bluuebunny/crossref_metadata_2025 huggingface dataset:
Enrollment Management in Undergraduate Medical School Admissions: A Complementary Framework to Holistic Review for Increasing Diversity in Medicine
Authors: Nakae Sunny , Porfeli Erik J. , Davis Dwight , Grabowski Christina J. , Harrison Leila E. , Amiri Leila , Ross Will
Published: December 2020

Medical schools implemented holistic review more than a decade ago, which led to more deliberate consideration and inclusion of applicants historically underrepresented in medicine. This article presents a theory of holistic enrollment management that unites holistic review with enrollment management principles. This theory contextualizes medical school admissions as a complex marketplace with multifaceted, competing forces. Applying an enrollment management framework of mission, market, means, and metrics can improve the capacity of a medical school to efficiently advance its mission over time. Medical schools employing a clear, compelling, and focused mission to direct all aspects of the medical education enterprise can more effectively attract applicants who are better prepared to enact that mission throughout their careers. Medical schools share a marketplace and collectively compete to identify, attract, admit, and matriculate the most mission-aligned student body within the pool of applicants they share. Institutions that deliberately mobilize resources within this dynamic marketplace will engage, admit, and matriculate the most suiting applicants and attract even more mission-aligned matriculants over time. Widespread adoption of this holistic framework of enrollment management may enhance the capacity of the medical education system to better capitalize on the existing diversity in the national pool of applicants, encourage more underrepresented applicants to apply in the future, admit and matriculate a more diverse national student body, and ultimately better prepare new physicians to meet the increasingly diverse health care needs of the nation.
The Medial Elevation Osteotomy for Late-presenting and Recurrent Infantile Blount Disease
Authors: Maré Pieter Herman , Thompson David Mungo , Marais Leonard Charles
Published: December 2020

Background:

Late-presenting or recurrent infantile Blount disease (IBD) is characterized by knee instability because of medial tibial plateau depression, multiplanar proximal tibial deformity, and potential distal femoral deformity. The surgical treatment strategy includes medial elevation osteotomy to stabilize the knee, together with proximal tibial osteotomy to correct alignment, and lateral epiphysiodesis to prevent a recurrence. This study’s primary aim was to describe the clinical outcomes of medial elevation osteotomy for the management of late-presenting and recurrent IBD.

Methods:

The authors reviewed the records of 48 children (64 limbs) who had medial elevation osteotomies and lateral epiphysiodesis, combined with proximal tibial realignment in 78% (50/64) of cases in the same setting. IBD was bilateral in 33% (16/48), 77% (37/48) were female individuals, and 42% (20/48) were obese.

Results:

The mean age at surgery was 8.6 years (SD, 1.6; range, 5.8 to 12.8). The mean preoperative tibiofemoral angle (TFA) was 28±11 degrees (8 to 55 degrees), and the mean angle of depression of the medial plateau (ADMP) was 49±8 degrees (26 to 65 degrees). Distal femoral valgus was present in 27% (17/62) and varus in 10% (6/62) children. At a median follow-up of 3.2 years (range, 1 to 6.2 y), the median TFA was 1-degree valgus (interquartile range, 7-degree varus to 5-degree valgus), whereas the ADMP was corrected to 25±8 degrees (8 to 45 degrees). Obesity was associated with more severe deformity as measured by TFA (P<0.001) but did not affect the extent of medial plateau depression (P=0.113). The good or excellent alignment was achieved in 75% (47/63) limbs. Obesity was associated with an increased risk of recurrence [odds ratio (OR), 5.21; 95% CI, 1.26-21.63; P=0.023]. Age at the surgery or previous surgery was not associated with recurrence (OR, 1.29; 95% CI, 0.88-1.88; P=0.195 and OR, 1.22; 95% CI, 0.36-4.17; P=0.746). Obesity and residual instability were associated with an increased risk of poor alignment at the latest follow-up (OR, 3.24; 95% CI, 1.02-10.31; P=0.047 and OR, 1.21; 95% CI, 1.05-1.40; P=0.008).

Conclusion:

Late-presenting or recurrent IBD is a surgical challenge. Obesity is associated with more severe deformity. Medial elevation osteotomy combined with lateral proximal tibial epiphysiodesis and metaphyseal tibial realignment osteotomy will result in restoration of lower limb alignment in a high proportion of cases. The recurrent deformity may be the result of failed epiphysiodesis. Obesity and residual instability are associated with an increased risk of poor alignment. Although complications are rare, surgical measures to decrease risk should be followed.

Level of Evidence:

Level IV.
Are Postcast Removal X-rays and a Second Follow-up Necessary in the Treatment of Nondisplaced Supracondylar Humerus Fractures?
Authors: Zakrzewski Allyson M. , Ferrick Michael R.
Published: December 2020

Background:

The utility of routine follow-up radiographs for the treatment of nondisplaced pediatric supracondylar humerus fractures has not been established. The purpose of this study is to (1) determine the frequency that postcast removal x-rays change patient management and (2) determine the role of routine follow-up for range of motion evaluation after cast removal in the treatment of nondisplaced supracondylar humerus fractures.

Methods:

We conducted a single center retrospective chart review of patients under the age of 18 years old that sustained nondisplaced supracondylar humerus fractures between January 1, 2010 and July 1, 2018. Demographic information, fracture characteristics, time to follow-up and each appointment outcome were recorded. A change in patient management after postcast removal x-ray was defined as a need for an additional period of immobilization, a delay in initiation of range of motion exercises, or need for operative intervention. In addition, the appointment for range of motion evaluation was considered to alter management if further activity restriction was required, a formal physical therapy program was recommended or an additional office visit required. Unscheduled appointments were also noted.

