bluuebunny/crossref_metadata_2025 huggingface dataset:
Management of Infected Calcific Myonecrosis: A Report of 2 Cases
Authors: Nagano Hisato , Yamamoto Naoto , Yanagibayashi Satoshi , Demitsu Toshio , Azuma Ryuichi , Kiyosawa Tomoharu
Published: May 2020

Calcific myonecrosis (CM) is a rare condition in which a large calcified mass develops after trauma. Generally, CM occurs in a lower extremity, and there have been no reports of its occurrence in the upper arm. We report 2 cases of infected CM, including a rare case of CM occurrence in the arm and a typical case in the leg. Case 1: An 84-year-old woman presented with a draining sinus and a large calcified mass in the arm and axillary region. The mass involved the neurovascular bundle; thus, complete resection was impossible. We performed surgical debridement and postoperative negative-pressure wound therapy with instillation and dwell. Case 2: A 43-year-old man presented with a large calcified mass in the right leg and 2 draining sinuses. After surgical debridement, negative-pressure wound therapy was initiated. However, the wound became infected, and we performed additional debridement, followed by a split thickness skin grafting. The infection was controlled in both patients, although complete resection was not feasible. Complete resection is generally considered the optimum treatment for infected CM, but it is difficult to achieve in some patients. Negative-pressure wound therapy with instillation and dwell appears as a good option for postoperative management if complete resection of infected CM cannot be achieved.
Barriers to Obtaining Informed Consent on Shortterm Surgical Missions
Authors: Čebron Urška , Honeyman Calum , Berhane Meklit , Patel Vinod , Martin Dominique , McGurk Mark
Published: May 2020

Background:

Short-term surgical missions (STSMs) enable visiting surgeons to help address inequalities in the provision of surgical care in resource-limited settings. One criticism of STSMs is a failure to obtain informed consent from patients before major surgical interventions. We aim to use collective evidence to establish the barriers to obtaining informed consent on STSMs and in resource-limited settings and suggest practical solutions to overcome them.

Methods:

A systematic review was performed using PubMed and Web of Science databases and following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. In addition to the data synthesized from the systematic review, we also include pertinent data from a recent long-term follow-up study in Ethiopia.

Results:

Of the 72 records screened, 11 studies were included in our review. The most common barrier to obtaining informed consent was a paternalistic approach to medicine and patient education. Other common barriers were a lack of ethics education among surgeons in low-income and middle-income countries, cultural beliefs toward healthcare, and language barriers between the surgeons and patients. Our experience of a decade of reconstructive surgery missions in Ethiopia corroborates this. In a long-term follow-up study of our head-and-neck patients, informed consent was obtained for 85% (n = 68) of patients over a 14-year period.

Conclusions:

This study highlights the main barriers to obtaining informed consent on STSMs and in the resource-limited setting. We propose a checklist that incorporates practical solutions to the most common barriers surgeons will experience, aimed to improve the process of informed consent on STSMs.
Resolution of Systemic Rheumatologic Symptoms following Breast Implant Removal
Authors: Marano Andrew A. , Cohen Michael H. , Ascherman Jeffrey A.
Published: May 2020

Reports of women with breast implants who suffer a wide variety of systemic symptoms have become more and more prevalent over the past several years. This entity has become known as breast implant illness in conventional news and social media outlets but has vague and nonspecific diagnostic criteria. As a result, the phenomenon is difficult to both identify and treat. The reported patient is a 76-year-old woman who underwent breast reconstruction with a latissimus dorsi flap and textured silicone implant 20 years before the onset of symptoms, which included debilitating joint pain. She had previously maintained an active lifestyle, but symptoms progressed to a point where she was unable to perform basic tasks. A full rheumatologic and connective tissue workup was done, but other than elevated markers of inflammation, it showed no diagnosable disease entity. After a lengthy discussion with her primary care physician and plastic surgeon, she decided to undergo removal of the implant. Following explantation, her symptoms quickly improved, and within several weeks, she was able to return to her active lifestyle.
Basics and Best Practices of Multimodal Pain Management for the Plastic Surgeon
Authors: Barker Jenny C. , Joshi Girish P. , Janis Jeffrey E.
Published: May 2020

Pain management is a central focus for the plastic surgeon’s perioperative planning, and it no longer represents a postoperative afterthought. Protocols that rely on opioid-only pain therapy are outdated and discouraged, as they do not achieve optimal pain relief, increase postoperative morbidity, and contribute to the growing opioid epidemic. A multimodal approach to pain management using non-opioid analgesic techniques is an integral component of enhanced recovery after surgery protocols. Careful perioperative planning for optimal pain management must be achieved in multidisciplinary collaboration with the perioperative care team including anesthesiology. This allows pain management interventions to occur at 3 critical opportunities—preoperative, intraoperative, and postoperative settings.
Pitfalls and Promise of 3-dimensional Image Comparison for Craniofacial Surgical Assessment
Authors: Matthews Harold S. , Burge Jonathan A. , Verhelst Pieter-Jan R. , Politis Constantinus , Claes Peter D. , Penington Anthony J.
Published: May 2020

