bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparing Force of Stream With a Standard Fill Voiding Trial After Surgical Repair of Apical Prolapse
Authors: Pilkinton Marjorie L. , Williams Kathryn S. , Sison Cristina P. , Shalom Dara F. , Winkler Harvey A.
Published: March 2019

OBJECTIVE:

To estimate whether the urinary force of stream method is noninferior to a standard fill voiding trial for rate of catheterization within 6 weeks after apical prolapse surgery in those discharged without a catheter.

METHODS:

A noninferiority randomized controlled trial was conducted in postoperative women comparing force of stream with standard fill voiding trials after vaginal, abdominal, or laparoscopic–robotic apical pelvic organ prolapse (POP) surgery. Before discharge, women in both groups were backfilled with 300 mL normal saline. Successful voiding criteria in the force of stream group was subjective force of stream of at least 50 using a visual analog scale; reporting less than 50 prompted a bladder scan. Successful voiding was defined as a postvoid residual volume of less than 500 mL. For the standard fill voiding trial group, voiding two thirds of the instilled amount indicated success. The primary outcome was the rate of catheterization within the 6-week postoperative period after surgical repair of apical prolapse among those discharged without a urinary catheter. Secondary endpoints included trial of void failure rates. A sample size of 59 patients per group who passed trial of void at discharge was needed to achieve 80% power using a noninferiority margin (delta of 10%). Total enrollment of 169 patients was necessary to account for an estimated 30% trial of void failure rate.

RESULTS:

From April 2016 and April 2017, 184 patients were enrolled (six enrolled before the trial registration date), with the first patient enrolled on April 1, 2016. One hundred seventy-four patients were randomized (86 in the force of stream group and 88 in the standard fill voiding trial group). No differences were observed in demographic or perioperative characteristics, except for stage 2 apical prolapse (52% in the force of stream group vs 36% in the standard fill voiding trial group). For the primary outcome, similar rates were found in those patients who passed their trial of void but subsequently needed catheterization for voiding dysfunction (force of stream 2.8% [2/71] vs standard fill voiding trial 3.1% [2/64]; difference −0.3%, 95% CI −8.69% to 8.08%). The incidence of trial of void failures at discharge was similar (force of stream 17.4% [15/86] vs standard fill voiding trial 26.4% [23/87]; risk ratio 0.65, 95% CI 0.37–1.18, P=nonsignificant).

CONCLUSION:

Force of stream was noninferior to standard fill voiding trial when comparing the rate of catheter insertion during the 6-week postoperative period after apical POP surgery in those discharged without a catheter.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, NCT02753920.
U.S. Food and Drug Administration–Approved Poly (ADP-Ribose) Polymerase Inhibitor Maintenance Therapy for Recurrent Ovarian Cancer
Authors: Dottino Joseph A. , Moss Haley A. , Lu Karen H. , Secord Angeles A. , Havrilesky Laura J.
Published: March 2019

OBJECTIVE:

We sought to determine whether use of a poly (ADP-ribose) polymerase inhibitor is cost effective for maintenance treatment of platinum-sensitive recurrent ovarian cancer.

METHODS:

A decision analysis model compared four maintenance strategies: 1) observation, 2) BRCA germline mutation testing and selective treatment of carriers (gBRCA only), 3) BRCA germline and tumor homologous recombination deficiency testing and selective treatment of either BRCA carriers or those with tumor HRD (gBRCA and HRD only), and 4) treat all with niraparib to progression (treat all). Costs were estimated in 2016 U.S. dollars. Incremental cost-effectiveness ratios were in dollars per progression-free quality-adjusted life-year (QALY). One-way sensitivity analyses tested multiple assumptions.

RESULTS:

Maintenance poly (ADP-ribose) polymerase inhibitor was costlier and more effective than observation. Mean costs and progression-free QALYs were $827 and 3.4 months for observation, $46,157 and 5.7 for a BRCA-only strategy, $109,368 and 8.5 for a gBRCA and homologous recombination deficiency–only strategy, and $169,127 and 8.8 for a treat-all strategy. gBRCA-only had an incremental cost-effectiveness ratio of $243,092/progression-free QALY compared with observation; other strategies did not approach cost effectiveness. Using the current U.S. Food and Drug Administration label for maintenance poly (ADP-ribose) polymerase inhibitor regardless of biomarker status, the third-party payer cost per month (28-day supply) would need to be reduced from approximately $14,700 to $3,600 to be considered cost effective compared with observation using a willingness to pay threshold of $100,000/progression-free QALY.

CONCLUSION:

Maintenance poly (ADP-ribose) polymerase inhibitor therapy for platinum-sensitive recurrent ovarian cancer is not cost effective. Treatment of patients with BRCA mutation alone or with homologous recombination deficiency–positive tumors are preferred strategies compared with a treat-all strategy. Lowering the cost may make selective niraparib maintenance therapy cost effective compared with observation.
Hysterectomy Practice Patterns in the Postmorcellation Era
Authors: Jorgensen Elisa M. , Modest Anna M. , Hur Hye-Chun , Hacker Michele R. , Awtrey Christopher S.
Published: March 2019

OBJECTIVE:

To characterize long-term national trends in surgical approach for hysterectomy after the U.S. Food and Drug Administration (FDA) warning against power morcellation for laparoscopic specimen removal.

METHODS:

This was a descriptive study using data from the American College of Surgeons National Surgical Quality Improvement Program from 2012 to 2016. We identified hysterectomies using Current Procedural Terminology codes. We used an interrupted time-series analysis to evaluate abdominal and supracervical hysterectomy trends surrounding The Wall Street Journal article first reporting morcellation safety concerns and the FDA safety communication. We compared categorical and continuous variables using χ2, t, and Wilcoxon rank sum tests.

