bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical Examination for the Prediction of Mortality in the Critically Ill: The Simple Intensive Care Studies-I
Authors: Hiemstra Bart , Eck Ruben J. , Wiersema Renske , Kaufmann Thomas , Koster Geert , Scheeren Thomas W.L. , Snieder Harold , Perner Anders , Pettilä Ville , Wetterslev Jørn , Keus Frederik , van der Horst Iwan C.C.
Published: July 2019

Objectives:

Caregivers use clinical examination to timely recognize deterioration of a patient, yet data on the prognostic value of clinical examination are inconsistent. In the Simple Intensive Care Studies-I, we evaluated the association of clinical examination findings with 90-day mortality in critically ill patients.

Design:

Prospective single-center cohort study.

Setting:

ICU of a single tertiary care level hospital between March 27, 2015, and July 22, 2017.

Patients:

All consecutive adults acutely admitted to the ICU and expected to stay for at least 24 hours.

Interventions:

A protocolized clinical examination of 19 clinical signs conducted within 24 hours of admission.

Measurements Main Results:

Independent predictors of 90-day mortality were identified using multivariable logistic regression analyses. Model performance was compared with established prognostic risk scores using area under the receiver operating characteristic curves. Robustness of our findings was tested by internal bootstrap validation and adjustment of the threshold for statistical significance. A total of 1,075 patients were included, of whom 298 patients (28%) had died at 90-day follow-up. Multivariable analyses adjusted for age and norepinephrine infusion rate demonstrated that the combination of higher respiratory rate, higher systolic blood pressure, lower central temperature, altered consciousness, and decreased urine output was independently associated with 90-day mortality (area under the receiver operating characteristic curves = 0.74; 95% CI, 0.71–0.78). Clinical examination had a similar discriminative value as compared with the Simplified Acute Physiology Score-II (area under the receiver operating characteristic curves = 0.76; 95% CI, 0.73–0.79; p = 0.29) and Acute Physiology and Chronic Health Evaluation-IV (using area under the receiver operating characteristic curves = 0.77; 95% CI, 0.74–0.80; p = 0.16) and was significantly better than the Sequential Organ Failure Assessment (using area under the receiver operating characteristic curves = 0.67; 95% CI, 0.64–0.71; p < 0.001).

Conclusions:

Clinical examination has reasonable discriminative value for assessing 90-day mortality in acutely admitted ICU patients. In our study population, a single, protocolized clinical examination had similar prognostic abilities compared with the Simplified Acute Physiology Score-II and Acute Physiology and Chronic Health Evaluation-IV and outperformed the Sequential Organ Failure Assessment score.
Lactated Ringer’s Versus 4% Albumin on Lactated Ringer’s in Early Sepsis Therapy in Cancer Patients: A Pilot Single-Center Randomized Trial
Authors: Park Clarice Hyesuk Lee , de Almeida Juliano Pinheiro , de Oliveira Gisele Queiroz , Rizk Stéphanie Itala , Fukushima Julia Tizue , Nakamura Rosana Ely , Mourão Matheus Moraes , Galas Filomena Regina Barbosa Gomes , Abdala Edson , Pinheiro Freire Maristela , Kalil Filho Roberto , Costa Auler Jose Otavio , Nardelli Pasquale , Martin Greg S. , Landoni Giovanni , Hajjar Ludhmila Abrahao
Published: July 2019

Objective:

To investigate the effects of the administration of 4% albumin on lactated Ringer’s, when compared with lactated Ringer’s alone, in the early phase of sepsis in cancer patients.

Design:

Single-center, randomized, double-blind, controlled-parallel trial.

Setting:

A tertiary care university cancer hospital.

Patients:

Cancer patients with severe sepsis or septic shock.

Interventions:

Between October 2014 and December 2016, patients were randomly assigned to receive either bolus of albumin in a lactated Ringer’s solution or lactated Ringer’s solution alone during the first 6 hours of fluid resuscitation after intensive care medicine (ICU) admission. Primary outcome was defined as death from any cause at 7 days. Secondary outcomes were defined as death from any cause within 28 days, change in Sequence Organ Failure Assessment scores from baseline to day 7, days alive and free of mechanical ventilation, days alive and free of vasopressor, renal replacement therapy during ICU stay, and length of ICU and hospital stay.

Measurements and Main Results:

A total of 360 patients were enrolled in the trial. At 7 days, 46 of 180 patients (26%) died in the albumin group and 40 of 180 (22%) died in the lactated Ringer’s group (p = 0.5). At 28 days, 96 of 180 patients (53%) died in the albumin group and 83 of 180 (46%) died in the lactated Ringer’s group (p = 0.2). No significant differences in secondary outcomes were observed.

Conclusions:

Adding albumin to early standard resuscitation with lactated Ringer’s in cancer patients with sepsis did not improve 7-day survival.
Discharge Destination As a Marker of Mobility Impairment in Survivors of Acute Respiratory Distress Syndrome
Authors: Jolley Sarah E. , Angus Derek C. , Clermont Gilles , Hough Catherine L.
Published: July 2019

Objectives:

Discharge destination is a commonly used surrogate for long-term recovery in rehabilitation studies. We determined the accuracy of discharge destination as a surrogate marker for 6-month mobility impairment in acute respiratory distress syndrome survivors.

Design/Setting:

Secondary analysis of the Economic Analysis of Pulmonary Artery Catheters study, a long-term observational sub-study of the National Institutes of Health/National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network Fluid and Catheter Treatment Trial.

