bluuebunny/crossref_metadata_2025 huggingface dataset:
Diagnosis and Management of Vasa Previa: A Comparison of 4 National Guidelines
Authors: Tsakiridis Ioannis , Mamopoulos Apostolos , Athanasiadis Apostolos , Dagklis Themistoklis
Published: July 2019

Importance

Vasa previa represents an uncommon and life-threatening condition for the fetus. The prenatal identification of the condition may improve the outcome.

Objective

The aim of this study was to synthesize and compare published evidence of 4 national guidelines on diagnosis and management of vasa previa.

Evidence Acquisition

A descriptive review of 4 recently published national guidelines on vasa previa was conducted: Royal College of Obstetricians and Gynaecologists on “Vasa Praevia: Diagnosis and Management,” Society for Maternal-Fetal Medicine on “Diagnosis and Management of Vasa Previa,” Society of Obstetricians and Gynaecologists of Canada on “Guidelines for the Management of Vasa Previa,” and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists on “Vasa Praevia.” These guidelines were compared regarding recommendations on diagnosis and management, while the quality of evidence was also reviewed based on each method of reporting.

Results

There were many similar recommendations in the compared guidelines regarding the diagnosis and management of vasa previa. Early prenatal diagnosis using ultrasound and color Doppler imaging, hospitalization or management as outpatients, and cesarean delivery in a tertiary center with experienced clinicians are the main recommendations.

Conclusions

Evidence-based guidelines may increase the awareness of the diagnosis and management of vasa previa among health care professionals and lead to more favorable perinatal outcomes.

Target Audience

Obstetricians and gynecologists, family physicians.

Learning Objectives

After participating in this activity, the learner should be better able to identify possible risk factors associated with vasa previa in pregnant women; describe the best diagnostic methods in pregnant women with vasa previa; and propose the appropriate management in cases of vasa previa.
Surrogate Molecular Classification of Invasive Breast Carcinoma: A Comparison Between Core Needle Biopsy and Surgical Excision, With and Without Neoadjuvant Therapy
Authors: Ambrosini-Spaltro Andrea , Zunarelli Elena , Bettelli Stefania , Lupi Massimo , Bernardelli Giuditta , Milani Marina , Ficarra Guido
Published: July 2019

Surrogate molecular classification identifies different subtypes of invasive breast carcinoma on the basis of their immunohistochemical markers. The purpose of the study is to verify whether the immunohistochemical markers and surrogate molecular subtypes can be correctly assessed on the core needle biopsy (CNB) when compared with the corresponding surgical excision (SE), with or without neoadjuvant treatment (NAT). Cases with invasive carcinomas identified on both CNB and SE were retrospectively selected. With immunohistochemistry for estrogen receptors (ER), progesterone receptors (PgR), Ki67, human epidermal growth factor receptor 2 (Her2), and molecular analysis for Her2, surrogate molecular classification was determined in 4 and 5 groups, according to the 2013 St Gallen consensus. A total of 1067 cases was considered and complete data for surrogate molecular classification were available for 988 cases (655 without NAT, 333 with NAT). Without NAT, concordance was strong for ER and Her2, moderate for PgR, and weak for Ki67; concordance for surrogate molecular classification was moderate. After NAT, lower concordance rates were recorded, with significant reduction of PgR (P<0.001) and Ki67 (P<0.001). Without NAT, the surrogate molecular subtypes of breast carcinoma can be reliably assessed on CNB; Ki67 and/or PgR may be repeated on SE when values are close to cutoffs to avoid tumor subtype misclassification. After NAT, it seems advisable to repeat at least Ki67 and PgR.
Cervical Mesonephric Adenocarcinoma With Novel FGFR2 Mutation
Authors: Skala Stephanie L. , Gregg Patricia A. , Orr James W. , Udager Aaron M. , Brown Noah A. , Cho Kathleen R.
Published: July 2019

Mesonephric adenocarcinoma is a rare tumor, accounting for <1% of cervical cancers. Well-differentiated mesonephric adenocarcinoma can be difficult to distinguish from diffuse mesonephric hyperplasia. Herein, we report a case of well-differentiated mesonephric adenocarcinoma with an FGFR2 mutation not previously reported in the literature. Nonselective tyrosine kinase inhibitors or FGFR2 inhibitors may represent options for targeted therapy.
Dual-Task Cost of Discrimination Tasks During Gait in People With Multiple Sclerosis
Authors: Gutiérrez-Cruz Carmen , Rojas Ruiz Francisco Javier , De La Cruz Marquez Juan Carlos , Gutiérrez-Davila Marcos
Published: July 2019

Purpose

The aim of the study was to assess dual-task cost to spatio-temporal gait parameters in people with multiple sclerosis and a matched control group.

Method

The multiple sclerosis group was composed of 17 participants with a diagnosis of multiple sclerosis and an Expanded Disability Status Scale score of less than 6. A total of 17 healthy participants were allocated to the control group by stratification. Controls were matched on the basis of age, sex, sociocultural habits, and body structure. Dual-task cost was determined by within-group repeated-measures analysis of variance. Participants were instructed to ambulate under normal conditions and perform a discrimination and decision-making task concurrently. Then, between-group analysis of variance was used to assess differences in mean dual-task cost between groups and determine dual-task cost differential. Testing was performed using three-dimensional photogrammetry and an electronic walkway.

Results

Based on dual-task cost differential, gait cycle time increase (−5.8%) and gait speed decrease (6.3%) because of multiple sclerosis–induced impairment.