RESULTS:

We identified 179,950 hysterectomies; laparoscopy was the most common mode of hysterectomy in every quarter. Before The Wall Street Journal article, there was no significant change in proportion of abdominal hysterectomies (0.3% decrease/quarter, P=.14). After The Wall Street Journal article, use of abdominal hysterectomy increased 1.1% per quarter for two quarters through the FDA warning (P<.001), plateaued for three quarters until March 2015 (P=.65), then decreased by 0.8% per quarter through 2016 (P<.001). Supracervical hysterectomy volume continuously decreased after the FDA warning (1.0% decrease per quarter, P<.001) and after three quarters (0.7% decrease per quarter, P=.01), then plateaued from April 2015 through 2016 (0.05% decrease per quarter, P=.40). Mode of supracervical hysterectomy was unchanged from 2012 to 2013 (P=.43), followed by two quarters of significant increase in proportion of supracervical abdominal hysterectomies (11.7%/quarter, P<.001). This change in mode of supracervical hysterectomy then plateaued through 2016 (P=.06).

CONCLUSION:

Despite early studies suggesting that minimally invasive hysterectomy decreased in response to safety concerns regarding power morcellation, we found that this effect reversed 1 year after the FDA safety communication. However, there was a sustained decline in supracervical hysterectomy, and the remaining supracervical hysterectomies were more likely to be performed using laparotomy.
Influence of Genetic Variants on Steady-State Etonogestrel Concentrations Among Contraceptive Implant Users
Authors: Lazorwitz Aaron , Aquilante Christina L. , Oreschak Kris , Sheeder Jeanelle , Guiahi Maryam , Teal Stephanie
Published: March 2019

OBJECTIVE:

To identify genetic variants that influence steady-state etonogestrel concentrations among contraceptive implant users.

METHODS:

We enrolled healthy, reproductive-age women in our pharmacogenomic study using etonogestrel implants for 12–36 months without concomitant use of hepatic enzyme inducers or inhibitors. We collected participant characteristics, measured serum etonogestrel concentrations, and genotyped each participant for 120 single nucleotide variants in 14 genes encoding proteins involved in steroid hormone (ie, estrogens, progestins) metabolism, regulation, or function. We performed generalized linear modeling to identify genetic variants associated with steady-state etonogestrel concentrations.

RESULTS:

We enrolled 350 women, who had a median serum etonogestrel concentration of 137.4 pg/mL (range 55.8–695.1). Our final generalized linear model contained three genetic variants associated with serum etonogestrel concentrations: NR1I2(PXR) rs2461817 (β=13.36, P=.005), PGR rs537681 (β=−29.77, P=.007), and CYP3A7*1C (β=−35.06, P=.025). Variant allele frequencies were 69.4%, 84.9%, and 5.1%, respectively. Our linear model also contained two nongenetic factors associated with etonogestrel concentrations: body mass index (BMI) (β=−3.08, P=7.0×10−7) and duration of implant use (β=−1.60, P=5.8×10−5); R2 for the model =0.17.

CONCLUSION:

Only BMI and duration of implant use remained significantly associated with steady-state etonogestrel concentrations. Of the three novel genetic associations found, one variant associated with increased etonogestrel metabolism (CYP3A7*1C) causes adult expression of fetal CYP3A7 proteins and can consequently alter steroid hormone metabolism. Women with this variant may potentially have increased metabolism of all steroid hormones, as 27.8% (5/18) of CYP3A7*1C carriers had serum etonogestrel concentrations that fell below the threshold for consistent ovulatory suppression (less than 90 pg/mL). More pharmacogenomic investigations are needed to advance our understanding of how genetic variation can influence the effectiveness and safety of hormonal contraception, and lay the groundwork for personalized medicine approaches in women's health.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, NCT03092037.
Which Children Are at Risk for Contralateral Anterior Cruciate Ligament Injury After Ipsilateral Reconstruction?
Authors: Patel Neeraj M. , Bram Joshua T. , Talathi Nakul S. , DeFrancesco Christopher J. , Lawrence John Todd R. , Ganley Theodore J.
Published: March 2019

Background:

Following anterior cruciate ligament (ACL) reconstruction, children are at significant risk for complications, including contralateral ACL rupture. The purpose of this study is to determine which children are at risk for a contralateral ACL tear after ipsilateral reconstruction.

Methods:

After review of medical records, we contacted patients who underwent primary ACL reconstruction between 2009 and 2016. Patients were included in the study if they were able to provide follow-up data either in person or remotely at least 2 years after surgery. Demographic data, sports participation, and intraoperative findings and techniques were recorded. All patients were also asked to confirm returning to sport information and postoperative complications (including contralateral ACL tear). Univariate analysis consisted of χ2 and independent samples t tests. Purposeful entry logistic regression was then conducted to control for confounding factors. Kaplan-Meier analysis was performed to assess contralateral ACL survival.