Patients:

Patients underwent functional assessment using the Health Utilities Index-2 mobility domains at 6 months. A score greater than or equal to 3 (i.e., need for assistive device) defined mobility impairment. Discharge to any institutional care constituted a care facility discharge. We used logistic regression to explore the association between discharge destination and mobility impairment. We generated test characteristics and receiver operating characteristics to assess the accuracy of discharge destination as a surrogate for mobility impairment.

Interventions:

None.

Measurements and Main Results:

A total of 591 patients were enrolled in Economic Analysis of Pulmonary Artery Catheters in whom 328 had functional measurements at 6 months with 116 (35%) of these patients discharged to a care facility. Care facility patients were older (mean age 53 vs 44 yr; p < 0.001) and had longer hospital durations (length of stay 29 vs 17 d; p < 0.001). Care facility discharge was associated with greater 6-month mobility impairment. Sensitivity and specificity of discharge to a care facility for mobility impairment were 40.5% (95% CI, 32.0–49.6%) and 79.3% (95% CI, 73.3–84.2%) at 6 months. Discharge destination alone was a poor discriminator of long-term mobility impairment (receiver operating characteristic area under the curve: 0.61 at 6 mo).

Conclusions:

Discharge to a care facility was strongly associated with mobility impairment 6 months after acute respiratory distress syndrome but discharge destination alone performed poorly as a surrogate for mobility impairment.
Infant, Maternal, and Neighborhood Predictors of Maternal Psychological Distress at Birth and Over Very Low Birth Weight Infants' First Year of Life
Authors: Greene Michelle M. , Schoeny Michael , Rossman Beverly , Patra Kousiki , Meier Paula P. , Patel Aloka L.
Published: July 2019

Objective:

To use a social-ecological conceptualization to analyze change of maternal distress, defined as depression, anxiety, and perinatal-specific post-traumatic stress (PPTS), across very low birth weight (VLBW) infants' first year of life and to identify infant, maternal, and neighborhood predictors of these changes over time.

Methods:

Mothers of VLBW infants (n = 69) completed psychological distress questionnaires 2 to 4 weeks after infant birth, 2 weeks before infant discharge from neonatal intensive care unit, and at infants' 4- and 8-month corrected age (age adjusted for prematurity). Infant and maternal sociodemographic data were collected from medical chart review. Neighborhood data were obtained through US census data. Multilevel linear growth modeling was used to (1) predict unstandardized estimates of mothers' initial levels of depression, anxiety, and PPTS at the time of infant's birth and the rate of change of these markers of distress over time and (2) model unstandardized estimates of infant, maternal, and neighborhood as predictors of distress at infants' birth and change over time.

Results:

Unstandardized estimates from multilevel linear growth modeling revealed depression (−2.8), anxiety (−1.4), and PPTS (−0.7) declined over infants' first year of life (<0.001). Mothers residing in lower-income homes and neighborhoods, respectively, reported lower anxiety (−11.2, p = 0.03) and PPTS (−31.1, p = 0.01) at infant birth. Greater infant birth weight predicted both lower anxiety (−0.02, p = 0.02) and lower PPTS (−0.02, p = 0.005).

Conclusion:

Mothers psychologically recover over VLBW infants' first year of life. Results add to a building literature about socioeconomically disadvantaged mothers of preterm infants, reporting lower distress; this warrants additional research.
Efficacy, Safety, and Subject Satisfaction After AbobotulinumtoxinA Treatment for Moderate to Severe Glabellar Lines
Authors: Monheit Gary D. , Baumann Leslie , Maas Corey , Rand Rhonda , Down Rebecca
Published: July 2019

BACKGROUND

The aesthetic use of botulinum toxins is widely accepted in routine treatment of glabellar lines.

OBJECTIVE

To strengthen existing efficacy and safety data, and examine subject satisfaction concerning abobotulinumtoxinA (ABO) treatment for moderate to severe glabellar lines.

MATERIALS AND METHODS

A 150-day prospective, single-dose, multicenter, randomized, parallel-group, placebo-controlled, double-blind study of 300 subjects treated with ABO (50 Units [U]). Response was defined as having no or mild glabellar lines after treatment (primary objective was Day 30 response). Glabellar line severity, onset and duration of effect, satisfaction, treatment emergent adverse events (TEAEs), and treatment-related adverse events (TRAEs) were assessed.

RESULTS

Median time to onset of effect was 2 days. Day 30, ABO treatment response was 89% and 85% for investigator and subject assessments, respectively (p < .001 vs placebo). At Day 120, 60% of subjects demonstrated ≥1 grade improvement and 45% at Day 150. Subject satisfaction concerning glabellar line appearance was high (93%) at Day 14 and maintained by 35% through Day 150 with ABO treatment. No serious AEs were related to study treatment.

CONCLUSION

Most ABO-treated subjects sustained ≥1 grade glabellar line improvements over 120 days, and satisfaction was maintained by >30% of subjects throughout 150 days. ABO was well tolerated.
Prevention of Progression of Lipedema With Liposuction Using Tumescent Local Anesthesia: Results of an International Consensus Conference
Authors: Sandhofer Matthias , Hanke C. William , Habbema Louis , Podda Maurizio , Rapprich Stefan , Schmeller Wilfried , Herbst Karen , Anderhuber Friedrich , Pilsl Ulrike , Sattler Gerhard , Sandhofer Martina , Moosbauer Werner , Sattler Sonja , Schauer Patrick , Faulhaber Jörg , Maier Sabine , Barsch Martin , Mindt Sonani , Halk Anne B.
Published: July 2019

BACKGROUND

Lipedema is a chronic, progressive disorder of subcutaneous adipose tissue that usually affects the lower extremities of women. Also known as “two-body syndrome,” the fat accumulations in lipedema are unsightly and painful. The disorder is well-known in Europe but is largely unrecognized and underdiagnosed in the United States.