Conclusions

During single- and dual-task conditions, gait speed was lower in multiple sclerosis participants, because of a shorter step length and increased swing time. Increased gait time might be the result of compensatory mechanisms adopted to maintain stability while walking specially during the double-support phases.
Anti-Inflammatory and Healing Effects of Pulsed Ultrasound Therapy on Fibroblasts
Authors: de Oliveira Perrucini Priscila Daniele , Poli-Frederico Regina Célia , de Almeida Pires-Oliveira Deise Aparecida , Dragonetti Bertin Larissa , Beltrão Pires Flavia , Shimoya-Bittencourt Walkiria , Martins Santos Viviane , Medeiros Coelho Julice , Franco de Oliveira Rodrigo
Published: July 2019

Objective

The aim of this study was to analyze the effects of low-intensity pulsed ultrasound therapy under different pulse regimes on cultures of semiconfluent L929 fibroblasts, evaluating cell viability, anatomical structural alterations, modulation of vascular endothelial growth factor, interleukin 6, collagen type 1 alpha 1, collagen type 1 alpha 2, and fibroblast growth factor 7, as well as the amount of inflammatory mediators interleukin 2, interleukin 4, interleukin 6, interferon γ, tumor necrosis factor, interleukin 17A, and interleukin 10 at 24, 48, and 72 hrs.

Design

The design was experimental study.

Methods

The treatments consisted of 0.2 W/cm2 doses at a frequency of 1 MHz, with a pulse rate of 10% and 20%. Viability was assessed by the MTT assay (3-(4,5-dimethylthiazole)-2,5-diphenyltetrazolium bromide), gene expression by real-time quantitative polymerase chain reaction, and cytokine quantification by flow cytometry.

Results

At 48 hrs, ultrasound enhanced cell viability and affected interleukin 6 cytokine production, vascular endothelial growth factor, interleukin 6, type 1 alpha 1 and alpha 2 collagens, and fibroblast growth factor 7 gene modulation.

Conclusions

Low-intensity pulsed ultrasound therapy had a biostimulatory effect on semiconfluent in vitro L929 fibroblast cells, where the group with a dose of 0.2 W/cm2-10% (G2) presented higher responses, in all the analyzed aspects, toward the dose pulsed to 20%, confirming its therapeutic properties related to the initial phases of tissue healing.
Weekend Admission to Inpatient Rehabilitation Facilities Is Associated With Transfer to Acute Care in a Nationwide Sample of Patients With Stroke
Authors: Shih Shirley L. , Flavin Marisa , Goldstein Richard , Slocum Chloe , Ryan Colleen M. , Singhal Aneesh , Frankel Jason , Zafonte Ross , Schneider Jeffrey C.
Published: July 2019

Objective

The aim of the study was to determine the impact of weekend versus weekday admission to an inpatient rehabilitation facility on the risk of acute care transfer in patients with stroke.

Design

This was a retrospective analysis using the Uniform Data System for Medical Rehabilitation, a national database comprising data from 70% of US inpatient rehabilitation facilities. A total of 1,051,436 adult (age ≥18 yrs) stroke cases were identified between 2002 and 2014 that met inclusion criteria. Logistic regression models were developed to test for associations between weekend (Friday–Sunday) versus weekday (Monday–Thursday) inpatient rehabilitation facility admission and transfer to acute care (primary outcome) and inpatient rehabilitation facility length of stay (secondary outcome), adjusting for relevant patient, medical, and facility variables. A secondary analysis examined acute care transfer from 2002 to 2009 before passage of the Affordable Care Act (ACA), 2010 to 2012 post–Affordable Care Act, and 2013 to 2014 after implementation of the Hospital Readmissions Reduction Program.

Results

Weekend inpatient rehabilitation facility admission was associated with increased odds of acute care transfer (odds ratio = 1.06, 95% confidence interval = 1.04–1.08) and slightly shorter inpatient rehabilitation facility length of stay (P < 0.001). Overall, the risk of acute care transfer decreased after the ACA and Hospital Readmissions Reduction Program.

Conclusions

Weekend admission to inpatient rehabilitation facility may pose a modest increase in the risk of transfer to acute care in patients with stroke.

To Claim CME Credits

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME

CME Objectives

Upon completion of this article, the reader should be able to: (1) Understand disparities in obesity rates among adolescents with mobility disabilities; (2) Describe limitations of current clinical screening methods of obesity in children with mobility disabilities; and (3) Identify potential alternatives for obesity screening in children with mobility disabilities.

Level

Advanced

Accreditation

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0
AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Projecting Cost Containment in the Operating Room Utilizing Incentivized Strategies to Reduce Healthcare Cost
Authors: Koppert Tanner , Tumin Dmitry , Tobias Joseph D. , Raman Vidya T.
Published: July 2019

Introduction:

Streamlining healthcare in United States is of paramount concern while maintaining standards of quality and safety. Incentivizing change may be even more effective in driving such measures. At Nationwide Children’s Hospital, we incentivize cost savings directly to the healthcare team member. In this project, we evaluated a simple substitution of a buretrol for Y-type tubing based on weight rather than age cutoffs.

Methods:

This was deemed a quality improvement project and therefore exempt from Institutional Review Board approval. We obtained costs of Y-type tubing versus buretrols. We interrogated the electronic medical record to quantify case volume in the main operating room according to age and weight. We calculated our costs to compare our current practice of using buretrol fo age ≤ 12 years and the planned practice of using buretrol for weight < 20 kg.

