bluuebunny/crossref_metadata_2025 huggingface dataset:
Lacrimal Gland Intravascular Micrometastasis From a Human Papillomavirus-Driven Anorectal Squamous Cell Carcinoma With a Review of Metastatic Disease to the Lacrimal Gland
Authors: Neerukonda Vamsee K. , Jakobiec Frederick A. , Freitag Suzanne K. , Stagner Anna M. , Wolkow Natalie
Published: December 2020

Purpose:

To document a unique case of anorectal squamous cell carcinoma that was metastatic to the microvasculature of the lacrimal gland in a patient with human immunodeficiency virus and to review previously reported cases of metastases to the lacrimal gland.

Methods:

Both a retrospective chart review and comprehensive literature review were performed. The unusual histopathologic pattern of the current case was illustrated with immunohistochemical studies (CD31, D2-40, pancytokeratin, p16, and p63) and in situ hybridization studies for high-risk human papillomavirus types 16 and 18.

Results:

The authors describe the first case of metastatic anorectal squamous cell carcinoma to the lacrimal gland. Only 24 cases of metastatic disease to the lacrimal gland have been reported, the majority from breast carcinomas. The metastasis did not form a macroscopic lesions, instead was composed of microscopic intravascular and intraparenchymal tumor deposits, a subtle phenomena. Immunohistochemistry confirmed the presence of the intravascular neoplastic cells. p16 served as a surrogate marker for human papillomavirus-associated squamous cell carcinoma and was confirmed with in situ hybridization for human papillomavirus 16 and 18. This testing, combined with the clinical history, defined the diagnosis and confirmed human papillomavirus as the tumor driver.

Conclusions:

Metastases to the lacrimal gland remain rare, but clinicians and pathologists alike must be attuned to the possibility of subtle microscopic foci of tumor as a pattern of metastasis in scenarios without a discrete mass-forming lesion, as this may portend a poor prognosis.
Ultrasonographic Visualization of Bilaterally Fused Eyelids in a Premature Neonate
Authors: Ruff Adam , Kassotis Alexis S. , Silverman Ronald H. , Dagi Glass Lora R.
Published: December 2020

In cases of significant prematurity, neonates born with eyelid fusion can undergo spontaneous eyelid disjunction. Here, the authors present such a case, along with ultrasound findings shortly before eyelid separation. All protected patient information extracted for this report was done so in accordance with the Health Insurance Portability and Accountability Act. This report was prepared in accordance with the tenants of the Declaration of Helsinki.
Nonosseous Periocular Manifestations of Langerhans Cell Histiocytosis: A Case Report and Systematic Review
Authors: Plemel David J.A. , Benson Matthew D. , Tong C. Maya , Mahmood Muhammad N. , Pollock Travis J.
Published: December 2020

Purpose:

Langerhans cell histiocytosis (LCH) is a disorder of dendritic cell proliferation that typically involves bone. It can be diagnostically challenging when LCH presents without bony involvement, leading to delays in diagnosis and treatment. In this study, the periocular manifestations of LCH in cases where the underlying orbital bones are not involved are described through a systematic review.

Methods:

A systematic review of the literature was performed to capture all cases of LCH that involved the periocular region but not the underlying orbital bones. These included LCH cases that involved the periocular skin, the ocular surface, and the orbital tissue. The authors also highlight an additional case where LCH presented with periocular edema and multifocal, nodular conjunctival lesions.

Result:

This review illustrates that LCH rarely presents with periocular infiltration without orbital bone involvement. In these atypical cases, LCH can present as an eyelid mass, a chalazion-like lesion, generalized periocular swelling, ocular surface lesions, or infiltration of any orbital structure. Ocular surface LCH has a higher rate of recurrence than other periocular LCH. Orbital LCH can involve any tissue including extraocular muscles, the lacrimal gland, or indistinct areas within the orbit.

Conclusions:

LCH is a clinicopathologic diagnosis. Although most cases involve the bone, any soft tissue can be involved. Biopsy is required to confirm the diagnosis of this heterogeneous disease.
Pupillary and Anterior Chamber Changes Following Upper Eyelid Blepharoplasty
Authors: Koçer Ali Mert , Sen Emine Malkoc
Published: December 2020

Purpose:

This study investigated the preoperative and postoperative pupillary and anterior chamber (AC) characteristics of patients undergoing upper eyelid blepharoplasty.

Methods:

This prospective, cross-sectional study examined 32 eyes from 20 dermatochalasis patients. Following a detailed ophthalmological examination, quantitative pupillometry and Scheimpflug corneal topography were used to evaluate the pupil and AC characteristics of eyes on the day of operation and postoperative days 1 and 7. Static and dynamic pupillometry characteristics, including scotopic, mesopic, low photopic, and high photopic pupil diameter (PD), resting diameter, amplitude, latency, duration, and velocity of pupil contraction, and latency, duration, and velocity of pupil dilation, were measured. Additionally, AC volume, depth, and angle parameters were analyzed.

Results:

There were significant differences between scotopic, mesopic, and resting PD and the amplitude of pupil contraction. Pairwise comparisons showed that postoperative day 1 scotopic, mesopic, and resting PD and amplitude of pupil contraction measurements were significantly higher than preoperative measurements (p = 0.008, p < 0.001, p = 0.006, and p = 0.033, respectively). Additionally, scotopic and resting PD were significantly lower on postoperative day 7 compared with postoperative day 1 (p = 0.001 and p = 0.041, respectively). However, there were no significant differences in AC parameters.