OBJECTIVE

To hold the First International Consensus Conference on Lipedema with the purpose of reviewing current European guidelines and the literature regarding the long-term benefits that have been reported to occur after lymph-sparing liposuction for lipedema using tumescent local anesthesia.

METHODS

International experts on liposuction for lipedema were convened as part of the First International Congress on Lipedema in Vienna, Austria, June 9 to 10, 2017.

RESULTS

Multiple studies from Germany have reported long-term benefits for as long as 8 years after liposuction for lipedema using tumescent local anesthesia.

CONCLUSION

Lymph-sparing liposuction using tumescent local anesthesia is currently the only effective treatment for lipedema.
Characteristics of Opioid Prescriptions by Mohs Surgeons in the Medicare Population
Authors: Feng Hao , Kakpovbia Efe , Petriceks Aldis P. , Feng Paula W. , Geronemus Roy G.
Published: July 2019

BACKGROUND

Prescription opioid use often precedes opioid misuse, abuse, and addiction.

OBJECTIVE

To characterize the national opioid prescription practices of Mohs surgeons, with general dermatologists serving as a comparison group.

METHODS

A retrospective cross-sectional study using Medicare prescription data to analyze opioid prescription characteristics.

RESULTS

In 2014, 2,190 Mohs surgeons prescribed a total of 86,526 opioids, whereas 10,347 non-Mohs dermatologists prescribed 45,033 opioids. Among Mohs surgeons, 51.8% prescribed more than 10 opioids, whereas 93.3% of non-Mohs dermatologists prescribed 0 to 10. The estimated opioid prescription rates for Mohs surgeons and non-Mohs dermatologists were 5.9% and 0.7%, respectively. Among those prescribing at least 10 opioid claims, the mean number of opioids supplied and mean opioid prescription rate was 72.4 and 13.5, respectively, for Mohs surgeons versus 32.5 and 5.1 , respectively, for non-Mohs dermatologists. The mean days' supply of opioids was 3.9 for Mohs surgeons versus 7.9 for non-Mohs dermatologists. There was a minimal-to-moderate association between the number of procedures performed and the number of opioids prescribed. Men and Mohs surgeons located in southern states tend to prescribe a greater number of opioids.

CONCLUSION

Mohs surgeons prescribed short courses of opioids and less than both the national average and providers that care for patients in pain.
CYP17A1 Polymorphisms Are Linked to the Risk of Coronary Heart Disease in a Case–Control Study
Authors: Lu Shijuan , Zhong Jianghua , Zhang Yingai , Huang Kang , Wu Miao , Zhou Yilei , Li Qiang , Chen Zibin , Zhang Shufang , Zhou Honghao
Published: July 2019

Background:

Cytochrome P450 17A1 (CYP17A1) catalyzes the formation and metabolism of steroid hormones and is required for cortisol and androgens. There is increasing evidence that CYP17A1 plays an important role in the development of coronary heart disease (CHD). However, the association of CYP17A1 polymorphisms and CHD susceptibility is still not clear.

Methods:

We conducted a case–control study with 396 CHD cases and 461 healthy controls from Hainan province, China. Using the Agena MassARRAY platform, we genotyped 4 genetic variants (rs3740397, rs1004467, rs4919687, and rs3781286) in CYP17A1. Logistic regression analysis was used to assess the association of CYP17A1 polymorphisms with CHD risk by odds ratios (ORs) and 95% confidence intervals (CIs).

Results:

It showed that A allele of CYP17A1 rs4919687 carried with a 1.59-fold increased risk of CHD (OR = 1.59; 95% CI = 1.26–1.99; P < 0.001). Also, rs4919687 was significantly associated with CHD risk under various models (homozygote: OR = 3.60; 95% CI = 1.64–7.83; P = 0.001; dominant: OR = 1.51; 95% CI = 1.06–2.13; P = 0.021; recessive: OR = 3.28; 95% CI = 1.51–7.14; P = 0.003; additive: OR = 1.56; 95% CI = 1.17–2.07; P = 0.002). Moreover, analysis showed that Ars1004467 Ars4919687 haplotype was a protective factor of CHD (OR = 0.64; 95% CI = 0.48–0.86; P = 0.002).

Conclusions:

Our study suggests that CYP17A1 polymorphisms are associated with CHD susceptibility in the Hainan Han Chinese population.
Activation of Liver X Receptors by GW3965 Attenuated Deoxycorticosterone Acetate–Salt Hypertension-Induced Cardiac Functional and Structural Changes
Authors: Bal Nur Banu , Han Sevtap , Usanmaz Suzan Emel , Kiremitci Saba , Sadi Gökhan , Uludag Orhan , Demirel-Yilmaz Emine
Published: July 2019