Three-dimensional (3D) photography is becoming widely used in plastic surgery. It provides an accurate and reproducible record of the facial surface anatomy and could be a versatile tool for treatment planning and assessment. However, the existing software tools available for the assessment of 3D facial imaging often give highly misleading results. The goal of this special topic article is to give clinicians an insight into methods of 3D image assessment and explain the reasons why results may be misleading. We point toward the advantages of an alternative approach using “nonrigid surface registration” for the comparison of pre- and postsurgical images. This approach is compared with the regular rigid surface registration, and this is illustrated by the assessment of a child with Crouzon syndrome before and after LeFort III osteotomy and distraction. Findings of the standard method imply that changes have occurred that are anatomically not possible, whereas the alternative approach indicates realistic changes. Furthermore, we demonstrate an exciting capacity of 3D image analysis to construct reference populations of normal head size and shape. These can be used to assess the parts of the head that are normal and abnormal pre- and posttreatment of the same child. We conclude that, while 3D image analysis has great potential in surgical assessment, existing software does not always give an adequate assessment. Collaboration among surgeons and engineering and computer science specialists should be encouraged. This way, more comprehensive and accurate techniques in patient assessment and surgical planning can be developed and applied in clinical practice.
Implant to Fat: A Breast Augmentation Technique Validated by BREAST-Q
Authors: Tahseen Hossam , Fayek Mina , Emara Dawlat , Taha Ahmed A.
Published: May 2020

Background:

Implant-based breast augmentation is the number one cosmetic procedure performed in the United States. However, it is associated with relatively high revision rates, reaching up to 24% at 4 years. This case series presents our experience in implant explantation with simultaneous breast augmentation using fat.

Methods:

This case series was conducted by the authors in Cairo, Egypt, during the period from January 2018 to June 2019. Following a detailed data collection, careful physical examination was done. Implant-to fat conversion was done for all cases. None of the cases needed >1 session of fat injection following the implant removal. Size of the implants removed ranged from 200 -350 cm3 (average of 310). Volume of fat injected ranged from 300 to 550 ml (average of 430). Patients' satisfaction was evaluated using the BREAST-Q questionnaire.

Results:

Twenty patients were included, with a mean age of presentation of 33.1 years (range, 26 -42 years; SD, 5.3). Mean body mass index was 26.9 kg/m2 (range, 24 -30; SD, 1.9). Implant complications were as follows: capsular contracture (10cases), implant migration (3 cases), breast asymmetry (3 cases), poor aesthetic outcome (3 cases), and palpable implant (1 case). Overall patient's satisfaction was evaluated by the BREAST-Q 1-year following surgery. The overall satisfaction score was 3.8, where a score of 4 indicates very satisfied and a score of 1 indicates very dissatisfied.

Conclusions:

Implant-to-fat conversion is a good option for complicated breast implant cases, with good long-term results and excellent patient’s satisfaction as verified by the BREAST-Q.
Hypertension and heart failure: focus on high-risk populations
Authors: Di Palo Katherine E.
Published: May 2020

Purpose of review

Hypertension is a common, modifiable precursor to heart failure. Lifetime risk for development varies across age, sex, race and ability to achieve adequate blood pressure control.

Recent findings

Although meta-analyses seemingly support intensive blood pressure control to reduce incident heart failure, randomized clinical trials are limited and do not enroll a large number of female, minority, elderly or treatment-resistant patients. Heterogeneity further adds to complexity; however, enhanced cognizance of these disparities can aid clinicians in creating patient-centered care plans.

High-risk populations constitute an overwhelming percentage of the comorbid disease burden. Future clinical trials must reflect this diverse population to truly determine appropriate blood pressure targets and pharmacotherapy to reduce cardiovascular events.
Birth Testing for Infant HIV Diagnosis in Eswatini: Implementation Experience and Uptake Among Women Living With HIV in Manzini Region
Authors: Teasdale Chloe A. , Tsiouris Fatima , Mafukidze Arnold , Shongwe Siphesihle , Choy Michelle , Nhlengetfwa Hlengiwe , Simelane Samkelisiwe , Mthethwa Simangele , Ao Trong , Ryan Caroline , Dale Helen , Rivadeneira Emilia , Abrams Elaine J.
Published: May 2020

Introduction:

HIV testing at birth of HIV-exposed infants (HEIs) may improve the identification of infants infected with HIV in utero and accelerate antiretroviral treatment (ART) initiation.

Methods:

ICAP at Columbia University supported implementation of a national pilot of HIV testing at birth (0–7 days) in Eswatini at 2 maternity facilities. Dried blood spot (DBS) samples from neonates of women living with HIV (WLHIV) were collected and processed at the National Molecular Reference Laboratory using polymerase chain reaction (PCR). Mothers received birth test results at community health clinics. We report data on HIV birth testing uptake and outcomes for HIV-positive infants from the initial intensive phase (October 2017–March 2018) and routine support phase (April–December 2018).

Results:

During the initial intensive pilot phase, 1669 WLHIV delivered 1697 live-born HEI at 2 health facilities and 1480 (90.3%) HEI received birth testing. During the routine support phase, 2546 WLHIV delivered and 2277 (93.5%) HEI received birth testing. Overall October 2017–December 2018, 22 (0.6%) infants of 3757 receiving birth testing had a positive PCR test, 15 (68.2%) of whom were successfully traced and linked for confirmatory testing (2 infants were reported by caregivers to have negative follow-up HIV tests). Median time from birth test to receipt of results by the caregiver was 13 days (range: 8–23). Twelve (60.0%) of 20 infants confirmed to be HIV-positive started ART at median age of 17.5 days (12–43). One mother of an HIV-positive infant who was successfully traced refused ART following linkage to care and another child died after ART initiation. Three infants (15.0%) had died by the time their mothers were reached and 4 (15.0%) infants were never located.