Results:

We identified 28,875 children ages 0-12 (60% weight <20kg) and 6,301 children ages 13-18 (0.1% weight <20kg) undergoing procedures in the main operating rooms over a 1-year period.. A unit cost savings of $4.40 substituting Y-type tubing for a buretrol was determined. Transitioning from age-based to weight-based criteria for buretrol use was determined to potentially save $51,260 over the period reviewed.

Conclusions:

Simple changes can impact efficiency and cost in healthcare. It is important to consider incentivizing such measures to help drive these changes. In the future, with more incentivized measures, hopefully we can successfully make an impact of efficiency and cost of healthcare in United States without compromising safety or quality.
Reversible tactile hypoesthesia associated with myofascial trigger points: a pilot study on prevalence and clinical implications
Authors: Moriwaki Katsuyuki , Shiroyama Kazuhisa , Yasuda Masako , Uesugi Fumihiko
Published: July 2019

Introduction:

Tactile hypoesthesia observed in patients with myofascial pain syndrome (MPS) is sometimes reversible when pain is relieved by trigger point injections (TPIs). We aimed to investigate the prevalence of such reversible hypoesthesia during TPI therapy and topographical relations between areas of tactile hypoesthesia and myofascial trigger points (MTrP) in patients with MPS.

Methods:

Forty-six consecutive patients with MTrP were enrolled in this study. We closely observed changes in areas of tactile hypoesthesia in patients who had tactile hypoesthesia at the first visit, and throughout TPI therapy. Tactile stimulation was given using cotton swabs, and the areas of tactile hypoesthesia were delineated with an aqueous marker and recorded in photographs.

Results:

A reduction in the size of hypoesthetic area with TPI was observed in 27 (58.7%) patients. All the 27 patients experienced a reduction in pain intensity by more than 50% in a numerical rating scale score through TPI therapy. In 9 patients, the reduction in the sizes of hypoesthetic areas occurred 10 minutes after TPI. Complete disappearance of tactile hypoesthesia after TPI therapy was observed in 6 of the 27 patients. Myofascial trigger points were located in the muscles in the vicinity of ipsilateral cutaneous dermatomes to which the hypoesthetic areas belonged.

Conclusion:

Our results indicate a relatively high prevalence of reversible tactile hypoesthesia in patients with MPS. Mapping of tactile hypoesthetic areas seems clinically useful for detecting MTrP. In addition, treating MTrP with TPI may be important for distinguishing tactile hypoesthesia associated with MPS from that with neuropathic pain.
Timing of Microsurgical Reconstruction in Lower Extremity Trauma: An Update of the Godina Paradigm
Authors: Lee Z-Hye , Stranix John T. , Rifkin William J. , Daar David A. , Anzai Lavinia , Ceradini Daniel J. , Thanik Vishal , Saadeh Pierre B. , Levine Jamie P.
Published: July 2019

Background:

Marko Godina, in his landmark paper in 1986, established the principle of early flap coverage for reconstruction of traumatic lower extremity injuries. The aim of this study was to determine how timing influences outcomes in lower extremity traumatic free flap reconstruction based on Godina’s original findings.

Methods:

A retrospective review identified 358 soft-tissue free flaps from 1979 to 2016 for below knee trauma performed within 1 year of injury. Patients were stratified based on timing of coverage: 3 days or less (early), 4 to 90 days (delayed), and more than 90 days (late). The delayed group was further divided into two groups: 4 to 9 days and 10 to 90 days. Flap outcomes were examined based on timing of reconstruction.

Results:

Flaps performed within 3 days after injury compared with between 4 to 90 days had decreased risk of major complications (OR, 0.40, p = 0.04). A receiver operating curve demonstrated day 10 to be the optimal day for predicting flap success. Flaps performed less than or equal to 3 days versus 4 to 9 days had no differences in any flap outcomes. In contrast, flaps performed within 4 to 9 days of injury compared to within 10 to 90 days were associated with significantly lower total flap failure rates (relative risk, 0.29, p = 0.025) and major complications (relative risk, 0.37, p = 0.002).

Conclusions:

Early free flap reconstruction performed within 3 days of injury had superior outcomes compared with the delayed (4 to 90 day) group, consistent with Godina’s original findings. However, as an update to his paradigm, this ideal early period of reconstruction can be safely extended to within 10 days of injury without an adverse effect on outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
The Impact of Cumulative Depression Along the HIV Care Continuum in Women Living With HIV During the Era of Universal Antiretroviral Treatment
Authors: Mills Jon C. , Pence Brian W. , Edmonds Andrew , Adedimeji Adebola , Schwartz Rebecca M. , Kassaye Seble , Cocohoba Jennifer , Cohen Mardge H. , Neigh Gretchen , Fischl Margaret A. , Kempf Mirjam-Colette , Adimora Adaora A.
Published: July 2019

Background:

Data are limited on cumulative impacts of depression on engagement in care and HIV outcomes in women living with HIV (WLWH) during the era of universal antiretroviral therapy (ART). Understanding the relationship of accumulated depression with HIV disease management may help identify benefits of interventions to reduce severity and duration of depressive episodes.

Setting:

A cohort of WLWH (N = 1491) from the Women's Interagency HIV Study at 9 sites across the US.