Conclusions:

This study revealed that static and dynamic pupil measurements changed following blepharoplasty, with postoperative increased PD occurring particularly under low-light conditions. Therefore, low-light environments should be avoided following blepharoplasty, and patients with angle-closure risk factors should be closely monitored in the early postoperative period.
Web-Based Versus Non-Web–Based Patient Referral Patterns and Factors Affecting Them
Authors: Abdolalizadeh Parya , Kashkouli Mohsen Bahmani , Gandomi-Mohammadabadi Alireza , Karimi Nasser , Chaibakhsh Samira , Jafarpour Soheila
Published: December 2020

Purpose:

To analyze the 8-year (2012–2019) change in the patient referral source trends to a plastic surgery practice and the factors affecting them.

Methods:

Data on demographics, referral source, and patient’s concern were recorded. The web-based referral sources were website and Instagram and non-web–based included other patients (word-of-mouth), medical professionals (physician, nurse, and optometrist), and others (printed media, TV, and radio). Patients’ concerns were divided into cosmetic and noncosmetic. The first (2012–2015) and second (2016–2019) half of the study period were also compared.

Results:

Included patients were 19,965. The 8-year referral sources, in order of frequency, were medical professionals (34%), other patients (32.7%), web-based sources (32.5%), and the others (0.7%). The web-based sources significantly increased by 2.4 times in the second half. While they had a third rank after the medical professionals and other patients in the first half of the study period, they became the first in the second half. The non-web–based source showed a decline during the study period. Type of referral sources was not significantly different between the 2 genders. A significantly higher percentage of the patients between 21 and 50 years of age were referred through web-based sources than the other age groups. Patients with cosmetic concerns were 2 times more likely to be referred through web-based sources.

Conclusion:

The web-based referral sources have significantly grown from the third rank in the beginning to the first one from 2015 till the end of study.
Accuracy of intraocular lens calculation formulas for flanged intrascleral intraocular lens fixation with double-needle technique
Authors: McMillin Jake , Wang Li , Wang Margaret Y. , Al-Mohtaseb Zaina , Khandelwal Sumitra , Weikert Mitchell , Hamill M. Bowes
Published: December 2020

Purpose:

To evaluate the refractive prediction error (RPE) of intraocular lens (IOL) calculation formulas in eyes that have undergone the Yamane technique for scleral fixation of IOLs.

Setting:

Alkek Eye Center, Cullen Eye Institute, Baylor College of Medicine, Houston, Texas.

Design:

Retrospective case series from electronic chart review.

Methods:

Patients who had undergone scleral fixation of secondary IOLs were selected. The IOL RPEs for 4 IOL prediction formulas—Barrett Universal II, Holladay 1, Hoffer Q, and SRK/T formulas—were obtained by subtracting the predicted spherical equivalent from the postoperative spherical equivalent. The arithmetic mean RPE, mean absolute error (MAE), and percentages of eyes with prediction error of 0.50 diopter (D) or lesser and 1.00 D or lesser were calculated and compared.

Results:

Forty eyes of 40 patients met inclusion criteria. All formulas produced hyperopic mean arithmetic RPE. MAE values were 0.73 D for Holladay 1, 0.76 D for Barrett Universal II, 0.80 D for SRK/T, and 0.86 D for Hoffer Q formulas. The percentage of eyes with prediction error of 0.50 D or lesser and 1.00 D or lesser with these formulas were 45% (18 eyes) and 75% (30 eyes) for Holladay 1, 38.5% (15 eyes) and 77% (30 eyes) for Barrett Universal II, 32.5% (13 eyes) and 67.5% (27 eyes) for SRK/T, and 27.5% (11 eyes) and 62.5% (25 eyes) for Hoffer Q formulas. There were no statistically significant differences in prediction errors between the 4 formulas.

Conclusions:

Refractive outcomes of the Yamane technique were less predictable than those of standard cataract surgery. Arithmetic RPE ranged from hyperopic to predicted values for all formulas tested.
Options and results in managing suction loss during small-incision lenticule extraction
Authors: Wan Kelvin H. , Lin Timothy P.H. , Lai Kenny H.W. , Liu Shu , Lam Dennis S.C.
Published: December 2020

Suction loss is an intraoperative complication in small-incision lenticule extraction (SMILE) that presents a management challenge for the refractive surgeon. The purpose of this review is to evaluate the visual, refractive, and wavefront outcomes after suction loss across the different stages of SMILE with various respective surgical treatments. Surgical management options include immediate re-SMILE by redocking or delayed re-SMILE, with or without adjustment of the laser parameters, conversion to femtosecond laser in situ keratomileusis, transepithelial photorefractive keratectomy, refractive lenticule extraction, or pseudo-SMILE. The restart treatment module on VisuMax provides appropriate retreatment recommendation. Most retreatment options for suction loss, immediate or delayed, resulted in effective, safe, and predictable outcomes, and patients were satisfied with their outcomes. Based on available level II evidence, immediate re-SMILE with or without adjustment to the laser settings achieve favorable visual and refractive outcomes in handling this intraoperative complication across all stages of SMILE.
Design and Computational Evaluation of a Pediatric MagLev Rotary Blood Pump
Authors: Tompkins Landon H. , Gellman Barry N. , Morello Gino F. , Prina Steven R. , Roussel Thomas J. , Kopechek Jonathan A. , Petit Priscilla C. , Slaughter Mark S. , Koenig Steven C. , Dasse Kurt A.
Published: December 2020