Conclusion:

This pilot of universal birth testing in Eswatini demonstrates the feasibility of using a standard of care approach in a low resource and high burden setting. We document high uptake of testing for newborns among HIV-positive mothers and very few infants were found to be infected through birth testing.
Epidemiology of Hand, Foot, and Mouth Disease Before and After the Introduction of Enterovirus 71 Vaccines in Chengdu, China, 2009–2018
Authors: Han Yutong , Chen Zhenhua , Zheng Ke , Li Xianzhi , Kong Jinwang , Duan Xiaoxia , Xiao Xiong , Guo Bing , Luan Rongsheng , Long Lu
Published: May 2020

Background:

Hand, foot, and mouth disease (HFMD) has posed a serious threat to children’s health. Three inactivated monovalent enterovirus 71 (EV71) vaccines are proved to be highly efficacious in phase III clinical trials and are now available in China.

Methods:

We analyzed the citywide surveillance data on HFMD cases in Chengdu during 2009–2018, and estimated cumulative first-dose EV71 vaccination coverage among children eligible to EV71 vaccination after August 2016 in Chengdu. Time series susceptible-infected-recovered model was developed to analyze basic reproduction number and herd immunity threshold of HFMD. Overall and serotype-specific HFMD incidences and severity risks were compared before and after the EV71 vaccination.

Results:

Among 3 laboratory-identified serotype categories, i.e. EV71, coxsackievirus A16 (CV-A16), and other enteroviruses, the major serotype attributed to HFMD has been changing across years. The cumulative first-dose EV71 vaccination coverage rate was estimated as 60.8% during the study period in Chengdu. By contrast, herd immunity threshold for EV71-related HFMD was 94.0%. After introduction of EV71 vaccines, the overall incidence of HFMD increased 60.8%, mainly driven by 173.7% and 11.8% increased in HFMD caused by other enteroviruses and CV-A16, respectively, which offset a significant reduction in the incidence of HFMD caused by EV71. The overall case-severity risk decreased from 1.4% to 0.3%, with significantly declined presented in all serotype categories.

Conclusions:

The incidence and severity of EV71-related HFMD decreased following implementation of EV71 vaccination. Developing multivalent vaccines and strengthening laboratory-based surveillance could further decline burden of HFMD.
Baloxavir Marboxil 2% Granules in Japanese Children With Influenza
Authors: Yokoyama Takato , Sakaguchi Hiroki , Ishibashi Toru , Shishido Takao , Piedra Pedro A. , Sato Chisako , Tsuchiya Kenji , Uehara Takeki
Published: May 2020

Background:

A granule formulation of baloxavir marboxil, a selective inhibitor of influenza cap-dependent endonuclease, was newly developed for children with difficulty swallowing tablets.

Methods:

A multicenter open-label study was conducted during the 2017–2018 influenza season to assess the safety, pharmacokinetics and clinical/virologic outcomes of single, oral, weight-based doses of baloxavir granules in Japanese children infected with influenza virus. The primary clinical endpoint was the time to illness alleviation of influenza.

Results:

All 33 enrolled children completed the study and received baloxavir (1 mg/kg for 12 children weighing <10 kg, 10 mg for 21 children weighing 10 to <20 kg). Detected viruses were influenza B (36.4%), A(H1N1)pdm09 (33.3%) and A(H3N2) (27.3%). Adverse events (AEs) were reported in 54.5% of children. No deaths, serious AEs or AEs leading to discontinuation were reported. The mean (SD) plasma concentrations of baloxavir acid at 24 hours post-dose were 72.8 (24.0) and 51.3 (19.3) ng/mL in the 1-mg/kg and 10-mg dose groups, respectively. The median time to illness alleviation (95% confidence interval) was 45.3 (28.5–64.1) hours. A >4-log decrease in infectious viral titer occurred on day 2 and a temporary 2-log increase on day 4. Polymerase acidic protein/I38T/M-substituted viruses were detected in 5 children infected with influenza A, but none with influenza B.

Conclusions:

Baloxavir granules and the weight-based dose regimen were considered to be well tolerated in children, with rapid influenza virus reduction and associated symptom alleviation. Evidence of baloxavir activity against influenza B was observed, but further data are required for confirmation.
A 14-year Prospective Study of Human Coronavirus Infections in Hospitalized Children
Authors: Calvo Cristina , Alcolea Sonia , Casas Inmaculada , Pozo Francisco , Iglesias María , Gonzalez-Esguevillas Mónica , Luz García-García María
Published: May 2020

Background:

Human coronaviruses (HCoVs) have been recognized as causative agents of respiratory tract infections.

Our aim was to describe HCoV infections in hospitalized children in a prospective surveillance study for 14 years and compare them with other respiratory viruses.

Methods:

As a part of an ongoing prospective study to identify the etiology of viral respiratory infections in Spain, we performed the analysis of HCoV infections in children hospitalized in a secondary hospital in Madrid, between October 2005 and June 2018. Clinical data of HCoV patients were compared with those infected by rhinovirus, respiratory syncytial virus and influenza.