Results:

A total of 489 patients met inclusion criteria. The average age was 4.90±2.68 years and 51.8% were female. A total of 487 patients had routine follow-up x-rays after cast removal. No patient had a change of management based on postcast removal radiographs. In all, 290 patients returned for range of motion follow-up with 94.8% of patients being discharged from care. There were 14 patients whose management changed based on this evaluation (4.8%). The most common reason was an additional appointment for range of motion evaluation (12/14 patients, 86%). There were 13 patients with unscheduled evaluation after discharge from care, 77% were secondary to repeat injury.

Conclusion:

This study suggests that postcast removal x-rays and routine follow-up after cast removal rarely change patient management and may not be necessary in the treatment of nondisplaced pediatric supracondylar humerus fractures.

Level of Evidence:

Level IV—case series.
Efficacy of Supraclavicular Scalenotomy Followed by External Neurolysis without Rib Resection for Post-traumatic Neurogenic Thoracic Outlet Syndrome
Authors: Yoshizumi Tetsuya , Murata Hidetoshi , Kanno Hiroshi , Shinonaga Masamichi
Published: December 2020

Mini

Most patients with neurogenic thoracic outlet syndrome (NTOS) have a history of trauma. Scar tissue formation within the scalene muscle and around the nerves after injury cause arm and hand symptoms. We report that supraclavicular scalenotomy followed by external neurolysis without rib resection is very effective as the surgical treatment.

Study Design.

Consecutive case series.

Objective.

Our aim was to evaluate the outcomes of patients who underwent supraclavicular scalenotomy followed by external neurolysis without rib resection for post-traumatic NTOS.

Summary of Background Data.

Neurogenic thoracic outlet syndrome (NTOS) comprises over 95% of all TOS patients, and most patients with NTOS have a history of trauma before the onset of their symptoms.

Methods.

Patients treated with supraclavicular scalenotomy and neurolysis without rib resection from September 2014 to December 2019 were retrospectively reviewed by using the medical records and operative notes. Patient's characteristics, clinical symptoms before treatment, operative findings, and short- and long-term outcomes were assessed. To assess clinical outcomes at 2 months after surgery (short-term outcomes) and 12 months later (long-term outcomes), we used a 4-grade categorization (Excellent, Good, Fair, and Poor) of patients’ subjective evaluations after surgery on the basis of modified Odom's criteria. Excellent and Good were defined as a successful outcome.

Results.

Ninety-six supraclavicular scalenotomies without rib resection were performed on patients with post-traumatic NTOS. The most common intraoperative observation was the fibrous bands within the anterior scalene muscle in 86 cases (89.6%). The short-term outcome with patients’ subjective evaluation in 96 operations at 2 months after surgery showed a 96.9% success rate (Excellent + Good). In 85 cases followed for more than 12 months after surgery, the success rate based on patients’ subjective evaluation at the last clinic follow-up appointment as a long-term outcome was 74.1%.

Conclusion.

In post-traumatic NTOS, it has been reported the arm and hand symptoms are due to pressure on the brachial plexus, which can stem from the swollen muscle following injuries and later from tightness of the scarred muscle. Considering this mechanism and our results, we concluded that supraclavicular scalenotomy and external neurolysis without rib resection made sense, as they were very effective and adequate to improve symptoms of NTOS.

Level of Evidence: 5
Reducing Wrong-level Spinal Surgeries Through Root Cause Analyses
Authors: Srivatsa Shaarada , Vira Shaleen , Schils Jean , Shook Steven , Gill Amanjit , Krishnaney Ajit A.
Published: December 2020

Mini

This study is a comprehensive narrative of all wrong-level spine surgeries and prevention strategies employed at our institution between 2008 and 2019, and aims to provide a roadmap for developing a rigorous prevention protocol. We systematically track root cause analyses and policy changes to determine which prevention strategies are most effective.

Study Design.

Retrospective review.

Objective.

We aim to create a comprehensive narrative of all wrong-level spinal surgeries (WLSS) and subsequent prevention strategies employed at our institution and provide a roadmap for developing a rigorous prevention protocol.

Summary of Background Data.

There is currently no published evidence-based protocol to prevent WLSS. Previous studies are limited to multi-institution surgeon surveys and opinion pieces; the impact of serial interventions to eliminate WLSS is lacking. No studies have longitudinally analyzed a single institution's serial root cause analyses (RCA) of individual WLSS cases and the stepwise impact of targeted interventions to reduce WLSS occurrence.

Methods.

We reviewed all wrong-site spine surgeries and prevention strategies employed at our institution between 2008 and 2019, and corresponding WLSS-related RCAs were collected from institutional records. We conducted a longitudinal analysis of these reports and tracked policy implementations that resulted along with the incidence of WLSS following each policy.

Results.

Fifteen WLSS were identified with 13 corresponding RCAs of 21,179 spine surgeries between 2008 and 2019. Three policy categories emerged: imaging, operating room (OR) culture, and vertebral body marking. The salient changes from each category were: requiring two immovable vertebral markers (2013); requiring intraoperative radiographs with markers and retractors positioned (2014); open-ended questioning during spinal level verification by residents and fellows (2015); and requiring an impartial radiologist to have verbal contact with the operating surgeon intraoperatively to collaboratively discuss localization (2018). Each change resulted in WLSS incidence decline (five in 2014, three in 2015, 0 in 2019).