Pediatric heart failure (HF) patients have been a historically underserved population for mechanical circulatory support (MCS) therapy. To address this clinical need, we are developing a low cost, universal magnetically levitated extracorporeal system with interchangeable pump heads for pediatric support. Two impeller and pump designs (pump V1 and V2) for the pediatric pump were developed using dimensional analysis techniques and classic pump theory based on defined performance criteria (generated flow, pressure, and impeller diameter). The designs were virtually constructed using computer-aided design (CAD) software and 3D flow and pressure features were analyzed using computational fluid dynamics (CFD) analysis. Simulated pump designs (V1, V2) were operated at higher rotational speeds (~5,000 revolutions per minute [RPM]) than initially estimated (4,255 RPM) to achieve the desired operational point (3.5 L/min flow at 150 mm Hg). Pump V2 outperformed V1 by generating approximately 30% higher pressures at all simulated rotational speeds and at 5% lower priming volume. Simulated hydrodynamic performance (achieved flow and pressure, hydraulic efficiency) of our pediatric pump design, featuring reduced impeller size and priming volume, compares favorably to current commercially available MCS devices.
Successful Lung Transplantation After 213 Days of Extracorporeal Life Support: Role of Oxygenator-Right Ventricular Assist Device
Authors: Sim Jae Kyeom , Jeon Kyeongman , Suh Gee Young , Chung Suryeun , Cho Yang Hyun
Published: December 2020

Venovenous extracorporeal membrane oxygenation (VV ECMO) can successfully support patients with refractory respiratory failure and is widely accepted as a bridge to recovery or bridge to transplantation. However, some problems hinder success. Recirculation, an innate complication of VV ECMO, hamper efficient oxygenation. Right ventricular (RV) failure secondary to respiratory failure is not uncommon and can be reversed by VV ECMO. But there are often times when RV failure gets worse, and since VV ECMO is no longer effective, additional measures are needed. Moreover, peripheral cannulation restricts active rehabilitation leading to weakness and weaning failure. Oxygenator-right ventricular assist device (OxyRVAD) refers any configuration that combines oxygenator and centrifugal pump. Compared to VV ECMO, it has advantages of hemodynamic support, elimination of recirculation, and facilitation of rehabilitation. In the present case, we overcame recirculation and impending RV failure by applying OxyRVAD to patient who was initially managed with VV ECMO. He underwent lung transplantation after about 6 months of OxyRVAD support with active rehabilitation, the longest maintenance period ever known.
Culture-negative sepsis
Authors: Thorndike Jonathan , Kollef Marin H.
Published: December 2020

Purpose of review

The traditional approach to sepsis treatment utilizes broad-spectrum antibiotics. Unfortunately, a significant proportion of infected patients have ‘culture-negative’ sepsis despite appropriate microbiologic assessment.

Recent findings

There has been increased interest in the past decade on the treatment of culture-negative sepsis. Outcome data comparing culture-negative sepsis with culture-positive sepsis are mixed and it is unclear if culture-negative sepsis is a distinct entity. Recent recommendations promoting antibiotic de-escalation in culture-negative sepsis can be difficult to implement. A variety of strategies have been suggested for limiting antibiotic courses among patients with negative cultures, including limiting antibiotic durations, use of antibiotic stewardship programs, early consideration of narrow antibiotics, rapid diagnostic technology, and eliminating anti-MRSA therapy based on surveillance swabs.

Owing to the difficulty inherent in studying the lack of positive data, and to the uncertainty surrounding diagnosis in patients with culture-negative sepsis, prospective data to guide antibiotic choices are lacking. However, antibiotic de-escalation in culture-negative sepsis is both recommended and feasible in patients showing clinical signs of improvement. Increased use of rapid diagnostics, careful consideration of antibiotic necessity, and antibiotic stewardship programs may result in less antibiotic days and better outcomes.
Best practice: antibiotic decision-making in ICUs
Authors: Brink Adrian John , Richards Guy
Published: December 2020

Purpose of review

A major challenge in the ICU is optimization of antibiotic use. This review assesses current understanding of core best practices supporting and promoting astute antibiotic decision-making.

Recent findings

Limiting exposure to the shortest effective duration is the cornerstone of antibiotic decision-making. The decision to initiate antibiotics should include assessment of risk for resistance. This requires synthesis of patient-level data and environmental factors to determine whether delayed initiation could be considered in some patients with suspected sepsis until sensitivity data is available. Until improved stratification scores and clinically meaningful cut-off values to identify MDR are available and externally validated, decisions as to which empiric antibiotic is used should rely on syndromic antibiograms and institutional guidance. Optimization of initial and maintenance doses is another enabler of enhanced outcome. Stewardship practices must be streamlined by re-assessment to minimize negative effects, such as a potential increase in duration of therapy and increased risk of collateral damage from exposure to multiple, sequential antibiotics that may ensue from de-escalation.

Multiple challenges and research priorities for antibiotic optimization remain; however, the best stewardship practices should be identified and entrenched in daily practice. Reducing unnecessary exposure remains a vital strategy to limit resistance development.
Diagnostic and therapy of severe Clostridioides difficile infections in the ICU
Authors: Guery Benoit , Barbut Frédéric , Tschudin-Sutter Sarah
Published: December 2020

Purpose of review

The purpose of the review is to provide all the recent data focusing on the diagnostic and treatment of Clostridioides difficile infection in patients admitted in the ICU.

