bluuebunny/crossref_metadata_2025 huggingface dataset:
Chief Resident Immersion Training in the Care of Older Adults: A Successful National Replication of an Interspecialty Educational Intervention
Authors: Levine Sharon A. , Chao Serena H. , Caruso Lisa B. , Jackson Angela H. , Russell Matthew L. , Young Megan E. , Brett Belle
Published: June 2018

Purpose

Nongeriatricians must acquire skills and knowledge in geriatric medicine to ensure coordinated care of older adults’ complex conditions by interspecialty and interprofessional teams. Chief residents (CRs) are an ideal target for an educational intervention. This study examined whether the Boston Medical Center Chief Resident Immersion Training (CRIT) in the Care of Older Adults was replicable at diverse medical institutions.

Method

Between 2008 and 2010, 12 institutions in 11 states received funding, technical support, and a common program model. Each implemented 2.5-day CRITs, consisting of a patient case, geriatrics-related lectures, CR leadership sessions, action project planning, and networking time. Site faculty conducted 21 CRITs for 295 CRs representing 28 specialties. CRs completed knowledge pre- and posttests, and self-report baseline and six-month follow-up surveys. Outcome measures were change in pre- and posttest score, and change from baseline to six months in self-reported surveys.

Results

Response rate for CRs was 99% (n = 293) for the pre–post tests and 78% (n = 231) for matchable baseline and follow-up surveys. Participants’ knowledge increased from 6.32 to 8.39 (P < .001) averaged from 12 questions. CRs’ self-reported ability to apply clinical problem-solving skills to older patients (P < .001), number of geriatrics topics taught (P < .001), frequency of geriatrician consultations (P = .017), confidence in leadership skills (P < .001), and confidence to conduct CR work (P < .001) increased from baseline to follow-up.

Conclusions

CRIT is an innovative way to give nongeriatricians knowledge and skills to treat complex older patients.
Drug-induced lupus erythematosus: an update on drugs and mechanisms
Authors: He Ye , Sawalha Amr H.
Published: June 2018

Purpose of review

Rapid introduction of newly developed drugs in the absence of clear understanding of the pathophysiologic mechanisms behind drug-induced lupus erythematosus (DILE) can sometimes make DILE difficult to recognize in clinical practice. The purpose of this review is to summarize drugs most recently reported to be involved in DILE and discuss the current landscape of diverse mechanisms involved.

Recent findings

A large number of proton pump inhibitor (PPI)-induced subacute cutaneous lupus erythematosus cases have been reported, suggesting a shift over time in the spectrum of drugs implicated in DILE. Twenty-two articles comprising 29 DILE case reports published within the last 2 years are summarized in this review, including 12 (41.4%) systemic DILE. Antitumor necrosis factor (anti-TNF) drugs were the most frequently (41.7%) reported to introduce systemic DILE in these cases. Chemotherapeutic drugs were the most common drug class (54.5%) involved in subacute cutaneous lupus erythematosus, with an observed higher incidence in female patients. Enhanced neutrophil extracellular trap (NET) formation induced by procainamide and hydralazine could be a new mechanism contributing to the pathogenesis of DILE.

The list of drugs implicated in triggering DILE is expanding as new drugs with novel mechanisms of action are being developed. It is important to recognize culprit drugs that may induce lupus erythematosus, as discontinuation usually results in improvement of drug-induced manifestations. Characterizing the mechanisms involved might help better understand the cause of idiopathic autoimmunity.
The Management of Complex Pediatric Fractures: Case Examples Demonstrating 5 Principles for Success
Authors: Flynn John M.
Published: June 2018

Advances in imaging, surgical techniques, and surgical implants have improved pediatric fracture care, yielding results that are demanded by families who expect anatomic reductions and rapid return to activities. There are 5 principles for success in the management of complex pediatric fractures: assessing for associated injuries, optimizing imaging and precisely define the injury preoperatively, thoughtfully completing preoperative planning and operating room set up, assuring reduction/fixation is optimal before leaving the operating room and getting immobilization, observation and follow-up just right.
Comparison of Decompression, Decompression Plus Fusion, and Decompression Plus Stabilization for Degenerative Spondylolisthesis
Authors: Inose Hiroyuki , Kato Tsuyoshi , Yuasa Masato , Yamada Tsuyoshi , Maehara Hidetsugu , Hirai Takashi , Yoshii Toshitaka , Kawabata Shigenori , Okawa Atsushi
Published: June 2018

Study Design:

This is a prospective, randomized controlled trial.

Objective:

To prospectively assess the long-term clinical results of decompression alone, decompression plus fusion, and decompression plus stabilization for degenerative spondylolisthesis.

Summary of Background Data:

Symptoms of lumbar spinal stenosis due to degenerative spondylolisthesis originate from compression of the dural sac or nerve root. Essentially, this condition is treated by performing a decompression of neural structures. Posterolateral lumbar fusion and posterior pedicle-based dynamic stabilization are additional techniques performed to ensure improved prognosis. However, to date, the selection of a surgical procedure for lumbar spinal stenosis due to degenerative spondylolisthesis remains debatable, especially in terms of the addition of instrumentation because of the few available prospective, randomized studies.