Results:

A total of 498 children with average follow-up of 4.3±2.1 years were included in the analysis. The mean age was 15.0±2.3 years and 262 patients (52.6%) were female. Thirty-five subjects (7.0%) sustained a contralateral ACL tear at a mean of 2.7±1.7 years following index reconstruction. Kaplan-Meier analysis revealed the median contralateral ACL survival time to be 8.9 years [95% confidence interval (CI): 8.3, 9.5 y]. In univariate analysis, 11.5% of female patients had a contralateral rupture compared with 2.1% of male patient (P<0.001). Patients with a contralateral tear had a mean age of 14.4±2.0 years compared with 15.1±2.3 years for those without an ACL injury in the opposite knee (P=0.04). After controlling for numerous factors in a multivariate model, female patients had 3.5 times higher odds of sustaining a contralateral ACL tear than male patients (95% CI: 1.1, 10.6; P=0.03). Each year of decreasing age raised the odds of contralateral injury by a factor of 1.3 (95% CI: 1.1, 1.6; P=0.02). Furthermore, children younger than 15 years had 3.1 times higher odds of contralateral rupture than those aged 15 and older (95% CI: 1.3, 7.2; P=0.01).

Conclusions:

After adjusting for confounding factors in a multivariate model, female patients were at increased risk of contralateral ACL tear following ipsilateral reconstruction, as were younger children. Specifically, ACL rupture in the opposite knee was more likely in patients below the age of 15 years.

Level of Evidence:

Level III—prognostic study.
Cellulite: Patient Selection and Combination Treatments for Optimal Results—A Review and Our Experience
Authors: Davis DiAnne S. , Boen Monica , Fabi Sabrina G.
Published: March 2019

BACKGROUND

More than 90% of women have reported concerns of cellulite on their skin. Both commercially advertised creams and topical pharmacological agents have shown limited improvement. Thus far, there has been a paucity of thorough review articles on how to address and treat this condition.

OBJECTIVE

To investigate how the etiology and pathogenesis of cellulite can help guide treatment combinations and provide a more algorithmic approach to comprehensively address a condition that affects so many women.

MATERIALS AND METHODS

A review of the literature surrounding treatment options for cellulite and the authors' experience in this area are provided.

CONCLUSION

This review summarizes available treatment options for cellulite, including topical agents, controlled subcision, energy-based devices, dermal fillers, and new injectable medications. Furthermore, the various ways that these treatments can be combined in an algorithmic and sequential approach based on the degree of volume loss, skin laxity, and excess adiposity associated with cellulite are addressed. These combination therapies for cellulite are supported both in the published literature and the authors' experience to help clinicians tailor a comprehensive treatment plan for the multiple factors that contribute to cellulite. Further clinical trials are needed to compare various devices and techniques for cellulite as well as combination treatments.
Effect of Postoperative Telephone Calls on Patient Satisfaction and Scar Satisfaction After Mohs Micrographic Surgery
Authors: Vance Stephen , Fontecilla Natalia , Samie Faramarz H. , Patel Vishal , Lewin Jesse M.
Published: March 2019

BACKGROUND

Mohs micrographic surgery is considered the gold standard for high-risk nonmelanoma skin cancer. Postoperative telephone follow-up (TFU) is linked to higher patient satisfaction; however, there are no randomized, blinded studies examining whether TFU after Mohs surgery improves patient satisfaction.

OBJECTIVE

To perform a randomized single-blinded prospective survey study examining whether patient satisfaction or scar satisfaction varied between Mohs patients who received a postoperative call and patients who did not.

METHODS

Patients were enrolled into “post-op call” or “no post-op call” groups. Both arms completed surveys at suture removal and 3-month follow-up visits.

RESULTS

One hundred four subjects were enrolled, and demographics, the number of Mohs stages, and type of repair were controlled. At suture removal, both arms reported similar overall high satisfaction on the 5-point Likert scale (4.90 “call arm” vs 4.88 “no-call arm”, p = .80). Patient and Observer Scar Assessment Scale (POSAS) scores were 3.37 in the “call arm” versus 3.81 in the “no-call arm”, p = .31. At 3-month follow-up, results were similar.

CONCLUSION

High overall satisfaction was reported in both arms. The TFU group reported higher overall satisfaction, but this difference was not significant. Scar satisfaction did not vary statistically between the arms, but POSAS scores in the call arm trended favorably.
Endometrial safety of low-dose vaginal estrogens in menopausal women: a systematic evidence review
Authors: Constantine Ginger D. , Graham Shelli , Lapane Kate , Ohleth Kathleen , Bernick Brian , Liu James , Mirkin Sebastian
Published: March 2019

Objective:

The aim of the study was to systematically review studies that evaluated endometrial hyperplasia or cancer incidence with unopposed vaginal estrogens.

Methods:

PubMed and EMBASE were searched from inception to August 2017 for relevant articles and abstracts. Bibliographies of review articles and abstracts of major women's health medical meetings were examined. Eligible studies (independently reviewed by 4 authors) had to report menopausal vaginal estrogen use and endometrial histology, or incidence of endometrial hyperplasia or cancer.

Results:

Of 5,593 abstracts from the literature search and 47 articles from other sources, 36 articles and 2 abstracts were eligible, describing 20 randomized controlled studies, 8 interventional studies, and 10 observational studies. Collectively, the studies did not support an increased risk of endometrial hyperplasia or cancer with low-dose vaginal estrogens. Rates of endometrial cancer and hyperplasia were 0.03% and 0.4%, respectively, from 20 randomized controlled trials (2,983 women) of vaginal estrogens. Overall, reports of endometrial hyperplasia were observed with various doses and durations and appeared sporadic (except 1.25 mg conjugated equine estrogens), consistent with endometrial hyperplasia rates in the general population. A Denmark registry study was an exception and may be of limited applicability to the United States. The Women's Health Initiative Observational Study showed no association (1.3 cases/1,000 women-years with vaginal estrogens versus 1.0/1,000 women-years for nonuse).