In this study, the effect of liver X receptor (LXR) activation on hypertension-induced cardiac structural and functional alterations was investigated. Hypertension was induced by deoxycorticosterone acetate (DOCA)-salt administration in uninephrectomized rats for 6 weeks. LXR agonist GW3965 (3-{3-[(2-chloro-3-trifluoromethyl-benzyl)-(2,2-diphenyl-ethyl)-amino]-propoxy}-phenyl)-acetic acid was given for the past week. Rhythmic activity and contractions of the isolated heart tissues were recorded. Biochemical parameters were assessed in ventricular tissue and plasma samples. Cardiac expressions of various proteins were examined, and histopathological evaluation was performed in the left ventricle and liver. GW3965 reduced systolic blood pressure and enhanced noradrenaline-stimulated papillary muscle contraction induced by DOCA-salt + uninephrectomy. Plasma and tissue total antioxidant capacity (TAC) increased and tissue 4-hydroxynonenal (4-HNE) levels decreased in the DOCA-salt group. GW3965 elevated plasma and tissue TAC levels in both of groups. Glucose-regulated protein-78 (GRP78), phospho-dsRNA-activated-protein kinase–like ER kinase (p-PERK), matrix metalloproteinase-2 (MMP-2), and nuclear factor-κB p65 (NF-κB p65) expression was augmented, and inhibitor-κB-α (IκB-α) expression was reduced in hypertensive hearts. The altered levels of all these markers were reversed by GW3965. Also, GW3965 ameliorated DOCA-salt + uninephrectomy-induced cardiac and hepatic inflammation and fibrosis. However, GW3965 unchanged the plasma lipid levels and hepatic balloon degeneration score. These results demonstrated that LXR activation may improve hypertension-induced cardiac changes without undesired effects.
Inhibiting NLRP3 Inflammasome Activity in Acute Myocardial Infarction: A Review of Pharmacologic Agents and Clinical Outcomes
Authors: Buckley Leo F. , Libby Peter
Published: July 2019

The NLRP3 inflammasome is an intracellular, multimeric protein complex that initiates a potent inflammatory response to danger signals. After acute myocardial infarction, NLRP3 inflammasome-dependent inflammation promotes adverse left ventricular remodeling and recurrent atherosclerotic events. Selective and nonselective inhibitors of the NLRP3 inflammasome or its downstream effectors (interleukin-1β and interleukin-18) may prevent adverse left ventricular remodeling and recurrent atherosclerotic events. In this review, we highlight strategies to inhibit NLRP3 inflammasome activity and their potential roles in the management of acute myocardial infarction.
Effects of Oral Anticoagulants on Patients With Atrial Fibrillation Aged 90 Years and Older: Comparison Among Direct Oral Anticoagulant, Warfarin Anticoagulant, and Nonanticoagulation
Authors: Yamaji Hirosuke , Higashiya Shunichi , Murakami Takashi , Hina Kazuyoshi , Kawamura Hiroshi , Murakami Masaaki , Kamikawa Shigeshi , Hirohata Satoshi , Kusachi Shozo
Published: July 2019

This study aimed to investigate the effects of anticoagulants on ultra-aged patients with nonvalvular atrial fibrillation (AF). We retrospectively studied 320 consecutive patients with AF (median age, 91 years; range 90–100.1 years). Patients were categorized as follows: patients taking direct oral anticoagulant (DOAC group, n = 93), those taking warfarin (warfarin group, n = 147), and those not taking oral anticoagulants (non-OAC group, n = 80). During the follow-up periods (median 3.00 years; first and fourth quantiles, 1.13 and 4.56 years, respectively), in thromboembolic events, the DOAC, warfarin, and non-OAC groups showed the lowest (0%, 0/93; 0%/year), intermediate (4.7%, 7/149; 1.43%/year), and highest (5%, 4/80; 2.65%/year) incidence rates, respectively. In major bleeding events, the DOAC, warfarin, and non-OAC groups showed the highest (9.67%, 9/96; 5.00%/year), intermediate (8.1%, 12/149; 2.46%/year), and lowest (0%, 0/80; 0%/year) incidence rates, respectively. These differences in the relationships of the 3 groups were statistically significant. Confounding factors did not affect these results. Bruises associated with impairment of motor function with aging caused major bleeding in approximately 60% of major bleeding cases. The Cox proportional hazards model revealed that warfarin decreased mortality, whereas antiplatelet drugs increased mortality. In conclusion, DOACs had considerably high incidence of major bleeding events, whereas absence of OAC treatment was associated with substantially high thromboembolic events. Warfarin showed acceptable incidence ratios of both events. At present, warfarin is thus believed to be adequate for ultra-aged (≥90 years) patients with nonvalvular AF. Avoidance of bruises was important to prevent major bleeding events. Antiplatelet drugs were suggested not to be adequate for these patients.
NLRP3 Inflammasome: A Novel Player in Metabolically Induced Inflammation—Potential Influence on the Myocardium
Authors: Sokolova Marina , Ranheim Trine , Louwe Mieke C. , Halvorsen Bente , Yndestad Arne , Aukrust Pål
Published: July 2019

Metabolic and immune systems are among the most fundamental requirements for survival. Many metabolic and immune response pathways or nutrient- and pathogen-sensing systems are evolutionarily conserved throughout species. As a result, the immune response and metabolic regulation are highly integrated and the proper function of each is dependent on the other. This interaction between metabolic disturbances and the immune system has been most extensively studied in disorders related to obesity such as insulin resistance, type 2 diabetes, and nonalcoholic fatty liver disease. Metabolically induced inflammation seems also to play a role in the development and progression of atherosclerosis including its complications such as myocardial infarction (MI) and post-MI remodeling. There are several lines of evidence suggesting that NOD-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome is a sensor of metabolic stress linking metabolic disturbances to inflammation. Here, we will discuss the role of the NLRP3 inflammasome in the pathogenesis of obesity and diabetes, 2 important risk factors for atherosclerosis and MI. We will also discuss the role of NLRP3 inflammasome in the interaction between metabolic disturbances and myocardial inflammation during MI and during metabolically induced myocardial remodeling.
Successful COMPASS, Disappointing COMMANDER HF, What Have We Learned From These Two Trials?
Authors: He Yuhu , Hu Xinqun , Zhou Shenghua
Published: July 2019