Recent findings

In the ICU, diagnosis remains complicated with a large number of alternative diagnosis. The treatment classically relies on vancomycin but fidaxomicin and fecal microbiota transplantation are now potential solutions in selected indications.

Data on ICU-related CDI remain limited and conflicting. To date, there is no unique and simple way to obtain a diagnosis for CDI, the combination of clinical signs and a two-step testing algorithm remains the recommended gold-standard. Two molecules can be proposed for first line treatment: vancomycin and fidaxomicin. Although metronidazole may still be discussed as a treatment option for mild CDI in low-risk patients, its use for ICU-patients does not seem reasonable. Several reports suggest that fecal microbiota transplantation could be discussed, as it is well tolerated and associated with a high rate of clinical cure. CDI is a dynamic and active area of research with new diagnostic techniques, molecules, and management concepts likely changing our approach to this old disease in the near future.
What is new in catheter use and catheter infection prevention in the ICU
Authors: Buetti Niccolò , Tabah Alexis , Timsit Jean-François , Zingg Walter
Published: December 2020

Purpose of review

Short-term intravascular catheters are instrumental in the care of critically ill patients. Despite their benefits, they also are potential entries for systemic infections. There is a growing body of literature on catheter use and the prevention of intravascular catheter infections in intensive care. This review highlights major recent contributions to the topic and put them into perspective to recommendations on best practice procedures.

Recent findings

Many studies published in the last years have evaluated prevention strategies applying technology and addressing behavior change. Skin disinfection with 2% alcoholic chlorhexidine-gluconate (CHG) and CHG-impregnated dressings are increasingly used in clinical practice. However, the role of universal CHG bathing remains controversial. A number of new and innovative technologies are in development. Recent qualitative research offers new perspectives about behavior change interventions to improve implementation.

Many options for effective intravascular catheter infection prevention are currently available. A number of recent systematic reviews and meta-analyses not only confirmed measures targeting best practice and technology at catheter insertion and catheter care but also challenged interventions, such as CHG bathing. More focus should be put to implementation strategies.
Biomarkers in acute respiratory distress syndrome
Authors: Jabaudon Matthieu , Blondonnet Raiko , Ware Lorraine B.
Published: December 2020

Purpose of review

This article provides an overview of protein biomarkers for acute respiratory distress syndrome (ARDS) and their potential use in future clinical trials.

Recent findings

The protein biomarkers studied as indices of biological processes involved in the pathogenesis of ARDS may have diagnostic and/or prognostic value. Recently, they also proved useful for identifying ARDS phenotypes and assessing heterogeneity of treatment effect in retrospective analyses of completed clinical trials.

This article summarizes the current research on ARDS biomarkers and provides insights into how they should be integrated as prognostic and predictive enrichment tools in future clinical trials.
n – 3 Docosapentaenoic acid: the iceberg n – 3 fatty acid
Authors: Ghasemi Fard Samaneh , Cameron-Smith David , Sinclair Andrew J.
Published: December 2020

Purpose of review

Docosapentaenoic acid (DPA) is a minor omega-3 fatty acid (FA) which has been frequently overlooked in lipid research. This review examines the biochemical and physiological outcomes of human trials which have used pure preparations of DPA (n − 3 DPA) and also recent developments in specialized proresolving lipid mediators (SPMs) derived from n − 3 DPA.

Recent findings

There have been only been two human studies and eleven animal studies with pure n − 3 DPA. The doses of n − 3 DPA used in the human trials have been 1–2 g/day. n − 3 DPA abundance is increased in blood lipid fractions within 3–4 days of supplementation. n − 3 DPA has the potential for unique properties, with a greater similarity in biological functioning with docosahexaenoic acid (DHA), than eicosapentaenoic acid (EPA). Despite the typically low levels of n − 3 DPA in most tissue lipids relative to EPA and DHA, unique SPMs, such as resolvins, maresins and protectins of the n − 3 DPA type, are involved in resolution of inflammation and regulating immune function.

We suggest that measurement of blood levels of n − 3 DPA gives no indication of its broad biological roles, but that the true functionality of this enigmatic n − 3 polyunsaturated fatty acid (PUFA) remains obscure until more is known about the properties of the unique DPA-derived SPMs.
Should evidence generated in well developed countries inform critical care nutrition in all countries?
Authors: Dixit Subhal , Uyar Mehmet , Khatib Khalid , Demirag Kubilay
Published: December 2020

Purpose of review

Critically ill patients who survive the ICU face issues such as reduced quality of life and increased disability and nutritional therapy during ICU stay may be used to reduce these adverse effects. Although evidence and guidelines are available to direct clinical nutrition for ICU patients, critical care practices and settings differ substantially between developed and developing countries.

Recent findings

The implementation of evidence generated in well developed countries regarding critical care nutrition depends heavily on factors such as operation model, the structure of the unit, different care processes, hospital size and country income.

