bluuebunny/crossref_metadata_2025 huggingface dataset:
Intratympanic Steroid for Menière's Disease: A Systematic Review
Authors: Devantier Louise , Djurhuus Bjarki Ditlev , Hougaard Dan Dupont , Händel Mina Nicole , Guldfred Frank Liviu-Adelin , Schmidt Jesper Hvass , Edemann-Callesen Henriette
Published: May 2019

Objectives:

To investigate the beneficial effects and safety of intratympanic steroid installation compared with placebo in patients with Menière's disease.

Methods:

We performed a systematic literature search in MEDLINE and EMBASE for existing systematic reviews and individual randomized controlled trials (RCTs). Studies were included if they investigated the usage intratympanic steroids in patients aged 18 and above, with definite or probable Menière's disease. The quality of the identified existing reviews was assessed using the AMSTAR tool. The risk of bias in RCTs was assessed using the Cochrane Risk of Bias Tool and overall quality of the individual outcomes was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) method.

Results:

The literature search provided four systematic reviews, from which one yielded a sufficient AMSTAR evaluation and subsequently provided three RCTs relevant for inclusion. Due to the lack of sufficient reporting of the data, quantitative synthesis was not applicable. In the qualitative synthesis for the primary outcome, the results from the RCTs showed that there was a slight indication of steroid treatment reducing the frequency of vertiginous attacks. No serious adverse events were reported. Based on the GRADE approach the quality for both findings is very low. No studies reported on the secondary outcomes.

Conclusion:

The effect of intratympanic steroid treatment in Menière's disease is questionable. There is a great need for further research to sufficiently assess whether steroid treatment may be considered as a safe and effective treatment for patients with Menière's disease.
The Impact of Canalplasty on Outcomes of Medial Graft Tympanoplasty
Authors: Morrison Daniel R. , O’Connell Brendan , Lambert Paul R.
Published: May 2019

Objective:

Both medial and lateral graft techniques are commonly employed in tympanoplasty with acceptable closure rates. Canalplasty is routinely performed to obtain adequate exposure in the lateral graft technique; this usually entails removal of the anterior canal wall skin with subsequent replacement as a free graft. While formal canalplasty can also be performed in conjunction with medial graft technique to improve exposure, it is not commonly described. The current study seeks to examine the impact of canalplasty on outcomes of medial graft tympanoplasty.

Methods:

A retrospective chart review was performed for patients undergoing tympanoplasty for chronic otitis media with the senior author. Audiometric data were recorded both preoperatively and postoperatively. Primary outcome measure was perforation closure with audiometric outcomes examined as secondary outcome measures.

Results:

One hundred seventy tympanoplasties without ossiculoplasty were included in our study. The overall rate of perforation closure postoperatively was 77%. Cartilage use portended a higher closure rate (100%) when compared with nonuse (75%) (p = 0.04). The success rates with lateral grafts (94%) and medial grafts with canalplasty (92%) were considerably higher than obtained with medial grafts without canalplasty (69%) (p = 0.005 and 0.02, respectively). In cases with anterior perforations greater than 25% of the tympanic membrane, our results demonstrated a significant advantage in performing canalplasty (p = 0.04).

Conclusions:

Data from the current study suggest that canalplasty offers benefit regarding closure rate in medial graft tympanoplasty. Use of cartilage also portended a higher rate of perforation closure. Canalplasty should be considered when using medial graft techniques if exposure is limited due to bony canal anatomy.
EPO Attenuates Cisplatin-Induced Ototoxicity in HEI-OC1 Auditory Cell Via the Nrf2-ARE Signaling Pathway
Authors: Sun Changling , Yao Ying , Zhang Chenwei , Tong Desheng , Xie Bingxue
Published: May 2019

Hypothesis:

Erythropoietin (EPO) may protect against cisplatin-induced ototoxicity in HEI-OC1 auditory cell line.

Background:

Cisplatin is a widely used chemotherapeutic agent for the treatment of human solid tumors limited by its high incidence of ototoxicity. Currently, there are no clinical solutions. EPO has been reported to have varieties of neuroprotective effects. However, nothing has yet been reported on its potential to prevent cisplatin ototoxicity in auditory cell lines and possible mechanism.

Methods:

HEI-OC1 cells were incubated with 20 μM of cisplatin for 48 hours, after application of various concentrations of EPO for 24 hours. Cell viability was determined using a Cell Counting Kit-8 (CCK-8) assay. Oxidative stress and apoptosis were assessed by reactive oxygen species (ROS) measurement, Hoechst 33258 staining, and flow cytometry (FC). Western blot (WB) and real-time quantitative PCR were used to detect nuclear factor erythroid 2-related factor 2 (Nrf2), NAD (P)H quinone oxidoreductase 1 (NQO1), heme oxygenase-1 (HO-1), Bcl-2 and Bcl-xl protein and mRNA expression levels.

Results:

Pretreatment with 40, 8, and 1.6 ng/mL of EPO for 24 hours before application of 20 μM cisplatin increased cell viability in HEI-OC1 cells. Besides, EPO enhanced the expression of Nrf-2, HO-1, and NQO1. Moreover, upregulation of the expression of Bcl-2 and bcl-xl were also observed.

Conclusion:

Our results suggest that EPO alleviates cisplatin-induced ototoxicity by activating Nrf2-ARE signaling.
Mechanical circulatory support devices in cardiogenic shock and acute heart failure: current evidence
Authors: Schrage Benedikt , Westermann Dirk
Published: May 2019

Purpose of review

The main purpose of this review is to highlight and summarize recently published studies on the usage of short-term mechanical circulatory support devices for treatment of cardiogenic shock. Importantly, this review will focus on percutaneously implanted devices.

