Behmel syndrome type 1 (SGBS1) is caused by mutations in GPC3 or in both GPC3 and GPC4. Physical manifestations of SGBS1 include fetal overgrowth and macrostomia, macroglossia. Subclinical hypothyroidism has never been reported in SGBS1 cases.

Patient concerns:

An 8-days-old boy was referred to our hospital with persistent hypoglycemia and special facies. And the infant showed elevated levels of thyroid-stimulating hormone (TSH). Free T4 and free T3 were normal.

Diagnoses:

Definitive diagnosis of SGBS1 depends on clinical features and genetic testing. A nonsense mutation (c.1515C > A, p. Cys505∗) was tested by whole-exome sequencing.

Interventions:

Normal blood glucose levels were maintained with glucose infusions. Levothyroxine was given to the patient for treating subclinical hypothyroidism.

Outcomes:

The parents decided to abandon the treatment of the patient. We learned that the patient died of a lung infection by a telephone follow-up.

Lessons:

Subclinical hypothyroidism could be added to the known clinical manifestations of SGBS1.
The clinical efficacy and safety of vancomycin loading dose
Authors: Mei Hekun , Wang Jin , Che Haoyue , Wang Rui , Cai Yun
Published: October 2019

Background:

The clinical significance of using vancomycin loading dose remains controversial. A systematic review and meta-analysis were performed to assess the clinical efficacy and safety of vancomycin loading dose in the treatment of infections.

Methods:

The Pubmed, Embase, Web of Science, and Cochrane Library databases were searched from their inception up to 5 May 2019. Randomized controlled trials (RCTs) and other observational studies were included if they provided clinical outcomes or trough concentrations of vancomycin loading dose (20–30 mg/kg) and conventional-dose (10–20 mg/kg) in the treatment of infections. Achievement of therapeutic concentration (serum trough concentrations of vancomycin reached 15–20 mg/L before the second dose), clinical response (clinical improvement or culture-negative), nephrotoxicity (serum creatinine increase ≥0.5 mg/dL or ≥50% increasing from the baseline), other adverse events (including pruritus, flushing, rash, and/or red man syndrome), and mortality were analyzed. Heterogeneity was identified using the Cochrane I

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statistic, and P-value <.10 or I

2
-values >50% indicated significant heterogeneity. Pooled estimates of the intervention effects were determined by the odds ratios (ORs) and 95% confidence intervals (CIs) in Review Manager program, version 5.3.5.

Results:

Two RCTs and 7 cohort studies including 2816 infected patients were selected for the analysis, in which serum trough concentrations of vancomycin following the use of vancomycin loading dose or other outcomes were available. Loading dose group had a significantly higher compliance rate of serum trough concentration of 15 to 20 mg/L (OR = 3.06; 95% CI = 1.15–8.15; P = .03) and significantly lower incidence of nephrotoxicity (OR = 0.59, 95% CI = 0.40–0.87; P = .008; I

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 = 29%) compared with control group. No significant difference was noted between loading dose group and control group in terms of other adverse events and clinical response (OR = 1.98, 95% CI = 0.80–4.93; P = .14; I

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 = 0%). The use of vancomycin loading doses in patients can indeed increase the achievement of therapeutic concentration.

Conclusion:

Vancomycin loading dose increases the achievement of therapeutic concentration without bringing extra risk of nephrotoxicity. However, well-designed large-scale RCTs remain needed to validate the clinical efficacy of vancomycin loading dose and to further evaluate other adverse reactions and mortality.

PROSPERO registration number CRD42018093927
Public needs for information disclosure on healthcare performance
Authors: Sasaki Noriko , Groenewoud Stef , Kunisawa Susumu , Westert Gert , Imanaka Yuichi
Published: October 2019

The accumulated healthcare performance data related to unwarranted practice variations are not necessarily disseminated to patients and citizens. To clarify the needs for public disclosure, we explored Japanese and Dutch citizens’ preferences and values towards information disclosure and healthcare disparity.

Online opt-in survey was conducted and we asked citizens their preference to know about the healthcare performance indicators of regions and hospitals, and their attitudes towards healthcare equity. After a descriptive statistical analysis, Chi-squared automatic interaction detection tree analysis was performed to explore the socio-demographic determinants which were associated with positive value for information disclosure and healthcare equity. Then, we compared the combination of attributes of the highest and the lowest subgroups of each country and compared within and between countries. Last, logistic regression analysis was performed to further evaluate the impact of each determinant.

Significant differences were observed between the 2 countries (Japan [JPN] 1038; Netherlands [NL] 1040). The crucial attributes identified were age, sex, educational background, and living area (JPN), along with age and sex (NL). Japanese comprised multiple subgroups with heterogeneous values, showed relatively low interest in knowing the information, and seemed to accept healthcare inequality, especially among urban males aged 20 to 59 years. Contrarily, Dutch people mostly showed high interest in both items. Female and older respondents valued information disclosure highly across countries.

To share healthcare performance knowledge and empowering the public, historical, cultural, and socio-demographic context including health literacy of citizens’ subgroups should be considered in making comprehensive public reports.