Guidelines and evidence generated by various societies, agencies and trials, which are focused towards developed world may not be fully appropriate and executable in the developing world. Also, the developing world is heterogenous. Hence, ‘one size fits all’ approach may not be appropriate. A holistic approach to guideline and evidence generation and its appropriate utilization in the developing world is binding on caregivers in both the developing and developed world so as to benefit the critically ill patient.
Local and Intra-articular Administration of Nonsteroidal Anti-inflammatory Drugs for Pain Management in Orthopedic Surgery
Authors: Bernthal Nicholas M. , Hart Christopher M. , Sheth Ketan R. , Bergese Sergio D. , Ho Hung S. , Apfel Christian C. , Stoicea Nicoleta , Rojhani Allen , Jahr Jonathan S.
Published: December 2020

Background:

Although growing evidence demonstrates the benefits of locally administered nonsteroidal anti-inflammatory drugs (NSAIDs) for postoperative pain management, there is ongoing debate regarding NSAID use in orthopedic surgery.

Areas of Uncertainty:

Current data largely support a local site of NSAID action and suggest that effective pain control can be achieved with delivery of NSAIDs intra-articularly (IA) and/or locally at the site of injury, where they can block peripheral production of inflammatory mediators and may desensitize nociceptors. Improvements in postoperative pain control with locally administered NSAIDs have been widely reported in the total joint arthroplasty literature and may offer benefits in patient's undergoing arthroscopic procedures and those with osteoarthritis as well. The purpose of this review is to examine the available evidence in the literature regarding the efficacy and safety profile of the use of local and IA NSAIDs in orthopedic surgery.

Data Sources:

Narrative literature review using keywords, expert opinion, either during or from live conference.

Therapeutic Advances:

Local and IA administration of NSAIDs for pain management in orthopedic surgery.

Conclusion:

There is convincing evidence that NSAIDs administered locally in and around the joint reduce postoperative pain scores and opioid consumption in patients undergoing total joint arthroplasty, yet further research is required regarding the risks of potential chondrotoxicity and the inhibition of bone and soft-tissue healing with locally administered NSAIDs.
Impact of ultra-processed food consumption on metabolic health
Authors: Costa de Miranda Renata , Rauber Fernanda , Levy Renata Bertazzi
Published: December 2020

Purpose of review

Ultra-processed foods (UPF) have been associated with poor diet quality and adverse health outcomes. Our aim in this review is to summarize recent research assessing the impact of UPF consumption, classified according to the NOVA system, on outcomes related to metabolic health.

Recent findings

Thirty recent studies with different design, quality and target population have investigated the impact of UPF consumption on parameters related to metabolic health, which were organized into: metabolic syndrome; body weight change and obesity indicators; blood pressure and hypertension; glucose profile, insulin resistance and type 2 diabetes; other metabolic risks and cardiovascular diseases and mortality. Most of the studies demonstrated adverse associations between high UPF consumption and metabolic health, mainly those with robust design and involving adults.

Most of the latest findings have revealed an adverse impact of high UPF consumption on metabolic health, including cardiovascular diseases and mortality. Scientific evidence is accumulating towards the necessity of curbing UPF consumption worldwide at different life stages. Nevertheless, other studies are needed to confirm the causality between UPF consumption and metabolic health in diverse scenarios and to better elucidate all likely mechanisms involved in this relationship.
Rewriting the playbook: infection prevention practices to mitigate nosocomial severe acute respiratory syndrome coronavirus 2 transmission
Authors: Scaggs Huang Felicia , Schaffzin Joshua K.
Published: December 2020

Purpose of review

Given the limited evidence and experience with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), this novel pathogen has challenged the field of infection prevention. Despite uncertainty, infection prevention principles and experience with similar diseases have helped guide how to best protect providers and patients against disease acquisition.

Recent findings

Guidance to date has relied on data from SARS-CoV-1 and MERS-CoV to guide practices on patient isolation and personal protective equipment (PPE) use. Although a face mask and eye protection are likely adequate for most clinical scenarios, published guidelines for PPE can be confusing and conflicting. Consensus for what constitutes a high-risk aerosol-generating procedure (AGP) is lacking, but most agree providers performing procedures such as bronchoscopy, intubation, and cardiopulmonary resuscitation would likely benefit from the use of an N95 respirator and eye protection.

Needed research to elucidate the predominant SARS-CoV-2 mode of transmission is not likely to be completed in the immediate future. Recommendations for PPE to mitigate procedure-associated risk remain controversial. Nonetheless, implementation of existing measures based on basic infection prevention principles is likely to prevent transmission significantly.
Variations in DNA methylation and allograft rejection
Authors: Boer Karin , Hesselink Dennis A. , Baan Carla C.
Published: December 2020

Purpose of review

DNA methylation is involved in gene transcription and as such important for cellular function. Here, the literature on DNA methylation in relation to acute rejection is summarized with a focus on the potential clinical utility of DNA methylation for monitoring transplant rejection.

Recent findings

The tight transcriptional control of DNA methylation in immune cell function, e.g. demethylation in regulatory T-cell-specific genes for stable immunosuppressive capacities, suggests an important role for DNA methylation variations in the antidonor-directed immune response. Until today, differentially methylated DNA in immune cells, however, has not been described at the moment of allograft rejection. The ability to locus-specific modify DNA methylation could facilitate the generation of stable cells for cellular therapy purposes. The unique cell-specific characteristics of DNA methylation provide the opportunity to identify its cellular origin. Examining methylation of cell-free DNA in blood or urine may serve as a ‘liquid biopsy’ enabling minimally invasive detection of allograft rejection.