Recent findings

In recent years, usage of active mechanical circulatory support devices, such as catheter-based left ventricular-assist devices and veno-arterial extracorporeal membrane oxygenation devices, has been widely adopted. Several device-specific strategies have been proposed to improve outcome of treated patients with cardiogenic shock, ranging from early identification and treatment of patients via dedicated shock protocols to combinatory usage of these devices. However, this is not supported by prospective, randomized trials but by retrospective analysis, which are significantly impacted by bias.

Randomized, controlled trials are utterly needed to guide treatment with mechanical circulatory support for patients with cardiogenic shock. Importantly, such trials should focus patient selection criteria.
Assessment of microcirculation in cardiogenic shock
Authors: Jung Christian
Published: May 2019

Purpose of review

Adequate tissue perfusion is of utmost importance to avoid organ failure in patients with cardiogenic shock. Within the recent years, the microcirculation, defined as the perfusion of the smallest vessels, has been identified to play a crucial role. Microcirculatory changes may include capillary flow disturbances as well as changes in the density of perfused vessels. Due to the availability of new technologies to assess the microcirculation, interesting new data came up and it is the purpose of this review to summarize recent studies in the field.

Recent findings

Nowadays, an increasing number of studies confirm parameters of the microcirculation, derived by intravital microscopy, to represent strong outcome predictors in cardiogenic shock. In addition, microcirculation as read-out parameter in innovative clinical studies has meanwhile been accepted as serious endpoint. Treatment strategies such as mechanical assist devices, blood pressure regulating agents or fluids use tissue perfusion and microcirculatory network density as targets in addition to clinical perfusion evaluation and decreasing serum lactate levels.

The parameter most frequently used to detect tissue malperfusion is serum lactate. Novel, noninvasive methods to quantify microvascular perfusion have the potential to guide treatment in terms of optimizing organ perfusion and oxygenation probably paving the way for an individualized therapy.
Usefulness of Full-spectrum Endoscopy for the Upper Gastrointestinal Tract
Authors: Yamada Hyuga , Shibata Tomoyuki , Terada Tsuyoshi , Osaki Hayato , Maeda Kohei , Tahara Tomomitsu , Nagasaka Mitsuo , Nakagawa Yoshihito , Ohmiya Naoki
Published: May 2019

Goals:

We determined whether full-spectrum endoscopy (FUSE) improved the visualization rates of blind spots in a single-center case control study.

Background:

FUSE provides a 210-degree angle of view with a left side-viewing camera in addition to a forward-viewing camera. FUSE can improve the detectability of blind spots in conventional forward-viewing esophagogastroduodenoscopy (EGD), such as the major duodenal papilla (MDP) and the anal side of the pyloric ring.

Study:

Between April 2016 and May 2017, successful visualization rates of the whole MDP and anal side of the pyloric ring were compared between 103 participants who underwent FUSE and 1045 participants who underwent EGD. Pain and discomfort at insertion and during and after the examination were assessed using a visual analog scale in 38 participants who underwent FUSE with a previous examination history of EGD.

Results:

The successful visualization rates of MDP and the anal side of the pyloric ring in the FUSE group were significantly higher than those in the conventional EGD group; 83.4% versus 35.1% for MDP (P<0.001) and 86.4% versus 7.1% for the anal side of the pyloric ring (P<0.001), respectively. The visual analog scale were not significantly different between FUSE and previous EGD in a portion of the FUSE group. In addition, the detection rate of the periampullary diverticula was also significantly higher in the FUSE group than that in the conventional EGD group (8.7% vs. 1.6%, P<0.001).

Conclusions:

This study provides evidence supporting that FUSE is superior to EGD for precise visualization of blind spots in the duodenum.
Increasing Clinical and Economic Burden of Nonalcoholic Fatty Liver Disease Among Hospitalized Adults in the United States
Authors: Hirode Grishma , Vittinghoff Eric , Wong Robert J.
Published: May 2019

Goals:

The aim of this study was to understand the burden of nonalcoholic fatty liver disease (NAFLD) among hospitalized patients in the United States.

Background:

A major driver of the rapidly increasing US clinical and economic burden of NAFLD is attributed to inpatient health care resource utilization.

Methods:

We performed a cross-sectional study of the 2007 to 2014 Nationwide Inpatient Sample. A total of 481,122 hospitalizations in patients with NAFLD were identified using ICD-9 codes after excluding other etiologies of chronic liver disease. We analyzed survey-weighted annual trends in national estimates of hospitalizations in patients with NAFLD, stratified by metabolic comorbidities, cirrhosis, and other liver-related complications. Annual trends in total hospitalization charges were inflation adjusted to 2014 USD.

Results:

From 2007 to 2014, hospitalizations in patients with NAFLD increased by 83.4% (42,060 to 77,143, P<0.0001), and the proportion of total hospitalizations represented by patients with NAFLD increased by 104.4% (6.34 to 13.0 per 1000 hospitalizations). During this time, there was a 159% increase in total inpatient hospitalization charges in patients with NAFLD ($7.7 billion in 2007 to $19.9 billion in 2014, P<0.001). This increasing clinical and economic burden was observed across all metabolic comorbidities and liver complications evaluated among hospitalizations in patients with NAFLD.

