bluuebunny/crossref_metadata_2025 huggingface dataset:
DIFFUSE CHORIORETINAL ATROPHY IN CHINESE HIGH MYOPIA
Authors: Liu Ran , Guo Xinxing , Xiao Ou , Li Zhixi , Zhang Jian , Lee Jonathan Tak Loong , Wang Decai , Sankaridurg Padmaja , Jong Monica , He Mingguang
Published: November 2018

Purpose:

To explore the associations between diffuse chorioretinal atrophy (DCA) and age, sex, axial length, spherical equivalent, and best-corrected visual acuity (BCVA) among highly myopic eyes.

Methods:

This study included right eyes of 857 bilaterally highly myopic individuals from the ZOC-BHVI Cohort Study. Participants underwent examinations, including BCVA, ocular biometry, autorefraction, and color fundus photography. An Early Treatment Diabetic Retinopathy Study grid was applied on the fundus photographs to evaluate the location of DCA, which was graded into four categories (D0–D3). The characteristics and ocular biometry were compared between participants' eyes with and without DCA.

Results:

Diffuse chorioretinal atrophy was found in 177 (20.6%) eyes. The proportion of participants with DCA in age groups of 7 to 11, 12 to 18, 19 to 39, and ≥ 40 years old was 20.9%, 9.2%, 23.1%, and 52.9%, respectively. The proportion of DCA significantly increased with longer axial length and worse myopic spherical equivalent. Eyes with DCA had poorer BCVA (Snellen visual acuity 20/36, logarithm of minimal angle of resolution 0.26 ± 0.25) than those without DCA (Snellen visual acuity 20/23, logarithm of minimal angle of resolution 0.06 ± 0.14) (P < 0.001). The BCVA gradually declined as the lesion got closer to the fovea (P
for trend < 0.001).

Conclusion:

The proportion of DCA increased with older age, longer axial length, and more myopic spherical equivalent. Diffuse chorioretinal atrophy is a vision-threatening complication of high myopia where BCVA gradually worsens with foveal involvement.
RETINAL CAPILLARY MACROANEURYSMS
Authors: Spaide Richard F. , Barquet Luis Arias
Published: November 2018

Purpose:

To investigate eyes with solitary large aneurysms arising from retinal capillaries.

Methods:

Consecutive patients with aneurysms greater than 200 µm in diameter were evaluated with a comprehensive ophthalmologic examination including optical coherence tomography, optical coherence tomography angiography, and fluorescein angiography. The aneurysms were solitary in the sense, and there was only one aneurysm larger than the threshold diameter and a few or no other aneurysms.

Results:

There were 5 patients, 3 male patients, who had aneurysms that reached a maximal mean size of 273.4 µm. One patient had stable diabetic retinopathy and had a documented growth of a capillary aneurysm to 331 µm over an 8-year 7-month period until the aneurysm was associated with widespread edema. The remaining 4 patients did not have diabetes or any discernable retinal vascular disease. Anti–vascular endothelial growth factor treatment was associated with a partial response in one patient and no apparent response in the others. Laser photocoagulation of the aneurysms resulted in resolution of the edema and involution of the lesions.

Conclusion:

Large aneurysms arising from retinal capillaries occur and have a candidate name of retinal capillary macroaneurysms. Histologic evaluation of retinal capillary aneurysms shows the presence of matrix metalloproteinase-9, which may function to decrease the wall strength in the face of increasing wall tension from aneurysmal expansion, as predicted by LaPlace's law. Thus, retinal capillary macroaneurysms may have multiple forces driving their formation.
Combined Keratectomy and Localized Limbal Cauterization for Treating Lisch Epithelial Corneal Dystrophy
Authors: Salvador-Culla Borja , Alonso-Agesta Maddi , Álvarez de Toledo Juan , Barraquer Rafael I.
Published: November 2018

Purpose:

To present a new technique for treating Lisch epithelial corneal dystrophy (LECD) in cases of recurrence of the disease.

Methods:

We present a single case report of a 41-year-old man who presented to the cornea clinic with progressive loss of vision in the right eye. Slit-lamp examination showed a large white-gray whorl-like epithelial opacity connected to the limbus, which spread over the visual axis, affecting visual acuity. The left eye was uninvolved.

Results:

After epithelial debridement was performed, histological analysis showed the nonkeratinized stratified flat epithelium, coalescent cytoplasmic vacuoles in some keratinocytes, and isolated cells with granular cytoplasm and small PAS negative nuclei, which confirmed the diagnosis of LECD. Despite partially successful treatment with several sequential epithelial debridements, the patient presented with confirmed recurrence of the disease soon after every treatment. Thus, focal epitheliectomy combined with localized cauterization of the limbal focus of origin was performed. Vision returned to normal, and there were no signs of recurrence at final follow-up 2 years later.

Conclusions:

Simple epitheliectomy combined with focal cauterization of the limbal focus of origin can be a simple, safe, and minimally invasive option for treatment of LECD.
Impact of Ceftazidime Use on Susceptibility Patterns in the Neonatal Intensive Care Unit
Authors: Miller Jamie L. , Johnson Peter N. , White Bryan P. , Neely Stephen B. , Chaaban Hala , Kassa Netsanet , Welliver Robert C.
Published: November 2018

Background:

Ceftazidime use in the neonatal intensive care unit (NICU) has increased after a cefotaxime shortage. The impact of this change is unknown. The purpose was to assess the effect of increased ceftazidime use on susceptibilities of Gram-negative organisms in the NICU.