Despite considerable progress in the field of heart failure about drugs and device therapy, the mortality rate of patients with heart failure remains high. Studies have shown that thromboembolism and stroke are associated with high mortality in patients with heart failure. Although warfarin therapy reduces the rate of ischemic stroke in patients with heart failure, the overall benefit from warfarin in this population seems to be offset by the increased bleeding risk. Thus, whether patients with chronic heart failure might benefit from anticoagulation, especially in patients with sinus rhythm, is still controversial. Rivaroxaban, a new oral anticoagulant, is a selective direct factor Xa inhibitor that is used to reduce thrombin generation, which may bring hope to anticoagulation in patients with heart failure. However, the COMPASS trial and recently published COMMANDER HF trial presented different results. By carefully analyzing 2 clinical trials, we think several factors might explain this different outcome.
Flow-oriented Venous Anastomosis to Control Lymph Flow of Lymphatic Malformation
Authors: Kato Motoi , Watanabe Shoji , Watanabe Azusa , Iida Takuya
Published: July 2019

Background:

Less-invasive surgeries, such as lymphaticovenular anastomosis (LVA), are the widely accepted intervention for lymphedema. This study aimed to assess the outcomes of flow-oriented LVA modification on lymphatic malformation (LM).

Methods:

We included 19 patients diagnosed with LM mixed type or microcystic type, who came to our clinic from June 2015 to December 2017. Under general anesthesia, all patients were administered an indocyanine green lymphography injection subcutaneously. In the case of a strong inflow, the patient underwent afferent lymph vessel of LM to venous anastomosis (LMVA). Otherwise, the side wall of LMVA was performed to the cysts. Outcomes were classified into the following groups based on the size changes: treatment effect (TE) 4 = >80% reduction rate; TE 3 = 50%–80% reduction rate; TE 2 = 20%–50% reduction rate; and TE 1 = 0%–20% reduction rate.

Results:

All cases underwent surgery, with no case having an increased size. The results were as follows: TE 4 = 4 (21%) patients; TE 3 = 6 (32%) patients; TE 2 = 5 (26%) patients; and TE 1 = 4 (21%) patients. No case required study termination due to disease progression. Minor complication occurred in 3 cases. One vesicle increased at the labial mucosa and one wound dehiscence that epithelized within 1 month.

Conclusion:

LMVA could be a novel, minimally invasive lymph flow-oriented surgical method for intractable LM.
A Novel Level I Oncoplastic Surgery Technique for Tumors Located in UIQ of the Breast Far from the Nipple: The “Cross” Technique
Authors: Kaviani Ahmad , Zand Sanaz , Ashraf-Ganjouei Amir , Younan Rami , Jacques Salmon Remy
Published: July 2019

Breast surgery was revolutionized with the use of oncoplastic reshaping techniques minimizing breast deformities and esthetic complications. However, the application of the current oncoplastic techniques becomes challenging in some situations such as small-size breasts and when the tumors are located in special locations of the breast, for example, upper inner quadrant. In this article, an optimized oncoplastic technique named the “Cross” technique is introduced to overcome the abovementioned problems in the surgery of breast tumors located in the upper inner quadrant far from the center of the breast. Nineteen oncoplastic surgeries were performed by the same breast surgeon. The mean diameter and weight of the excised specimens were 20 mm and 74 g. The mean age of the patients was 51 years. Clear surgical margins were obtained in all patients. There was no marked deformity in the breast after surgery. The optimized technique produced promising results in our hands when applied to a selected group of patients. Moreover, the technique was found to reduce the need for revision surgery in ptotic breasts, as the alteration in the shape of the breast undergoing surgery is not significant enough to introduce asymmetry to the breasts.
RETINAL HYPERREFLECTIVE FOCI IN TYPE 1 DIABETES MELLITUS
Authors: Schreur Vivian , de Breuk Anita , Venhuizen Freerk G. , Sánchez Clara I. , Tack Cees J. , Klevering B. Jeroen , de Jong Eiko K. , Hoyng Carel B.
Published: July 2019

Purpose:

To investigate hyperreflective foci (HF) on spectral-domain optical coherence tomography in patients with Type 1 diabetes mellitus across different stages of diabetic retinopathy (DR) and diabetic macular edema (DME) and to study clinical and morphological characteristics associated with HF.

Methods:

Spectral-domain optical coherence tomography scans and color fundus photographs were obtained of 260 patients. Spectral-domain optical coherence tomography scans were graded for the number of HF and other morphological characteristics. The distribution of HF across different stages of DR and DME severity were studied. Linear mixed-model analysis was used to study associations between the number of HF and clinical and morphological parameters.

Results:

Higher numbers of HF were found in patients with either stage of DME versus patients without DME (P < 0.001). A trend was observed between increasing numbers of HF and DR severity, although significance was only reached for moderate nonproliferative DR (P = 0.001) and proliferative DR (P = 0.019). Higher numbers of HF were associated with longer diabetes duration (P = 0.029), lower high-density lipoprotein cholesterol (P = 0.005), and the presence of microalbuminuria (P = 0.005). In addition, HF were associated with morphological characteristics on spectral-domain optical coherence tomography, including central retinal thickness (P = 0.004), cysts (P < 0.001), subretinal fluid (P = 0.001), and disruption of the external limiting membrane (P = 0.018).

Conclusion:

The number of HF was associated with different stages of DR and DME severity. The associations between HF and clinical and morphological characteristics can be of use in further studies evaluating the role of HF as a biomarker for disease progression and treatment response.
MULTIMODAL EVIDENCE OF TYPE 3 NEOVASCULARIZATION IN ENHANCED S-CONE SYNDROME
Authors: Maldonado Ramiro S. , Zein Wadih M. , Cukras Catherine
Published: July 2019

Purpose:

To investigate, using multimodal imaging, the anatomy of neovascularization in eyes with enhanced S-cone syndrome.

Methods:

Three eyes with neovascularization, from two patients with enhanced S-cone syndrome, were analyzed using fluorescein angiography, indocyanine-green and optical coherence tomography angiography imaging.