Materials and Methods:

We randomly assigned patients who had 1 level lumbar spinal stenosis due to degenerative spondylolisthesis at the L4/5 level to undergo either decompression alone (decompression group), decompression plus fusion (fusion group), or decompression plus stabilization (stabilization group). Outcomes were assessed using the Japanese Orthopaedic Association and Visual Analogue Scale scores.

Results:

In total, 85 patients underwent randomization. The follow-up rate at 5 years was 86.4%. The fusion and stabilization groups showed higher blood loss and a longer operative time than the decompression group. The fusion group showed longer postoperative hospital stay than the decompression group. In terms of clinical outcomes, all scores significantly improved postoperatively, and these outcomes were maintained at 5 years postoperatively in each group. There were no significant differences among the groups at 1 and 5 years postoperatively.

Conclusions:

Additional instrumentation operation for low-grade (<30%) degenerative spondylolisthesis did not result in superior results to decompression alone at 1 and 5 years postoperatively.

Level of Evidence:

Level II.
Estimating the Impact of Changes to Occupational Standards for Silica Exposure on Lung Cancer Mortality
Authors: Keil Alexander P. , Richardson David B. , Westreich Daniel , Steenland Kyle
Published: June 2018

Background:

Respiratory exposure to silica is associated with the risk of death owing to malignant and nonmalignant disease. 2.3 million US workers are exposed to silica. Occupational exposure limits for silica are derived from a number of lines of evidence, including observational studies. Observational studies may be subject to healthy worker survivor bias, which could result in underestimates of silica’s impact on worker mortality and, in turn, bias risk estimates for occupational exposure limits.

Methods:

Using data on 65,999 workers pooled across multiple industries, we estimate the impacts of several hypothetical occupational exposure limits on silica exposure on lung cancer and all-cause mortality. We use the parametric g-formula, which can account for healthy worker survivor bias.

Results:

Assuming we could eliminate occupational exposure, we estimate that there would be 20.7 fewer deaths per 1,000 workers in our pooled study by age 80 (95% confidence interval = 14.5, 26.8), including 3.91 fewer deaths owing to lung cancer (95% CI = 1.53, 6.30). Less restrictive interventions demonstrated smaller but still substantial risk reductions.

Conclusions:

Our results suggest that occupational exposure limits for silica can be further strengthened to reduce silica-associated mortality and illustrate how current risk analysis for occupational limits can be improved.
Ambient Particulate Matter Concentrations and Hospital Admissions in 26 of China’s Largest Cities: A Case–Crossover Study
Authors: Liu Hui , Tian Yaohua , Xiang Xiao , Juan Juan , Song Jing , Cao Yaying , Huang Chao , Li Man , Hu Yonghua
Published: June 2018

Background:

Few studies have evaluated the short-term impacts of ambient particulate matter (PM) pollution on morbidity in China. The aims of this study were to examine the short-term association between hospital admissions and ambient PM and also to explore whether PM2.5 at levels below current regulatory limits also increases the risk of hospitalizations in 26 Chinese cities.

Methods:

We identified 14,569,622 all-cause, 2,008,786 cardiovascular, and 916,388 respiratory admissions during 2014–2015. We employed conditional logistic regression to estimate the association between hospital admissions and ambient PM.

Results:

A 10 μg/m3 increase in PM2.5 at lag 0 day corresponded to increases of 0.19% (95% confidence interval [CI] = 0.18%, 0.20%) in all-cause, 0.23% (95% CI = 0.20%, 0.26%) in cardiovascular, and 0.26% (95% CI = 0.22%, 0.31%) in respiratory admissions. For PM10, the values were 0.12% (95% CI = 0.11%, 0.13%) for all-cause, 0.15% (95% CI = 0.13%, 0.17%) for cardiovascular, and 0.21% (95% CI = 0.17%, 0.24%) for respiratory admissions. The associations held at PM2.5 levels below the current Chinese and European/WHO standards. Among individuals with exposure levels below 25 μg/m3, increasing PM2.5 levels from below 15 μg/m3 to above 15 μg/m3 was associated with increases of 1.8% (odds ratio, 1.018; 95% CI = 1.015, 1.022) in all-cause admissions and 2.5% (odds ratio, 1.025; 95% CI = 1.017, 1.034) in cardiovascular admissions.

Conclusions:

Short-term PM exposures were associated with increased hospitalizations, even for exposure levels not exceeding the current regulatory limits.
Response-inhibition capacity in spontaneously hypertensive and Wistar rats: acquisition of fixed minimum interval performance and responsiveness to d-amphetamine
Authors: Rojas-Leguizamón Maryed , Baroja José L. , Sanabria Federico , Orduña Vladimir
Published: June 2018