Methods:

Retrospective study of Gram-negative isolates identified in blood, urine, cerebrospinal fluid, tracheostomy, abdominal fluid and pleural fluid cultures from a single-center NICU over a 5-year period. Duplicate cultures that occurred within 90 days were noted. Pre- and postshortage periods were defined based on cessation of cefotaxime. Third- and fourth-generation cephalosporin susceptibility rates were compared between periods, as well as rates of extended-spectrum beta-lactamase (ESBL) Escherichia coli and Klebsiella species.

Results:

Analysis included 666 isolates. Twelve (1.8%) were duplicate isolates that occurred after a 90-day period. The preshortage period included 464 (69.7%) isolates, and the postshortage included 202 (30.3%). No significant differences in susceptibility rates were noted when excluding duplicates. No difference in ESBL rates for E. coli were noted between periods (3.8% vs. 4.9%, P =1.000). No ESBL-positive Klebsiella species were identified. A post-hoc analysis of duplicate isolates demonstrated significant lower susceptibility rates for Pseudomonas aeruginosa to ceftazidime (risk ratio 0.58; 95% CI: 0.43–0.79) and cefepime (risk ratio 0.66; 95% CI: 0.51–0.86).

Conclusions:

Ceftazidime use did not appear to affect susceptibility rates for third- and fourth-generation cephalosporins for most Gram-negative organisms in the short-term of 1.5 years. However, susceptibility rates for P. aeruginosa decreased when evaluating duplicate isolates. Long-term monitoring is needed to assess the true impact.
Predictors of Palliative Care Knowledge Among Nursing Students in Saudi Arabia: A Cross-Sectional Study
Authors: ABOSHAIQAH Ahmad E.
Published: November 2018

Background:

Societal aging, a concern in many countries worldwide, is increasing the demand for quality palliative care in Saudi Arabia. Nursing education is responsible for providing nursing students with high levels of knowledge and competency related to palliative care.

Purpose:

The aim of this study was to investigate the predictors of palliative care knowledge among nursing students in Saudi Arabia.

Methods:

A convenience sample of 409 nursing students from one public academic institution and one private academic institution in Saudi Arabia was surveyed from November to December 2017 in this descriptive, cross-sectional study. The 20-item Palliative Care Quiz for Nursing was used to collect the data. Descriptive statistics were used to fully describe the demographic characteristics and palliative care knowledge of the participants. One-way analysis of variance and t test were used to examine the associations between palliative care knowledge and the demographic characteristics. Multiple regression analysis was conducted to identify the significant demographic predictors of this knowledge.

Results:

The mean score of the participants was 5.23 (SD = 3.24, range = 0–12), indicating poor palliative care knowledge. The participants lacked palliative care knowledge in terms of palliative care principles and philosophy, management of pain and other symptoms, and psychosocial and spiritual care. Being enrolled in a private university, being in the second year of a nursing program, having attended palliative care education sessions outside a university setting, and attending a palliative care course in the nursing program were identified as significant predictors of higher palliative care knowledge.

Conclusions/Implications for Practice:

This study may be used as a basis for formulating education policies and interventions to enhance palliative care education and clinical training among nursing students and ensure the quality of palliative care not only in Saudi Arabia but also in other countries.
Infective endocarditis complicated with nonobstructive ST elevation myocardial infarction related to septic embolism with intracranial hemorrhage
Authors: Liu Yi-Hsueh , Lee Wen-Hsien , Chu Chun-Yuan , Su Ho-Ming , Lin Tsung-Hsien , Yen Hsueh-Yei , Voon Wen-Chol , Lai Wen-Ter , Sheu Sheng-Hsiung , Hsu Po-Chao
Published: November 2018

Rationale:

Infective endocarditis (IE) complicated with obstructive ST elevation myocardial infarction (STEMI) has been reported in the literature and which were mostly related to coronary artery embolism, obstruction, or compression. However, there has been no reported case discussing about IE complicated with nonobstructive STEMI.

Patient concerns:

In this report, we report a 38-year-old female suffering from intermittent fever and was later diagnosed as IE. Initially antibiotic was given and mitral valve surgery was also arranged due to large vegetation with severe mitral regurgitation. Nevertheless, sudden conscious loss with desaturation happened and brain computed tomography (CT) showed intracranial and subdural hemorrhage related to possible septic embolism. In addition, electrocardiography (ECG) revealed ST elevation over precordial leads, and elevation of cardiac enzymes was also noted.

Diagnoses:

Emergent coronary angiography was arranged but result showed normal coronary arteries without any evidence of stenosis. The diagnoses of IE complicated with nonobstructive STEMI were made.

Interventions:

After coronary angiography, the patient underwent craniotomy and subdural hematoma removal. Surprisingly, follow-up ECG also revealed ST segment resolution.

Outcomes:

The patient received full course antibiotic treatment and follow-up brain CT also showed improvement of intracranial hemorrhage (ICH) and subdural hemorrhage. Because follow-up echocardiography still revealed severe mitral regurgitation with mitral valve prolapse due to leaflet destruction with partially decreased vegetation size, mitral valve replacement with bioprosthetic valve was performed and the patient was finally discharged smoothly.