Results:

The study population consisted of 5131 hospitalizations for respiratory causes in children. A total of 3901 cases (75.9%) had a positive viral identification and 205 cases (4.1%) were positive for HCoV. Only 41 cases (20%) of HCoV infection were detected as single infections. Episodes of recurrent wheezing were the most common diagnosis, and 112 children (54%) had hypoxia. Clinical data in HCoV cases were similar to those associated with rhinovirus; however, patients with HCoV were younger. Other viruses were associated with hypoxia more frequently than cases with HCoV; high fever was more common in influenza infections and bronchiolitis in respiratory syncytial virus group. Although a slight peak of circulation appears mostly in winter, HCoV has been detected throughout the year as well.

Conclusions:

HCoV infections represent a small fraction of respiratory infections that require hospitalization in children and their characteristics do not differ greatly from other respiratory viral infections.
Patients' perspectives of pain in dialysis: systematic review and thematic synthesis of qualitative studies
Authors: Zhang Kelly , Hannan Elyssa , Scholes-Robertson Nicole , Baumgart Amanda , Guha Chandana , Kerklaan Jasmijn , Hanson Camilla S. , Craig Jonathan C. , Davison Sara N. , Hecking Manfred , Tong Allison
Published: May 2020

Pain is a severe and common symptom in patients receiving dialysis but remains inadequately managed in clinical practice. Understanding patient experiences of pain can inform strategies to address this patient-important symptom. We aimed to describe patients' perspectives on causes, experiences, and impacts of dialysis-associated pain. MEDLINE, Embase, PsycINFO, and CINAHL were searched to August 2019 for all qualitative studies that described the perspectives of pain in adults aged 18 years or older receiving dialysis. Findings from the primary studies were analyzed using thematic synthesis. We included 60 studies across 14 countries involving 1343 participants (1215 receiving hemodialysis and 128 receiving peritoneal dialysis), and identified 6 themes: gripped by an all-consuming agony (draining cognitive capacity, exacerbating other symptoms); suffering in silence (surrendering to the inevitable, ignored or dismissed, hiding symptoms to protect others); provoking fear of treatment (resistance to cannulation, avoiding dialysis, anxious from witnessing other patients in pain); preventing life participation (preventing fulfilment of valued roles, depleting the will to live); coping aided by connection with others (shared understanding among patients, comforted and supported by others); and developing awareness, assertiveness, and self-reliance (procedural vigilance, finding strategies to minimize pain, bodily understanding and knowing thresholds, positive thinking). Struggling with pain in dialysis involved a progression of agony, fear, avoidance, and despair. However, support from others and self-management strategies were used to cope with pain. Strategies to empower patients to report and minimize pain and its consequences in dialysis are needed.
Eruptive Cutaneous Collagenoma: Report of Two Cases
Authors: Wu Jian , Cai Mei-Hong , Chen Ling-Ling , Wu Lei , Chen Xiao-Jian , Zhu Hong-Yan , Shi Feng
Published: May 2020

Introduction:

Eruptive cutaneous collagenoma is non familial connective tissue nevi of unknown etiology presented with an abrupt onset. To date, the literatures on eruptive cutaneous collagenoma are extremely rare in china. Here, we report two women with eruptive cutaneous collagenoma.

Case present:

Two women presented with multiple asymptomatic, skin-colored papules and nodules on the trunk and extremities with no systemic involvement. Histopathology revealed dense, coarse collagen fibers by hematoxylin-esoin stain and decreased, fragmented elastic fibers by Elastic stain compared with the normal skin. Basing on these findings, the diagnosis of eruptive cutaneous collagenoma was made. No specific treatment was given.

Discussion:

Eruptive cutaneous collagenoma is a very rare dermatosis that is often misdiagnosed as other connective tissue nevi. The pathogenesis is unclear, and also no efficient treatment is available. It is usually diagnosed based on clinical and histopathological findings.

Conclusion:

The present cases are relatively rare type of eruptive cutaneous collagenoma that provide more experience for clinician, and may be helpful for them to make correct diagnosis for suspicious cases.
Recognizing asthma in patients with chronic obstructive pulmonary disease
Authors: Shedd Glenn Clinton , Thompson Alexandra , Calvert Robert Owen
Published: May 2020

Newer guidelines for the use of inhaled corticosteroids in chronic obstructive pulmonary disease (COPD) state that they should be reserved for those patients who are likely to derive the greatest benefits from this medication class. This makes the latest Global Initiative for Chronic Obstructive Lung disease (GOLD) guidelines of great importance. This article examines the utility of a previous diagnosis of asthma, the presence of eosinophilia, elevated immunoglobulin E, and positive bronchodilator response in identifying the people with COPD who also have asthma, and it presents two case studies of patients with COPD to illustrate the use of the GOLD guidelines in clinical practice.
Improving efficiency within a trauma nurse practitioner team
Authors: Atkinson Shelley , Crutcher Terri D. , King Joan E.
Published: May 2020

Background:

Clinicians, including nurse practitioners (NPs), face a number of challenges in delivering high-quality care including frequent interruptions that can potentially compromise patient safety and job satisfaction.

Local Problem:

Trauma NPs voiced frustration with their efforts to provide efficient, high-quality care with frequent interruptions, most commonly pager alerts. The purpose of this quality improvement (QI) initiative was to increase trauma NPs' perceptions of patient safety and improve NPs' job satisfaction by reducing workflow interruptions.

Methods:

The Model for Improvement guided this initiative.