Methods:

This longitudinal observational cohort study (2013–2017) followed WLWH for a maximum of 9 semiannual visits. Depression was quantified as a time-updated measure of percent of days depressed (PDD) created from repeated assessments using the Center for Epidemiologic Studies Depression scale. Marginal structural Poisson regression models were used to estimate the effects of PDD on the risks of missing an HIV care appointment, <95% ART adherence, and virological failure (≥200 copies/mL).

Results:

The risk of missing an HIV care appointment [risk ratio (RR) = 1.16, 95% confidence interval = 0.93 to 1.45; risk difference (RD) = 0.01, −0.01 to 0.03], being <95% ART adherent (RR = 1.27, 1.06–1.52; RD = 0.04, −0.01 to 0.07), and virological failure (RR = 1.09, 1.01–1.18; RD = 0.01, −0.01 to 0.03) increased monotonically with increasing PDD (comparing those with 25 to those with 0 PDD). The total effect of PDD on virological failure was fully (%100) mediated by being <95% ART adherent.

Conclusions:

Time spent depressed increases the risk of virological failure through ART adherence, even in the era of universal ART regimes forgiving of imperfect adherence.
Improved Liver Diffusion-Weighted Imaging at 3 T Using Respiratory Triggering in Combination With Simultaneous Multislice Acceleration
Authors: Tavakoli Andrej , Attenberger Ulrike I. , Budjan Johannes , Stemmer Alto , Nickel Dominik , Kannengiesser Stephan , Morelli John N. , Schoenberg Stefan O. , Riffel Philipp
Published: July 2019

Objectives

The aim of this study was to retrospectively compare optimized respiratory-triggered diffusion-weighted imaging with simultaneous multislice acceleration (SMS-RT-DWI) of the liver with a standard free-breathing echo-planar DWI (s-DWI) protocol at 3 T with respect to the imaging artifacts inherent to DWI.

Materials and Methods

Fifty-two patients who underwent a magnetic resonance imaging study of the liver were included in this retrospective study. Examinations were performed on a 3 T whole-body magnetic resonance system (MAGNETOM Skyra; Siemens Healthcare, Erlangen, Germany). In all patients, both s-DWI and SMS-RT-DWI of the liver were obtained. Images were qualitatively evaluated by 2 independent radiologists with regard to overall image quality, liver edge sharpness, sequence-related artifacts, and overall scan preference. For quantitative evaluation, signal-to-noise ratio was measured from signal-to-noise ratio maps. The mean apparent diffusion coefficient (ADC) was measured in each liver quadrant. The Wilcoxon rank-sum test was used for analysis of the qualitative parameters and the paired Student t test for quantitative parameters.

Results

Overall image quality, liver edge sharpness, and sequence-related artifacts of SMS-RT-DWI received significantly better ratings compared with s-DWI (P < 0.05 for all). For 90.4% of the examinations, both readers overall preferred SMS-RT-DWI to s-DWI. Acquisition time for SMS-RT-DWI was 34% faster than s-DWI. Signal-to-noise ratio values were significantly higher for s-DWI at b50 but did not statistically differ at b800, and they were more homogenous for SMS-RT-DWI, with a significantly lower standard deviation at b50. Mean ADC values decreased from the left to right hepatic lobe as well as from cranial to caudal for s-DWI. With SMS-RT-DWI, mean ADC values were homogeneous throughout the liver.

Conclusions

Optimized, multislice, respiratory-triggered DWI of the liver at 3 T substantially improves image quality with a reduced scan acquisition time compared with s-DWI.
Acellular Dermal Matrix–sparing Direct-to-implant Prepectoral Breast Reconstruction
Authors: Viezel-Mathieu Alex , Alnaif Nayif , Aljerian Albaraa , Safran Tyler , Brabant Gordon , Boileau Jean-François , Dionisopoulos Tassos
Published: July 2019

Introduction

Refined mastectomy techniques, the advent of new technologies and materials such as acellular dermal matrix (ADM), cohesive gel silicone implants, and intraoperative tissue perfusion analysis, have fueled a resurgence in prepectoral breast reconstruction. This article aims to compare an immediate direct-to-implant prepectoral ADM-sparing approach with the traditional subpectoral 2-stage immediate reconstruction. A cost analysis within a Canadian-run single-payer system is also presented.

Methods

A retrospective 2-group comparative chart review study was performed (June 2015–January 2017) to identify all patients who underwent prepectoral direct-to-implant breast reconstruction using an ADM-sparing technique. The comparison group consisted of patients having undergone traditional 2-stage subpectoral reconstruction with ADM. All countable variables were included in the cost analysis, which was performed in Canadian dollars.

Results

A total of 77 patients (116 reconstructed breasts) were included. Both the prepectoral and subpectoral groups were comparable in size, demographics including age, diabetic and smoking status, and receiving neoadjuvant chemotherapy and postmastectomy radiotherapy. Patients having undergone direct-to-implant prepectoral reconstruction benefited from fewer follow-up visits (3.8 vs 5.4, respectively) and from less complications (24.7% vs 35.6%, respectively) including animation deformity. In addition, direct-to-implant prepectoral reconstruction costs 25% less than the 2-stage subpectoral reconstruction when all associated costs were considered.