Conclusion:

This systematic review supports the use of low-dose vaginal estrogens for treating vulvar and vaginal atrophy in menopausal women without a concomitant progestogen. This review does not support increased endometrial hyperplasia or cancer risk with low-dose, unopposed vaginal estrogens; however, longer-term, real-world data are needed.
Life-long endogenous estrogen exposure is associated with prevalence of allergic rhinitis in postmenopausal women
Authors: Lee Kijeong , Hong Yeji , Choi Jimi , Lee Sang Hag , Kim Tae Hoon
Published: March 2019

Objectives:

The aim of the study was to investigate the influence of life-long endogenous estrogen exposure on prevalence of chronic rhinitis including allergic rhinitis (AR) in the postmenopausal period.

Methods:

In this cross-sectional study, a total of 3,043 postmenopausal women who participated in the Korea National Health and Nutrition Examination Survey V were included. Participants with symptoms including sneezing, rhinorrhea, nasal obstruction, or nasal itching were considered to have chronic rhinitis. In subgroup analysis, the AR group comprised participants with rhinitis with positive findings in at least one of three specific immunoglobulin E. Univariable and multivariable logistic analyses were performed to evaluate the relationship between rhinitis and estrogen-related factors including age at menarche, age at menopause, age at first delivery, parity, and duration of breast-feeding.

Results:

Participants with chronic rhinitis (17.6%) had higher parity (odd ratio [OR] = 1.17, P = 0.0135) and shorter duration of breast-feeding (OR = 0.98, P = 0.0388) than controls. In subgroup analysis, participants with AR (7.1%) had younger age at menarche (OR = 0.56, P = 0.0028) and older age at menopause (OR = 1.42, P = 0.0060) after adjustment of confounding factors. There was a positive association between age at menopause and specific immunoglobulin E for both cockroach (OR = 1.38, P = 0.0132) and dogs (OR = 1.38, P = 0.0302). Longer postmenopausal duration was positively associated with cockroach allergen sensitization (OR = 1.25, P = 0.201).

Conclusions:

Longer duration of reproductive period was associated with higher prevalence of AR and aeroallergen sensitization in the postmenopausal period. Moreover, cockroach allergen sensitization was associated with a longer postmenopausal period.
A Comparative Study of Radon Levels in Federal Buildings and Residential Homes in Canada
Authors: Whyte Jeffrey , Falcomer Renato , Chen Jing
Published: March 2019

Shortly after revision of the Canadian radon guideline from 800 to 200 Bq m−3, Health Canada established the Federal Building Testing Program in 2007 to demonstrate federal leadership in raising awareness about radon risk and the need for testing. By the end of 2017, more than 7,600 federal workplaces had been tested for radon. As is the case in all radon surveys, radon levels vary widely; federal building results ranged from below the detection limit to more than 2,500 Bq m−3 in a few rooms of a few buildings. Weighted by the population of federal public servants across Canada, the average radon distribution in federal workplaces has a geometric mean of 22.0 Bq m−3 with a geometric standard deviation of 2.3. The population-weighted arithmetic mean is 34.3 Bq m−3, significantly lower than the population-weighted average radon concentration of 72.9 Bq m−3 in residential homes across Canada. On average, 2% of federal workplaces have radon concentrations above 200 Bq m−3, which is also significantly lower than the 7% of residential homes that tested above 200 Bq m−3. This comparative study demonstrated clearly that radon education and awareness in Canada should focus more on residential testing and remediation actions to effectively reduce the burden of radon-induced lung cancer.
Virtual Grand Rounds: A Curricular Model for Translating Evidence-Based Practice From the Classroom to the Clinic
Authors: Fay Deanne , Bordenave Lori M. , Wilkinson Tawna
Published: March 2019

Background and Purpose.

The physical therapy profession supports educating physical therapist graduates to use evidence-based practice (EBP) skills in the clinical environment. Educational interventions to teach EBP include a variety of formats, but most focus on changing student and clinician knowledge and skills rather than changing actual clinician behavior. The literature suggests that for clinician behavior to change, educational interventions must be integrated into clinical practice. To describe the restructuring of the ATSU research and EBP curriculum including the development of a course, Virtual Grand Rounds (VGR), that focused on EBP skills and took place during clinical experiences.

Method/Model Description and Evaluation.

The curriculum and VGR course were designed for students to learn EBP skills, develop tolerance for uncertainty, implement EBP within time demands of the clinic, and use workplace supports. All physical therapy students completed both the Evidence-Based Practice Beliefs (EBPB) scale and the Evidence-Based Practice Implementation (EBPI) scale at program entry and at the end of years 1, 2, and 3 (graduation).

Outcomes.

A total of 727 EBPB and 719 EBPI surveys were completed and analyzed. Using an analysis of variance with Scheffe post hoc analyses, significant differences (P < .05) were found between the EBPB and EBPI scores for each year of data collection with the exception of a nonsignificant change between year 1 and year 2 (P = .998 and P = .702). The overall EBPI score at graduation indicated that during the final clinical year, students performed each EBP skill somewhere between 1 and 5 times during the clinical experience. Changes in individual question scores indicated increases in students' skills, knowledge, and application throughout all years.

Discussion and Conclusion.