Interventions:

The aims of this initiative were to reduce the percentage of nonurgent workflow interruptions via pager alerts by 20% and to increase the utilization of a standardized trauma NP patient rounding process from 0% to 50%.

Results:

Use of the standardized rounding process improved from 0% to 87%. Interruptions via pager alerts decreased by 36.2%. All nine (100%) trauma NP survey responses revealed an improvement in NP perception of patient safety and job satisfaction.

Conclusion:

The QI initiative found that increasing communication during rounds by using a standardized rounding process involving the bedside registered nurse can minimize interruptions and improve the efficiency of a trauma NP team. The key to the success of the QI initiative was the implementation of a standardized rounding process.
The role of uric acid in inflammasome-mediated kidney injury
Authors: Braga Tarcio Teodoro , Foresto-Neto Orestes , Camara Niels Olsen Saraiva
Published: May 2020

Purpose of review

Uric acid is produced after purine nucleotide degradation, upon xanthine oxidase catalytic action. In the evolutionary process, humans lost uricase, an enzyme that converts uric acid into allantoin, resulting in increased serum uric acid levels that may vary according to dietary ingestion, pathological conditions, and other factors. Despite the controversy over the inflammatory role of uric acid in its soluble form, crystals of uric acid are able to activate the NLRP3 inflammasome in different tissues. Uric acid, therefore, triggers hyperuricemic-related disease such as gout, metabolic syndrome, and kidney injuries. The present review provides an overview on the role of uric acid in the inflammasome-mediated kidney damage.

Recent findings

Hyperuricemia is present in 20–35% of patients with chronic kidney disease. However, whether this increased circulating uric acid is a risk factor or just a biomarker of renal and cardiovascular injuries has become a topic of intense discussion. Despite these conflicting views, several studies support the idea that hyperuricemia is indeed a cause of progression of kidney disease, with a putative role for soluble uric acid in activating renal NLRP3 inflammasome, in reprograming renal and immune cell metabolism and, therefore, in promoting kidney inflammation/injury.

Therapies aiming to decrease uric acid levels prevent renal NLRP3 inflammasome activation and exert renoprotective effects in experimental kidney diseases. However, further clinical studies are needed to investigate whether reduced circulating uric acid can also inhibit the inflammasome and be beneficial in human conditions.
Interobserver and intraobserver agreement on prostate-specific membrane antigen PET/CT images according to the miTNM and PSMA-RADS criteria
Authors: Demirci Emre , Akyel Reşit , Caner Biray , Alan-Selçuk Nalan , Güven-Meşe Şermin , Ocak Meltem , Kabasakal Levent
Published: May 2020

Aim

In this study, we aimed to measure interobserver and intraobserver agreement in Ga-68–prostate-specific membrane antigen (PSMA) PET/computed tomography (CT) image interpretation. In addition, the limitations of these criteria and levels of personal confidence reported by the readers when reporting the findings were determined. The effects of interpersonal differences on clinical decisions were also investigated.

Methods

PSMA PET images from 133 cases were reported independently by four different readers at different times according to the molecular imaging TNM (miTNM) and PSMA-reporting and data system (RADS) templates.

Results

There was substantial interobserver agreement for overall positivity, miT, miN and miM staging (Fleiss’ κ = 0.65, 0.625, 0.731, and 0.779). Substantial agreement levels were observed in reporting of seminal vesicle invasion, the number of lymph node stations with metastasis, total number of intraprostatic areas containing tumors, and lymph node metastasis staging (Fleiss’ κ = 0.622 and 0.779). The highest variation was seen in the reporting of intraprostatic distribution: In International Society of Urological Pathology (ISUP) grade group 1, moderate agreement was observed, and it was seen that the agreement level for the T staging increased with an increasing ISUP group in the staging group (Fleiss’ κ = 0.531 vs. 0.655). There was near-perfect interobserver agreement in the reporting of five-point PSMA-RADS scoring [intraclass correlation coefficient (ICC) κ = 0.904; 95% CI, 0.865–0.934]. Disagreement according to miTNM staging had a major effect on clinical management in only 9% (n = 12) of the patients.

Conclusion

PSMA PET has a lower interobserver variability and higher reproducibility than other imaging methods used for imaging of prostate cancer do, including CT, MRI, and bone scintigraphy. The miTNM template provides a reporting format that is highly reproducible and has a high level of agreement among readers, but the prostatic template needs development. In contrast, the PSMA-RADS system leads to slightly increased interobserver reporting differences and reduces personal confidence, but at the same time, it still exhibits almost-perfect agreement in terms of scoring.
The treatment approach to inflammatory bowel disease in 2020
Authors: Vachon Ashley , Scott Frank I.
Published: May 2020

Purpose of review

Multiple new medications with novel mechanisms of action are now available to treat inflammatory bowel disease (IBD). Identifying the appropriate patients in whom to use these therapies is critical in maximizing benefit and reducing unnecessary risks. Once the appropriate therapy is selected, using a treat-to-target algorithm including symptomatic, biochemical, and endoscopic monitoring can improve clinical outcomes. If symptoms recur, these same principles, coupled with therapeutic drug monitoring, should be considered to confirm inflammation and determine next therapeutic steps.

Recent findings

Multiple network meta-analyses can assist clinicians in determining the ideal biologic or small molecule therapy for patients with moderate-to-severe IBD. Once selected, several clinical trials have demonstrated that follow-up in 3 to 4 months, coupled with fecal calprotectin or C-reactive protein monitoring, can improve clinical remission and mucosal healing rates. Structural assessment should be performed via colonoscopy, enterography, or capsule endoscopy, dependent on disease location, at 9--12 months to confirm healing.