Conclusion

Prepectoral implant placement avoids many of the disadvantages of the traditional 2 stage subpectoral reconstruction, including pectoralis muscle dissection, animation deformity, and multiple surgeries. As the first comparative cost analysis study on the subject, our ADM-sparing direct-to-implant prepectoral reconstruction method costs 25% less than the traditional 2-stage subpectoral reconstruction with a comparable complication profile.
Extensive Microsurgical Reconstruction of Chest Wall Defects for Locally Advanced Breast Cancer
Authors: Song Dajiang , Liu Dequan , Pafitanis Georgios , Liu Zeyang , Wang Xi , Zhou Xiao , Liu Jieqiong , Li Zan
Published: July 2019

Background

Despite improvements in the early detection of breast cancer, locally advanced breast cancer (LABC) involving the chest wall exists in developing countries. Surgical resection remains a controversial management option. This study aims to demonstrate the value of chest wall reconstructive techniques for large LABC defects and report long-term outcomes.

Materials and Methods

We report a 10-years single-unit experience in the reconstruction of large defects (>300 cm2). From 2007 to 2017, all LABC cases managed with large surgical resection with immediate microsurgical chest wall reconstruction were included in this study. Herein, we present the demographics, comorbidities, clinicopathological LABC characteristics, surgical techniques (free flap choice, recipient vessels), and outcomes (survival, complication, cosmesis, and patient satisfaction).

Results

Of the 104 LABC cases, free deep inferior epigastric artery perforator flap was performed in 41 (39.4%) cases, free anterolateral thigh flap in 5 (4.8%), free deep inferior epigastric artery perforator combined with pedicled transverse rectus abdominis myocutaneous (TRAM) flap in 23 (22.1%), free muscle-sparing transverse rectus abdominis muscle flap in 30 (28.9%), and free transverse upper gracilis flap in 5 (4.8%). Complications were low. Over a median follow-up of 49.5 months, the 3-year local recurrence rate and distant metastasis–free survival were 13.9% and 84.9%, respectively. In addition, the 3-year disease-free survival and overall survival were 84.2% and 92.0%, respectively. The rate of excellent and good ratings by the esthetic assessment panel was 83.0%, and the patient satisfaction rate was 90.0%.

Conclusion

Wide resection and microvascular free tissue transfer is oncologically safe in LABC with huge tumors and provides versatile solutions for the reconstruction of extensive chest wall defects. With favorable long-term survival and cosmetic outcomes, surgical resection of LABC combined with flap reconstruction may offer a practical approach in difficult and complicated cases.

Implications for Practice

In this retrospective review, it was demonstrated that wide resection followed by distinct chest wall reconstructive free flaps transfer is oncologically safe in LABC with huge tumors and provides useful solutions for the reconstruction of extensive chest wall defects.
Updates in opioid and nonopioid treatment for chronic breathlessness
Authors: Abdallah Sara J. , Jensen Dennis , Lewthwaite Hayley
Published: July 2019

Purpose of review

Chronic breathlessness is a troublesome symptom experienced by people with advanced malignant and nonmalignant disease. Disease-directed therapies are often insufficient in the management of chronic breathlessness. Therefore, pharmacological and nonpharmacological breathlessness-specific interventions should be considered for select patients.

Recent findings

There is some evidence to support the use of low-dose opioids (≤30 mg morphine equivalents per day) for the relief of breathlessness in the short term. However, additional studies are needed to understand the efficacy of opioids for chronic breathlessness in the long term.

Nonopioid therapies, including inspiratory muscle training, fan-to-face therapy, l-menthol and inhaled nebulized furosemide show some promise for the relief of breathlessness in advanced disease. There is insufficient evidence to support the use of anxiolytics and benzodiazepines and cannabis for chronic breathlessness.

More research is needed to identify therapies for the management of chronic breathlessness.
Impact of a National Private Health Insurer’s Prior Authorization Policy on Utilization of Vaginal Hysterectomy
Authors: Swenson Carolyn W. , Kamdar Neil S. , Seiler Kristian , Morgan Daniel M.
Published: July 2019

Objectives

On April 6, 2015, the largest private health insurer in the United States implemented a policy requiring prior authorization for all hysterectomies except those done as outpatient vaginal. The purpose of this policy was to increase utilization of vaginal hysterectomy; however, it is unknown whether this policy had its intended effect. We sought to analyze trends in hysterectomy routes before and after implementation of the prior authorization policy to see if utilization of vaginal hysterectomy increased.

Methods

This was a retrospective study using the Optum Clinformatics Data Mart national claims database of women enrolled in a single national private health insurer who underwent hysterectomy for any indication between January 1, 2010, and June 30, 2016. Per-quarter utilization of hysterectomy routes (abdominal, laparoscopic, vaginal, and laparoscopic-assisted vaginal) was compared between the prepolicy and postpolicy periods using interrupted time series analyses.

Results

Data for 305,139 hysterectomies were available—248,821 in the prepolicy period and 56,318 in the postperiod. Outpatient vaginal hysterectomy had the greatest increase in utilization of all routes and types; the average utilization per quarter in the prepolicy period was −0.61%, and this increased to 0.21% in the postpolicy period (P < 0.0001). Outpatient laparoscopic hysterectomy had the greatest decrease in utilization, with an average decrease of −1.50% per quarter.

Conclusions

The prior authorization policy was associated with a short-term increase in utilization of vaginal hysterectomy.
Weight Gain After Simultaneous Kidney and Pancreas Transplantation
Authors: Knight Richard J. , Islam Ana K , Pham Christine , Graviss Edward A. , Nguyen Duc T. , Moore Linda W. , Kagan Anna , Sadhu Archana R. , Podder Hemangshu , Gaber A. Osama
Published: July 2019

Background.

Excessive weight (EW) gain is common after solid organ transplantation, but there is little information concerning obesity after pancreas transplantation. The study goal was to characterize EW gain after kidney-pancreas (KP) transplantation.