Conclusion.

Stepwise process improvement based on WLSS case review is necessary, as no one change in standard operating procedure effectively eliminated WLSS. Improvements in communication between OR staff, surgeon, and radiologist, as well as intraoperative imaging and marking optimization all contributed to improvements in WLSS rates. By focusing on lessons learned from RCAs using this methodology, institutions can iteratively improve rates of WLSS.

Level of Evidence: 4
Effects of CYP2D6 Genotypes on Venlafaxine Metabolism in Japanese Psychiatric Patients With Depression
Authors: Komahashi-Sasaki Hazuki , Yasui-Furukori Norio , Sasaki Taro , Shinozaki Masataka , Hayashi Yuki , Kato Kazuko , Inoue Yoshimasa , Tsuchimine Shoko , Watanabe Takashi , Sugawara Norio , Shimoda Kazutaka
Published: December 2020

Background:

Venlafaxine (VEN) is primarily metabolized by CYP2D6. Although several studies have reported the significant effects of CYP2D6 on VEN and O-desmethylvenlafaxine (ODV) pharmacokinetics in Whites, limited data are available regarding the effects of the Asian-specific CYP2D6 genotype on VEN metabolism. This study evaluated the effects of the CYP2D6*10 and CYP2D6*5 genotypes on the steady-state plasma concentrations of VEN and ODV in Japanese patients.

Methods:

This study included 75 Japanese patients with depression who were treated with VEN. Steady-state plasma concentrations of VEN and ODV were measured using liquid chromatography. Polymerase chain reaction was used to determine CYP2D6 genotypes. A stepwise multiple regression analysis was performed to analyze the relationship between independent variables (sex, age, smoking habit, and number of mutated alleles, CYP2D6*10 and CYP2D6*5), subject-dependent variables (plasma concentrations of VEN and ODV [all corrected for dose and body weight]), and the ODV/VEN ratio.

Results:

Significant correlations were observed between the daily dose of VEN (corrected for body weight) and plasma concentrations of VEN (r = 0.498, P < 0.001) and ODV (r = 0.380, P = 0.001); ODV plasma concentrations were approximately 3.2 times higher than VEN plasma concentrations (VEN versus ODV = 18.60 ng/mL versus 59.10 ng/mL). VEN plasma concentrations (corrected for dose and body weight) did not differ with differing numbers of CYP2D6-mutated alleles. However, the ODV/VEN ratio decreased as the number of mutated CYP2D6 alleles increased (P = 0.001).

Conclusions:

This is the first study to examine the effects of CYP2D6*10 in a clinical setting. Although no effects on the plasma concentrations of VEN or ODV were observed, CYP2D6 polymorphism affects the ODV/VEN ratio. Further studies are needed to confirm the clinical relevance of these findings.
Medications for Pregnant Women With Obesity: Special Considerations
Authors: MAGGIO LINDSAY
Published: December 2020

Pregnant women with obesity are at increased risk of a multitude of complications of pregnancy and adverse perinatal outcomes. The risk of some of these complications, such as neural tube defects or preeclampsia, may be mitigated by some medications. Other complications, such as diabetes, venous thromboembolism, and infections, require treatment with medications. Given the changes in pharmacokinetics and pharmacodynamics during pregnancy, which is further enhanced by obesity, the optimal medication and its dose is often researched. This chapter further explores the different complications and common medications that women with obesity are likely to require.
Strategic use of health information exchange and market share, payer mix, and operating margins
Authors: Vest Joshua R. , Freedman Seth , Unruh Mark Aaron , Bako Abdulaziz T. , Simon Kosali
Published: December 2020

Background

Health information exchange (HIE) capabilities are tied to health care organizations’ strategic and business goals. As a technology that connects information from different organizations, HIE may be a source of competitive advantage and a path to improvements in performance.

Purpose

The aim of the study was to identify the impact of hospitals’ use of HIE capabilities on outcomes that may be sensitive to changes in various contracting arrangements and referral patterns arising from improved connectivity.

Methodology

Using a panel of community hospitals in nine states, we examined the association between the number of different data types the hospital could exchange via HIE and changes in market share, payer mix, and operating margin (2010–2014). Regression models that controlled for the number of different data types shared intraorganizationally and other time-varying factors and included both hospital and time fixed effects were used for adjusted estimates of the relationships between changes in HIE capabilities and outcomes.

Results

Increasing HIE capability was associated with a 13 percentage point increase in a hospital’s discharges that were covered by commercial insurers or Medicare (i.e., payer mix). Conversely, increasing intraorganizational information sharing was associated with a 9.6 percentage point decrease in the percentage of discharges covered by commercial insurers or Medicare. Increasing HIE capability or intraorganizational information sharing was not associated with increased market share nor with operating margin.

Conclusions

Improving information sharing with external organizations may be an approach to support strategic business goals.

Practice Implications

Organizations may be served by identifying ways to leverage HIE instead of focusing on intraorganizational exchange capabilities.
LONGITUDINAL FLUORESCENCE LIFETIME IMAGING OPHTHALMOSCOPY ANALYSIS IN PATIENTS WITH MACULAR TELANGIECTASIA TYPE 2 (MacTel)
Authors: Sauer Lydia , Vitale Alexandra S. , Modersitzki Natalie K. , Bernstein Paul S.
Published: December 2020

Purpose:

Fluorescence lifetime imaging ophthalmoscopy (FLIO) shows characteristic patterns in macular telangiectasia Type 2 (MacTel). This study investigates FLIO changes over time to better understand disease progression.