Appropriate disease stratification, coupled with biologic or small molecule medication selection and treat-to-target follow-up, can greatly assist clinicians who are managing patients with IBD in achieving the greatest potential benefits of medical therapy.
Understanding the Impacts of Caregiver Stress
Authors: Broxson Janna , Feliciano Leilani
Published: May 2020

Purpose/Objectives:

Identifying risk factors associated with caregiver stress and suggesting methods for systematic caregiver screening for caregiver strain, depression, and anxiety.

Primary Practice Setting:

Emergency department, primary care, and other health care settings.

Findings/Conclusions:

Caregiver stress can lead to multiple negative outcomes including declines in physical health, increased mental health concerns, and overall decreased quality of life. Caregiver stress also leads to increased financial costs to the person, family, and health care systems, making it a public health issue. Recognizing caregiver stress is the initial step to identifying those in need of support and to providing quality care. Fortunately, caregiver stress can be prevented or reduced using a culturally competent multidimensional approach to addressing social determinants of health and unmet physical, psychological, and social/emotional needs of caregivers.

Implications for Case Management:

Case management plays a critical role in assessing, educating, advocating, creating care plans, and advocating for both the caregiver and the care recipient.
Essential Case Management Practices Amidst the Novel Coronavirus Disease 2019 (COVID-19) Crisis: Part 2
Authors: Tahan Hussein M.
Published: May 2020

Objectives:

This is the second of a 2-part article that discusses essential case management practices and strategies amidst the novel coronavirus disease 2019 (COVID-19). The series showcases the potential professional case managers have in support of managing during a crisis such as a global pandemic. Part II continues to describe reenvisioned roles and responsibilities of case managers and their leaders to meet the needs of patients/support systems during the crisis. It focuses on the increased need for end-of-life care, impact on workers' compensation case management practice, and the self-care needs of the professional case manager.

Primary Practice Settings:

Applicable to the various case management practice settings across the continuum of health and human services, with special focus on acute care.

Findings/Conclusions

The COVID-19 global pandemic has resulted in a crisis case managers and other health care professionals never faced something like it before. At the same time, it has provided opportunities for innovation and creativity including use of digital and telecommunication technology in new ways to ensure the continued delivery of health and human services to those who need them regardless of location. It has also resulted in the development of necessary and impactful partnerships within and across different health care organizations and diverse professional disciplines. Most importantly, this pandemic has required special attention to the increased need of patients for timely palliative and end-of-life care. In addition, it has prompted a focus on the safety, health, and well-being of case managers and other health care professionals, resulting in expanded workers' compensation case management practice coupled with the need for self-care and resilience.

Implications for Case Management Practice:

Professional case managers are integral members of interprofessional health care teams. Their roles and responsibilities are even more necessary during the uncertainty of a global pandemic such as COVID-19. So far, the experience of this crisis has resulted in a deliberate need to ensure the safety of both, those who are the recipients of health care services and those who are responsible for the provision of care. Self-care and resilience of health care professionals and case managers, especially due to the complex dynamics of the COVID-19 pandemic, have advanced a desirable and necessary view of remote/virtual practice and as a strategy for enhancing the person's health and well-being. This pandemic has forced the development of impactful partnerships and collaborations among the diverse contexts of health care organizations and support service providers. These contexts of care delivery have also emphasized the necessary legal and ethical practice of case managers and the other involved parties. Experts agree that the innovative care delivery methods practiced during the pandemic will undoubtedly remain as desirable beyond the current crisis period.
A Proposed Grading Scheme for Medullary Thyroid Carcinoma Based on Proliferative Activity (Ki-67 and Mitotic Count) and Coagulative Necrosis
Authors: Fuchs Talia L. , Nassour Anthony J. , Glover Anthony , Sywak Mark S. , Sidhu Stan B. , Delbridge Leigh W. , Clifton-Bligh Roderick J. , Gild Matti L. , Tsang Venessa , Robinson Bruce G. , Clarkson Adele , Sheen Amy , Sioson Loretta , Chou Angela , Gill Anthony J.
Published: May 2020

We investigated the prognostic value of a range of histologic parameters in medullary thyroid carcinoma (MTC) to design a grading system to predict overall survival. We assessed 76 patients with MTCs undergoing primary tumor resection for age, sex, tumor size, vascular space invasion, lymph node metastasis, multiple endocrine neoplasia type 2 (MEN2) status, mitotic count, Ki-67 proliferative index, spindled morphology, sheet-like growth pattern, coagulative necrosis, incipient necrosis, nuclear grade, multinucleation, prominent nucleoli, fibrosis, and amyloid deposition. In addition to the clinical features of age and the diagnosis of MEN2, the only histologic features that significantly predicted reduced overall survival were Ki-67 proliferative index, mitotic count, and the presence of coagulative necrosis. Using a combination of these 3 variables, we propose a 3-tiered grading system based solely on proliferative activity (Ki-67 proliferative index and mitotic count) and necrosis. There were 62 (82%) low-grade MTCs (low proliferative activity, no necrosis), 9 (12%) intermediate grade (low proliferative activity and necrosis present, or intermediate proliferative activity and no necrosis), and 5 (7%) high grade (intermediate proliferative activity and necrosis present, or high proliferative activity with or without necrosis). The mean overall survival was 193, 146, and 45 months, respectively (P=0.0001) for the 3 grades. The grading system remained prognostic when controlled for other factors associated with survival including age and known MEN2 syndrome. We conclude that this proposed grading system, which uses only a combination of proliferative activity (Ki-67 index, mitotic count) and coagulative necrosis, is a strong predictor of overall survival in MTC.
Mirrored Ribs: A Sign for Pneumothorax in Neonates*
Authors: Küng Erik , Aichhorn Lukas , Berger Angelika , Werther Tobias
Published: May 2020

Objectives:

To evaluate if “mirrored ribs”—a mirroring of chest structures—is a sign for pneumothorax in lung ultrasound in neonates.