Actual research publications on DNA methylation in relation to allograft rejection are scarce, which makes it challenging to determine its potential clinical value. Extensive research is needed to investigate the value of DNA methylation in early recognition, diagnosis, and/or successful treatment of allograft rejection.
Psychiatric Medication Changes Associated With Increased Rate of Medical Readmissions in Patients With Serious Mental Illness
Authors: Germack Hayley D. , Weissinger Guy , Bizhanova Zhadyra , Martsolf Grant R.
Published: December 2020

To identify the impact of postdischarge psychiatric medication changes on general medical readmissions among patients with serious mental illness (SMI; bipolar disorder, major depressive disorder, and schizophrenia), claims from a 5% national sample of Medicare fee-for-service (FFS) beneficiaries hospitalized between 2013 and 2016 were studied. A total of 165,490 Medicare FFS beneficiaries with SMI 18 years or older with at least 1 year of continuous Medicare enrollment were identified. Within 30 days of discharge from index admission, 47.4% experienced a psychiatric medication change—including 75,892 beneficiaries experiencing a deletion and 55,713 experiencing an addition. After adjusting for potential confounders, those with a medication change experienced an 10% increase in the odds of 30-day readmission (odds ratio, 1.10; SE, 0.019; p < 0.001). Comorbid drug use disorder was also associated with an increased odds of readmission after controlling for other covariates. These findings suggest important factors that clinicians should be aware of when discharging patients with SMI.
Nurse Educators
Authors: Ruth-Sahd Lisa A. , Grim Rodney
Published: December 2020

Background

Professional quality of life (ProQoL) is the balance between compassion satisfaction (CS) and compassion fatigue (CF). The experience of CF results from secondary traumatic stress stemming from compassionate caregiving and burnout.

Purpose

This study sought to identify the ProQoL of nurse educators and what conditions for work effectiveness affect this ProQoL.

Methods

An email survey link was sent to nurse educators from the northeastern region of the United States asking for participation. This included demographics, the ProQoL Version 5, and the Conditions for Work Effectiveness Questionnaire version II (CWEQ-II).

Results

The 211 nurse educators reported relatively high CS and relatively low burnout and secondary traumatic stress. When the measures of the CWEQ-II increased, so did their CS. In addition, as the measures of the CWEQ-II increased, their secondary traumatic stress and burnout decreased.

Conclusions

Findings suggest that conditions for work effectiveness such as access to opportunity, resources, information, support, and formal and informal power have a relationship to the nurse educator's ProQoL.
Objective Structured Clinical Examinations as a Method of Competency Evaluation in a Primary Care Nurse Practitioner Program
Authors: Hickey Mary T.
Published: December 2020

Background

Objective structured clinical examinations (OSCEs) are an effective method of instruction and evaluation. Their use in nurse practitioner (NP) programs as a means of evaluation warrants further exploration.

Purpose

The purpose of this project was to test the applicability and feasibility of implementation of OSCEs as a means of formative evaluation in a primary care NP program and to determine student feedback about the experience.

Methods

This project evaluated the implementation of an educational intervention using 2 previously developed and tested OSCE scenarios with standardized patients.

Results

Mean scores were computed for the subcategories, as well as for global rating scores on the OSCE. Strong correlations were found across categories within the scenario; no correlations were found between scenarios. Moderate intraclass correlation coefficients were achieved. Student feedback about the experience, including perceived competence and confidence, was overwhelmingly positive.

Conclusions

This project demonstrates success of a pilot OSCE program.
Early Mobilization in a PICU: A Qualitative Sustainability Analysis of PICU Up!*
Authors: Patel Ruchit V. , Redivo Juliana , Nelliot Archana , Eakin Michelle N. , Wieczorek Beth , Quinn Julie , Gurses Ayse P. , Balas Michele C. , Needham Dale M. , Kudchadkar Sapna R.
Published: December 2020

Objectives:

To identify staff-reported factors and perceptions that influenced implementation and sustainability of an early mobilization program (PICU Up!) in the PICU.

Design:

A qualitative study using semistructured phone interviews to characterize interprofessional staff perspectives of the PICU Up! program. Following data saturation, thematic analysis was performed on interview transcripts.

Setting:

Tertiary-care PICU in the Johns Hopkins Hospital, Baltimore, MD.

Subjects:

Interprofessional PICU staff.

Interventions:

None.

Measurements and Main Results:

Fifty-two staff members involved in PICU mobilization across multiple disciplines were interviewed. Three constructs emerged that reflected the different stages of PICU Up! program execution: 1) factors influencing the implementation process, 2) staff perceptions of PICU Up!, and 3) improvements in program integration. Themes were developed within these constructs, addressing facilitators for PICU Up! implementation, cultural changes for unitwide integration, positive impressions toward early mobility, barriers to program sustainability, and refinements for more robust staff and family engagement.