Evidence-based practice implementation increased throughout the 3 years and was at the highest following the final clinical year when students participated in the newly developed VGR. By situating practice of EBP within the time constraints of the clinical environment, the setting where EBP takes place, students are equipped to move away from the reliance on clinical expertise to evidence-based physical therapy. The development of the VGR course described in this article shifts EBP from an academic exercise in the classroom to an activity imbedded in real clinical practice. Other programs may find this integrated course helpful in removing barriers to EBP and developing graduates equipped to integrate EBP in the clinical environment.
Estimation of Central Venous Pressure by Pacemaker Lead Impedances in Left Ventricular Assist Device Patients
Authors: Imamura Teruhiko , Moss Joshua D. , Flatley Erin , Rodgers Daniel , Kim Gene , Raikhelkar Jayant , Sarswat Nitasha , Kalantari Sara , Nguyen Ann , Juricek Colleen , Burkhoff Daniel , Song Tae , Ota Takeyoshi , Jeevanandam Valluvan , Sayer Gabriel , Uriel Nir
Published: March 2019

Volume status assessment in left ventricular assist device (LVAD) patients remains challenging. Cardiac resynchronization therapy (CRT) devices are common in LVAD patients, and the impedance across the CRT leads may be associated with hemodynamics and serve as a tool for noninvasive estimation of volume status. Ninety-one sets of measurements including cardiac filling pressures and lead impedances were prospectively obtained during ramp tests from 11 LVAD patients (65.5 ± 9.7 years old; nine male) with CRT devices. Right atrial (RA), right ventricular (RV), and left ventricular (LV) lead impedances were all significantly associated with central venous pressure (CVP) (p < 0.05). We derived the following equation: estimated CVP = 47.90–(0.086 × RA lead impedance) + (0.013 × RV lead impedance)–(0.020 × LV lead impedance). The estimated CVP had a significant correlation (r = 0.795) and good agreement with the measured CVP (mean difference –0.14 ± 1.77 mmHg). Applying the above equation on the validation cohort of twenty-one patients also maintained a strong association with measured CVP (r = 0.705). In conclusion, we have derived a novel equation to estimate CVP using lead impedance measurements. This finding may allow noninvasive monitoring of volume status in LVAD patients.
Neutrophil to Lymphocyte Ratio Is Related to Thrombotic Complications and Survival in Continuous Flow Left Ventricular Assist Devices
Authors: Ferrera Carlos , Gonzalez Fernandez Oscar , Bouzas Noelia , Castrodeza Javier , Green Thomas , Woods Andrew , Robinson-Smith Nicola , Tovey Sian , Jakovljevic Djordje G. , Shah Asif , Booth Karen , Parry Gareth , Schueler Stephan , MacGowan Guy A.
Published: March 2019

Left ventricular assist devices (LVADs) have become an established treatment for advanced heart failure, although with long-term support these patients are potentially exposed to serious complications. Our purpose was to assess the role of the neutrophil to lymphocyte ratio (NLR) in LVAD complications and to evaluate if higher values of NLR after 4–6 months on LVAD support (NLR 4_6m) are associated with worse prognosis. All consecutive patients who received a HeartWare LVAD (N = 188, age 50 ± 13 years), as bridge to transplant from December 2009 to January 2018 were included. Neutrophil to lymphocyte ratio was recorded pre-LVAD, post-LVAD, after 4–6 months on support and in case of a first adverse event to occur after the 4–6 months NLR was recorded. Median NLR values were pre-LVAD 4.26 (interquartile range [IQR], 3.1–6.9), at 1 day postoperative 11.6 (IQR, 8.3–16.6), and NLR 4_6m 4.4 (IQR, 3.0–6.4) (p < 0.001). Neutrophil to lymphocyte ratio increased significantly when patients had an infection, stroke, or pump thrombosis, as compared with the NLR 4_6m (all p < 0.05). Patients with NLR 4_6m ≥ median had higher rates of stroke and mortality. Survival time was shorter among patients with NLR 4_6m ≥ 4.4 (log-rank test p = 0.006). Neutrophil to lymphocyte ratio 4_6m was found to be predictive of increased mortality (area under the curve of 0.62, p = 0.007). After multivariate analysis, NLR 4_6m remained independently associated with increased mortality (hazard ratio [HR] 1.67; 95% confidence interval [CI], 1.03–2.7; p = 0.037). Neutrophil to lymphocyte ratio 4_6m values significantly increase in association with adverse events on LVAD support and are independently associated with mortality. This association suggests presence of inflammation adversely affects LVAD outcomes.
Collaboration in Health Care and Social Service Networks for Older Adults
Authors: Brewster Amanda L. , Yuan Christina T. , Tan Annabel X. , Tangoren Caroline G. , Curry Leslie A.
Published: March 2019

Background:

Services targeting social determinants of health—such as income support, housing, and nutrition—have been shown to improve health outcomes and reduce health care costs for older adults. Nevertheless, evidence on the properties of effective collaborative networks across health care and social services sectors is limited.

Objectives:

The main objectives of this study were to identify features of collaborative networks of health care and social services organizations associated with avoidable health care use and spending for older adults.

Research Design:

Through a 2017 survey, we collected data on collaborative ties among health care and social service organizations in 20 US communities with either high or low performance on avoidable health care use and spending for Medicare beneficiaries. Six types of ties were measured: any collaboration, referrals, sharing information, cosponsoring projects, financial contracts, and joint needs assessment. We examined how characteristics of collaborative networks were associated with performance.

Results:

High-performing networks were distinguished from low-performing networks by 2 features: (1) health care organizations occupied positions of significantly greater centrality (P<0.01), and (2) subnetworks of cosponsorship ties were more cohesive, as measured by centralization (P=0.05) and density (P=0.06). Across all networks, Area Agencies on Aging were more centrally positioned than any other type of organization (P<0.05).