Conclusions:

With the rising prevalence of NAFLD in the United States, the inpatient clinical and economic burden of NAFLD is also rapidly rising. In 2014, total estimated national hospitalization charges in patients with NAFLD reached nearly $20 billion, with metabolic comorbidities and liver-related complications being major contributors to this rising burden.
Safety, Feasibility, and Efficacy of Pancolonic Retroflexed Viewing Using a Short-turn Radius Colonoscope
Authors: Robles-Medranda Carlos , Soria-Alcívar Miguel , Oleas Roberto , Vargas María , Ospina Jesenia , Abarca Francisco , Puga-Tejada Miguel , Baquerizo-Burgos Jorge , Pitanga-Lukashok Hannah
Published: May 2019

Goals:

The goal of this study was to evaluate the safety and feasibility of routine segmental retroflexed withdrawal viewing (RV) of the colon with the RetroView colonoscope.

Materials and Methods:

This was a prospective, single-center, 2-stage diagnostic trial. After cecal intubation, mucosal evaluation by forward viewing (FV) and RV was performed by segment (right, transverse, left, and sigmoid colon, and rectum). Lesions detected during FV were removed and/or marked before retroflexion. Safety and feasibility were measured through adverse event and technical success rates. All lesions detected and removed endoscopically were recorded.

Results:

Two hundred twenty-five patients underwent colonoscopy with the RetroView colonoscope. Retroflexion by segment was successful in the right, transverse, left, and sigmoid colon, and rectum in 98.9%, 100%, 100%, 82.6%, and 100% of cases, respectively. The mean total procedure time was 16.6 minutes. Ninety-four lesions were detected through retroflexion evaluation, for an increase in the lesions’ detection rate of 30.7%. The per-adenoma miss rate of standard colonoscopy (FV) was 35.71%. The adenoma detection rate (ADR) for FV was 16%, whereas, when performing FV and RV, the ADR increased to 24.9%. Adverse events were recorded in 0.4% of cases. Therapeutic procedures were performed successfully through the retroflexed position in 81/225 patients.

Conclusions:

Routine retroflexion evaluation of the colonic mucosa by segment using the RetroView colonoscope is safe and feasible. Retroflexion evaluation increases the detection rate of colonic lesions behind folds, including the number of adenomas per colonoscopy and ADR, offering a complete screening colonoscopy. All therapeutic procedures are feasible through retroflexion.
Acute pancreatitis in end-stage renal disease patients in the USA: a nationwide, propensity score-matched analysis
Authors: Cheungpasitporn Wisit , Thongprayoon Charat , Ungprasert Patompong , Wijarnpreecha Karn , Raimondo Massimo , Kroner Paul T.
Published: May 2019

Background

Limited data exist regarding the effects of end-stage renal disease (ESRD) on acute pancreatitis (AP). This study aimed to evaluate the association between ESRD and outcomes and resource utilization of AP.

Materials and methods

The 2014 National Inpatient Sample database was used to identify all hospitalized patients with a principal diagnosis of AP. Propensity score matching was performed to create a matched cohort of ESRD and non-ESRD patients. The in-hospital mortality, morbidity, resource utilization and expenditures of AP in ESRD patients were compared to non-ESRD patients. Multivariate analysis was performed for further adjustment for potential confounders.

Results

Of 382 595 AP patients, 7380 ESRD patients and 8050 non-ESRD patients were created after propensity score matching. ESRD patients had more tendency to have hypercalcemia-related or AP-related to other/unspecified causes, whereas non-ESRD patients had more tendency to have alcohol-related, gallstone-related, and hypertriglyceridemia-related AP. In multivariate analysis, ESRD was associated with increased in-hospital mortality, increased length of hospital stay, and increased hospitalization costs and charges. No differences were observed in inpatient morbidity, imaging study use, and procedures performed during hospitalization.

Conclusion

In this large nationwide study using inpatient USA database, we demonstrate higher AP-related mortality, and resource utilization among ESRD patients when compared with non-ESRD patients.
Diabetes mellitus increases the risk of hepatic encephalopathy after a transjugular intrahepatic portosystemic shunt in cirrhotic patients
Authors: Yin Xiaochun , Zhang Feng , Xiao Jiangqiang , Wang Yi , He Qibin , Zhu Hao , Leng Xiafei , Zou Xiaoping , Zhang Ming , Zhuge Yuzheng
Published: May 2019

Objective

The aim of this study was to examine the effect of diabetes mellitus (DM) on the rate of hepatic encephalopathy (HE) in patients with decompensated liver cirrhosis after the creation of a transjugular intrahepatic portosystemic shunt (TIPS).

Patients and methods

This study retrospectively reviewed 436 consecutive patients with cirrhosis receiving TIPS in our department from 2008 to 2016. By comparing two groups of patients, with or without DM, the incidence of developing overt HE after TIPS, as well as the correlation between diabetes and HE, was analyzed. Data were analyzed using the χ
2-tests, unpaired t-tests, logistic regression, and Kaplan–Meier curves. After the initial data processing, we used a regression model to analyze whether or not DM is associated with the development of HE after TIPS.

Results

Of the 436 patients who underwent TIPS, 85 (19.5%) had diabetes at admission and 126 (28.9%) had HE after TIPS. Patients with DM more frequently had HE compared with those without DM (44.7 vs. 25.1%; P = 0.000). The logistic regression analysis showed that DM (P = 0.015) and age (P = 0.002) were independent risk factors for HE after TIPS. Finally, using the Kaplan–Meier curves, we found that diabetes significantly increases the incidence of overt HE (log-rank P = 0.026).