Conclusions:

Three years after implementation, PICU Up! remains well-received by staff, positively influencing role satisfaction and PICU team dynamics. Furthermore, patients and family members are perceived to be enthusiastic about mobility efforts, driving staff support. Through an ongoing focus on stakeholder buy-in, interprofessional engagement, and bundled care to promote mobility, the program has become part of the culture in the Johns Hopkins Hospital PICU. However, several barriers remain that prevent consistent execution of early mobility, including challenges with resource management, sedation decisions, and patient heterogeneity. Characterizing these staff perceptions can facilitate the development of solutions that use institutional strengths to grow and sustain PICU mobility initiatives.
Acute Peripheral and/or Cutaneous Ischemic Syndrome
Authors: Santiago Mittermayer B. , Paz Adriane
Published: December 2020

In daily practice, the frequent appearance of limb and/or skin necrosis, which we term “acute peripheral and/or cutaneous ischemic syndrome” (APCIS), can be a manifestation of numerous underlying diseases, or it can sometimes be a clinical phenomenon whose etiology is undefined even after a wide investigation. The mechanisms for the development of APCIS include vessel wall abnormalities (atherosclerosis, vasculitis, and calciphylaxis), embolic processes (infectious endocarditis, atrial myxoma, and cholesterol emboli), local thrombotic injuries (genetic or acquired thrombophilias and heparin- and warfarin-induced ischemia), dysproteinemias (cryoglobulinemia and cryofibrinogenemia), or venous limb gangrene. Here, we report 5 illustrative cases of APCIS with different pathogenetic mechanisms, thereby highlighting some clinical conditions that cause APCIS that may be of special interest for rheumatologists, such as antiphospholipid syndrome, primary and secondary vasculitis, and cryoproteinemias. Furthermore, we describe a large spectrum of other causes of APCIS beyond the scope of rheumatology. Because there are no validated guidelines for APCIS, we tentatively propose an initial diagnostic workup and a therapeutic approach based on full-dose anticoagulation and immunosuppressive therapy.
Preconception Obstetrics and Rheumatology Consultation
Authors: Javinani Ali , Radmard Fatemeh , Razavinia Fatemeh Sadat , Masoumi Maryam
Published: December 2020

Background

Autoimmune rheumatic disorders are a group of illnesses that significantly affect pregnancy outcomes.

Aim

The aim of this study was to evaluate the incidence and risk factors of spontaneous abortion and its association with maternal medical care in women with autoimmune rheumatic diseases.

Methods

In this medical record review study, we recruited patients who were referred to our clinic from September 2014 to September 2019. All confirmed pregnancies (based on a positive pregnancy test and sonogram) were included. Binary logistic regression was applied to construct the statistical model.

Findings

The present study involved 97 women (215 total confirmed pregnancies) who were diagnosed with 7 different autoimmune rheumatic disorders. The rate of spontaneous abortion was 28.8%. In the univariate analysis, the preconception obstetrics and rheumatology consultation were negatively associated with spontaneous abortion (p < 0.001; odds ratio [OR], 0.255; 95% confidence interval [CI], 0.136–0.480; and p < 0.001; OR, 0.042; 95% CI, 0.015–0.122, respectively). Perinatal obstetric care had a significant protective effect (p < 0.001; OR, 0.260; 95% CI, 0.139–0.486). The multivariate analysis showed that the preconception rheumatology consultation (p = 0.003; OR, 0.062; 95% CI, 0.010–0.393) was negatively associated with spontaneous abortions. The presence of active diseases before pregnancy (p = 0.005; OR, 9.978; 95% CI, 2.023–49.223), anti-SSA/Ro (p < 0.001; OR, 22.927; 95% CI, 4.921–106.818), and anticardiolipin IgM (p = 0.004; OR, 298.207; 95% CI, 6.209–14,323.037) were associated with a heightened risk of spontaneous abortion.

Conclusions

A collaborative work carried out by maternal-fetal medicine specialists and rheumatologists could remarkably improve pregnancy outcomes.
Incidental Finding of Bilateral Thalamic Glioma on 99mTc TRODAT-1 SPECT/CT
Authors: Kuo Ni-Chun , Hu Chin , Chiu Yu-Li , Peng Nan-Jing , Chan Hung-Pin
Published: December 2020

99mTc-TRODAT-1 SPECT/CT has been used to evaluate parkinsonian disorders. We present an interesting case of a 63-year-old woman with progressive tremulousness over the left side of the body for 6 months. Bilateral thalamic glioma with reduced uptake was shown on 99mTc-TRODAT-1 SPECT/CT. Secondary parkinsonism was impressed in this case.
Metastatic Medulloblastoma
Authors: ArunRaj Sreedharan Thankarajan , Kumar Arunav , KP Haresh , Mohan Nikhil , Gupta Subhash , Tripathi Madhavi , Bal Chandrasekhar
Published: December 2020

We describe the utility of molecular imaging with 18F-FDG and 68Ga-DOTANOC PET for treatment response assessment in a case of metastatic medulloblastoma. 18F-FDG and 68Ga-DOTANOC PET/CT revealed extensive metastases to bone and bone marrow. Patient subsequently had an excellent response to systemic chemotherapy which was evidenced by resolution of tracer-avid skeletal lesions on both FDG and DOTANOC PET/CT.
A Blueprint for Creating Mentored, Collaborative Networks for Early-Career Physician-Scientists
Authors: Mueller Margaret G. , Andy Uduak , Brennaman Lisa , Dieter Alexis A. , Kirby Anna C. , Shepherd Jonathan , Gregory W. Thomas , Amundsen Cindy L.
Published: December 2020

Objectives

The objective is to improve the high-quality collaborative research of early-career investigators, the American Urogynecologic Society/Pelvic Floor Disorders Foundation funded and developed the Junior Faculty Research Network (JFRN). The purpose of this report is to describe the process of development of the network, discuss barriers, acknowledge accomplishments, and provide a framework for future collaborations.