Methods.

This was a retrospective single-center review of 100 KP recipients transplanted between September 2007 and June 2015.

Results.

The median percent weight gain for all recipients at 1 year posttransplant was 10% (interquartile range, 2.7%–19.3%) of baseline weight. EW gain, defined as greater than or equal to a 19% 1-year increase in weight, included all recipients (n = 26) above the upper limit of interquartile range for weight gain at 1 year. In multivariate analysis, recipient age <40 years, the use of tacrolimus/mammalian target of rapamycin immunosuppression, and an acute rejection event were independent risk factors for EW gain. At a mean follow-up of 43±23 months, there was no difference in patient or graft survival between the EW and non-EW cohorts. Although mean hemoglobin A1c levels between groups were equivalent, the EW versus non-EW cohort displayed a significant increase in mean insulin levels and a trend towards higher C-peptide levels. Criteria for posttransplant metabolic syndrome was met in 34.6% of EW versus 17.6% of non-EW cohorts (P = 0.07).

Conclusions.

At intermediate-term follow-up, EW gain after KP transplantation was not associated with an increased risk of death or graft loss, although there was a trend toward a greater risk of posttransplant metabolic syndrome. There may be a metabolic consequence of successful pancreas transplantation that results in EW gain in a proportion of recipients, leading to an increased risk of long-term cardiovascular complications.
A Comparison of Electronic and Paper Versions of the Montreal Cognitive Assessment
Authors: Wallace Sarah E. , Donoso Brown Elena V. , Simpson Richard C. , D’Acunto Kristin , Kranjec Alexander , Rodgers Mackenzie , Agostino Caroline
Published: July 2019

Objective:

The objective of this study was to investigate older adults’ performance on the paper and electronic Montreal Cognitive Assessment (eMoCA).

Design:

Repeated measures and correlational design.

Participants:

A convenience sample of 40 adults over 65 years of age living in the community.

Interventions:

Participants completed the eMoCA and paper Montreal Cognitive Assessment (MoCA) in a randomized order during 1 session. Participants reported their touchscreen experience and comfort and indicated their modality preferences.

Main Outcome Measures:

The primary outcome measures were paper MoCA and eMoCA total and subscale scores. Secondary outcome measures included participants’ reported touchscreen experience and comfort, as well as post-administration preferences.

Results:

A moderate statistically significant correlation was found between eMoCA and paper MoCA performance across all participants. Analysis comparing first administration modality only (eMoCA vs. paper MoCA) found no statistically significant difference in total scores; however, there was a statistically significant difference for the visuospatial/executive subscale, which required physical interaction with paper or the tablet. For this subscale, participants scored lower on the eMoCA versus paper MoCA. There was a statistically significant correlation between experience with touchscreen devices and performance on the eMoCA, but not between modality preference and performance.

Conclusion:

Modality of administration can affect performance on cognitive assessments. Clinicians should consider individuals’ level of touchscreen experience before selecting administration modality.
Imaging in amyotrophic lateral sclerosis: MRI and PET
Authors: Kassubek Jan , Pagani Marco
Published: July 2019

Purpose of review

Neuroimaging with MRI and PET has become a well-established technical tool for amyotrophic lateral sclerosis (ALS). This review summarizes current developments in the advanced neuroimaging assessment of ALS and explores their potential in a clinical and neuroscientific setting.

Recent findings

With a focus on diffusion-weighted imaging, MRI-based neuroimaging has shown to provide reliable measures for monitoring disease progression and should be included in the clinical workup of ALS. There have been efforts to improve the clinical utility of fluorodesoxyglucose (FDG)-PET, and multivariate analysis has made advances in discriminating patients from controls and for prognostic assessment. Beyond FDG-PET, promising investigations have been carried out implementing novel radiotracers.

MRI and PET studies in ALS have consistently shown patterns of functional and structural changes considered to be the pathological signature of the disease. The constant advance of neuroimaging techniques encourages to investigate the cascade of ALS neurodegeneration and symptoms at finer and more specific level. Multicenter studies and the implementation of novel methodologies might confer a pivotal role to neuroimaging in the clinical setting in the near future, accelerating ALS diagnosis and allowing a prompt prognosis about disease progression.
Relationship Between Cauda Equina Conduction Time and Type of Neurogenic Intermittent Claudication due to Lumbar Spinal Stenosis
Authors: Nagao Yuji , Imajo Yasuaki , Funaba Masahiro , Suzuki Hidenori , Nishida Norihiro , Kanchiku Tsukasa , Sakai Takashi , Taguchi Toshihiko
Published: July 2019

Introduction:

This study investigated whether the prolongation of the cauda equina conduction time (CECT) was related to the type of neurogenic intermittent claudication due to lumbar spinal stenosis.

Methods:

In total, 149 patients who underwent surgery due to lumbar spinal stenosis with neurogenic intermittent claudication were classified into three groups as follows: cauda equina-type(n = 67), radicular-type(n = 29), and mixed-type(n = 53). Cauda equina conduction time was measured by placing disc electrodes on the abductor hallucis muscle, electrically stimulating the tibial nerve of the ankle and recording the compound muscle action potentials and F-waves. Motor evoked potentials from the abductor hallucis muscle were measured after magnetically stimulating the lumbosacral spine. Cauda equina conduction time was calculated from the latencies of compound muscle action potentials, F-waves, and motor evoked potentials. The measurement of the dural sac cross-sectional area were assessed using computed tomography myelography or MRI.