Conclusion

Similar to old age, DM may increase the risk of HE in cirrhotic patients after the creation of TIPS.
The effect of emergency department delays on 30-day mortality in Central Norway
Authors: Asheim Andreas , Nilsen Sara Marie , Carlsen Fredrik , Eide Næss-Pleym Lars , Uleberg Oddvar , Dale Jostein , Bache-Wiig Bjørnsen Lars P. , Bjørngaard Johan Håkon
Published: May 2019

Objective:

To assess whether prolonged length of stay in the emergency department was associated with risk of death.

Methods:

We analysed data from 165,183 arrivals at St. Olav’s University Hospital’s emergency department from 2011 to 2018, using an instrumental variable method. As instruments for prolonged length of emergency department stay, we used indicators measured before arrival of the patient. These indicators were used to study the association between prolonged length of emergency department stay and risk of death, being discharged from the emergency department and length of hospitalisation for those who were hospitalised.

Results:

Mean length of stay in the emergency department was 2.9 hours, and 30-day risk of death was 3.4%. Per hour prolonged length of stay in the emergency department, the overall change in risk of death was close to zero, with a narrow 95% confidence interval of −0.5 to 0.7 percentage points. Prolonged emergency department stay was associated with a higher probability of being discharged from the emergency department without admission to the hospital. We found no substantial differences in length of hospitalisation for patients who were admitted.

Conclusion:

In this study, prolonged emergency department stay was not associated with increased risk of death.
Prediction Accuracy With Electronic Medical Records Versus Administrative Claims
Authors: Zeltzer Dan , Balicer Ran D. , Shir Tzvi , Flaks-Manov Natalie , Einav Liran , Shadmi Efrat
Published: May 2019

Objective:

The objective of this study was to evaluate the incremental predictive power of electronic medical record (EMR) data, relative to the information available in more easily accessible and standardized insurance claims data.

Data and Methods:

Using both EMR and Claims data, we predicted outcomes for 118,510 patients with 144,966 hospitalizations in 8 hospitals, using widely used prediction models. We use cross-validation to prevent overfitting and tested predictive performance on separate data that were not used for model training.

Main Outcomes:

We predict 4 binary outcomes: length of stay (≥7 d), death during the index admission, 30-day readmission, and 1-year mortality.

Results:

We achieve nearly the same prediction accuracy using both EMR and claims data relative to using claims data alone in predicting 30-day readmissions [area under the receiver operating characteristic curve (AUC): 0.698 vs. 0.711; positive predictive value (PPV) at top 10% of predicted risk: 37.2% vs. 35.7%], and 1-year mortality (AUC: 0.902 vs. 0.912; PPV: 64.6% vs. 57.6%). EMR data, especially from the first 2 days of the index admission, substantially improved prediction of length of stay (AUC: 0.786 vs. 0.837; PPV: 58.9% vs. 55.5%) and inpatient mortality (AUC: 0.897 vs. 0.950; PPV: 24.3% vs. 14.0%). Results were similar for sensitivity, specificity, and negative predictive value across alternative cutoffs and for using alternative types of predictive models.

Conclusion:

EMR data are useful in predicting short-term outcomes. However, their incremental value for predicting longer-term outcomes is smaller. Therefore, for interventions that are based on long-term predictions, using more broadly available claims data is equally effective.
Change in Patient Outcomes After Augmenting a Low-level Implementation Strategy in Community Practices That Are Slow to Adopt a Collaborative Chronic Care Model
Authors: Smith Shawna N. , Almirall Daniel , Prenovost Katherine , Liebrecht Celeste , Kyle Julia , Eisenberg Daniel , Bauer Mark S. , Kilbourne Amy M.
Published: May 2019

Background:

Implementation strategies are essential for promoting the uptake of evidence-based practices and for patients to receive optimal care. Yet strategies differ substantially in their intensity and feasibility. Lower-intensity strategies (eg, training and technical support) are commonly used but may be insufficient for all clinics. Limited research has examined the comparative effectiveness of augmentations to low-level implementation strategies for nonresponding clinics.

Objectives:

To compare 2 augmentation strategies for improving uptake of an evidence-based collaborative chronic care model (CCM) on 18-month outcomes for patients with depression at community-based clinics nonresponsive to lower-level implementation support.

Research Design:

Providers initially received support using a low-level implementation strategy, Replicating Effective Programs (REP). After 6 months, nonresponsive clinics were randomized to add either external facilitation (REP+EF) or external and internal facilitation (REP+EF/IF).

Measures:

The primary outcome was patient 12-item short form survey (SF-12) mental health score at month 18. Secondary outcomes were patient health questionnaire (PHQ-9) depression score at month 18 and receipt of the CCM during months 6 through 18.

Results:

Twenty-seven clinics were nonresponsive after 6 months of REP. Thirteen clinics (N=77 patients) were randomized to REP+EF and 14 (N=92) to REP+EF/IF. At 18 months, patients in the REP+EF/IF arm had worse SF-12 [diff, 8.38; 95% confidence interval (CI), 3.59–13.18] and PHQ-9 scores (diff, 1.82; 95% CI, –0.14 to 3.79), and lower odds of CCM receipt (odds ratio, 0.67; 95% CI, 0.30–1.49) than REP+EF patients.