Methods

The development of the JFRN provided sponsorship and mentorship, supported collaboration, and created a network structure for early-career investigators. A request for applications was circulated, requiring a competitive submission process, and 6 physician-scientists were selected to participate in a multicenter trial whose initial focus was on the urinary microbiome and its interaction with sacral neuromodulation.

Results

The JFRN infrastructure consisted of early-career investigators, senior advisors, and research support staff. Study development and roll-out progressed over monthly conference calls. Initial barriers included the development of institutional participation agreements, logistics of funding disbursement, and coordination of support staff. In addition to the inaugural research project, the network continued to collaborate, and the initial grant provided pilot data for a National Institutes of Health-funded project.

Conclusions

The JFRN is a successful mentored collaborative of early-career investigators. The creation of this self-sustaining, independent research network may serve as a blueprint for other early-career physician-scientists to participate in productive multicenter research.
Rates of Sling Procedures and Revisions—A National Surgical Quality Improvement Program Database Study
Authors: Bretschneider C. Emi , Geynisman-Tan Julia , Mueller Margaret G. , Collins Sarah A. , Lewicky-Gaupp Christina , Kenton Kimberly
Published: December 2020

Objective

The aim of this study was to describe trends in sling procedures and revisions, including fascial slings and midurethral slings (MUS) using a large, national database with respect to the 2011 U.S. Food and Drug Administration (FDA) mesh-related safety communication.

Methods

This was a cross-sectional cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2010 to 2018, evaluating the prevalence of sling revision and fascial slings and their trends over time. Patients who underwent MUS, fascial slings, and sling revisions were identified by Current Procedural Terminology codes. Sling revisions and fascial slings were evaluated as a proportion of the total number of MUS performed per year. Three distinct periods were evaluated in relation to the 2011 FDA communication: 2010 to 2012, 2012 to 2015, and 2015 to 2018. Observed trends were assessed with Pearson correlation coefficients with a P value less than 0.05 considered significant.

Results

During the study period, 32,657 slings were captured: 32,389 MUS and 268 fascial slings. The rate of sling revisions was low (0.4% in 2010 to 1.2% in 2015). Between 2012 and 2015, the rate of sling revision increased significantly (R = 1, P = 0.002); following 2015, the rate of sling revisions decreased significantly over time (R = −0.96, P = 0.04). The rate of fascial slings between 2012 and 2015 increased significantly (R = 0.95, P = 0.047); however, the rate plateaued starting in 2015 (R = −0.49, −P = 0.51).

Conclusions

Our data suggest that MUS remain the preferred procedure for treatment of stress urinary incontinence despite the recent FDA communications with MUS representing 99% of sling procedures during the study period.
Chronic Histologic Changes Are Present Regardless of HLA Mismatches: Evidence from HLA-Identical Living Donor Kidney Transplants
Authors: D’Costa Matthew R. , Bentall Andrew , Denic Aleksandar , Schinstock Carrie A. , Merzkani Massini A. , Park Walter D. , Ryan Margaret S. , Alexander Mariam P. , Smith Byron H. , Gandhi Manish J. , Stegall Mark D.
Published: December 2020

Background.

At 5 and 10 y after kidney transplantation, chronic histologic changes such as arteriolar hyalinosis and mesangial expansion are common; however, determining cause is difficult. We compared surveillance biopsies in living donor kidney transplants (LDKTx) from HLA-matched siblings (termed HLA-identical [HLA-ID]) with HLA non-ID to investigate which histologic changes were likely due to alloimmune injury and which were due to nonalloimmune injury.

Methods.

We performed a retrospective, cohort study comparing HLA-ID sibling LDKTx (n = 175) with HLA non-ID LDKTx (n = 175; matched for age, sex, and year of transplant ±2 y) performed at a single institution from March 1999 to November 2018.

Results.

Baseline characteristics and maintenance immunosuppression were similar. Mortality rates were similar, but in the HLA-ID group, 10-y death-censored graft survival was higher (93.8% versus 80.9% HLA non-ID LDKTx; P < 0.001), rejection rates were lower (after 1 y 9.6% versus 27.1%; P < 0.001), and Banff inflammation scores including glomerulitis and peritubular capillaritis were lower on surveillance biopsies at 1, 5, and 10 y. In contrast, chronic Banff scores (interstitial fibrosis, arteriolar hyalinosis, mesangial expansion, etc) were similar in prevalence and severity on surveillance biopsies at 1, 5, and 10 y.

Conclusions.

HLA-ID LDKTx have less inflammation and less transplant glomerulopathy, but most chronic histologic changes were similar to less well-matched LDKTx. We conclude that these types of chronic changes are not associated with HLA mismatches and may be due to nonimmunologic causes (hypertension, obesity, etc), suggesting that new management approaches to prevent these lesions may be needed.
Unconscious mental imagery
Authors: Nanay Bence
Published: December 2020

Historically, mental imagery has been defined as an experiential state—as something necessarily conscious. But most behavioural or neuroimaging experiments on mental imagery—including the most famous ones—do not actually take the conscious experience of the subject into consideration. Further, recent research highlights that there are very few behavioural or neural differences between conscious and unconscious mental imagery. I argue that treating mental imagery as not necessarily conscious (as potentially unconscious) would bring much needed explanatory unification to mental imagery research. It would also help us to reassess some of the recent aphantasia findings inasmuch as at least some subjects with aphantasia would be best described as having unconscious mental imagery.

This article is part of the theme issue ‘Offline perception: voluntary and spontaneous perceptual experiences without matching external stimulation’.