Results:

The eyes reported had a demonstrable Type 3 neovascularization with evidence of retinal–retinal anastomoses on fluorescein angiography, indocyanine-green and optical coherence tomography angiography imaging. One eye that was initially without neovascularization, but with chronic macular edema developed a macular hemorrhage. This eye was treated with 8 injections of intravitreal bevacizumab over 29-months resulting in a final fibrovascular lesion. The characteristics of this final lesion share similarities to the two other eyes described. In all eyes and all exams, retinal vessels are observed to communicate with the subretinal fibrovascular lesion.

Conclusion:

We provide evidence of retinal arteriovenous anastomosis of the superficial retinal plexus to a subretinal neovascular complex in patients with enhanced S-cone syndrome and point to similarities with Type 3 neovascularization in macular telengiectasia Type 2 (MacTel2) and age-related macular degeneration. These findings provide insights into the anatomy of neovascularization in these pathologies and may lead to hypotheses of their etiologies.
A randomized controlled efficacy trial of mindfulness-based stress reduction compared with an active control group and usual care for fibromyalgia: the EUDAIMON study
Authors: Pérez-Aranda Adrián , Feliu-Soler Albert , Montero-Marín Jesús , García-Campayo Javier , Andrés-Rodríguez Laura , Borràs Xavier , Rozadilla-Sacanell Antoni , Peñarrubia-Maria Maria T. , Angarita-Osorio Natalia , McCracken Lance M. , Luciano Juan V.
Published: July 2019

Fibromyalgia (FM) syndrome represents a great challenge for clinicians and researchers because the efficacy of currently available treatments is limited. This study examined the efficacy of mindfulness-based stress reduction (MBSR) for reducing functional impairment as well as the role of mindfulness-related constructs as mediators of treatment outcomes for people with FM. Two hundred twenty-five participants with FM were randomized into 3 study arms: MBSR plus treatment-as-usual (TAU), FibroQoL (multicomponent intervention for FM) plus TAU, and TAU alone. The primary endpoint was functional impact (measured with the Fibromyalgia Impact Questionnaire Revised), and secondary outcomes included “fibromyalginess,” anxiety and depression, pain catastrophising, perceived stress, and cognitive dysfunction. The differences in outcomes between groups at post-treatment assessment (primary endpoint) and 12-month follow-up were analyzed using linear mixed-effects models and mediational models through path analyses. Mindfulness-based stress reduction was superior to TAU both at post-treatment (large effect sizes) and at follow-up (medium to large effect sizes), and MBSR was also superior to FibroQoL post-treatment (medium to large effect sizes), but in the long term, it was only modestly better (significant differences only in pain catastrophising and fibromyalginess). Immediately post-treatment, the number needed to treat for 20% improvement in MBSR vs TAU and FibroQoL was 4.0 (95% confidence interval [CI] = 2.1-6.5) and 5.0 (95% CI = 2.7-37.3). An unreliable number needed to treat value of 9 (not computable 95% CI) was found for FibroQoL vs TAU. Changes produced by MBSR in functional impact were mediated by psychological inflexibility and the mindfulness facet acting with awareness. These findings are discussed in relation to previous studies of psychological treatments for FM.
Frequency, Risk Factors, and Clinical Significance of Incorrect Dose of Alteplase Due to Weight Estimation in Acute Ischemic Stroke Patients: A Single-Center Retrospective Study
Authors: Staszewski Jacek , Dębiec Aleksander , Derbich Marta , Antoniak Mateusz , Stępień Adam
Published: July 2019

Stroke is a clinical emergency requiring urgent recombinant tissue-type plasminogen activator treatment in eligible patients. The dosage of thrombolytic agent (alteplase) is weight dependent. However, many patients receive thrombolytic therapy based on weight estimation. Here, we assess the frequency of incorrect thrombolytic therapy dose as a result of weight estimation and evaluate the short-term safety and efficacy of alteplase misdose. Of 237 patients, weight was estimated in 147 (62%), of which 33 patients (22.4%) were treated with an erroneous dose of alteplase. An incorrect dose was associated with neither poor outcome nor a lower risk of hemorrhage. We conclude that hospitals should implement reliable methods for measuring patients’ weight that could be easily applied and would not cause delays to the treatment of stroke patients.
Relationship Between Anticoagulant Medication Adherence and Satisfaction in Patients With Stroke
Authors: Oliveira-Kumakura Ana Railka de Souza , Pacheco Ingrid , de Oliveira Henrique Ceretta , Rodrigues Roberta Cunha Matheus
Published: July 2019

AIM: The aim of this study was to investigate the accuracy of the self-reported measure of adherence and the relation between adherence to warfarin use, demographic and clinical variables, and the satisfaction with the treatment in patients affected by stroke. METHODS: This is a correlational, quantitative, and cross-sectional study, carried out in the outpatient clinics of a public university hospital from October 2017 to April 2018. Sociodemographic and clinical data were collected through interviews and hospital charts, as well as by applying the Measurement of Treatment Adherence (MTA) and the Duke Anticoagulation Satisfaction Scale, in their Brazilian versions. Results of the international normalized ratio (INR) were collected. Measurements of accuracy of the MTA scale were calculated in relation to the INR classification. RESULTS: Of 99 patients (55.6% male with a mean age of 58.6 years), 57.6% presented with therapeutic INR values and 75.8% of the patients were adherent to the oral anticoagulant therapy according to the MTA. The accuracy analysis of the measurement provided by the MTA scale in relation to the INR classification showed a sensitivity of 77.2% and a specificity of 26.2%. The patients’ satisfaction with the treatment was high. The Duke Anticoagulation Satisfaction Scale had an average total score of 46.4, with the dimension impact in the field having the highest score (20.3). CONCLUSION: Stroke patients were adherent and satisfied with the oral anticoagulant therapy. The MTA had good sensitivity and poor specificity. Sociodemographic and clinical characteristics identified were not associated with adherence and satisfaction with treatment.
Physical and Emotional Burden of the Epley Maneuver in the Elderly
Authors: Maas Britta D. P .J. , Bruintjes Tjasse D. , van der Zaag-Loonen Hester J. , Winters Stephanie M. , Masius-Olthof Sylvia , Colijn Carla , Benthem Peter Paul G. van , van Leeuwen Roeland B.
Published: July 2019