Reduced response-inhibition capacity is a defining feature of attention-deficit hyperactivity disorder. The fixed minimum interval (FMI) schedule has been systematically validated to assess such capacity in rats. On each FMI trial, the first lever press initiates an inter-response time (IRT); a potentially consummatory response terminates the IRT; only IRTs longer than a target interval result in access to food. Despite task validity, steady-state FMI performance in the most common animal model of attention-deficit hyperactivity disorder, the spontaneously hypertensive rat (SHR), is similar to normotensive control performance, even though SHR performs at lower levels, especially during acquisition, in similar response-withholding tasks. To determine whether such limitations of the model are specific to stable-state performance, this experiment compared FMI 6-s performance in SHR and Wistar rats during acquisition and in steady state, and assessed the effect of acute d-amphetamine (AMP) administration (0.1, 0.5, and 1.0 mg/kg) on steady-state performance. Median latencies to first lever press were consistently shorter in SHR than in Wistar rats; IRTs were shorter for SHR than for Wistar rats during acquisition, but substantially less so during asymptotic performance. AMP dose-dependently reduced latencies, shortened IRTs, and, at the highest dose, increased the proportion of IRTs under schedule control. These results suggest that, relative to Wistar rats, SHR have a reduced capacity to learn to withhold a reinforced response; once the FMI is acquired, high doses of d-AMP disrupt withholding performance in both strains, but they also enhance the responsiveness of both strains to reinforcement contingencies.
The role of androgens in the treatment of genitourinary syndrome of menopause (GSM): International Society for the Study of Women's Sexual Health (ISSWSH) expert consensus panel review
Authors: Simon James A. , Goldstein Irwin , Kim Noel N. , Davis Susan R. , Kellogg-Spadt Susan , Lowenstein Lior , Pinkerton JoAnn V. , Stuenkel Cynthia A. , Traish Abdulmaged M. , Archer David F. , Bachmann Gloria , Goldstein Andrew T. , Nappi Rossella E. , Vignozzi Linda
Published: June 2018

Objective:

The objective of this consensus document is to broaden the perspective on clinical management of genitourinary syndrome of menopause to include androgens.

Methods:

A modified Delphi method was used to reach consensus among the 14 international panelists representing multiple disciplines and societies.

Results:

Menopause-related genitourinary symptoms affect over 50% of midlife and older women. These symptoms have a marked impact on sexual functioning, daily activities, emotional well-being, body image, and interpersonal relations. Tissues in the genitourinary system are both androgen and estrogen-dependent. The clitoris, vestibule, including minor and major vestibular glands, urethra, anterior vaginal wall, periurethral tissue, and pelvic floor are androgen-responsive. Historically, treatment of postmenopausal genitourinary symptoms involved both androgens and estrogens. This subsequently gave rise to predominantly estrogen-based therapies. More recently, double-blind, placebo-controlled clinical trials have demonstrated that local vaginal dehydroepiandrosterone improves symptoms in postmenopausal women, including moderate to severe dyspareunia. Limited data suggest that systemic testosterone treatment may improve vaginal epithelial health and blood flow. Open-label studies that have used high doses of intravaginal testosterone in the presence of aromatase inhibitor therapy for breast cancer have resulted in supraphysiological serum testosterone levels, and have been reported to lower vaginal pH, improve the vaginal maturation index, and reduce dyspareunia.

Conclusions:

Vaginal dehydroepiandrosterone, hypothesized to enhance local production of both androgen and estrogen, is effective for the management of dyspareunia in menopause. Vaginal testosterone offers potential as a treatment for genitourinary syndrome of menopause, but more studies are needed.
Provider Agreement in the Assessment of Glaucoma Progression Within a Team Model
Authors: Shah Saumya M. , Choo Clara , Odden Jamie , Zhao Bingying , Fang Chengbo , Schornack Muriel , Stalboerger Gina , Bennett Jeffrey R. , Khanna Cheryl L.
Published: June 2018

Purpose:

Glaucoma specialists and optometrists who work in a team model at a single institution utilize a common definition of glaucoma progression and treatment algorithm. The purpose of this study was to assess the consistency of agreement in identifying glaucoma progression among glaucoma specialists and optometrists of 1 team.

Methods:

In total, 399 eyes of 200 patients age 18 or older with glaucoma were enrolled over 2 years. Clinical data, disc photographs, optical coherence tomography (OCT), and visual fields were independently reviewed by 2 masked optometrists and 2 masked fellowship-trained glaucoma specialists. Each eye was judged as progression or no progression of glaucomatous disease. The following were assessed: (1) agreement among optometrists; (2) agreement among glaucoma specialists; and (3) agreement among optometrists and glaucoma specialists. The frequency of use of testing modality to determine progression was also studied. κ statistics were used to evaluate agreements.

Results:

Optometrists agreed with each other for 74.2% of the eyes assessed (κ=0.42), whereas glaucoma specialists agreed with each other for 78.7% of eyes (κ=0.39). All 4 providers agreed with each other for 54.4% of the eyes evaluated (κ=0.37). Providers had the highest agreement when the progression decision was based on disc hemorrhage (92%) and the lowest agreement when based on OCT progression analysis (36%). Compared with optometrists, glaucoma specialists used OCT (P≤0.01) more frequently to determine disease progression.

Conclusions:

Fair to moderate agreement levels were found among providers in their assessment of glaucoma progression, suggesting that a team approach to glaucoma management may be effective. Further work is needed to investigate ways to optimize consistency within the glaucoma team.
Retinal Arteriolar Narrowing in Young Adults With Glaucomatous Optic Disc
Authors: Adiarti Rossada , Ekantini Retno , Agni Angela N. , Wong Tien Y. , Sasongko Muhammad B.
Published: June 2018

Purpose:

Glaucomatous optic disc (GOD) might represent various subclinical processes. However, whether the presence of GOD is related to vascular processes is less clear. This study aimed to assess the retinal vessel diameter, as surrogate markers of vascular regulation, in healthy young adults with GOD compared with normal.