Conclusions:

Cross-sector engagement by health care organizations, particularly development of deeper types of collaborative ties such as cosponsorship, may reduce preventable health care use and spending. Efforts to foster effective partnerships could leverage the Area Agencies on Aging, which are already positioned as network brokers.
The Significance of Ascites in Patients With Pancreatic Ductal Adenocarcinoma
Authors: Baretti Marina , Pulluri Bhargavi , Tsai Hua-Ling , Blackford Amanda L. , Wolfgang Christopher L. , Laheru Daniel , Zheng Lei , Herman Joseph , Le Dung T. , Narang Amol K. , de Jesus-Acosta Ana
Published: March 2019

Objective

Limited data exist on the impact of ascites in pancreatic ductal adenocarcinoma (PDAC). We evaluated the survival outcomes of patients with PDAC and ascites.

Methods

Retrospective, single-institution, case-control study including patients with newly diagnosed PDAC from 2007 to 2016. One hundred fifty-four patients with ascites at diagnosis (case group) and 154 controls were matched on age, sex, stage, Eastern Cooperative Oncology Group performance, surgical treatment, lymph node, and margin status. Ascites was defined as computed tomography–detected fluid in the pelvic/peritoneal cavity. Overall survival was compared between groups via Cox proportional hazards models with a gamma frailty term to account for the correlation between matched pairs on entire cohort and by disease stages for subgroup analysis.

Results

The 154 matched cases included 24 resectable, 19 borderline resectable, 51 locally advanced, and 60 metastatic disease. Patients with ascites had higher risk of death compared with those without (conditional hazard ratio, 1.58; 95% confidence interval, 1.23–2.03; P < 0.001). Stratified analysis showed a significant association between ascites and poor prognosis in patients with localized disease (conditional hazard ratio, 1.62; 95% confidence interval, 1.18–2.24; P = 0.003).

Conclusions

Radiographic ascites is a poor prognostic factor in PDAC. Our findings may aid physicians in considering systemic therapy prior to attempting local treatments.
Stakeholders External Evaluation of the Clinical Nurse Transition Program
Authors: Seimetz John A.
Published: March 2019

Nurse transition programs have predominantly used internal evaluations to evaluate quality outcomes, and thus, there appears to be a lack of current literature on external evaluation of these programs. External evaluation provides an objective and valuable tool for the nursing professional development practitioner to demonstrate return on investment. The results support the use of the innovative and groundbreaking Clinical Nurse Transition Program Evaluation Tool to externally evaluate the nurse transition program.
Comparison of Measures to Predict Mortality and Length of Stay in Hospitalized Patients
Authors: Liu Jianfang , Larson Elaine , Hessels Amanda , Cohen Bevin , Zachariah Philip , Caplan David , Shang Jingjing
Published: March 2019

Background

Patient risk adjustment is critical for hospital benchmarking and allocation of healthcare resources. However, considerable heterogeneity exists among measures.

Objectives

The performance of five measures was compared to predict mortality and length of stay (LOS) in hospitalized adults using claims data; these include three comorbidity composite scores (Charlson/Deyo age-comorbidity score, V W Elixhauser comorbidity score, and V W Elixhauser age-comorbidity score), 3 M risk of mortality (3 M ROM), and 3 M severity of illness (3 M SOI) subclasses.

Methods

Binary logistic and zero-truncated negative binomial regression models were applied to a 2-year retrospective dataset (2013–2014) with 123,641 adult inpatient admissions from a large hospital system in New York City.

Results

All five measures demonstrated good to strong model fit for predicting in-hospital mortality, with C-statistics of 0.74 (95% confidence interval [CI] [0.74, 0.75]), 0.80 (95% CI [0.80, 0.81]), 0.81(95% CI [0.81, 0.82]), 0.94 (95% CI [0.93, 0.94]), and 0.90 (95% CI [0.90, 0.91]) for Charlson/Deyo age-comorbidity score, V W Elixhauser comorbidity score, V W Elixhauser age-comorbidity score, 3 M ROM, and 3 M SOI, respectively. The model fit statistics to predict hospital LOS measured by the likelihood ratio index were 0.3%, 1.2%, 1.1%, 6.2%, and 4.3%, respectively.

Discussion

The measures tested in this study can guide nurse managers in the assignment of nursing care and coordination of needed patient services and administrators to effectively and efficiently support optimal nursing care.
Prevalence and Risk Factors of Trichomonas vaginalis Among Female Sexual Workers in Nairobi, Kenya
Authors: Lockhart Alexandre , Senkomago Virginia , Ting Jie , Chitwa Michael , Kimani Joshua , Gakure Hannah , Kwatampora Jessie , Patel Suha , Mugo Nelly , Smith Jennifer S.
Published: March 2019

Background

Trichomonas vaginalis (TV) is the most common curable sexually transmitted infection (STI) worldwide. Trichomonas vaginalis infection is associated with an increased risk of pelvic inflammatory disease, human immunodeficiency virus transmission, and preterm birth in women. Data on the prevalence and risk factors for TV infection in sub-Saharan African countries remain scarce.

Methods

A total of 350 Kenyan female sex workers, aged 18 to 50 years, participated in a 2-year longitudinal study of the acquisition of STIs, including TV infection. Every 3 months, cervical and vaginal brush samples were collected for STI testing. At baseline, a sociodemographic and behavior questionnaire was administered. Testing for TV, Chlamydia trachomatis (CT), Neisseria gonorrhoeae, Mycoplasma genitalium, and high-risk human papillomavirus was performed using APTIMA assays.