Design:

Retrospective study.

Setting:

Medical University Vienna/General Hospital, Vienna, Austria.

Patients:

All neonates admitted with clinical signs of pneumothorax between July 2018 and February 2019.

Interventions:

Chest radiograph and lung ultrasound in succession.

Measurements and Main Results:

Anterior-posterior chest radiograph and lung ultrasound were compared. “Mirrored ribs” were defined as mirroring of at least one rib and intercostal muscles in B-mode in the absence of B-lines. Twenty-nine cases in 26 patients were considered. Pneumothorax was diagnosed in 55% of cases using reported signs for pneumothorax in lung ultrasound and in 31% using chest radiograph. Lung ultrasound identified all pneumothoraces visible in chest radiograph. “Mirrored ribs” were visible in all patients with signs for pneumothorax and in none without signs for pneumothorax in lung ultrasound, representing a specificity and sensitivity of 100% compared with reported signs for pneumothorax in lung ultrasound.

Conclusions:

The occurrence of “mirrored ribs” in lung ultrasound in combination with absence of lung sliding, absence of B-lines and lung point might facilitate the rapid recognition of pneumothorax in neonates.
Outcomes After In-Hospital Pediatric Recurrent Cardiac Arrests*
Authors: Brown Stephanie R. , Brogan Thomas V. , McMullan D. Michael , Roberts Joan S.
Published: May 2020

Objectives:

The objective of this study is to determine outcomes of recurrent cardiac arrest events in the general pediatric inpatient population.

Design:

Retrospective cohort study of inpatients in a single institution.

Setting:

A tertiary care free-standing children’s hospital.

Patients:

All patients less than 18 years old at Seattle Children’s Hospital with recurrent cardiac arrest events occurring from January 1, 2010, to March 1, 2018, were included.

Interventions:

None.

Measurements and Main Results:

Overall survival to hospital discharge was 50% and all survivors had a good neurologic outcome, defined as Pediatric Cerebral Performance Category of 3 or less, or unchanged from baseline. Survival among patients who received extracorporeal life support was 43% and among those who received extracorporeal cardiopulmonary resuscitation, 33%. Initial arrest factors associated with survival included initial rhythm of ventricular tachycardia or ventricular fibrillation, shorter duration of cardiopulmonary resuscitation, and absence of multiple organ dysfunction. Additionally, nonsurvivors had more severe metabolic acidosis in the prearrest and postarrest period.

Conclusions:

Survival after pediatric in-hospital recurrent cardiac arrest is higher than previously reported. There is also evidence that initial rhythm other than ventricular tachycardia/ventricular fibrillation and longer duration of cardiopulmonary resuscitation as well as multiple organ dysfunction and more severe lactic acidosis in the peri-arrest period are associated with poor outcomes.
Successful Increase of Outpatient Clinic Continuity in a Fellowship Quality Improvement Project
Authors: Srinivasan Ranjini , Sambatakos Peter , Lane Mariellen , Krishnan Usha , Weller Rachel , Flyer Jonathan N. , Robinson Keith , Glickstein Julie
Published: May 2020

Background:

Patient-to-physician continuity is the result of coordinated and consistent care. Optimizing continuity can be a challenge in medical training without impacting work hours. We sought to use quality improvement science during graduate medical training to increase outpatient continuity.

Objective:

The primary goal was to improve outpatient continuity in our pediatric cardiology fellowship, without increasing trainee clinic hours, from a baseline of 38% to ≥70% within 18 months.

Methods:

Our fellowship conducted a quality improvement project across 3 years to improve continuity-of-care in our outpatient clinic using the Institute for Healthcare Improvement model for improvement. We conducted Plan-Do-Study-Act cycles and completed a key driver diagram using a multidisciplinary team. We defined continuity as a patient being evaluated by their primary fellow or a different fellow that was provided a handoff. The outcome measure was the continuity rate over 2-week periods.

Results:

Continuity improved from 38% to ≥80%. The improvement resulted from a series of interventions, including creating a handoff system among fellows, identifying follow-up patients in advance, and communicating this information to the clinic team. Although we anticipated a decrease when new fellows were incorporated, continuity continued to be ≥70%. This system retained continuity above 90% one year after completion of the project.