Lessons:

In our knowledge, this case should be the 1st case of IE complicated with nonobstructive STEMI, which reminds physicians that nonobstructive STEMI is still an extremely rare but possible complication of IE and septic embolism related ICH should be carefully surveyed in this rare patient group.
Blood pressure lowering effect of calcium channel blockers on perioperative hypertension
Authors: Lin Yu , Ma Lina
Published: November 2018

Background:

Acute perioperative hypertension has been associated with poor outcomes of surgery, and the role of calcium channel blockers (CCB) on controlling perioperative blood pressure (BP) remains controversial. Thus, this meta-analysis was designed to assess the efficacy and safety of CCB in treating perioperative hypertension compared with other antihypertensive agents.

Methods:

PubMed, Medline, Cochrane, and EMABSE databases was systematically searched up to January 2018 for randomized control trials (RCTs) or other control studies comparing the efficacy of CCB versus other antihypertensive medicines for perioperative hypertension modulation. The efficacy and safety of CCB in treating perioperative hypertension were assessed through pooling mean difference (MD) with its 95% confidence interval (CI) or risk ratio (RR) with its 95% CI.

Results:

In total, 14 studies were included in the meta-analysis. There is no significant difference regarding successful treatment (RR = 2.64, 95% CI: 0.95, 7.29; I2 = 97%, P <.05), systolic blood pressure (SBP) (MD = −7.05, 95% CI: −16.27, 2.17; I2 = 78%, P <.05), overall adverse events (RR = 0.88, 95% CI: 0.66, 1.16; I2 = 54%, P = .02), atrial fibrillation (RR = 0.80, 95% CI: 0.60, 1.07; I2 = 32%, P = .20) and heart rates (MD = −1.05, 95% CI: −7.81, 5.71; I2 = 84%, P < .05) between patients treated by CCB and other drugs. In the subgroup analysis, statistical significance can be observed regarding successful treatment (RR = 3.46, 95%CI: 1.67, 7.18; I2 = 84%, P <.05) and postoperative SBP (MD = −9.98, 95%CI: −20.03, 0.08; I2 = 97%, P <.05) in the RCTs subgroup.

Conclusion:

CCB was highly effective and well tolerated for treating perioperative hypertension.
Long-term outcomes of a patient with late-onset multiple acyl-CoA dehydrogenase deficiency caused by novel mutations in ETFDH
Authors: Wang Juan , Wu Jun-Cang , Yu Xu-En , Han Yong-Zhu , Yang Ren-Min
Published: November 2018

Rationale:

Late-onset multiple acyl-coenzyme A dehydrogenase deficiency (MADD) mainly affects the neck extensor muscle group, which has been confirmed by novel mutations in electron-transferring-flavoprotein dehydrogenase (ETFDH). So far, a few cases have been reported with long-term follow-up. Here we report a case of late-onset MADD where the patient was followed up for 8 years during which time he underwent 2 muscle biopsies and 2 pathological examinations and his symptoms were significantly alleviated after appropriate treatments.

Patient concerns:

In September 2009, a 16-year-old male patient was hospitalized due to gradually increasing difficulty in raising his head and weakness in limb muscles over a 6-month period. During the physical examination, the patient's neck extensor muscle strength was grade III–IV. His proximal limb muscle strength was grade IV, and his distal muscle strength was normal. His blood creatine kinase (CK) was 783 U/L.

Diagnosis:

Muscle biopsy revealed a large number of vacuolar fibers, which were mainly type I fibers. These findings were consistent with the diagnosis of lipid storage myopathy (LSM). ETFDH gene test detected C.736G > A at exon 7 and C.920C > G at exon 8.

Interventions:

Coenzyme Q10 treatment was administered. The first coenzyme Q10 40 mg tid was treated for three months, with the change of coenzyme Q10 20 mg tid for 6 months, followed by the change of coenzyme Q10 10 mg tid for long-term use.

Outcomes:

The patient's condition significantly improved after 3 months. At 7th year follow-up the patient's blood CK was normal, and a second muscle biopsy revealed no muscle vacuolar fibers and no increase in lipid droplets. Subsequently, the patient was withdrawn from the coenzyme Q10 treatment, and the condition of the patient remained normal.

Lessons:

Muscle biopsy was the main method used to determine LSM. Treatment with riboflavin should be started when the diagnosis of LSM is definitive. Furthermore, ETFDH gene tests should be performed for further classification. Moreover, coenzyme Q10 may be another effective drug for MADD.
Neonatal lethal hypophosphatasia
Authors: Castells Laura , Cassanello Pía , Muñiz Felix , de Castro María-José , Couce María L.
Published: November 2018

Rationale:

Hypophosphatasia (HPP) is a very rare metabolic bone disease caused by loss-of-function mutations in the ALPL gene encoding the tissue nonspecific alkaline phosphatase. The severe neonatal form is considered lethal but insights into manifestations of the disease can help to increase our knowledge of the natural history for an early initiation of treatment and improvement of survival.

Patient concerns:

We report the case of a newborn in which his fetal imaging showed findings of skeletal dysplasia disorder, considering initially achondroplasia as a potential diagnosis.

Diagnosis:

A definitive diagnosis compatible with perinatal lethal HPP was established in the 1st days due to the presentation at birth with thoracic and pulmonary hypoplasia, bone hypomineralization, and undetectable alkaline phosphatase. The genetic analysis identified a new heterozygous c.413G>C mutation and another 1 c.473-2G>C previously described in the ALPL gene.