Methods:

Thirty-three patients with MacTel (age 60 ± 15 years) were followed at the Moran Eye Center with a prototype Heidelberg Engineering FLIO. The mean follow-up time was 19 ± 8 months (range 6–34 months). Fundus autofluorescence was excited at 473 nm, and FLIO lifetimes were recorded in in short (498–560 nm) and long (560–720 nm) spectral wavelengths channels

Results:

Autofluorescence lifetimes imaging ophthalmoscopy lifetimes from the MacTel area prolonged significantly over time (subfield T1, baseline: short spectral channel 210 ± 54 ps, long spectral channel 269 ± 58 ps; follow-up: short spectral channel 225 ± 59 ps, P < 0.001, long spectral channel 282 ± 64 ps, P < 0.01). The average 12-months prolongation of FLIO lifetimes was 9 ps (short spectral channel) and 8 ps (long spectral channel). Autofluorescence lifetimes changes correlated positively with ellipsoid zone loss and negatively with changes in retinal thickness.

Conclusion:

Autofluorescence lifetimes in MacTel slowly prolong over time, and temporal patterns progress to full rings. Detailed knowledge about FLIO changes will aid in understanding disease development and progression.
Use of Provider Scorecards to Improve Early Postoperative Recovery—Initial Implementation Study
Authors: Khadge Shradha D. , Tanella Anthony , Mtuke Francis , Deiner Stacie , Hyman Jaime B.
Published: December 2020

Intraoperative anesthetic technique directly impacts immediate postoperative recovery, yet there are few opportunities for anesthesiologists to receive feedback and no easily available benchmarks, making it difficult to reflect on one's own practice. This initial implementation study used retrospective data from 5,712 ambulatory surgery cases with healthy adult patients undergoing general anesthesia in 2018 at a large tertiary care academic center. It examines variation in practice among anesthesiologists for eight surgical specialties. Scorecards assessing intraoperative and postoperative opioids, antiemetics, nonopioid analgesics, regional blocks, recovery time, and severe postoperative pain compared with peers were given to anesthesiologists with prefeedback and postfeedback surveys assessing their attitudes toward feedback. Before receiving their scorecard, 71% of providers predicted their performance was average, and 29% predicted their performance was above average. After receiving their scorecards, 42% rated their quality of recovery as worse than expected, 42% rated it as expected, and 16% rated it as better than expected. Thirteen percent disagreed, 44% were neutral, and 44% agreed that this feedback will change their practice. Implementing a scorecard of patient-centered measures that shows where an anesthesiologist stands in the distribution of their peers was well-received, provides a benchmark, and has the potential to change practice.
Integrated Pharmacy and PrEP Navigation Services to Support PrEP Uptake: A Quality Improvement Project
Authors: Coleman Megan , Hodges Ashley , Henn Sarah , Lambert Crystal Chapman
Published: December 2020

Preexposure prophylaxis (PrEP) is highly effective in preventing HIV among both men and women, with the reduction in risk directly linked to medication adherence. Navigation services and other adherence interventions have demonstrated efficacy in medication uptake; however, their use may not be fully integrated into clinic operations or their roles clearly defined. This quality improvement (QI) project developed an evidenced-based PrEP Navigation (PN) tool to identify patient-reported barriers to uptake and to support process improvement at a large community health center in Washington, DC. Outcomes related to patient-reported barriers, patient demographics, and time to medication pickup from the pharmacy were measured before and after implementation. A total of 198 patients were included in this analysis. Mean days from initial prescription to medication pickup was reduced by 1.42 days (p = .030) following PN tool implementation. The evidenced-based PN tool is modifiable to the needs of the individual clinic and the patients they care for to support wide-scale PrEP uptake and continuous system process improvements.
Reasoned Action Approach Correlates of Physical Activity Among African American Men Living With HIV: A Cross-Sectional Study
Authors: Kelly Terri-Ann , Woko Chioma , Jemmott Loretta S. , Icard Larry , Chittamuru Deepti , Jemmott John B.
Published: December 2020

Physical activity (PA) is associated with a reduced incidence of chronic diseases. However, little is known about the predictors of PA among African American men living with HIV. We report secondary analyses examining the strength of the relationships between the reasoned action approach constructs, attitude, subjective norm, descriptive norm, and self-efficacy and intention to exercise and self-reported adherence to Department of Health and Human Services PA guidelines using baseline data from a trial of a PA intervention with 302 African American men, between 40 and 88 years of age (M = 53.9; SD = 7.2) living with HIV. Multiple regression revealed that attitude, subjective norm, and self-efficacy were positively associated with intention. Logistic regression revealed higher odds of meeting PA guidelines as self-efficacy increased. Self-efficacy and descriptive norm predicted meeting the aerobic guideline. Self-efficacy predicted meeting the muscle-strengthening guideline. Interventions targeting reasoned action approach variables may contribute to efforts to improve PA among African American men living with HIV.
Age- and Race-Related Differences in Advertised Health Behaviors Among Male Sex Workers in San Francisco Who Have Sex With Men
Authors: Jackson Kristopher J. , Judge Shana M.
Published: December 2020