Results

The TV baseline prevalence was 9.2% (95% confidence interval [95% CI], 6.3–12.7%) and 2-year cumulative TV incidence was 8.1 per 1000 person months (6.9–9.3). Risk factors for higher TV prevalence at baseline were CT infection (adjusted prevalence ratio [PR], 8.53; 95% CI, 3.35–21.71), human immunodeficiency virus seropositivity (PR, 3.01; 95% CI, 1.45, 6.24) and greater than 4 years of sex work (PR, 2.66; 95% CI, 1.07–6.60). Risk factors for elevated 2-year TV incidence were CT (hazard ratio [HR], 4.28; 95% CI, 1.36–13.50), high-risk human papillomavirus infection (HR, 1.91; 95% CI, 1.06–3.45) and history of smoking (HR, 2.66; 95% CI, 1.24–5.73).

Discussion

CT infection was positively associated with both prevalent and 2-year incident TV infections.
Central Macular Thickness in Diabetic Patients: A Sex-based Analysis
Authors: Arthur Edmund , Young Stuart B. , Elsner Ann E. , Baskaran Karthikeyan , Papay Joel A. , Muller Matthew S. , Gast Thomas J. , Haggerty Bryan P. , Clark Christopher A. , Malinovsky Victor E. , Brahm Shane G. , Litvin Taras V. , Ozawa Glen Y. , Cuadros Jorge A.
Published: March 2019

SIGNIFICANCE

The pathological changes in clinically significant diabetic macular edema lead to greater retinal thickening in men than in women. Therefore, male sex should be considered a potential risk factor for identifying individuals with the most severe pathological changes. Understanding this excessive retinal thickening in men may help preserve vision.

PURPOSE

The purpose of this study was to investigate the sex differences in retinal thickness in diabetic patients. We tested whether men with clinically significant macular edema had even greater central macular thickness than expected from sex differences without significant pathological changes. This study also aimed to determine which retinal layers contribute to abnormal retinal thickness.

METHODS

From 2047 underserved adult diabetic patients from Alameda County, CA, 142 patients with clinically significant macular edema were identified by EyePACS-certified graders using color fundus images (Canon CR6-45NM). First, central macular thickness from spectral domain optical coherence tomography (iVue; Optovue Inc.) was compared in 21 men versus 21 women without clinically significant macular edema. Then, a planned comparison contrasted the greater values of central macular thickness in men versus women with clinically significant macular edema as compared with those without. Mean retinal thickness and variability of central macular layers were compared in men versus women.

RESULTS

Men without clinically significant macular edema had a 12-μm greater central macular thickness than did women (245 ± 21.3 and 233 ± 13.4 μm, respectively; t
40 = −2.18, P = .04). Men with clinically significant macular edema had a 67-μm greater central macular thickness than did women (383 ± 48.7 and 316 ± 60.4 μm, P < .001); that is, men had 55 μm or more than five times more (t
20 = 2.35, P = .02). In men, the outer-nuclear-layer thickness was more variable, F
10,10 = 9.34.

CONCLUSIONS

Underserved diabetic men had thicker retinas than did women, exacerbated by clinically significant macular edema.
Neuroendocrine Tumors (NETs) of the Minor Papilla/Ampulla
Authors: Vanoli Alessandro , Albarello Luca , Uncini Stefania , Fassan Matteo , Grillo Federica , Di Sabatino Antonio , Martino Michele , Pasquali Claudio , Milanetto Anna C. , Falconi Massimo , Partelli Stefano , Doglioni Claudio , Schiavo-Lena Marco , Brambilla Tatiana , Pietrabissa Andrea , Sessa Fausto , Capella Carlo , Rindi Guido , La Rosa Stefano , Solcia Enrico , Paulli Marco
Published: March 2019

Neuroendocrine tumors (NETs) of the minor papilla/ampulla (MIPA) are rare and poorly studied. Only individual case reports and no comprehensive analysis are available from the literature. We collected 16 MIPA NETs and investigated their clinicopathologic and immunohistochemical features, including markers such as somatostatin, pancreatic polypeptide, gastrin, serotonin, MUC1, cytokeratin 7, and somatostatin receptors type 2A and 5. The median age at diagnosis was 57.5 years, and the female-to-male ratio was 2.2:1. The median NET size was 1.45 cm, and most (94%) were low-grade (G1) tumors. Similarly to what was observed in the major ampulla, 3 histotypes were found: (i) ampullary-type somatostatin-producing tumors (ASTs, 10 cases), characterized by somatostatin expression in most tumor cells, focal-to-extensive tubulo-acinar structures, often with psammoma bodies, MUC1 reactivity, and no or rare membranous reactivity for somatostatin receptor type 2A; (ii) gangliocytic paragangliomas (3 cases), characterized by the coexistence of 3 tumor cell types: epithelioid, often reactive for pancreatic polypeptide, ganglion-like cells, and S100 reactive sustentacular/stromal cells; and (iii) ordinary nonfunctioning NETs (3 cases), resembling those more commonly observed in the extra-ampullary duodenum. Comparable histotypes could also be recognized among the 30 MIPA NETs from the literature. No NET-related patient death among MIPA cases was observed during a median follow-up of 38 months; however, MIPA ASTs showed lymph node metastases and invasion of the duodenal muscularis propria or beyond in 44% and 40% of cases, respectively. In conclusion, MIPA NETs closely resemble tumors arising in the major ampulla, with predominance of ASTs.
Varied Clinical Presentations of Acute Dystonic Reaction Due to Metoclopramide
Authors: EL Çiğdem , Çelikkaya Mehmet Emin
Published: March 2019

Objectives

In this article, in light of the literature, we aimed at discussing data obtained from patients in which extrapyramidal adverse effects that are misdiagnosed as varied clinical presentations developed due to metoclopramide, which is frequently prescribed in pediatric emergency services and in family practice centers for its powerful and rapid antiemetic action.