Conclusions:

Our fellowship created a system change to improve primary patient-to-fellow continuity care rates. We achieved sustainable continuity by working with a multidisciplinary team without altering staffing, infrastructure, or fellow work hours. This project engaged trainees to address the practical application of quality improvement methodology to solve a common clinical problem.
A Comparative Study Evaluating Speech Outcomes in Classic versus Occult Submucous Cleft Palate Using a Primary Furlow Palatoplasty Technique
Authors: Denadai Rafael , Chou Pang-Yun , Bergonzani Michela , Sato Nobuhiro , Yun Claudia , Lo Lun-Jou
Published: May 2020

Background:

No consensus exists on the selection of procedures for the treatment of submucous cleft palate, with scarce reports on long-term outcomes from single-surgeon experience. This study assessed the outcomes of using extended indication criteria of Furlow palatoplasty as the first-line procedure for the management of submucous cleft palate–associated velopharyngeal insufficiency.

Methods:

Consecutive nonsyndromic patients with submucous cleft palate (n = 216) treated by a single surgeon between 1998 and 2018 were reviewed. Furlow palatoplasty was performed in all patients diagnosed with submucous cleft palate–associated velopharyngeal insufficiency, regardless of the age cutoff, number of Calnan triad features, or velopharyngeal gap size and pattern. Postoperative velopharyngeal function outcome (adequate, marginal, or inadequate) and the need for secondary surgery were investigated. Age at surgery, sex, submucous cleft palate type (classic and occult), and presence of complication were evaluated for potential associations with this outcome.

Results:

Forty-seven patients aged 8.3 ± 4.6 years with occult submucous cleft palate were significantly (p < 0.001) older than those with the classic type (n = 169; 5.6 ± 3.1 years). Most (p < 0.001) of the included patients [n = 181 (83.8 percent)] achieved adequate postoperative velopharyngeal function outcome. Three patients (1.4 percent) presented surgery-related complications, including bleeding and partial wound disruption. Secondary speech surgery was recommended in 24 patients (11.1 percent). In the bivariate and multivariate analyses, none of the tested variables was found to be associated (all p > 0.05) with the postoperative velopharyngeal function outcome.

Conclusion:

The extended indication criteria of Furlow palatoplasty provided adequate velopharyngeal insufficiency management with a low complication rate and satisfactory speech outcome.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, III.
Brief Report: Associations Between Self-Reported Substance Use Behaviors and PrEP Acceptance and Adherence Among Black MSM in the HPTN 073 Study
Authors: Okafor Chukwuemeka N. , Hucks-Ortiz Christopher , Hightow-Weidman Lisa B. , Magnus Manya , Emel Lynda , Beauchamp Geetha , Kuo Irene , Hendrix Craig , Mayer Kenneth H. , Shoptaw Steven J.
Published: May 2020

Background:

Pre-exposure prophylaxis (PrEP) is efficacious for HIV prevention. Black men who have sex with men (MSM) accounted for the largest proportion of new HIV diagnoses in the United States relative to other racial/ethnic groups. Black MSM who use substances are at an increased risk for HIV infection and are ideal candidates for PrEP, but barriers to maintaining PrEP adherence remain a concern. We assessed whether substance use behaviors are associated with initiation and adherence to PrEP among a sample of black MSM in the United States.

Methods:

Data for this analysis come from the HIV Prevention Trails Network Study 073 (HPTN 073). Substance use behaviors—including alcohol, marijuana, poppers (ie, alkyl nitrites), and stimulants (ie, methamphetamine/cocaine use) including use of these substances before/during condomless anal intercourse (CAI)—were assessed longitudinally through self-report. PrEP adherence was assessed by pharmacological testing in blood. Generalized estimating equations were used to evaluate association between substance use behaviors and PrEP initiation and adherence.

Results:

Among 226 HIV-negative black MSM, the majority (60%) were 25+ years of age. Most of the substance use behaviors were not significantly associated with PrEP initiation or adherence. However, stimulant use before/during CAI was significantly associated with lower odds of PrEP adherence (adjusted odds ratio = 0.21, 95% confidence interval = 0.07 to 0.61; P = <0.01).

Conclusions:

These findings suggest that PrEP adherence is feasible among black MSM who use substances. However, black MSM who engage in stimulant use before/during CAI may present a unique group for additional study and support with enhanced behavioral health and support services.
Future of Diagnostic Computed Tomography
Authors: Shahid Imran , Lancelot Eric , Desché Pierre
Published: May 2020

Iodinated contrast media (CM) are utilized in approximately 40% of the 300 million computed tomography (CT) scans undertaken annually. This review focuses on the physicochemical properties and safety of iodinated CM, and the development of new x-ray CM, and it explores methods to optimize CT scanning parameters. It concludes that good x-ray CM should have high structural stability, hydrophilicity, and CT attenuation; low viscosity, osmolality, and protein binding; no metabolism and tissue accumulation; and a complete elimination.
Metastatic Parathyroid Hormone-Secreting Prostate Adenocarcinoma Mimicking Ectopic Parathyroid Adenoma Demonstrated on 99mTc-MIBI Image
Authors: Chen Yu-Hung , Hsu Yung-Hsiang , Chen Hwa-Tsung , Chang Bee-Song , Liu Shu-Hsin
Published: May 2020

99mTc-MIBI has long been used to localize hyperfunctioning parathyroid tissue in patients with hyperparathyroidism. This tracer can also concentrate in various neoplastic tissues including prostate adenocarcinoma. We herein report a case with parathyroid hormone-secreting metastatic prostate cancer mimicking an ectopic parathyroid adenoma on the 99mTc-MIBI scan. We conclude that metastatic prostate cancer should be included as one of the differential diagnoses when interpreting 99mTc-MIBI scan.