Materials and Methods:

This was a clinic-based case-control study of 54 participants, aged between 18 and 30 years. We included patients with GOD (confirmed with slit-lamp and optical coherence tomography examination having cup-to-disc ratio ≥0.5), intraocular pressure ≤21 mm Hg, no history of hypertension, cardiovascular and kidney disease, anemia, diabetes mellitus, and spherical correction of ≤−1.5 D. Controls were healthy subjects with similar criteria but no sign of GOD. Retinal vessel diameters were measured using semiautomated program [Singapore I Vessel Assessment (SIVA) version 4.0] and expressed as central retinal arteriolar equivalent (CRAE) and central retinal venular equivalent.

Results:

The mean CRAE was significantly narrower in patients with GOD than controls (110.6±12.16 vs. 118.6±12.17; P=0.019). Central retinal venular equivalent was not significantly different. A CRAE narrower than 107.1 μm was significantly associated with GOD (odds ratio, 8.59; 95% confidence interval, 1.68-43.9; P<0.001) compared with controls.

Conclusions:

Retinal arterioles were narrower in young adults with GOD compared with normal, suggesting that the presence of GOD might be associated with subclinical changes in retinal vascularization even in the absence of increased intraocular pressure. However, the clinical significance of these findings deserves further studies.
Scleral Patch Graft Melt After Tube Shunt Surgery: Grading and Identification of Risk Factors
Authors: Xia Tian , Khouri Albert S.
Published: June 2018

Purpose:

To identify scleral patch graft (SG) melting trends in patients after tube shunt surgery and validate a grading scale for SG health.

Methods:

Patients with glaucoma who underwent tube shunt surgery with a SG were enrolled consecutively at Rutgers New Jersey Medical School from September, 2016 to June, 2017. SG images that were acquired through slit-lamp photography were graded independently by 3 researchers for surface area remaining, thickness and vascularity of the conjunctiva. Interobserver correlation coefficient (kappa) was performed for these scores using our grading system. A chart review of patient records was conducted to investigate comorbid conditions and the student t test was performed with significance P<0.05 to identify associations with SG melt.

Results:

In total, 67 eyes (mean age 60±20 y, 65% female, 35% male) were enrolled. In total, 124 SG images were acquired, but the 67 best captured images were evaluated by 3 graders. Mean percentage of surface area remaining area were 46.2±44.1 (kappa=0.82). The average measured surface area remaining was 6.8 mm2 from reference of 16 mm2. For the 3 graders, mean thickness scores were 1.0±0.9 (kappa=0.79), and mean vascularity scores were 1.1±0.6 (kappa=0.83). Time from surgery at which SG were evaluated was: 17 eyes (25%) <3 months, 11 (16%) 3 to 12 months, 8 (12%) 12 to 24 months, 16 (24%) 2 to 5 years, and 15 (23%) >5 years. At those time point: average percentage SG remaining were 72.9, 60, 31.3, 30.7, and 33.3%, respectively (P<0.05 comparing <1 to >1 y) and SG thickness score 1.6, 1.2, 0.6, 0.6, and 0.7, respectively (P<0.05 comparing <3 mo to 12 to 24 mo). The rate of SG melt (measured by surface area remaining) over time was higher in patients with ocular surface disease (P<0.01).

Conclusions:

SG melts gradually after tube shunt surgery with the most dramatic melt occurring after 12 months postoperatively. This simple and consistent SG grading scale has high interrater agreement and can be may be used to assess and follow graft health over time.
Anatomic Considerations in Thyroid Eye Disease
Authors: Dutton Jonathan J.
Published: June 2018

Purpose:

To review and summarize the clinical findings in thyroid eye disease (TED) related to the unique anatomical structures of the eyelids and orbit.

Methods:

A PubMed search was performed searching for anatomical relationships between eyelid and orbital anatomy and the clinical findings of TED.

Results:

The major clinical findings associated with TED are varied. They typically involve both the eyelid and the orbit. In the eyelid, usual findings include upper eyelid retraction, contour abnormalities, eyelid edema, prolapsed orbital fat, conjunctival injection and chemosis, caruncular edema, and meibomian gland dysfunction. The exact causes of these changes remain a matter of controversy, but numerous hypotheses have been proposed, most with limited experimental support. In the orbit, inflammation and congestion characterize the acute active phase, with tissue expansion and fibrosis persisting into the chronic inactive phase. All of these findings result, at least in part, from the unique anatomy of the eyelids and orbit and their interaction with the immunologic processes underlying TED. Here we review these major characteristics of TED, with special reference to their anatomic relationships.

Conclusions:

The major findings characterizing TED are related to unique anatomic features in the eyelid, including Müller muscle, the levator palpebrae superioris muscle, and suspensory ligaments of the conjunctiva. In the orbit, Graves-related remolding results from the special physiologic features of the extraocular muscles, the structure of the orbital walls and their relations to adjacent paranasal sinuses, and the reaction of orbital fat to immunologic challenges.
Role of Retrobulbar Hyaluronidase in Filler-Associated Blindness: Evaluation of Fundus Perfusion and Electroretinogram Readings in an Animal Model
Authors: Hwang Catherine J. , Mustak Hamzah , Gupta Adit A. , Ramos Regina M. , Goldberg Robert A. , Duckwiler Gary R.
Published: June 2018

Purpose:

Hyaluronic acid gel filler-associated blindness is an uncommon but devastating complication. Hyaluronidase can potentially dissolve intravascular filler and improve perfusion; however, its role in filler-associated blindness has yet to be determined. The purpose of this study is to determine the effect of retrobulbar hyaluronidase on hyaluronic acid gel-induced ophthalmic artery occlusion in a rabbit model.