Outcomes:

The patient died on the 4th day by clinical course complicated without having started enzyme replacement therapy (ERT). Retrospectively, previous analyzes of the parents already showed both a decreased alkaline phosphatase.

Lessons:

This report highlights the importance of prenatal differential diagnosis of bone dysplasia with the key biochemical marker of alkaline phosphatase in the parents. Substitutive ERT administered very soon after birth, seems to change the prognosis in these patients with neonatal HPP.
Atypical purpura location in a pediatric patient with Henoch-Schönlein purpura
Authors: Zhang Fanhui , Chen Lihua , Shang Shiqiang , Jiang Kewen
Published: November 2018

Rationale:

The presence of purpura is a compulsory criteria for the diagnosis of Henoch-Schönlein purpura (HSP). Typical purpura of HSP is distributed symmetrically over the extensor surfaces of the lower limbs, buttocks, and forearms with the occasional involvement of trunk and face in children. It occurs only involving the bottom of the feet has never been reported.

Patient concerns:

A 7-year-old girl was admitted to the hospital with abdominal pain, vomiting, and fever.

Diagnoses:

Combining clinical manifestations with results of radiologic examinations, acute appendicitis was suspected and a laparotomy was considered. Purpura was found on the bottom of her feet when she was in the operating room and HSP was diagnosed.

Interventions:

The patient was treated with glucocorticosteroids, antibiotics, cimetidine, and restriction of feeding.

Outcomes:

The abdominal pain and purpura resolved at discharge and there were no recurrences in the subsequent 3-, 6-, and 12-month follow-ups.

Lessons:

Careful examination of skin including the bottom of the feet can help to direct the diagnostic workup for children with abdominal pain.
Doppler myocardial performance index combined with plasma B-type natriuretic peptide levels as a marker of cardiac function in patients with decompensated cirrhosis
Authors: Wang Li-Kun , An Xiao-Fei , Wu Xue-Liang , Zhang Su-Mei , Yang Rui-Min , Han Chao , Yang Jie-Lin , Wang Yi-Cheng
Published: November 2018

Background:

In chronic liver diseases, cirrhosis ranks as the 14th highest death cause worldwide, developing into decompensated cirrhosis. A potential and feasible technique in assessing cardiac function is urgent. This study explores if the Doppler myocardial performance (Tei) index combined with the plasma B-type natriuretic peptide (BNP) levels can assess cardiac function in patients with decompensated cirrhosis.

Methods:

A total of 140 individuals were selected in the study and were classified into 3 groups: control group (n = 40, healthy individuals), compensated cirrhosis group (n = 50), and decompensated cirrhosis group (n = 50). Plasma BNP levels, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), and albumin (ALB) were identified by an enzyme-linked immunosorbent assay (ELISA). The correlation of Tei index between left ventricle (LV) and right ventricle (RV) as well as plasma BNP levels with cardiac function was assessed using a Pearson test analysis. All patients were subjected to this experiment for 1 year to analyze the relationship between Tei index and plasma BNP levels in prognosis of decompensated cirrhosis patients.

Results:

Patients with decompensated cirrhosis showed significantly elevated levels of ALT, AST, and TBIL level in contrary to a reduced ALB level. Cirrhosis patients also showed a significantly reduced ejection fraction (ET) index, but an increase in isovolumetric contraction time (ICT), isovolumetric relaxation time (IRT), Tei index, and plasma BNP levels in comparison to healthy individuals. ICT, IRT, Tei index, and plasma BNP levels were elevated in decompensated cirrhotic patients as opposed to compensated cirrhotic patients. These results indicate a positive correlation of both Tei index and plasma BNP levels with cirrhosis and its progression. Tei index and plasma BNP levels are positively associated with Child–Pugh classification and negatively correlated with both cardiac function and prognosis in patients suffering from decompensated cirrhosis.

Conclusion:

The study provided evidence supporting the correlation of Tei index and plasma BNP levels in decompensated cirrhotic patients with cardiac function, highlighting a potential value for evaluation.
Prevention of type 2 diabetes mellitus with acupuncture
Authors: Shi Liwei , Feng Ling , Yang Yanan , Li Xiaowen , Zhang Meizhen , Zhang Yueying , Ni Qing
Published: November 2018

Background:

Prediabetes is prevalent and significantly increases lifetime risk of progression to type 2 diabetes mellitus (T2DM). Acupuncture has been increasingly used for prediabetes in China but its effect is unclear. We aim to assess the efficacy and safety of acupuncture in preventing or delaying incident diabetes among individuals with prediabetes.

Methods:

The following 8 databases will be searched from inception to September 1, 2018: the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, PubMed, Embase, Chinese National Knowledge Infrastructure database, Chinese Biomedical Literature database, Chinese Scientific Journal database, Wan Fang database, and Clinical Trials. The incidence of diabetes and regression toward normoglycemia will be accepted as the primary outcomes. The Cochrane Risk of Bias tool will be used to evaluate the methodologic quality of eligible studies. Meta-analysis will be performed by Review Manager 5.3.

Results:

This study will provide a high-quality synthesis of current evidence of acupuncture in the prevention of T2DM from several aspects including the incidence of diabetes, regression toward normoglycemia, fasting plasma glucose, 2-hour plasma glucose level after a 75-g oral glucose tolerance test, glycosylated hemoglobin level, body mass index, and adverse drug events.