Given the stigma surrounding sex work and the illegal nature of many aspects of commercial sex activity, empirical research is lacking regarding the health-related behaviors of sex workers, particularly male sex workers who have sex with men (MSM sex workers). To better understand the MSM sex worker community and their potential health needs, we analyzed certain sexual health-related behaviors as advertised online by MSM sex workers in the San Francisco area. Using descriptive and bivariate statistical tests, we examined whether age- and race-related differences existed among these sex workers in the following publicly advertised behaviors: use of pre-exposure prophylaxis and a willingness to engage in illicit drug use or condomless anal intercourse. Although we found no significant differences by race in terms of advertised pre-exposure prophylaxis use or willingness to engage in condomless sex, our results show statistically significant differences by race with respect to willingness to use drugs. This difference could be driven by the younger average age of the non-White sex workers in our sample. These findings help inform our understanding of MSM sex work and its associated risks.
Geographic Accessibility of HIV Preventive Services for Young Latino Men in Miami, Florida: A Cross-Sectional Study
Authors: Kanamori Mariano , Shrader Cho-Hee , Stoler Justin , Aguilar de Santana Sheyla , Williams Mark
Published: December 2020

The U.S. HIV incidence has decreased or stabilized among all subgroups except for young Latino men who have sex with men (YLMSM). Previous research has suggested that Latinos experience geographic accessibility barriers to YLMSM-friendly HIV prevention services. We aimed to characterize the geographic accessibility of young Latinos ages 15–29 years to HIV preventive services in Miami-Dade County, the domestic HIV epicenter. Using ArcMap, we created a density map of 18 YLMSM-friendly HIV programs, then used Network Analysis Tools to generate service areas describing time and travel distance for walking, public transit, and driving. Our results show that accessibility to YLMSM-friendly HIV prevention services by YLMSM varies by mode of transportation. Of YLMSM, HIV prevention services are available to 2% by walking, 19% by public transit, and 70% by driving. To increase accessibility, future public health interventions should use geographic information system and geodemographic data to identify areas for culturally appropriate service expansion.
Relationship Between Emotional Labor and Perceived Health Status Among Service and Sales Workers
Authors: Ahn Joonho , Kang Young Joong , Kim Taeshik , Kang Mo-Yeol
Published: December 2020

Objectives:

This study examined the relationship between emotional labor and general health status in a nationally representative sample of South Korean service and sales workers.

Methods:

Data were obtained from the 2007 to 2009 Korea National Health and Nutrition Examination Survey. A total of 1907 subjects were included in the analysis. Multiple logistic regression was performed to determine the relationship between emotional labor and perceived health status (PHS).

Results:

The adjusted odds ratio (95% confidence interval) of poor PHS was 1.869 (1.464 to 2.391) among high emotional labor group, compared with the low emotional labor group as the reference. Perceived stress accounted for 35.57% of the variance in the relationship between high emotional labor and poor PHS.

Conclusions:

Emotional labor was associated with increased risk of poor PHS.
Effects of exercise training on bone mineral density and some health-related outcomes in HIV conditions
Authors: Ajidahun Adedayo Tunde , Myezwa Hellen , Ibeneme Sam Chidi , Magobotha Sebastian , Fortwengel Gerhard , Jingo Maxwell , Milner Brenda , Ravat Sadiya , Okoye Ifeoma , Schnaid Edward , Bischoff Faith
Published: December 2020

Introduction:

Human Immunodeficiency Virus (HIV) infection remains prevalent co-morbidity, and among fracture patients. Few studies have investigated the role of exercise interventions in preventing bone demineralization in people who have fractures and HIV. If exercise exposed, HIV-infected individuals may experience improved bone health outcomes (BMD), function, quality of life (QoL). The study will aim to assess the impact of home based exercises on bone mineral density, functional capacity, QoL, and some serological markers of health in HIV infection among Nigerians and South Africans.

Methods and design:

The study is an assessor-blinded randomized controlled trial. Patients managed with internal and external fixation for femoral shaft fracture at the study sites will be recruited to participate in the study. The participants will be recruited 2 weeks post-discharge at the follow-up clinic with the orthopaedic surgeon. The study population will consist of all persons with femoral fracture and HIV-positive and negative (HIV-positive medically confirmed) aged 18 to 60 years attending the above-named health facilities. For the HIV-positive participants, a documented positive HIV result, as well as a history of being followed-up at the HIV treatment and care center. A developed home based exercise programme will be implemented in the experimental group while the control group continues with the usual rehabilitation programme. The primary outcome measures will be function, gait, bone mineral density, physical activity, and QoL.

Discussion:

The proposed trial will compare the effect of a home-based physical exercise-training programme in the management of femoral fracture to the usual physiotherapy management programmes with specific outcomes of bone mineral density, function, and inflammatory markers.

Trial registration:

The study was prospectively registered with the Pan African Clinical Trials Registry (Reference number – PACTR201910562118957) on October 21, 2019. (https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9425).
Value of 18F-FDG PET/CT in patients with hepatic metastatic carcinoma of unknown primary
Authors: Li Yuekai , Li Fengcai , Li Xin , Qu Lili , Han Jiankui
Published: December 2020

Purpose

This retrospective study aimed to investigate the clinical value of -deoxy-2-(18F)-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) in detecting primary lesions of hepatic metastases.

Methods

A total of 124 patients with hepatic metastatic carcinoma of unknown primary underwent whole body 18F-FDG PET/CT imaging. According to the final diagnoses for both primary sites and hepatic metastases that were confirmed either histopathologically or by clinical follow up, all patients were divided into 4 groups: a true positive group (TP, 95 cases), a false positive group (FP, 9), a true negative group (TN, 8) and a false negative group (FN, 12).