Methods:

New Zealand red rabbits were used to simulate hyaluronic acid gel filler-associated vascular occlusive blindness. Ophthalmic artery occlusion and subsequent ischemia were confirmed by both retinal fundus photography and electroretinogram changes. Retrobulbar hyaluronidase 1,000 IU was injected 30 minutes after occlusion. Fundus photography and electroretinogram changes were recorded at 30, 60, 90, and 120 after administration of retrobulbar hyaluronidase.

Results:

A total of 6 rabbits were used, for a total of 12 eyes. Four eyes were used as controls. Of the 8 experimental eyes, 2 eyes had recorded partial occlusion and 6 eyes had fully occluded ophthalmic arteries by angiographic evaluation. One of the partially occluded eyes demonstrated some improvement in perfusion 60 minutes after injection of retrobulbar hyaluronidase; however, electroretinogram readings remained flat over the 120-minute period of observation. Six eyes with completely occluded ophthalmic arteries showed no improvement in retinal perfusion with corresponding flat electroretinogram readings at 120 minutes following retrobulbar hyaluronidase injection.

Conclusions:

In this rabbit model, 1,000 IU of retrobulbar hyaluronidase administered 30 minutes after occlusion failed to reverse obstruction or restore function following hyaluronic acid gel occlusion of the ophthalmic artery.
Choroidal Neovascularization Secondary to Intense Pulsed Light Injury
Authors: Chang Chih-Yao , Sheu Shwu-Jiuan
Published: June 2018

The authors report a 26-year-old medical device saleswoman developing choroidal neovascularization after injury by intense pulsed light with detection and monitoring by optical coherence tomography angiography and treatment with intravitreal injection of ranibizumab. This is the first intense pulsed light–related choroidal neovascularization case, which reminds the importance of using appropriate eye protection throughout the course of treatment for all individuals present in the therapy room.
Role of glucagon in protein catabolism
Authors: Thiessen Steven E. , Gunst Jan , Van den Berghe Greet
Published: June 2018

Purpose of review

Glucagon is known as a key hormone in the control of glucose and amino acid metabolism. Critical illness is hallmarked by a profound alteration in glucose and amino acid metabolism, accompanied by muscle wasting and hypoaminoacidemia. Here we review novel insights in glucagon (patho)physiology and discuss the recently discovered role of glucagon in controlling amino acid metabolism during critical illness.

Recent findings

The role of glucagon in glucose metabolism is much more complex than originally anticipated, and glucagon has shown to be a key player in amino acid metabolism. During critical illness, the contribution of glucagon in bringing about hyperglycemia appeared to be quite limited, whereas increased glucagon availability seems to contribute importantly to the typical hypoaminoacidemia via stimulating hepatic amino acid breakdown, without affecting muscle wasting. Providing amino acids further increases hepatic amino acid breakdown, mediated by a further increase in glucagon.

Glucagon plays a crucial role in amino acid metabolism during critical illness, with an apparent feedback loop between glucagon and circulating amino acids. Indeed, elevated glucagon may, to a large extent, be responsible for the hypoaminoacidemia in the critically ill and infusing amino acids increases glucagon-driven amino acid breakdown in the liver. These novel insights further question the rationale for amino acid administration during critical illness.
Continuous or intermittent feeding: pros and cons
Authors: Bear Danielle E. , Hart Nicholas , Puthucheary Zudin
Published: June 2018

Purpose of review

There has been a recent shift in the focus of providing nutrition support to critically ill adults towards enhancing recovery and promoting survivorship. With this has come an evaluation of our current approaches to nutrition support, which includes whether continuous feeding is optimal, particularly for reducing muscle wasting, but also for managing blood glucose levels and feeding intolerance and at the organizational level. This review will discuss the pros and cons of using intermittent and continuous feeding relating to several aspects of the management of critically ill adults.

Recent findings

Few studies have investigated the effect of intermittent feeding over continuous feeding. Overall, intermittent feeding has not been shown to increase glucose variability or gastrointestinal intolerance, two of the reasons continuous feeding is the preferred method. A current study investigating the effect of intermittent vs. continuous feeding is awaited to provide insight into the effect of muscle wasting.

Although there are limited studies investigating the safety and efficacy of an intermittent rather than continuous feeding regimen in critically ill adults, there are several theoretical advantages. Further studies should investigate these and in the meantime, feeding regimens should be devised based on individual patient factors.
Vasodilatory shock in the ICU and the role of angiotensin II
Authors: Wakefield Brett J. , Sacha Gretchen L. , Khanna Ashish K.
Published: June 2018

Purpose of review

There are limited vasoactive options to utilize for patients presenting with vasodilatory shock. This review discusses vasoactive agents in vasodilatory, specifically, septic shock and focuses on angiotensin II as a novel, noncatecholamine agent and describes its efficacy, safety, and role in the armamentarium of vasoactive agents utilized in this patient population.