Conclusions:

Patients at sites receiving the more intensive REP+EF/IF saw less improvement in mood symptoms at 18 months than those receiving REP+EF and were no more likely to receive the CCM. For community-based clinics, EF augmentation may be more feasible than EF/IF for implementing CCMs.
Inheritance of high and low HDL: mechanisms and management
Authors: Sourlas Andreas , Kosmas Constantine E.
Published: May 2019

Purpose of review

The inverse association between plasma high-density lipoprotein cholesterol (HDL-C) concentration and the incidence of cardiovascular disease (CVD) has been unequivocally proven by many epidemiological studies. There are several genetic disorders affecting HDL-C plasma levels, either providing atheroprotection or predisposing to premature atherosclerosis. However, up to date, there has not been any pharmacological intervention modulating HDL-C levels, which has been clearly shown to prevent the progression of CVD. Thus, clarifying the exact underlying mechanisms of inheritance of these genetic disorders that affect HDL is a current goal of the research, as key roles of molecular components of HDL metabolism and function can be revealed and become targets for the discovery of novel medications for the prevention and treatment of CVD.

Recent findings

Primary genetic disorders of HDL can be either associated with longevity or, in contrast, may lead to premature CVD, causing high morbidity and mortality to their carriers. A large body of recent research has closely examined the genetic disorders of HDL and new promising therapeutic strategies have been developed, which may be proven beneficial in patients predisposed to CVD in the near future.

We have reviewed recent findings on the inheritance of genetic disorders associated with high and low HDL-C plasma levels and we have discussed their clinical features, as well as information about new promising HDL-C-targeted therapies that are under clinical trials.
Recent developments in lipodystrophy
Authors: Melvin Audrey , Stears Anna , Savage David B.
Published: May 2019

Purpose of review

Lipodystrophy syndromes have an estimated prevalence of 1.3–4.7 cases per million and as with other rare diseases conducting research can be challenging. The present review highlights recently published work that has provided insights into the field of non-HIV--associated lipodystrophy syndromes.

Recent findings

Lipodystrophies are a heterogenous group of disorders, as such research is often focused on specific subtypes of the condition. The identification of children carrying LMNA mutations has provided insights into the natural history of FPLD2, specifically that the adipose tissue phenotype predates the onset of puberty. Recent reports of PLIN1 heterozygous null variant carriers and the apparent absence of a lipodystrophy phenotype challenges our understanding of the molecular biology of perilipin 1 and its role in the pathogenesis of FPLD4. With a focus on therapeutics, studies delineating the differential responsiveness of PPARγ mutants to endogenous and synthetic ligands has illustrated the potential for pharmacogenetics to inform therapeutic decisions in lipodystrophy related to PPARG mutations, whereas robust human studies have provided insight into the food independent metabolic effects of leptin in lipodystrophy. Finally, rare syndromes of lipodystrophy continue to serve as an exemplar for the contribution of genetically determined adipose tissue expandability to metabolic disease in the general population.

Lipodystrophy research continues to illuminate our understanding of this rare disease and the possibility that lipodystrophy syndromes and the metabolic syndrome may have shared pathophysiology.
Role of serum amyloid A in atherosclerosis
Authors: Shridas Preetha , Tannock Lisa R.
Published: May 2019

Purpose of review

Acute phase serum amyloid A (SAA) is persistently elevated in chronic inflammatory conditions, and elevated levels predict cardiovascular risk in humans. More recently, murine studies have demonstrated that over-expression of SAA increases and deficiency/suppression of SAA attenuates atherosclerosis. Thus, beyond being a biomarker, SAA appears to play a causal role in atherogenesis. The purpose of this review is to summarize the data supporting SAA as a key player in atherosclerosis development.

Recent findings

A number of pro-inflammatory and pro-atherogenic activities have been ascribed to SAA. However, the literature is conflicted, as recombinant SAA, and/or lipid-free SAA, used in many of the earlier studies, do not reflect the activity of native human or murine SAA, which exists largely lipid-associated. Recent literatures demonstrate that SAA activates the NLRP3 inflammasome, alters vascular function, affects HDL function, and increases thrombosis. Importantly, SAA activity appears to be regulated by its lipid association, and HDL may serve to sequester and limit SAA activity.

SAA has many pro-inflammatory and pro-atherogenic activities, is clearly demonstrated to affect atherosclerosis development, and may be a candidate target for clinical trials in cardiovascular diseases.
Diagnosis of Invasive Fungal Infection Among Pediatric Oncology Patients
Authors: Hodgman Erica I. , Compton Jeffrey , Qureshi Faisal G. , Murphy Joseph T.
Published: May 2019

Introduction:

The diagnosis of pulmonary invasive fungal infection (IFI) in the pediatric oncology patient is challenging. Consensus criteria developed in 2008 state that bronchioalveolar lavage (BAL) results cannot confirm this diagnosis. A video-assisted thoracoscopic biopsy (VATS-biopsy) of lungs has been increasingly used to assist in evaluating these children for IFI. Our goal was to evaluate the impact of BAL and VATS-biopsy results on the management of IFI among pediatric oncology patients.

Methods:

A retrospective review of all oncology patients evaluated for IFI with VATS-biopsy and/or BAL over 9 years was carried out at a single free-standing children’s hospital. The primary outcome was management changes in the use of antifungal therapy on the basis of diagnostic procedure, fungal culture results, lung imaging, and serological markers.

Results:

A total of 102 patients underwent 122 diagnostic evaluations for IFI. Ninety-one workups included only BAL, 17 evaluations involved only VATS-biopsy, and 14 cases involved both BAL and VATS-biopsy. The diagnostic yield of VATS-biopsy (38.7%) was superior to that of BAL (27.6%). There was poor concordance between VATS-biopsy and BAL results in the 14 cases where both were performed. Upon workup completion, IFI was proven in 12 children, probable in 29, and possible in 52. The odds of continuing antifungals increased 3-fold for patients with probable IFI and 12.7 times for those with the proven disease.