Objective:

To analyze and compare experiences of anxiety and discomfort caused by the Epley maneuver and the willingness for a potential retreatment between younger (≤70 yr) and older (>70 yr) patients.

Study Design:

Prospective, observational cohort study.

Setting:

Tertiary referral center.

Methods:

Dutch adults, diagnosed with posterior canal benign paroxysmal positional vertigo, were included. Patients with dementia or subjected to an Epley maneuver ≤4 months before the hospital visit were excluded. Patients were asked about their experiences with the Epley maneuver directly after the maneuver, after 2 weeks and after 2 months. Differences in experiences between the age groups were tested with the Fisher's exact test and subgroup analyses were performed using multivariable logistic regression.

Results:

Out of 179 included patients, 115 (64%) were aged ≤70 and 134 (75%) were female. In both groups, 25% reported anxiety directly after the Epley maneuver. Two weeks later, 19 and 27%, respectively (p = 0.26) reported anxiety. In the young group, 30% expressed discomfort directly after treatment compared with 45% in the elderly (OR 1.98, 95% CI 1.05–3.75,p = 0.04). Two weeks later, this was 36 and 38%, respectively (p = 0.87). This decreased to 24 and 33%, respectively (p = 0.37), after 2 months. There was no significant difference in willingness for potential retreatment between both groups after 2 weeks (93 and 95%, respectively,p = 0.75) nor after 2 months (97 and 92%, respectively,p = 0.13).

Conclusion:

The Epley maneuver results in little anxiety and discomfort both in young and in elderly patients. Most patients show willingness for potential retreatment in case symptoms recur.
Is it time to abandon glucose control in critically ill adult patients?
Authors: Krinsley James S. , Preiser Jean-Charles
Published: July 2019

Purpose of review

To summarize the advances in literature that support the best current practices regarding glucose control in the critically ill.

Recent findings

There are differences between patients with and without diabetes regarding the relationship of glucose metrics during acute illness to mortality. Among patients with diabetes, an assessment of preadmission glycemia, using measurement of Hemoglobin A1c (HgbA1c) informs the choice of glucose targets. For patients without diabetes and for patients with low HgbA1c levels, increasing mean glycemia during critical illness is independently associated with increasing risk of mortality. For patients with poor preadmission glucose control the appropriate blood glucose target has not yet been established. New metrics, including stress hyperglycemia ratio and glycemic gap, have been developed to describe the relationship between acute and chronic glycemia.

A ‘personalized’ approach to glycemic control in the critically ill, with recognition of preadmission glycemia, is supported by an emerging literature and is suitable for testing in future interventional trials.
Diagnosing invasive pulmonary aspergillosis in ICU patients: putting the puzzle together
Authors: Blot Stijn , Rello Jordi , Koulenti Despoina
Published: July 2019

Purpose of review

The approach to diagnose invasive pulmonary aspergillosis in the absence of lung biopsy in ICU patients is reviewed. This approach should be based on four pillars: mycology, medical imaging, underlying conditions, and acute disease expression.

Recent findings

Diagnosing invasive pulmonary aspergillosis in the absence of histopathologic evidence is a matter of probability weighting. Initiating antifungal therapy in an early phase and with a lower likelihood of disease might outweigh further diagnostic workout with further delay in appropriate treatment. However, in ICU patients, a preemptive antifungal strategy has not been established yet.

For mycology, a positive galactomannan test on serum or broncho-alveolar lavage fluid is highly indicative of invasive pulmonary aspergillosis. The meaning of positive culture results, lateral-flow device test, or PCR-assay is ambiguous. A negative galactomannan or PCR test has high negative predictive value. Clinical features suggestive for invasive fungal disease on CT-scan are highly indicative but rare in ventilated patients. An immunocompromised status indicates high-risk. chronic obstructive pulmonary disease, hepatic cirrhosis, and AIDS indicate moderate risk. Invasive pulmonary aspergillosis in the absence of underlying conditions is rare. Acute diseases frequently associated with invasive pulmonary aspergillosis include sepsis and/or respiratory insufficiency because of influenza, acute respiratory distress syndrome, or pneumonia.
Immunotherapies for thyroid eye disease
Authors: Kahaly George J.
Published: July 2019

Purpose of review

Thyroid eye disease is a complex autoimmune disorder which causes substantial morbidity. It can result in orbital disfigurement, double vision, and visual loss. Consequently, it has a substantial negative effect on quality of life, mental health, and socioeconomic status. Most signs and symptoms of thyroid eye disease (TED) can be explained by the expansion of the orbital contents. Steroids are the mainstay of treatment in TED. However, recurrence may occur once steroids are withdrawn. Furthermore, in most cases, normal orbital anatomy is not restored, and skilled rehabilitative surgery is required to reduce disfigurement, double vision, and to preserve vision. Therefore, novel, causal, and more efficacious treatment strategies are warranted.