Results

The TP rate of primary lesions, detected by 18F-FDG PET/CT, was 76.61%, the FP rate 7.26%, the TN rate 6.45% and the FN rate 9.68%. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 18F-FDG PET/CT in the detection of primary tumors were 88.78%, 52.94%, 91.35%, 40%, and 83.06%, respectively. Accurate diagnosis groups (TP, TN) showed a significantly higher SUVmax (standard uptake maximum value) level than that in error diagnosis groups (FP, FN). The SUVmax between hepatic metastases and primary lesions had a positive correlation. The primary tumor sites of hepatic metastases were mainly located in the gastrointestinal organs and the lungs.

Conclusions

Whole body 18F-FDG PET/CT imaging was sensitive for detecting primary sites/lesions with hepatic metastatases of unknown primary, especially when the SUVmax of hepatic metastases were greater than 4.7.
Case report of tracheobronchial injuries after acid ingestion: CT findings with serial follow-up
Authors: Kim Nokjung , Lee Han Na , Kim Jung Im , Shin So Youn , Kang Sung Wook
Published: December 2020

Rationale:

Tracheobronchial injury from acid ingestion is a less reported clinical presentation than injury of the gastrointestinal tract, but it can occur due to direct exposure from acid aspiration and cause fatal complications.

Patient concerns:

A 43-year-old man presented to the emergency department after ingesting nitric acid complaining of chest pain and dyspnea.

Diagnoses:

The initial chest computed tomography (CT) images revealed an acute lung injury related to acid aspiration. The follow-up chest CT showed acute and late tracheobronchial injures.

Interventions:

Bronchoscopy showed deep caustic airway injuries consisting of hemorrhage, sloughing of the mucosa, and ulceration of the trachea and left-side bronchial tree.

Outcomes:

Progressive narrowing of the left main bronchus with total collapse of the left lung occurred as a late complication of acid ingestion.

Lessons:

Tracheobronchial injury should be considered in cases of aspiration pneumonia after acid ingestion; chest CT can be used to detect and assess acute and late complications of tracheobronchial injuries.
PLA2R Immunohistochemistry Staining in Membranous Glomerulopathy: A Challenging Stain to Interpret But a Potentially Useful Diagnostic Tool
Authors: Del Sordo Rachele , Covarelli Carla , Brugnano Rachele , Sciri Raffaela , Bellezza Guido , Mandarano Martina , Sidoni Angelo
Published: December 2020

Circulating autoantibodies to phospholipase A2 receptor (PLA2R-Ab) are detected in >70% of patients with primary membranous glomerulonephritis (MGN). Detection of PLA2R antigen in renal tissue, with immunohistochemistry (PLA2R IHC), strongly correlates with serum PLA2R-Ab, although it is more sensitive. As PLA2R IHC in literature has no univocal interpretation, we suggest reliable criteria for a standard approach for the assessment of immunostaining for differential diagnosis between primary and secondary MGN. We analyzed PLA2R IHC expression in 40 biopsies of patients with MGN and serum PLA2R-Ab titer at the time of biopsy. We carefully evaluated, at high magnification, the immunostaining pattern and distribution, regardless of intensity, in capillary loops, mesangium, and podocytes of all glomeruli.We defined, adopting this approach, positive stain when a granular pattern, coarse and/or fine, diffuse or focal, and global or segmental were observed. Negative stain was defined by mesangial staining, when there was a dirty pattern, or a peripheral staining of capillary loops with a smoky linear pattern. Podocytes showed homogenous cytoplasmatic stain both in positive and negative cases and in external negative controls. We found PLA2R IHC and serum PLA2R-Ab positivity in early-middle stage MGN compared with advanced stage more frequently. Correct stratification of patients with MGN needs PLA2R-Ab detection in serum and renal tissue. PLA2R IHC test, although a challenging stain, can be an easy diagnostic tool but requires reliable interpretation keys for a standard approach to the assessment of immunostaining.
Apolipoprotein A-I mimetics attenuate macrophage activation in chronic treated HIV
Authors: Mu William , Sharma Madhav , Heymans Rachel , Ritou Eleni , Rezek Valerie , Hamid Philip , Kossyvakis Athanasios , Sen Roy Shubhendu , Grijalva Victor , Chattopadhyay Arnab , Papesh Jeremy , Meriwether David , Kitchen Scott G. , Fogelman Alan M. , Reddy Srinivasa T. , Kelesidis Theodoros
Published: December 2020

Objective(s):

Despite antiretroviral therapy (ART), there is an unmet need for therapies to mitigate immune activation in HIV infection. The goal of this study is to determine whether the apoA-I mimetics 6F and 4F attenuate macrophage activation in chronic HIV.

Design:

Preclinical assessment of the in-vivo impact of Tg6F and the ex-vivo impact of apoA-I mimetics on biomarkers of immune activation and gut barrier dysfunction in treated HIV.

Methods:

We used two humanized murine models of HIV infection to determine the impact of oral Tg6F with ART (HIV+ART+Tg6F+) on innate immune activation (plasma human sCD14, sCD163) and gut barrier dysfunction [murine I-FABP, endotoxin (LPS), LPS-binding protein (LBP), murine sCD14]. We also used gut explants from 10 uninfected and 10 HIV-infected men on potent ART and no morbidity, to determine the impact of ex-vivo treatment with 4F for 72 h on secretion of sCD14, sCD163, and I-FABP from gut explants.