Recent findings

The Angiotensin II for the Treatment of High-Output Shock 3 study evaluated angiotensin II use in patients with high-output, vasodilatory shock and demonstrated reduced background catecholamine doses and improved ability to achieve blood pressure goals associated with the use of angiotensin II. A subsequent analysis showed that patients with a higher severity of illness and relative deficiency of intrinsic angiotensin II and who received angiotensin II had improved mortality rates. In addition, a systematic review showed infrequent adverse reactions with angiotensin II demonstrating its safety for use in patients with vasodilatory shock.

With the approval and release of angiotensin II, a new vasoactive agent is now available to utilize in these patients. Overall, the treatment for vasodilatory shock should not be a one-size fits all approach and should be individualized to each patient. A multimodal approach, integrating angiotensin II as a noncatecholamine option should be considered for patients presenting with this disease state.
Assessment of human leukocyte antigen immunogenicity: current methods, challenges and opportunities
Authors: Copley Hannah C. , Elango Madhivanan , Kosmoliaptsis Vasilis
Published: June 2018

Purpose of review

Donor–recipient human leukocyte antigen (HLA) matching improves outcomes after solid-organ transplantation, but current assessment of HLA incompatibility is inadequate as it does not consider the relative immunogenicity of individual HLA mismatches. In this article, we review existing strategies for assessing HLA immunogenicity and discuss current challenges and future opportunities in this field.

Recent findings

Current HLA immunogenicity algorithms focus primarily on the humoral component of the alloimmune response and aim to determine a measure of ‘dissimilarity’ between donor and recipient HLA. This can be achieved by deriving information from comparison of donor and recipient HLA at the amino acid sequence, structural and/or the physicochemical level, accounting for both B-cell and T-cell pathways of alloreactivity. Substantial evidence now supports the superiority of this molecular definition of HLA incompatibility, over conventional enumeration of HLA antigenic differences, for assessing the risk of humoral alloimmunity and for predicting graft outcomes after transplantation.

Significant progress has been made in developing computational HLA immunogenicity algorithms that offer exciting opportunities for a more rational approach to determining the degree of donor–recipient HLA incompatibility and to defining HLA-related immunological risk. A number of challenges now need to be overcome to enable their implementation into clinical practice.
Heterozygosity for CMT Type 4 Predicts a Severe Vincristine-induced Polyneuropathy Phenotype: A Case Report and Review of Literature
Authors: Sy Andrew , Cheng Jerry , Cooper Robert , Mueller Lisa
Published: June 2018

Vincristine (VCR) is a common chemotherapeutic agent used in the treatment of multiple types of pediatric tumors. VCR’s adverse effects are well documented and commonly involve peripheral neuropathy via axonal degeneration. Neuropathic severity is dose-dependent, with sensory deficits occurring with as little as 4 mg cumulative dose. Severe peripheral neuropathy is generally rare, but its effects become additive when given to patients with undiagnosed hereditary peripheral neuropathy such as Charcot-Marie-Tooth. We report a case of an effect of VCR administration given to a patient who developed grade 4 neuropathy and was found to be a carrier of Charcot-Marie-Tooth disease type 4.
Leveraging Technology to Increase Patient and Family Engagement and Improve Outcomes
Authors: Clavelle Joanne T.
Published: June 2018

Engaging persons in their health care influences the quality of care and improves patient safety, health outcomes, and the patient experience. Emerging technology is enabling patients to be more fully engaged in their care. At the same time, the rapid emergence of these solutions is impacting nursing professional practice, workflows, and care delivery models across the continuum. Faced with a sustained and continued technology explosion, nurse executives are uniquely positioned to lead care transformation that leverages technology to engage patients at the point of care, redefine nursing practice, and improve empirical outcomes.
Mission Critical
Authors: Lown Beth A.
Published: June 2018

Compassion, the foundation of Nursing, is a source of both healing for those who suffer and of purpose and meaning for those who seek to heal others. Increasingly, however, the fast pace and volume of care and documentation requirements diminish time with patients and families and hinder the enactment of compassion. These issues and other aspects of the work environment decrease the satisfaction and well-being of professional caregivers and are contributing to a rising tide of burnout. Research suggests that employee engagement emerges from their satisfaction and well-being; however, it is difficult for an individual to engage when she or he feels depleted and unsupported. Nursing leaders and managers can play a significant role in support of compassionate practices for staff and improvement of the work environment and staff well-being. Compassion practices that recognize employees for the caring they show to patients and each other, and that provide the support needed to sustain their caring and compassion, are associated with significantly better patient ratings of their care experiences in hospitals and ambulatory settings. This article describes an example of a compassion practice, Schwartz Rounds®, a program that has been implemented internationally to enhance staff caring and compassion, teamwork, and psychological well-being. Schwartz Rounds have been included as a component of organizational initiatives to enhance staff well-being and patient experience, and as an individual program. Nurse leaders and managers who wish to engage their staff can do so by supporting their compassion and well-being.
Engaging Employees in Well-Being
Authors: Jacobs Barbara , McGovern Julie , Heinmiller Jamie , Drenkard Karen
Published: June 2018