Discussion:

On the basis of the inferior diagnostic yield of BAL, we believe that VATS-biopsy may be a more useful diagnostic adjuvant in the diagnosis of IFI in the immunocompromised pediatric oncologic patient population.
A Review of Infants With Localized Neuroblastoma That Evolve to Stage 4s Disease
Authors: Caroleo Anna M. , De Bernardi Bruno , Avanzini Stefano , Gigliotti Anna R. , Muraca Monica , Pota Elvira , Provenzi Massimo , Mazzocco Katia , Sementa Angela R. , Granata Claudio , Sorrentino Stefania
Published: May 2019

The authors describe a newborn diagnosed with localized neuroblastoma that evolved to stage 4s at the age of 5 months. Peculiar features of the case included a bilateral adrenal primary, the skin as the only metastatic site, and the development of a muscular lesion late in the clinical course. The patient underwent left adrenalectomy and all other lesions regressed without further therapy. The case prompted a search for similar cases both in the Italian Neuroblastoma Registry and in the literature. All patients identified, although variously treated, survived with the exception of the 2 with MYCN gene amplification. We conclude that infants with neuroblastoma who undergo a transition from a localized to stage 4s disease could be less rare than expected. In the absence of unfavorable biology, a wait-and-see policy with strict follow-up could be adopted for these patients, avoiding potentially damaging systemic therapy.
The Value of Magnet® Recognition for Specialty Hospitals
Authors: Graystone Rebecca
Published: May 2019

Now in its 29th year, the American Nurses Credentialing Center's Magnet Recognition Program® stands as the premier international acknowledgment of nursing excellence in healthcare organizations around the world. The program's applicability in general hospitals, community hospitals, and academic medical centers is established, but what about specialty hospitals? In this month's Magnet Perspectives, nursing leaders from 3 specialty sectors, rehabilitation hospitals, cancer hospitals, and children's hospitals, discuss the ways in which the Magnet framework enriches the practice environment and promotes outstanding nurse and patient outcomes. Insights are shared about how the Magnet® journey provides the foundation to address current challenges in healthcare, including nurse staffing shortages, burnout, unit effectiveness, safety and quality imperatives, patient experience, and more.
A Model of Academic and Service Partnership Focused on the Clinical Nurse Specialist
Authors: Iseler Jackeline , Wehrwein Teresa , Jensen Camille
Published: May 2019

Advancing healthcare transformation includes recommendations for transforming healthcare through enhanced partnerships between academia and health centers. This article describes an innovative approach to building a partnership through the joint appointment of a full-time faculty member in a contracted clinical nurse specialist position in a community hospital. Readers will learn how a successful partnership was achieved and met the needs of the university, hospital, and clinical nurse specialist.
Leveraging Technology to Sustain Extraordinary Care
Authors: Clavelle Joanne T. , Sweeney Cynthia D. , Swartwout Ellen , Lefton Cindy , Guney Senem
Published: May 2019

OBJECTIVE

Meaningful recognition of nurses submitted by patients and families using interactive patient care (IPC) technology was analyzed using artificial intelligence (AI) to identify the themes and behaviors associated with extraordinary nursing.

BACKGROUND

Meaningful recognition positively impacts nursing and organizational outcomes. The use of AI techniques such as natural language processing and machine learning to identify and describe behaviors impacting patient experiences is an emerging science.

METHODS

Nurse recognition comments were collected from a convenience sample of 3 organizations via an IPC inpatient platform and analyzed using the AI techniques of natural language processing, machine learning, sentiment analytics, and corollary dictionaries based on rules of linguistics.

RESULTS

The top theme of nursing recognition comments was courtesy and respect with the behaviors of empathy/compassion, helpfulness, kindness, attentiveness, and emotional comfort. The theme of skills/knowledge was the 2nd most common, with the behaviors of being professional, knowledgeable, keeping track, competence, dedication, and being thorough.

CONCLUSIONS

AI techniques for qualitative analysis of comments collected through IPC reveal nurse themes and behaviors most meaningful to patients and their family members. Nurses can advance the science of AI and guide its evolution so that nurse caring behaviors associated with establishing human connections that positively influence patient and family experience are accurately represented.
Evaluating the Use of High-Reliability Principles to Increase Error Event Reporting
Authors: Duffey Pam , Oliver JoAnn S. , Newcomb Patricia
Published: May 2019

OBJECTIVE

Assess the relationship between educating caregivers about high-reliability principles and reporting of potential adverse safety events.

BACKGROUND

Persuading caregivers to report potential safety events is challenging. Learning high-reliability principles may help caregivers identify and report potential safety problems.

METHODS

Event reports submitted by caregivers 6 months before and after high-reliability training were examined for event types, event significance, and shift when events occurred. χ
2 Tests assessed relationships between variables.

RESULTS

The number and type of caregiver event reports before and after training were not significantly different; however, clinical process error reports significantly decreased (χ
2 = 9.251, P = .003). There was a significant difference in reports submitted by day and night shifts (χ
2 = 5.942, P = .02).

CONCLUSIONS

Trends suggest staff report actual, rather than potential, events regardless of training. Further research is needed to determine what motivates caregivers to report safety concerns.
System- and Unit-Level Care Quality Outcome Improvements After Integrating Clinical Nurse Leaders Into Frontline Care Delivery
Authors: Bender Miriam , Murphy Elizabeth A. , Cruz Maricela , Ombao Hernando
Published: May 2019

OBJECTIVE

This study determined whether 1 health system's frontline nursing model redesign to integrate clinical nurse leaders (CNLs) improved care quality and outcome score consistency.