Methods

The files of patients who presented to a pediatric clinic at the research hospital of Mustafa Kemal University between January 2017 and January 2018 and who were diagnosed as having acute dystonic reaction were reviewed retrospectively.

Results

Generalized hypertonicity in 4 patients, abnormal involuntary movements in 2 patients, oculogyric crisis in 2 patients, local hypertonia in the wrist and fingers in 2 patients, spasmodic cervical hypertonicity in 2 patients, and trismus in 1 patient were found. Of the patients, 2 were directed to our clinic with early diagnosis of hypocalcemia, 2 with conversion, 3 with meningitis, 1 with epileptic seizure, 1 with status, 1 with mandibular luxation, 1 with tetanus, and 2 with intracranial pathology.

Conclusions

The extrapyramidal adverse effects of metoclopramide, which is frequently prescribed in pediatric emergency services and in family practice centers, are highly terrifying for children and parents. Furthermore, it may cause severe anxiety especially in pediatric emergency services because it may mimic many serious diseases.
Long-Term Serial Measurement of Muscle Volume in TRAM Flaps Using the Eclipse Treatment Planning System
Authors: Han Woo Yeon , Lee Sumin , Kim Eun Key , Lee Taik Jong
Published: March 2019

Background:

Muscle flaps used in reconstructive surgery are known to lose volume over time because of denervation and disuse atrophy. However, there is currently no agreement on a quantitative approach to evaluating volume changes. Here, long-term serial measurement of muscle volume in transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction has been conducted using the Eclipse treatment planning system.

Methods:

This was a retrospective review of the medical records of patients who underwent unilateral immediate breast reconstruction using a pedicled TRAM flap between January of 2004 and December of 2007. Patients who completed three serial follow-up computed tomographic scans and did not have history of recurrence and/or radiation therapy were included. Eclipse software was used for segmentation and three-dimensional reconstruction of the computed tomographic images; the volume of the pedicled rectus abdominis muscle was calculated, and the contralateral side served as the control.

Results:

Among 451 patients undergoing TRAM flap surgery during the study period, 35 met the inclusion requirements. Serial measurement of rectus abdominis muscle volume of the flap showed a mean volume ratio of 27.1 percent, 22.1 percent, and 19.8 percent at 15, 30, and 51 months, respectively. The extrapolated volume ratio finally converged at 19.4 percent. Contralateral muscle volume did not change significantly over time.

Conclusions:

The muscle of a TRAM flap loses more than 70 percent of its volume in the first 15 months, ultimately reducing to approximately 20 percent of its original size. Eclipse can be used retrospectively for volume measurement after a variety of reconstructive procedures using computed tomographic or magnetic resonance images.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Twenty-Five Years of Experience with the Submental Flap in Facial Reconstruction: Evolution and Technical Refinements following 311 Cases in Europe and Africa
Authors: Bertrand Baptiste , Honeyman Calum Sinclair , Emparanza Angel , McGurk Mark , Ousmane Hamady Issa Elh , Schmidt Andreas , Sinna Raphael , Pittet-Cuénod Brigitte , Zwetyenga Narcisse , Martin Dominique
Published: March 2019

Background:

The submental flap is a pedicled island flap with excellent color match for facial reconstruction. The flap can be raised with muscle, submandibular gland, or bone and can be transposed to reach defects up to two-thirds of the face. The authors report the primary author’s (D.M.) experience of 25 years using the submental flap from its original description to most recent technical evolutions in both Europe and Africa.

Methods:

This is a retrospective study including all patients with facial defects who underwent reconstruction using a submental flap between 1991 and 2016. This study included the use of all four variations of the submental flap: platysmal, digastric, extended, and superextended. The authors report technical adaptations and complications encountered.

Results:

The authors performed 311 facial reconstructions using submental flaps: 32 platysmal, 133 digastric, 91 extended, and 45 superextended variations. In conjunction with these reconstructions, the authors performed 10 osteocutaneous submental flaps and two free flaps. The authors report two cases of total flap necrosis (0.6 percent) and 28 minor complications, including 23 cases of distal skin necrosis (7 percent), one reversible mandibular facial nerve palsy (0.3 percent), and three hematomas (1 percent).

Conclusions:

The submental flap has proven to be a reliable flap for head and neck reconstruction. The four technical modifications described use varying amounts of soft tissue to replace tissue lost and can include vascularized bone from the mandibular margin. This flap exemplifies Gillies’ principle of “replacing like with like” and should be discussed as an alternative to free tissue transfer in facial reconstruction, especially in settings where resources are limited.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Sonographic Diagnosis of Velamentous and Marginal Placental Cord Insertion
Authors: Kelley Brendan P. , Klochko Chad L. , Atkinson Sarah , Hillman Daniel , Craig Brian M. , Sandberg Sharon A. , Gaba Arthur R. , Halabi Safwan S.
Published: March 2019

Routine second trimester ultrasound (US) examinations include an assessment of the umbilical cord given its vital role as a vascular conduit between the maternal placenta and fetus during fetal development. Placental cord insertion abnormalities can be identified during prenatal US screening and are increasingly recognized as independent risk factors for various complications during pregnancy and delivery. The purpose of this pictorial review is to illustrate examples of velamentous and marginal placental cord insertion with an emphasis on how to differentiate their morphology using color Doppler US.