Anne Arundel Medical Center has been on a 3-year journey to improve employee well-being with the assumption that employee well-being and employee engagement are interconnected. Improvements in employee well-being will result in increased employee engagement and will be a pivotal driver to assist the health system meet its goals. Historically, Anne Arundel Medical Center successfully differentiated itself in the market by being the region's high-quality, low-cost provider of health services delivered through intense collaboration with patients and families. The financial, quality, and patient satisfaction results are in the top percentiles nationwide. However, as the pace of change accelerates and the organization faces increased pressure to improve outcomes, keeping employees from becoming burned out and disengaged becomes an increasing concern. The WellBeing framework was developed on the basis of the work of Tom Rath and Jim Harter as the model to support Anne Arundel's WellBeing work. The efforts around well-being are comprehensive and impact all aspects of how work is conducted. Employee well-being has been elevated to an equal third prong along with providing high-quality low-cost care in a patient-centered environment. This focus on leading an employee WellBeing Program has resulted in improved engagement scores at Anne Arundel Medical Center.
International Nursing: Job Satisfaction Among Critical Care Nurses in a Governmental Hospital in Saudi Arabia
Authors: Mari Mohammad , Alloubani Aladeen , Alzaatreh Mohammad , Abunab Hamzeh , Gonzales Analita , Almatari Mohammad
Published: June 2018

Job satisfaction improves the outcome of health care services. Nurses' job satisfaction should receive more attention in Saudi Arabia, and worldwide. This study was undertaken to measure factors that affect job satisfaction among critical care nurses at King Khalid Hospital in Saudi Arabia. This study used a quantitative, cross-sectional method. A convenient sample of 190 critical care nurses was recruited from the main government hospital in Saudi Arabia. Job satisfaction scales were used in this study. Overall, the staff nurses were neither satisfied nor dissatisfied with their work. The majority of participating nurses were moderately satisfied with their relationships with coworkers (mean = 4.24, standard deviation [SD] = 1.66) and nature of their jobs (mean = 4.13, SD = 0.74). Their lowest satisfaction scores were related to communication (mean = 3.42, SD = 0.82), followed by pay (mean = 3.7, SD = 0.65), and supervision (mean = 3.75, SD = 0.55). Job satisfaction of staff nurses is marginal. This calls for leadership intervention. Decision-makers must consider this when adopting new policies to enhance nurses' job satisfaction.
Sustained Sexual Behavior Change After Acute HIV Diagnosis in Malawi
Authors: Rucinski Katherine B. , Rutstein Sarah E. , Powers Kimberly A. , Pasquale Dana K. , Dennis Ann M. , Phiri Sam , Hosseinipour Mina C. , Kamanga Gift , Nsona Dominic , Massa Cecilia , Hoffman Irving F. , Miller William C. , Pettifor Audrey E.
Published: June 2018

Background

Identification of acute HIV infection (AHI) allows for important opportunities for HIV prevention through behavior change and biomedical intervention. Here, we evaluate changes in sexual risk behaviors among persons with AHI enrolled in a combined behavioral and biomedical intervention designed to reduce onward transmission of HIV.

Methods

Participants were randomized to standard HIV counseling, a multisession behavioral intervention, or a multisession behavioral intervention plus antiretrovirals. Sexual behaviors were assessed periodically over 1 year.

Results

Four weeks after diagnosis, the predicted probability of reporting multiple sexual partners decreased from 24% to 9%, and the probability of reporting unprotected sex decreased from 71% to 27%. These declines in sexual risk behaviors were sustained over follow-up irrespective of study arm.

Conclusions

Diagnosis of AHI alone may be sufficient to achieve immediate and sustained behavior change during this highly infectious period.
Repeat Chlamydia Diagnoses Increase the Hazard of Pelvic Inflammatory Disease among US Army Women: A Retrospective Cohort Analysis
Authors: Bautista Christian T. , Hollingsworth Bruce P. , Sanchez Jose L.
Published: June 2018

Background

In the US military, chlamydia is the mostly commonly diagnosed bacterial sexually transmitted infection and the rates of pelvic inflammatory disease (PID) have remained high since the early 2000s.

Methods

The relationship between the number of chlamydia diagnoses and hazard of PID was investigated in a retrospective cohort analysis among US Army women from 2006 to 2012. Cox regression model was used to estimate hazard ratios for associations between the number of repeat chlamydia diagnoses and PID.

Results

The study population comprised 33,176 women with chlamydia diagnosis. Of these, 25,098 (75%) were diagnosed only once (“nonrepeaters”). By comparison, 6282 (19%), 1435 (4%), and 361 (1%) women had one, two and three repeat chlamydia diagnoses, respectively. Among these 4 groups, 1111, 325, 72, and 25 PID diagnoses were noted. According to the Cox regression analysis, for every additional diagnosis of chlamydia, the hazard of PID increased by 28% (95% confidence interval, 19%–38%) compared with women with a single diagnosis or nonrepeaters. Moreover, the corresponding adjusted hazard ratio of 1.28, 1.35, and 1.97 represented a significantly greater risk for PID among the three “repeater” groups compared with nonrepeaters.