Results:

The values of CECT were as follows: cauda equina-type, 5.6 ± 1.1 ms; mixed-type, 5.1 ± 0.9 ms; and radicular-type, 4.0 ± 0.9 ms. The values of dural sac cross-sectional area were as follows: cauda equina-type, 42.8 ± 18.7 mm2; mixed-type, 49.6 ± 20.9 mm2; and radicular-type, 75.3 ± 19.1 mm2. In the cauda equina-type and mixed-type patients, CECT was significantly prolonged and there were negative correlations between CECT and dural sac cross-sectional area.

Conclusions:

Cauda equina conduction time differed according to the type of lumbar spinal stenosis. The prolongation of CECT may be caused by the demyelination of the CE. Cauda equina conduction time may be a useful measure for evaluating the dysfunction of the CE rather than radiculopathy for patients with lumbar spinal stenosis.
The Gut Microbiome of Exudivorous Marmosets in the Wild and Captivity
Authors: Malukiewicz Joanna , Cartwright Reed A. , Dergam Jorge A. , Igayara Claudia S. , Kessler Sharon , Moreira Silvia B. , Nash Leanne T. , Nicola Patricia A. , Pereira Luiz C.M. , Pissinatti Alcides , Ruiz-Miranda Carlos R. , Ozga Andrew T. , Quirino Adriana A. , Roos Christian , Silva Daniel L. , Stone Anne C. , Grativol Adriana D.
Published: July 2019

Mammalian captive dietary specialists like folivores are prone to gastrointestinal distress and primate dietary specialists suffer the greatest gut microbiome diversity losses in captivity compared to the wild. Marmosets represent another group of dietary specialists, exudivores that eat plant exudates, but whose microbiome remains relatively less studied. The common occurrence of gastrointestinal distress in captive marmosets prompted us to study the Callithrix gut microbiome composition and predictive function through bacterial 16S ribosomal RNA V4 region sequencing. We sampled 59 wild and non-wild Callithrix across four species and their hybrids. Host environment had a stronger effect on the gut microbiome than host taxon. Wild Callithrix gut microbiomes were enriched for Bifidobacterium, which process host-indigestible carbohydrates. Captive marmoset guts were enriched for Enterobacteriaceae, a family containing pathogenic bacteria. While gut microbiome function was similar across marmosets, Enterobacteriaceae seem to carry out most functional activities in captive host guts. More diverse bacterial taxa seem to perform gut functions in wild marmosets, with Bifidobacterium being important for carbohydrate metabolism. Non-wild marmosets showed gut microbiome composition aspects seen in human gastrointestinal diseases. Thus, captivity may perturb the exudivore gut microbiome, which raises implications for captive exudivore welfare and calls for husbandry modifications.
High-resolution view of the type III secretion export apparatusin situreveals membrane remodeling and a secretion pathway
Authors: Butan Carmen , Lara-Tejero Maria , Li Wenwei , Liu Jun , Galán Jorge E.
Published: July 2019

Type III protein secretion systems are essential virulence factors for many important pathogenic bacteria. The entire protein secretion machine is composed of several substructures that organize into a holostructure or injectisome. The core component of the injectisome is the needle complex, which houses the export apparatus that serves as a gate for the passage of the secreted proteins through the bacterial inner membrane. Here we describe a high-resolution structure of the export apparatus of theSalmonellatype III secretion system in association with the needle complex and the underlying bacterial membrane, both in isolation andin situ. We show the precise location of the core export apparatus components within the injectisome and bacterial envelope and demonstrate that their deployment results in major membrane remodeling and thinning, which may be central for the protein translocation process. We also show that InvA, a critical export apparatus component, forms a multi-ring cytoplasmic conduit that provides a pathway for the type III secretion substrates to reach the entrance of the export gate. Combined with structure-guided mutagenesis, our studies provide major insight into potential mechanisms of protein translocation and injectisome assembly.
Viscoadaptation controls intracellular reaction rates in response to heat and energy availability
Authors: Persson Laura , Ambati Vardhaan S. , Brandman Onn
Published: July 2019

Summary/Abstract

Cells must precisely orchestrate thousands of reactions in both time and space. Yet reaction kinetics are highly dependent on uncontrollable environmental conditions such as temperature. Here, we report a novel mechanism by which budding yeast influence reaction rates through adjustment of intracellular viscosity. This “viscoadaptation” is achieved by production of two carbohydrates, trehalose and glycogen, which combine to create a more viscous cellular environment in which biomolecules retain solubility. We demonstrate that viscoadaptation functions as both an acute response to temperature increase as well as a homeostatic mechanism, allowing cells grown at temperatures spanning from 22°C to 40°C to maintain equivalent rates of intracellular diffusion and diffusion-controlled chemical reactions. Multiple conditions that lower ATP trigger viscoadaptation, suggesting that viscoadaptation may be a general cellular response to low energy. Viscoadaptation reveals viscosity to be a tunable property of cells through which they can regulate diffusion-controlled processes dynamically in response to a changing environment.
Energy landscape analysis elucidates the multistability of ecological communities across environmental gradients
Authors: Suzuki Kenta , Nakaoka Shinji , Fukuda Shinji , Masuya Hiroshi
Published: July 2019