METHODS

Interrupted time-series design was used to measure patient satisfaction with 7 metrics before and after formally integrating CNLs into a Michigan healthcare system. Analysis generated estimates of quality outcome: a) change point; b) level change; and c) variance, pre-post implementation.

RESULTS

The lowest-performing unit showed significant increases in quality scores, but there were no significant increases at the hospital level. Quality metric consistency increased significantly for every indicator at the hospital and unit level.

CONCLUSIONS

To our knowledge, this is the 1st study quantifying quality outcome consistency before and after nursing care delivery redesign with CNLs. The significant improvement suggests the CNL care model is associated with production of stable clinical microsystem practices that help to reduce clinical variability, thus improving care quality.
Registered Nurses’ Self-Assessed Knowledge of Evidence-Based Practice and Research
Authors: Nickles Kenneth P. , Mathews Deborah W. , Nimmagadda Heather , Bailey Mary E. , Cox Tina M. , Franklin Michelle , Rhodes-King Alfreda , Standish Cynthia , Teichman Elise , Hagle Mary
Published: May 2019

By 2020, most clinical decisions should be supported by best evidence. Therefore, nurses need institutional support and education about evidence-based practice (EBP) and research. The aim of this study was to describe nurses’ self-assessed knowledge of EBP and research. Findings revealed nurses’ knowledge of EBP and research ranged from no knowledge to high knowledge with opportunities for education. Providing for the use of best evidence is a dynamic process involving clinicians, educators, and administrators.
Two Cases of Crystal-storing Histiocytosis Diagnosed by Morphology, Immunohistochemistry, and Ultrastructural Examination
Authors: Vogel Ashley N. , Casey James , Kaur Jashanpreet , Uppal Guldeep
Published: May 2019

Crystal-storing histiocytosis (CSH) is a non-neoplastic histiocytic proliferation containing crystalline material, usually associated with an underlying lymphoproliferative or plasmacytic disorder. The crystalline structures are typically derived from kappa light chain immunoglobulins. The lesions of CSH are comprised of sheets of histiocytes with abundant eosinophilic cytoplasm containing variably prominent, elongated crystals. This rare phenomenon is important to recognize, as it is known to morphologically obscure an underlying neoplasm. Histologically, the cells of CSH may closely mimic Gaucher cells, as well as the “pseudo-Gaucher” cells sometimes encountered in chronic myeloid leukemia. The distinction between the cells of CSH and that of histologic mimics may be made more definitively through the use of electron microscopy, as the crystalline inclusions seen in CSH display characteristic size, shape, and localization within the cells. Here, we report 2 rare cases of CSH diagnosed by morphology, immunohistochemistry, and ultrastructural examination. The first case presented was diagnosed concurrently with plasma cell myeloma, and the second case discussed was diagnosed in association with marginal zone lymphoma.
The Incidence of Labelling of Non–Lung Adenocarcinomas With Antibodies Against TTF-1 and Diagnostic Implications
Authors: Prabhakaran Sarita , Woo Wei Lam Winifred , Xing Guang , Moffat David , Hussey Mathew , Henderson Douglas W. , Klebe Sonja
Published: May 2019

Thyroid transcription factor 1 (TTF-1) is an immunohistochemical marker in the identification of lung and thyroid tumors. However, positive labelling for TTF-1 can occur in tumors from other sites, and this can result in misdiagnosis if only a limited panel of antibodies is used. We assessed the frequency of expression of 3 TTF-1 antibody clones, namely, 8G7G3/1, SPT24, and SP141 on a tissue microarray of 104 colorectal cancer (CRC), and whole-tumor sections of 165 CRC with known microsatellite instability (MSI) status. We also analyzed the expression of TTF-1 in a tissue microarray of 112 prostatic adenocarcinomas. The association of TTF-1 expression with clinicopathologic parameters and patient survival was analyzed. Six of 104 (5.7%) primary colorectal carcinomas expressed TTF-1 with SPT24 and SP141 clones, whereas only 2 (2%) of these tumors labeled positive for TTF-1 with clone 8G7G3/1. A significant association of TTF-1 expression with younger age at diagnosis (P=0.001) was found, but not with stage, or survival. The SP141 clone also labelled 24/165 (14.5%) of 165 CRC with known MSI status. There was an association with younger age (P<0.001), but not with MSI status or survival. TTF-1 expression was found in 39/112 (34%) prostate adenocarcinomas with 6/112 (5.3%) labelling with clone 8G7G3/1, 26/112 (23%) with clone SP141, and 31/112 (28%) with clone SPT24. TTF-1 expression appeared to be associated with extracapsular extension (P=0.022) and with higher stage (P=0.039). Here too TTF-1 expression was not associated with survival. The mRNA expression of TTF-1 in these tumors was confirmed by RTPCR, indicating that this is not false-positive labelling. Depending on the clone used, TTF-1 expression can vary with the SP141 and SPT24 clones exhibiting higher incidence of labelling. Pathologists should be aware of the differences in performance profiles of the different TTF-1 clones in diagnostic practice.
Macrotrabecular Hepatocellular Carcinoma
Authors: Jeon Yejoo , Benedict Mark , Taddei Tamar , Jain Dhanpat , Zhang Xuchen
Published: May 2019