Conclusions

We found an increased hazard of PID among US Army women with repeat chlamydia diagnoses and the characterization of a dose-response relationship. These findings reinforce the notion that early diagnosis and treatment of chlamydia is necessary to avoid subsequent PID and associated morbidity.
ALK Expression in Angiomatoid Fibrous Histiocytoma
Authors: Cheah Alison L. , Zou Youran , Lanigan Christopher , Billings Steven D. , Rubin Brian P. , Hornick Jason L. , Goldblum John R.
Published: June 2018

We recently encountered a case of primary pulmonary angiomatoid fibrous histiocytoma (AFH), which was initially misdiagnosed as inflammatory myofibroblastic tumor (IMT) based in part on anaplastic lymphoma kinase (ALK) expression by immunohistochemistry (IHC). Prompted by this experience, we evaluated ALK expression in 11 AFH, 15 IMT, and 11 follicular dendritic cell sarcomas using 3 different antibody clones: D5F3, 5A4, and ALK1. ALK IHC positive cases were analyzed with fluorescence in situ hybridization (FISH) using dual color ALK break-apart probe kit. The majority of AFH cases studied were positive for ALK IHC with at least 1 antibody (9/11 D5F3, 6/9 5A4, 1/9 ALK1), most demonstrating moderate to strong cytoplasmic staining. AFH with positive ALK IHC showed no ALK gene rearrangement by FISH (0/8) with ALK copy number ranging from 1.6 to 2.1. Sixty-seven percent of IMT were ALK positive by IHC (10/15 D5F3, 8/15 5A4, 7/15 ALK1), and 9 of the 10 cases were positive for ALK gene rearrangement by FISH. All follicular dendritic cell sarcomas were negative for ALK by IHC (D5F3 and 5A4). Our results indicate that ALK expression in AFH is common, particularly with the highly sensitive D5F3 and 5A4 antibodies and enhanced detection systems, and may be a potential source of diagnostic confusion with IMT. The underlying mechanism of ALK expression in AFH is unclear, although it does not appear to be from ALK rearrangement or amplification.
Narrative Medicine in Amyotrophic Lateral Sclerosis and a Rehabilitation Project Based on International Classification of Functioning, Disability and Health
Authors: Ciotti Silvia , Bianconi Fortunato , Saraceni Vincenzo Maria , Vulpiani Maria Chiara , Rinonapoli Giuseppe , Caraffa Auro , Zampolini Mauro
Published: June 2018

Objective

The aim of the study was to systematize the disability condition related to amyotrophic lateral sclerosis patients using the International Classification of Functioning, Disability and Health (ICF) and narrative medicine approach as a common tool to identify a patient's functional problems. Once identified, this can be used as the basis for an individual rehabilitation project.

Design

This is an observational study on patients residing in a central region of Italy with a diagnosis of amyotrophic lateral sclerosis. The narrative approach involved listening to the patients' stories while guiding them with a semistructured questionnaire of 19 ICF items taken from the WHO Disability Assessment Schedule. A score from 0 to 4 for capacity (C) and performance (P) was adopted to evaluate each patient's functioning in their daily living activities.

Results

The ICF questionnaire was able to discriminate among responders (P < 0.001). The disability areas were in daily activities and social life (capacity 3–4, performance 3–4), whereas the performance items using facilitators were in the areas of communication, movement, personal care, and interaction with people (capacity 3–4, performance 1–2).

Conclusions

Narrative medicine using ICF in amyotrophic lateral sclerosis highlighted the main rehabilitation goals necessary to personalize a rehabilitation program, emphasizing the gap between capacity and performance. The environmental factors facilitating the areas of communication, movement, personal care, and interaction with people and not influencing daily activities and social life were identified.
Surgical Management and Outcomes of Pierre Robin Sequence: A Comparison of Mandibular Distraction Osteogenesis and Tongue-Lip Adhesion
Authors: Zhang Rosaline S. , Hoppe Ian C. , Taylor Jesse A. , Bartlett Scott P.
Published: June 2018

There is a paucity of literature directly comparing tongue-lip adhesion versus mandibular distraction osteogenesis in surgical treatment of patients with Pierre Robin sequence. This study comprehensively reviews the literature for evaluating airway and feeding outcomes following mandibular distraction osteogenesis and tongue-lip adhesion. A search was performed using the MEDLINE and Embase databases for publications between 1960 and June of 2017. English-language, original studies subjects were included. Extracted data included prevention of tracheostomy (primary airway outcome) and ability to feed exclusively by mouth (primary feeding outcome). A total of 67 studies were included. Ninety-five percent of subjects (657 of 693) treated with mandibular distraction osteogenesis avoided tracheostomy, compared to 89% of subjects (289 of 323) treated with tongue-lip adhesion. Eighty-seven percent of subjects (323 of 370) treated with mandibular distraction osteogenesis achieved full oral feeds at latest follow-up. Seventy percent of subjects (110 of 157) treated with tongue-lip adhesion achieved full oral feeds at latest follow-up. The incidence of second intervention for recurrent obstruction ranged from 4 to 6 percent in mandibular distraction osteogenesis studies, compared to a range of 22 to 45 percent in tongue-lip adhesion studies. Variability of patient selection, surgical techniques, outcomes measurement methods, and follow-up length across studies precluded meta-analysis of the data. Both mandibular distraction osteogenesis and tongue-lip adhesion are effective alternatives to tracheostomy for patients who fail conservative management and improve feeding. Mandibular distraction osteogenesis may be superior to tongue-lip adhesion in long-term resolution of airway obstruction and avoidance of gastrostomy, but is associated with notable complications.