Conclusions:

The conclusion of this review will provide evidence to judge whether acupuncture is an effective and safe intervention for prediabetes.

PROSPERO registration number:

PROSPERO CRD42018111236.
Role of SH2B3 R262W gene polymorphism and risk of coronary heart disease
Authors: Hong Lu , Jiang Yu-Feng , Chen Min , Zhang Nan-Nan , Yang Hua-Jia , Rui Qing , Zhou Ya-Feng
Published: November 2018

Background:

More susceptibility genes have been proved to be associated with coronary heart disease (CHD). The goal of our study is to evaluate the association between the R262W polymorphism of SH2B3 gene and risk of CHD.

Methods:

A systematic search was conducted using PubMed, Embase, Web of Science, CNKI, and WanFang databases up to March of 2018. The data of individual study were individually performed by 2 reviewers. The meta-analysis was performed by Stata software and expressed by the pooled odds ratio (OR) and the 95% confidence interval (CI), which were calculated by specific model according to heterogeneity.

Results:

Our research was based on 12 studies involving 25,845 patients and 68,910 healthy controls. Significant association between the variant R262W and CHD were found in overall populations (OR = 1.12, 95%CI = 1.09–1.15, P = .389, I
2 = 5.4%), but not found in Asian (OR = 1.05, 95%CI = 0.98–1.12, I
2 = 0.0%) in subgroup analysis by ethnicity. In another subgroup analysis, when classified into CHD and myocardial infarction (MI), there was a significance association between R262W and CHD (OR = 1.11,95% CI = 1.07–1.15, I
2 = 13.5%) and MI (OR = 1.13, 95%CI = 1.08–1.18, I
2 = 0.0%). The Begg's funnel plot revealed no significant publication bias.

Conclusions:

The R262W polymorphism is associated with risk of CHD or MI in Europeans, but not in Asians.
Effectiveness of 18F-FDG PET/CT in the diagnosis, staging and recurrence monitoring of Ewing sarcoma family of tumors
Authors: Huang Tao , Li Feng , Yan Zexing , Ma Yupeng , Xiong Fei , Cai Xia , Zhang Qingyu , Liu Fanxiao , Dong Jinlei
Published: November 2018

Background:

To investigate the value of positron emission tomography (PET) and PET/computed tomography (CT) using fluorine-18-fluorodeoxyglucose (18F-FDG) in the diagnosis, staging, restaging and recurrence monitoring of Ewing sarcoma family of tumors (ESFTs), a meta-analysis was performed through systematically searching PubMed, Embase, and Cochrane Central library to retrieve articles.

Methods:

After screening and diluting out the articles that met inclusion criteria to be used for statistical analysis the pooled evaluation indexes including sensitivity, specificity, and diagnostic odd ratio (DOR) as well as the summary receiver operating characteristic curve (SROC) were calculated involving diagnostic data (true positive, false positive, false negative, and true negative) extracted from original studies.

Results:

Screening determined that out of 2007, 23 studies involving a total of 524 patients were deemed viable for inclusion in the meta-analysis. The results of the analysis showed that the sensitivity and specificity were at 86% and 80%, respectively. Additionally, a satisfactory accuracy of18F-FDG PET and PET/CT was observed in detecting ESFT recurrence, lung metastasis, and osseous metastasis.

Conclusion:

This meta-analysis suggests that18F-FDG PET and PET/CT with an extremely high accuracy could be considered a valuable method for detecting distant metastasis and post-operational recurrence of ESFT, which might have a profound impact on the development of treatment protocols for ESFT.
Undifferentiated carcinoma with osteoclast-like giant cells of pancreas
Authors: Guo Yun-lei , Ruan Li-tao , Wang Qiu-ping , Lian Jie
Published: November 2018

Rationale:

Undifferentiated carcinoma with osteoclast-like giant cells (UC-OGCs) of the pancreas is an extremely rare and aggressive pancreatic malignancy. To our knowledge, the computed tomography (CT) findings of this disease have rarely been analyzed.

Patient concerns:

A 65-year-old man who experienced weight loss of about 4 kg over 3 months presented to our clinic. The abdominal ultrasound (US) detected a 5.8 × 5.5 cm well-defined, cystic-solid mass in the head of the pancreas, which had been present for 1 month.

Diagnosis:

A benign pancreatic tumor was initially suspected on the basis of the US findings. The patient then received serum tumor markers and CT examinations for further diagnosis, including carbohydrate antigen 199 (CA199), carcinoembryonic antigen (CEA), carbohydrate antigen 125 (CA125), contrast-enhanced CT (CECT) and CT angiography (CTA). His CA199, CEA, and CA125 marker levels were normal, which supported the diagnosis of a benign tumor. CECT showed a well-defined cystic-solid mass in the head of the pancreas, with a slightly enhanced solid portion and pancreatic ductal dilatation, which led us to consider the possibility of a malignant tumor. CTA revealed that the tumor nourishing arteries emitted from the pancreaticoduodenal superior and inferior arteries into the mass. Then, the patient underwent a pancreaticoduodenectomy. Finally, postoperative pathology and immunohistochemistry confirmed UC-OGC of the pancreas.

Interventions:

The patient has been treated by a pancreaticoduodenectomy alone.