Results:

When compared with mice treated with ART alone (HIV+ART+), HIV+ART+Tg6F+ mice attenuated macrophage activation (h-sCD14, h-sCD163), gut barrier dysfunction (m-IFABP, LPS, LBP, and m-sCD14), plasma and gut tissue oxidized lipoproteins. The results were consistent with independent mouse models and ART regimens. Both 4F and 6F attenuated shedding of I-FABP and sCD14 from gut explants from HIV-infected and uninfected participants.

Conclusion:

Given that gut barrier dysfunction and macrophage activation are contributors to comorbidities like cardiovascular disease in HIV, apoA-I mimetics should be tested as therapy for morbidity in chronic treated HIV.
Evaluation of FRAX Performance Without Bone Mineral Density Calibrated for Mexico to Recognize Women at Risk of Fragility Fractures in Routine Clinical Care
Authors: Horta-Baas Gabriel
Published: December 2020

Objective

To evaluate FRAX clinical performance without bone mineral density (BMD) to approach people with fracture risk.

Methods

A cross-sectional study was carried out from July 2012 to February 2020 at outpatient clinic of rheumatology in 2 public hospitals. Postmenopausal women between 40 and 90 years of age were chosen if no previous osteoporosis treatment was received and had femoral neck BMD determination. Clinical performance of FRAX without BMD was evaluated using agreement and diagnostic test statistics.

Results

Four hundred seventy-seven women with a mean age of 62.85 years were included. FRAX without BMD classified 46.03% of them at low risk, 45.82% intermediate risk, and 8.16% high risk. When BMD was included, 17.19% of them revealed high risk. Not incorporating BMD value in the risk assessed a higher percentage of error in the fracture risk classification in high-risk patients; otherwise, including BMD reclassified it as risk below treatment threshold in 20.51% of the patients. The percentage of agreement between the recommendations based on FRAX with and without BMD was 94.98%. Agreement between FRAX score with or without BMD was good to very good (κ = 0.79, Gwet = 0.93). FRAX without BMD presented a positive predictive value of 79.5% and negative predictive value of 97.7%.

Conclusions

FRAX without BMD correctly classified most women evaluated, primarily low-risk women. In order to identify accurately women at high fracture risk, it would be advisable to determine the BMD in women with moderate to high risk of FRAX without BMD.
Preferred Strategies for Delivering Health Information to Patients With Musculoskeletal Disorders
Authors: Lopez-Olivo Maria A. , des Bordes Jude K. A. , Jibaja-Weiss Maria , Volk Robert J. , Suarez-Almazor Maria E.
Published: December 2020

Background

Patients' information needs may differ from what their care providers may perceive to be the patients' needs. This discordance needs to be recognized and addressed.

Objective

We conducted a qualitative study to explore the perceptions of patients with selected musculoskeletal disorders and those of rheumatologists, on their preferred strategies for delivery of disease management information.

Methods

Fifty-two patients diagnosed with either rheumatoid arthritis, knee osteoarthritis, or osteoporosis took part in 6 focus groups and 18 individual semistructured interviews. In addition, 11 rheumatologists participated in 2 focus groups and 4 semistructured individual interviews. Data were explored by thematic content analysis. Perceived preferences were identified and compared between patients and rheumatologists regarding (a) media, (b) setting, (c) messengers, and (d) key message content.

Results

Patients' preferred media for disease management information were electronic (television and videos delivered as digital optical discs or the Internet), group instruction, and printed material. Patients preferred the information to be delivered in the setting of their homes, doctor's offices, or clinic waiting areas by the rheumatologists and patients with disease experience, addressing healthy lifestyle changes, medication adherence, and consequences of noncompliance. For rheumatologists, the perceived preference for information delivery was through printed material (brochures, booklets, and pamphlets) delivered in waiting areas by nurses and physicians, addressing nature of the disease, complications, and treatment adverse effects.

Conclusions

Provider perspectives on strategies for education may differ from those of patients. Our findings highlight the need for considering different stakeholder perspectives in designing educational tools and decision support materials for patients with chronic diseases.

Take-Home Message

Rheumatologists' preferences on strategies for education (mode of delivery, delivery setting, messengers, and topics) differ from those of patients. For example, patients want to learn about lifestyle changes and consequences of compliance versus noncompliance, whereas rheumatologists considered more important for patients to understand their disease, treatment adverse effects, and consequences of noncompliance.
Epileptiform Abnormalities in Acute Ischemic Stroke: Impact on Clinical Management and Outcomes
Authors: Dhakar Monica B. , Sheikh Zubeda , Kumari Polly , Lawson Eric C. , Jeanneret Valerie , Desai Dhaval , Rodriguez Ruiz Andres , Haider Hiba A.
Published: December 2020

Purpose:

Studies examining seizures (Szs) and epileptiform abnormalities (EAs) using continuous EEG in acute ischemic stroke (AIS) are limited. Therefore, we aimed to describe the prevalence of Sz and EA in AIS, its impact on anti-Sz drug management, and association with discharge outcomes.

Methods:

The study included 132 patients with AIS who underwent continuous EEG monitoring >6 hours. Continuous EEG was reviewed for background, Sz and EA (lateralized periodic discharges [LPD], generalized periodic discharges, lateralized rhythmic delta activity, and sporadic epileptiform discharges). Relevant clinical, demographic, and imaging factors were abstracted to identify risk factors for Sz and EA. Outcomes included all-cause mortality, functional outcome at discharge (good outcome as modified Rankin scale of 0–2 and poor outcome as modified Rankin scale of 3–6) and changes to anti-Sz drugs (escalation or de-escalation).