The macrotrabecular (MT) pattern of hepatocellular carcinoma (HCC) has been suggested to represent a distinct HCC subtype. We retrospectively reviewed 231 HCC cases. Detailed pathologic evaluation for histologic patterns, including MT-pattern, was performed for each case and recorded as percentage involved at 10% intervals. MT-pattern was defined as having trabeculae >6 cells thick. After excluding all recognized HCC subtypes, remaining cases were deemed conventional HCC (CV-HCC) and served as controls. HCCs with a component of ≥10%, ≥30% and ≥50% MT-pattern were identified in 41 (17.7%), 24 (10.4%) and 4 (1.7%) cases, respectively. The clinicopathologic features of HCCs with 10% to 29% MT-pattern (n=17, 7.4%) were largely similar to CV-HCC. No significant difference was observed between the 30% and 49% (n=20) and ≥50% (n=4) MT groups, hence these were combined for further analysis as MT-HCC. MT-HCCs (≥30% MT-pattern) were larger tumors (5.5 vs. 3.1 cm), were less likely to be associated with cirrhosis (54% vs. 79%), were more likely to have hepatitis B (21% vs. 5%) and less likely hepatitis C infection (33% vs. 58%) compared with CV-HCC. MT-HCC was associated with the presence of anaplastic tumor cells (42% vs. 14%), higher alpha‐fetoprotein level, higher AJCC stage, and higher histologic grade. Compared with patients with CV-HCC, patients with MT-HCC had poorer overall survival. Patients with MT-HCC who underwent primary resection or transplantation had a higher recurrence rate and worse recurrence-free survival. Our findings suggest that ≥30% MT-pattern could be used as the more appropriate cut-off for defining MT‐HCC, which represents a unique and aggressive HCC histologic subtype.
“That's Not His Regular Formula”
Authors: Dodson Jeannette , Feng Sing-Yi , Rodriguez David
Published: May 2019

Introduction

Organophosphates (OPs) are the basis of many insecticides and herbicides and are also used as nerve agents. Approximately 1 million unintentional and 2 million suicidal poisonings as well as more than 300,000 fatalities that are reportedly due to OPs are reported each year worldwide. The mortality rate from OP toxicity is reported as approximately 20%. We present a rare pediatric exposure to OPs.

Case

This is an unintentional OP poisoning in an infant who presented to a pediatric emergency department with obtundation, respiratory distress, and copious secretions. The infant was intubated, treated with atropine and pralidoxime after resuscitation, and eventually recovered with no neurologic sequelae.

Discussion

Symptoms from OP toxicity are secondary to effects on muscarinic and nicotinic cholinergic receptors in the autonomic and central nervous systems. Symptoms include diaphoresis, diarrhea, urination, miosis, bradycardia, bronchospasm, bronchorrhea, emesis, lethargy, lacrimation, and salivation. Treatment starts with titrated doses of atropine and oximes (eg, pralidoxime) after resuscitation and decontamination. Severity of toxicity and recovery can be monitored via plasma and whole blood acetylcholinesterase levels, respectively. Once aging has occurred, oximes will not be able to reverse acetylcholinesterase inhibition. Despite early treatment, rare cases may result in delayed neurologic complications associated with sensory and motor axonal degeneration of the peripheral nerves and spinal cord known as OP-induced delayed neuropathy.

Conclusions

This case highlights the importance of safety education for families. It also demonstrates how to recognize and treat OP toxicity in an infant. It emphasizes starting treatment early to avoid complications secondary to aging.
Predictors for Acute Appendicitis in Children
Authors: Malia Laurie , Sturm Jesse J. , Smith Sharon R. , Brown R. Timothy , Campbell Brendan , Chicaiza Henry
Published: May 2019

Background

Acute appendicitis in children is the most common condition requiring urgent evaluation and surgery in the emergency department. At times, despite the appendix being seen on ultrasound (US), there can be discrepancy as to whether a patient has clinical appendicitis. Secondary findings suggestive of appendicitis can be helpful in identifying and evaluating these children.

Objective

The aim of this study was to determine if specific US findings and/or laboratory results are predictive of appendicitis in children with a visualized appendix on US.

Methods

A prospective study was conducted on children (birth to 18 years) presenting to the pediatric emergency department with suspected appendicitis who underwent right-lower-quadrant US. Ultrasound findings analyzed appendix diameter, compressibility, increased vascularity, presence of appendicolith, inflammatory changes, right-lower-quadrant fluid near the appendix, lower abdominal fluid, tenderness during US, and lymph nodes. Diagnosis was confirmed via surgical pathology.

Results

There were 1252 patients who enrolled, 60.8 (762) had their appendix visualized, and 39.1 (490) did not. In children where the appendix was seen, 35.2% (268) were diagnosed with appendicitis. Among patients with a visualized appendix, the likelihood of appendicitis was significantly greater if the appendix diameter was 7 mm or greater (odds ratio [OR], 12.4; 95% confidence interval [CI], 4.7–32.7), an appendicolith was present (OR, 3.9; 95% CI, 1.5–10.3), inflammatory changes were seen (OR, 10.2; 95% CI, 3.9–26.1), or the white blood cell (WBC) count was 10,000/μL (OR, 4.8; 95% CI, 2.4–9.7). A duration of abdominal pain of 3 days or more was significantly less likely to be associated with appendicitis (OR, 0.3; 95% CI, 0.08–0.99). The absence of inflammatory changes, WBC count of less than 10,000/μL, and appendix diameter of 7 mm or less had a negative predictive value of 100%.

Conclusions

When the appendix is seen on US but diagnosis of appendicitis is questioned, the absence of inflammatory changes, WBC count of less than 10,000/μL, and appendix diameter of 7 mm or less should decrease suspicion for appendicitis.