Outcomes:

The operation had no complications, and the patient recovered well after surgery. Ten months after surgery, the patient reviewed the CECT, and no recurrence or metastasis was noted.

Lessons:

Old patients with cystic-solid lesions in the pancreas should be aware of UC-OGC. CT findings usually show a clear boundary and a slightly enhanced mass with pancreatic duct expansion.
Dietary Fiber and the Risk of Pancreatic Cancer
Authors: Koulouris Andreas I. , Luben Robert , Banim Paul , Hart Andrew R.
Published: November 2018

Objectives

High dietary fiber may protect against pancreatic ductal adenocarcinoma (PDAC). We investigated associations between fiber intake and the risk of PDAC using for the first time 7-day food diaries.

Methods

Participants in the European Prospective Investigation Into Cancer–Norfolk completed the 7-day food diaries at recruitment. The cohort was followed up for 17 years to identify those who developed PDAC. Participants were divided into quintiles of fiber intake, and hazard ratios (HR) were estimated with their 95% confidence intervals (CIs). Fiber was tested for effect modification of high red and processed meat intake and smoking and the risk of PDAC.

Results

No significant associations for any quintiles of intake (HR Q5 vs Q1, 1.08; 95% CI, 0.56–2.08) were detected with no trend across quintiles. A high-fiber diet modified positive associations between red and processed meats with the development of PDAC (HR trends, 0.89 [95% CI, 0.47–1.69] and 1.02 [95% CI, 0.55–1.88], respectively) but not those with lower fiber intake. Fiber intake did not modify the risk of PDAC in past and current smokers.

Conclusion

The findings do not suggest that fiber protects against PDAC, although it may decrease potential deleterious effects of meats.
Risk Factors for Pancreatic Stone Formation in Type 1 Autoimmune Pancreatitis
Authors: Ito Tetsuya , Kawa Shigeyuki , Matsumoto Akihiro , Kubota Kensuke , Kamisawa Terumi , Okazaki Kazuichi , Hirano Kenji , Hirooka Yoshiki , Uchida Kazushige , Masuda Atsuhiro , Ohara Hirotaka , Shimizu Kyoko , Arakura Norikazu , Masamune Atsushi , Kanno Atsushi , Sakagami Junichi , Itoi Takao , Ito Tetsuhide , Ueki Toshiharu , Nishino Takayoshi , Inui Kazuo , Mizuno Nobumasa , Yoshida Hitoshi , Sugiyama Masanori , Iwasaki Eisuke , Irisawa Atsushi , Shimosegawa Tooru , Chiba Tsutomu
Published: November 2018

Objective

Autoimmune pancreatitis (AIP) has the potential to transform into chronic pancreatitis with pancreatic stone involvement. This retrospective investigation sought to clarify the risk factors for stone formation in type 1 AIP.

Methods

Questionnaires on patients with type 1 AIP were sent to 22 high-volume medical centers across Japan to compare the clinical features of patients with and without pancreatic stone formation.

Results

Of the completed records on 624 type 1 AIP patients, 31 (5%) had experienced pancreatic stones. Median follow-up duration was 1853 days. Bentiromide test values at diagnosis were significantly lower, and hemoglobin A1c values after corticosteroid treatment were significantly higher in patients with pancreatic stones. Imaging results disclosed that pancreatic atrophy and hilar or intrahepatic bile duct stenosis were significantly more frequent in patients with pancreatic stone formation. Pancreatic head swelling tended to be more frequent in this group as well. On the other hand, a shorter follow-up period was associated with the nonformation of pancreatic stones.

Conclusions

The increased frequency of pancreatic head swelling in type 1 AIP patients exhibiting pancreatic stones indicated a propensity for pancreatic juice stasis with subsequent stone development and pancreatic dysfunction occurring over longer periods of disease duration.
Factors Influencing Do-Not-Resuscitate Status in Children During Last Month of Life: Single Institution Experience
Authors: Moaed Bilal , Mordechai Oz , Weyl Ben-Arush Myriam , Tamir Sharon , Ofir Ruth , Postovsky Sergey
Published: November 2018

Background:

It is currently expected that about 20% of children with cancer will ultimately die. Writing advanced life directives sufficiently long before the actual death of a child ensues allows both parents and medical staff to develop optimal treatment plans in the best interests of the child.

Aim of the study:

The aim of the study was to evaluate factors that may influence the process of decision-making regarding Do-Not-Resuscitate (DNR) status.

Methods:

Retrospective single institution study.

Results:

Totally, 79 patients died between September 01, 2011 and August 31, 2017. Median age of the children was 10.5 years (range, 1 to 24 y). Forty-five were males. There were 37 Muslims, 27 Jews, 9 Druze, and 6 Christians. Twenty-one patients had sarcomas, 20 had CNS tumors, 10 had neuroblastoma, 17 had leukemias/lymphomas, 11 had carcinomas, and other rare tumors as well as nonmalignant diseases. No statistically significant association between all evaluated factors and DNR order status was found.