Results:

The frequency of Sz was 7.6%, and EA was 37.9%. Patients with Sz or EA were more likely to have cortical involvement (84.6% vs. 67.5% P = 0.028). Among the EAs, the presence of LPD was associated with an increased risk of Sz (25.9% in LPD vs. 2.9% without LPD, P = 0.001). Overall, 21.2% patients had anti-Sz drug changes because of continuous EEG findings, 16.7% escalation and 4.5% de-escalation. The presence of EA or Sz was not associated with in-hospital mortality or discharge functional outcomes.

Conclusions:

Despite the high incidence of EA, the rate of Sz in AIS is relatively lower and is associated with the presence of LPDs. These continuous EEG findings resulted in anti-Sz drug changes in one-fifth of the cohort. Epileptiform abnormality and Sz did not affect mortality or discharge functional outcomes.
Effects of hepatitis B vaccine boosters in different levels of epidemic areas on anti-HBs-negative children after primary vaccination
Authors: Zhu Lu , Ye Kangli , Zheng Yuanyuan , Qiu Yan , Wu Zikang , Ren Jingjing , Yao Jun
Published: December 2020

Introduction. The widespread of hepatitis B virus is a severe global public problem, and the infant hepatitis B vaccine has been proved effective. But the failure of the immune response was reported in studies, and boosters were recommended. There were few studies about the effect of hepatitis B vaccine boosters in different levels of the epidemic area.

Hypothesis. Booster immunization is recommended because there may be a lack of immunization in infants vaccinated with the hepatitis B vaccine. In order to verify the effectiveness of booster immunization, this study hypothesized that it worked well in different levels of endemic areas.

Aim. To evaluate the effects of hepatitis B vaccine boosters on children from the areas with different prevalence of hepatitis B whose hepatitis B surface antibody (anti-HBs) were negative (<10 mIU ml−1).

Methodology. A total of 940 children were initially enrolled in screening; however, 421 were excluded. The participants were divided into three groups according to the different areas they come from: group I, low epidemic area; group II, middle epidemic area; and group III, high epidemic area. In total, 519 subjects were administered three doses of booster hepatitis B vaccine (0–1–6 months, 10 µg). The antibody titre changes were examined at four time points: 1 month after dose 1, 1 month, 1 year and 5 years after dose 3.

Results. The protective seroconversion rates in three groups were 96.30, 97.16, 96.63% at 1 month after dose 1, and 100.00, 100.00, 100.00% at 1 month after dose 3, and 97.79, 100.00, 98.50% at 1 year after dose 3, and 90.77, 93.67, 93.59% at 5 years after dose 3 (P>0.05).

Conclusions. This study demonstrates that three doses of booster vaccination have a longtime effect, no matter whether it is in low, middle or high prevalence areas in which subjects live.
Transcranial direct current stimulation (tDCS) combined with cognitive training in adolescent boys with ADHD: a double-blind, randomised, sham-controlled trial
Authors: Westwood Samuel J. , Criaud Marion , Lam Sheut-Ling , Lukito Steve , Wallace-Hanlon Sophie , Kowalczyk Olivia S. , Kostara Afroditi , Mathew Joseph , Agbedjro Deborah , Wexler Bruce E. , Kadosh Roi Cohen , Asherson Philip , Rubia Katya
Published: December 2020

Background

Transcranial direct current stimulation (tDCS) could be a side-effect free alternative to psychostimulants in Attention-Deficit/Hyperactivity Disorder (ADHD). Although there is limited evidence for clinical and cognitive effects, most studies were small, single-session, and stimulated left dorsolateral prefrontal cortex (dlPFC). No sham-controlled study has stimulated right inferior frontal cortex (rIFC), which is the most consistently under-functioning region in ADHD, with multiple sessions of anodal tDCS combined with cognitive training (CT) to enhance effects.

Objective/Hypothesis

To investigate clinical and cognitive effects of multi-session anodal tDCS over rIFC combined with CT in a double-blind, randomised, sham-controlled trial (RCT).

Methods

50 boys with ADHD (10-18 years) received 15 weekday sessions of anodal or sham tDCS over rIFC combined with CT (20mins, 1mA). ANCOVA, adjusting for baseline measures, age, and medication status, tested group differences in clinical and ADHD-relevant executive functions at posttreatment and after 6-months.

Results

ADHD-Rating Scale, Conners ADHD Index, and adverse effects were significantly lower at post-treatment after sham relative to real tDCS. No other effects were significant.

Conclusions

This rigorous multi-session RCT of tDCS over the rIFC in ADHD combined with CT, showed no evidence of improvement of ADHD symptoms or cognitive performance. Findings extend limited meta-analytic evidence of cognitive and clinical effects in ADHD after 1-5 tDCS sessions over mainly left dlPFC. Given that tDCS is commercially and clinically available, the findings are important as they suggest that rIFC stimulation may not be indicated as a neurotherapy for cognitive or clinical remediation for ADHD

Highlights

tDCS has been suggested as an alternative treatment for ADHD

We combined 15-session anodal tDCS over the rIFC with cognitive training in ADHD children

Real versus sham tDCS showed no cognitive or symptom improvements

Conversely, real tDCS showed lower ADHD symptoms and higher adverse effects

Multi-session tDCS of rIFC shows no clinical or cognitive benefits in ADHD