Compositional multistability is widely observed in multispecies ecological communities. Since differences in community composition often lead to differences in community function, understanding compositional multistability is essential to comprehend the role of biodiversity in maintaining ecosystems. In community assembly studies, it has long been recognized that the order and timing of species migration and extinction influence structure and function of communities. The study of multistability in ecology has focused on the change in dynamical stability across environmental gradients, and was developed mainly for low-dimensional systems. As a result, methodologies for studying the compositional stability of empirical multispecies communities are not well developed. Here, we show that models previously used in ecology can be analyzed from a new perspective - the energy landscape - to unveil compositional stability in observational data. To show that our method can be applicable to real-world ecological communities, we simulated assembly dynamics driven by population level processes, and show that results were mostly robust to different simulation assumptions. Our method reliably captured the change in the overall compositional stability of multispecies communities over environmental change, and indicated a small fraction of community compositions that may be channels for transitions between stable states. When applied to murine gut microbiota, our method showed the presence of two alternative states whose relationship changes with age, and suggested mechanisms by which aging affects the compositional stability of the murine gut microbiota. Our method provides a practical tool to study the compositional stability of communities in a changing world, and will facilitate empirical studies that integrate the concept of multistability from different fields.
Shade-avoidance responses become more aggressive in warm environments
Authors: Romero-Montepaone Sofía , Poodts Sofía , Fischbach Patrick , Sellaro Romina , Zurbriggen Matias D. , Casal Jorge J.
Published: July 2019

When exposed to neighbour signals, competitive plants increase the growth of the stem to reduce the degree of current or future shade. Plants can experience similar neighbour cues under different weather conditions and the aim of this work is to investigate the impact of daily average temperature and irradiance and thermal amplitude on the magnitude of shade-avoidance responses in Arabidopsis thaliana. For this purpose, we first generated a growth database and elaborated under controlled conditions a model that predicts hypocotyl growth during the photoperiod as a function of the light-modulated activity of the main photo-sensory receptors (phytochromes A and B, cryptochromes 1 and 2), temperature-modulated activity of phytochrome B and an independent temperature input. Thermal amplitude (lower temperatures during the morning and afternoon that at midday) reduced growth of genotypes with normally fast morning growth, and this effect was incorporated to the model. Thermal amplitude also decreased the abundance of the growth-promoting transcription factor PHYTOCHROME-INTERACTING FACTOR 4. The model predicted growth in the field through different seasons with reasonable accuracy. Then, we used the model in combination with a worldwide dataset of current and future whether conditions. The analysis predicted enhanced shade-avoidance responses as a result of higher temperatures due to the geographical location or global warming. Irradiance and thermal amplitude had no effects. These trends were also observed for our local growth measurements. We conclude that, if water and nutrients do not become limiting, warm environments enhance the shade avoidance response.
Regulatory T cells control the dynamic and site-specific polarization of total CD4 T cells followingSalmonellainfection
Authors: Clay Slater L. , Bravo-Blas Alberto , Wall Daniel M. , MacLeod Megan K.L. , Milling Simon W. F.
Published: July 2019

FoxP3+regulatory T cells (Tregs) control inflammation and maintain mucosal homeostasis, but their functions during infection are poorly understood. Th1, Th2 and Th17 cells can be identified by master transcription factors (TFs) T-bet, GATA3 and RORγT; Tregs also express these TFs. While T-bet+Tregs can selectively suppress Th1 cells, it is unclear whether distinct Treg populations can alter Th bias. To address this, we usedSalmonella entericaserotype Typhimurium to induce non-lethal colitis. Following infection, we observed an early colonic Th17 response within total CD4 T cells, followed by a Th1 bias. The early Th17 response, which contains both Salmonella-specific and non-Salmonella-specific cells, parallels an increase in T-bet+Tregs. Later, Th1 cells and RORγT+Tregs dominate. This reciprocal dynamic may indicate that Tregs selectively suppress Th cells, shaping the immune response. Treg depletion 1-2 days post-infection shifted the early Th17 response to a Th1 bias; however, depletion 6-7 days post-infection abrogated the Th1 bias. Thus, Tregs are necessary for the early Th17 response, and for a maximal Th1 response later. These data show that Tregs shape the overall tissue CD4 T cell response and highlight the potential for subpopulations of Tregs to be used in targeted therapeutic approaches.
PAREameters: computational inference of plant microRNA-mRNA targeting rules using RNA sequencing data
Authors: Thody Joshua , Moulton Vincent , Mohorianu Irina
Published: July 2019

MicroRNAs (miRNAs) are short, non-coding RNAs that influence the translation-rate of mRNAs by directing the RNA-induced silencing complex to sequence-specific targets. In plants, this typically results in cleavage and subsequent degradation of the mRNA. This can be captured on a high-throughput scale using degradome sequencing, which supports miRNA target prediction by aligning degradation fragments to reference mRNAs enabling the identification of causal miRNA(s). The current criteria used for target prediction were inferred on experimentally validated A. thaliana interactions, which were adapted to fit that specific subset of miRNA interactions. In addition, the miRNA pathway in other organisms may have acquired specific changes, e.g. lineage-specific miRNAs or new miRNA-mRNA interactions, thus previous criteria may not be optimal. We present a new tool, PAREameters, for inferring targeting criteria from RNA sequencing datasets; the stability of inferred criteria under subsampling and the effect of input-size are discussed. We first evaluate its performance using experimentally validated miRNA-mRNA interactions in multiple A. thaliana datasets, including conserved and species-specific miRNAs. We then perform comprehensive analyses on the differences in flower miRNA-mRNA interactions in several non-model organisms and quantify the observed variations. PAREameters highlights an increase in sensitivity on most tested datasets when data-inferred criteria are used.