Conclusions:

It is possible that, other than demographic, clinical-associated, or therapy-associated factors play an important role in the process of decision-making regarding DNR. We feel that sincere communication between parents, their child (when appropriate) and medical and psychosocial staff may have a more crucial role when such decisions have to be made.
Cytokine Profile, Apoptosis, Glucocorticoid Receptor, and P-glycoprotein Expression Before and After Megadose Methylprednisolone Treatment in Children With Acute Immune Thrombocytopenia
Authors: Yalinbaş Emine E. , Sezgin Evim Melike , Bör Özcan , Gülbaş Zafer
Published: November 2018

Objective:

Immune thrombocytopenia (ITP) is an autoimmune disease, and it has become evident that T lymphocytes play an important role in the pathogenesis of ITP. We investigated the role of T helper (Th) intracellular IL-2, IL-4, IL-6, IFN-γ, and T lymphocyte apoptosis in the pathogenesis of acute ITP and the effect of glucocorticoid treatment on cytokine profile. We investigated also P-glycoprotein (P-gp) and glucocorticoid receptor (GCR) expression as a possible mechanism for glucocorticoid resistance.

Material and Methods:

The study includes 20 children with acute ITP having a platelet count <20,000/mm3 and 20 healthy children as a control group. Patients with acute ITP were treated with megadose methylprednisolone (MDMP) (MDMP in the dose of 30 mg/kg/d between day 1 and 3 and 20 mg/kg/d between day 4 and 7). Th intracellular IL2, IL-4, IL-6, and IFN-γ percentages, T-cell P-gp expression, T-cell and monocyte GCR expression, and T-cell apoptosis were evaluated before and after treatment in acute ITP patients and in the control group.

Results:

Acute ITP patients had significantly higher Th IL-2, IL-4, IL-6, and IFN-γ percentages compared with the control group (P<0.05). Th IL-2 and IFN-γ percentages were significantly lowered with MDMP treatment (P<0.05). IFN-γ/IL-4 ratio was also lowered with the MDMP treatment (P<0.05). T-lymphocyte P-gp expression and T lymphocyte and monocyte GCR expression were all similar between acute ITP pretreatment and control groups (P>0.05). T-lymphocyte P-gp expression was higher in the posttreatment group than in the pretreatment group (P<0.05). Both T lymphocyte and monocyte GCR expression percentages were not different in the pretreatment and posttreatment groups (P>0.05). Early apoptosis in T lymphocytes was significantly lower in the pretreatment acute ITP group than in the control group (P<0.05). Necrotic apoptosis in T lymphocytes was significantly increased with MDMP treatment (P<0.05).

Conclusions:

Th1 and Th2 cytokine profile is observed in acute ITP pathogenesis, and MDMP treatment causes Th1 to Th2 cytokine profile shift and induction of T-lymphocyte apoptosis. There is a need to have a greater number of resistant cases in order to better evaluate the P-gp and GCR expression in glucocorticoid resistance in acute ITP.
Integrating Research and Quality Improvement Using TeamSTEPPS
Authors: Beiler Joseph , Opper Kristi , Weiss Marianne
Published: November 2018

Purpose/Objectives:

The purpose of this article is to describe an innovative approach to the integration of quality improvement and research processes. A project with the objective of improving health team communication about hospital discharge provides an exemplar case.

Description of the Project/Program:

The TeamSTEPPS 10-step action planning guide provided the structure for planning, developing, and evaluating a redesign of interprofessional health team communication to improve hospital discharge led by 2 clinical nurse specialists. The redesign involved development of processes for team bedside rounding, registered nurse bedside shift reports, and briefing tools to support the rounding processes.

Outcome:

Using the TeamSTEPPS process, a 4-phase combined quality improvement and research project was designed and implemented. Implementation is ongoing, supported by process evaluation for continuing process improvement. Longitudinal analysis of research outcomes will follow in the future.

Conclusions:

Led by unit-based clinical nurse specialists, use of an integrated process of quality improvement and research creates evidence-based innovation to solve interprofessional practice problems. Incorporating research within the project design allows for data-based decisions to inform the clinical process improvement, as well as documentation of both the processes and outcomes of the local improvements that can inform replications in other sites.
Programmed Death-ligand 1 (PD-L1) Expression in Thymic Epithelial Tumors
Authors: Bedekovics Judit , Beke Livia , Mokanszki Attila , Szilagyi Szabolcs , Mehes Gabor
Published: November 2018

Thymic epithelial tumors (TETs) are uncommon neoplasms of the mediastinum. The gold standard treatment is complete surgical resection which can be followed by radio/chemotherapy in selected cases. Targeted tyrosine kinase inhibition can be considered in only a limited number of aggressive or metastatic tumors as EGFR, BRAF, or c-kit mutations are rare. However, previous studies have demonstrated the efficacy of immune checkpoint inhibitors in epithelial neoplasias, such as in programmed cell death ligand 1 (PD-L1) expressing nonsmall cell lung carcinoma. Because of their rare occurrence the data on PD-L1 distribution in thymic neoplasias are limited. PD-L1 and PD-1 expression in tumor cells and tumor infiltrating immune cells was determined in TETs according to criteria published for lung carcinomas. Comparison with major clinical, pathologic, and biological features was also done. In total, 36 TETs (29 thymomas and 7 thymic carcinomas) were analyzed. PD-L1 immunohistochemical staining (Ventana PD-L1 clone SP142) was performed in all cases. The percentage of the positive tumor cells (TC value), the percentage of tumor area occupied by positive immune cells (IC value) was evaluated. Evaluation of PD-L1 expression in tumor cells showed a good reproducibility (κ-value: 0.840; Spearman r=0.966; P<0.0001). About 69% of thymomas (20/29) and 43% of thymic carcinomas (3/7) showed high positivity rate (TC≥50% or IC ≥10%), which may indicate therapeutic advantage similar to nonsmall cell lung cancers defined by the same conditions. PD-L1 expression is common in different epithelial tumors of the thymus, which suggests the potential effectiveness of drugs targeting the PD-1/PD-L1 interactions in these neoplasms.
Paroxysmal Sympathetic Hyperactivity After Severe Traumatic Brain Injury in Children: Prevalence, Risk Factors, and Outcome*
Authors: Alofisan Tariq O. , Algarni Yasser A. , Alharfi Ibrahim M. , Miller Michael R. , Charyk Stewart Tanya , Fraser Douglas D. , Tijssen Janice A.
Published: November 2018