Recent findings

In the last decade, the pathophysiology of TED has also been revised with the identification of new potential therapeutic targets. Recent clinical trials have shown that considerable benefit may be derived from the addition of antiproliferative agents (e.g., mycophenolate sodium) in preventing deterioration after steroid cessation. In addition, targeted biologic therapies have shown promise, including teprotumumab (anti-IGFR) which appears to substantially reduce proptosis, rituximab (anti-CD20) which reduces inflammation and tocilizumab (anti-IL-6) which potentially benefits both of these parameters.

This short review summarizes the recent research developments in this area.
Identifying Common Predictors of Multiple Adverse Outcomes Among Elderly Adults With Type-2 Diabetes
Authors: Kabue Samuel , Liu Vincent , Dyer Wendy , Raebel Marsha , Nichols Greg , Schmittdiel Julie
Published: July 2019

Objective:

As part of a multidisciplinary team managing patients with type-2 diabetes, pharmacists need a consistent approach of identifying and prioritizing patients at highest risk of adverse outcomes. Our objective was to identify which predictors of adverse outcomes among type-2 diabetes patients were significant and common across 7 outcomes and whether these predictors improved the performance of risk prediction models. Identifying such predictors would allow pharmacists and other health care providers to prioritize their patient panels.

Research Design and Methods:

Our study population included 120,256 adults aged 65 years or older with type-2 diabetes from a large integrated health system. Through an observational retrospective cohort study design, we assessed which risk factors were associated with 7 adverse outcomes (hypoglycemia, hip fractures, syncope, emergency department visit or hospital admission, death, and 2 combined outcomes). We split (50:50) our study cohort into a test and training set. We used logistic regression to model outcomes in the test set and performed k-fold validation (k=5) of the combined outcome (without death) within the validation set.

Results:

The most significant predictors across the 7 outcomes were: age, number of medicines, prior history of outcome within the past 2 years, chronic kidney disease, depression, and retinopathy. Experiencing an adverse outcome within the prior 2 years was the strongest predictor of future adverse outcomes (odds ratio range: 4.15–7.42). The best performing models across all outcomes included: prior history of outcome, physiological characteristics, comorbidities and pharmacy-specific factors (c-statistic range: 0.71–0.80).

Conclusions:

Pharmacists and other health care providers can use models with prior history of adverse event, number of medicines, chronic kidney disease, depression and retinopathy to prioritize interventions for elderly patients with type-2 diabetes.
Intestinal lymphatic vessels and their role in chylomicron absorption and lipid homeostasis
Authors: Hokkanen Krista , Tirronen Annakaisa , Ylä-Herttuala Seppo
Published: July 2019

Purpose of review

In this review, we describe novel findings related to intestinal lipid transport in lymphatic vessels.

Recent findings

Studies have shown that chylomicron entry to lacteals and lymph movement in intestinal lymphatic capillaries is an active process. Regulators of this intestinal chylomicron transport include among others the autonomous nervous system, transcription factors like PLAGL2, and molecular regulators, such as VEGF-A/Nrp1/VEGFR1, VEGF-C/VEGFR3, DLL4, CALCRL and GLP-2. Chylomicron transport in intestinal lymphatics is now emerging not only as an option for drug delivery but also as a new candidate for drug targeting in lipid-related disorders.

Dysfunctions of lymphatic lipid transport can result in conditions such as dyslipidaemia. Intestinal lymphatics also provide several potential therapeutic possibilities: molecular regulation of lacteal cell-to-cell junctioning and lymph flow could provide new ways of treating conditions like hyperlipidaemia and associated diseases, such as atherosclerosis and other cardiovascular diseases, obesity, diabetes and fatty-liver disease. The intestinal lymphatic system can also be employed to deliver lipid nanoparticles as drug carriers to the venous circulation for improved treatment outcome. These findings highlight the importance and need for research on the different players of intestinal lymphatics in dietary lipid handling and therapeutic applications.
Monocytes and macrophages in atherogenesis
Authors: Amengual Jaume , Barrett Tessa J.
Published: July 2019

Purpose of review

Monocytes and macrophages are key players in the pathogenesis of atherosclerosis and dictate atherogenesis growth and stability. The heterogeneous nature of myeloid cells concerning their metabolic and phenotypic function is increasingly appreciated. This review summarizes the recent monocyte and macrophage literature and highlights how differing subsets contribute to atherogenesis.

Recent findings

Monocytes are short-lived cells generated in the bone marrow and released to circulation where they can produce inflammatory cytokines and, importantly, differentiate into long-lived macrophages. In the context of cardiovascular disease, a myriad of subtypes, exist with each differentially contributing to plaque development. Herein we describe recent novel characterizations of monocyte and macrophage subtypes and summarize the recent literature on mediators of myelopoiesis.

An increased understanding of monocyte and macrophage phenotype and their molecular regulators is likely to translate to the development of new therapeutic targets to either stem the growth of existing plaques or promote plaque stabilization.
Regulatory barriers to xenotransplantation
Authors: Goerlich Corbin E. , Chan Joshua L. , Mohiuddin Muhammad M.
Published: July 2019

Purpose of review

There is a grave discordance between supply and demand for patients with failing organs largely due to an insufficient donor pool for transplantation. Xenotransplantation has been proposed as a solution to bridge this gap.

Recent findings

Recent success over the last decade in nonhuman primate models, due to emerging gene-editing technologies combined with novel immunosuppression regimens, has produced promising results in pancreatic islet cell, heart, lung, kidney and liver xenotransplantations.

As the prospect of xenotransplantation is realized, safety and ethical considerations have come to the forefront of discussion. The WHO and World Health Assembly have encouraged member states to form regulatory bodies to govern human xenotransplantation studies with the highest standards. Here, we summarize the current regulatory landscape governing preclinical advances toward the first human clinical trials.