Objective:

To describe paroxysmal sympathetic hyperactivity in pediatric patients with severe traumatic brain injury using the new consensus definition, the risk factors associated with developing paroxysmal sympathetic hyperactivity, and the outcomes associated with paroxysmal sympathetic hyperactivity.

Design:

Retrospective cohort study.

Setting:

Academic children’s hospital PICU.

Patients:

All pediatric patients more than 1 month and less than 18 years old with severe traumatic brain injury between 2000 and 2016. We excluded patients if they had a history of five possible confounders for paroxysmal sympathetic hyperactivity diagnosis or if they died within 24 hours of admission for traumatic brain injury.

Measurements and Main Results:

Our primary outcome was PICU mortality. One hundred seventy-nine patients met inclusion criteria. Thirty-six patients (20%) had at least eight criteria and therefore met classification of “likelihood of paroxysmal sympathetic hyperactivity.” Older age was the only factor independently associated with developing paroxysmal sympathetic hyperactivity (odds ratio, 1.08; 95% CI, 1.00–1.16). PICU mortality was significantly lower for those with paroxysmal sympathetic hyperactivity compared with those without paroxysmal sympathetic hyperactivity (odds ratio, 0.08; 95% CI, 0.01–0.52), but PICU length of stay was greater in those with paroxysmal sympathetic hyperactivity (odds ratio, 4.36; 95% CI, 2.94–5.78), and discharge to an acute care or rehabilitation setting versus home was higher in those with paroxysmal sympathetic hyperactivity (odds ratio, 5.59; 95% CI, 1.26–24.84; odds ratio, 5.39; 95% CI, 1.87–15.57, respectively). When paroxysmal sympathetic hyperactivity was diagnosed in the first week of admission, it was not associated with discharge disposition.

Conclusions:

Our study suggests that the rate of paroxysmal sympathetic hyperactivity in patients with severe traumatic brain injury is higher than previously reported. Older age was associated with an increased risk for developing paroxysmal sympathetic hyperactivity, but severity of the trauma and the brain injury were not. For survivors of severe traumatic brain injury beyond 24 hours who developed paroxysmal sympathetic hyperactivity, there was a lower PICU mortality but also greater PICU length of stay and a lower likelihood of discharge home from the admitting hospital, suggesting that functional outcome in survivors with paroxysmal sympathetic hyperactivity is worse than survivors without paroxysmal sympathetic hyperactivity.
Benefits of Early Mobilization After Pediatric Liver Transplantation*
Authors: Tsuboi Norihiko , Hiratsuka Miku , Kaneko Setsushi , Nishimura Nao , Nakagawa Satoshi , Kasahara Mureo , Kamikubo Takeshi
Published: November 2018

Objective:

To evaluate the impact of early mobilization after pediatric liver transplantation in the PICU.

Design:

A 70-month retrospective before-after study.

Setting:

Medical and surgical PICU with 20 beds at a tertiary children’s hospital.

Patients:

Seventy-five patients 2–18 years old who underwent liver transplantation and could walk before surgery.

Intervention:

We meticulously planned and implemented an early mobilization intervention, a multifaceted framework for early mobilization practice in the PICU focusing on a multidisciplinary team approach.

Measurements and Main Results:

There was a significant increase in the proportion of patients who received physical therapy in the PICU (66% vs 100%; p < 0.001), especially within the first 48 hours after transplantation (9% vs 78%; p < 0.001). Furthermore, the time spent for physical therapy per eligible patient and per eligible PICU day increased (8.1 min [interquartile range, 0–10.6 min] vs 17.4 min [13.2–26.6 min]; p < 0.001). Compared with patients in the pre-early mobilization period, patients in the post-early mobilization period were able to walk again for more than 50 yards without a rolling walker earlier (28 [16–66] vs 23 [19–31] postoperative days; p = 0.015 by the Gray test), and the length of hospital stay of the post-early mobilization group was shorter than that of the pre-early mobilization group (55 [37–99] vs 40 [31–54] postoperative days; p = 0.012).

Conclusions:

Through implementation of early mobilization for pediatric patients who underwent liver transplantation, the duration from liver transplantation to regaining the ability to walk again without a rolling walker became shorter. Early mobilization intervention was beneficial for pediatric patients who underwent liver transplantation and could walk before surgery.
Fluid Management Practices After Surgery for Congenital Heart Disease: A Worldwide Survey*
Authors: Hanot Jan , Dingankar Adil R. , Sivarajan V. Ben , Sheppard Cathy , Cave Dominic , Garcia Guerra Gonzalo
Published: November 2018

Objectives:

To determine common practice for fluid management after cardiac surgery for congenital heart disease among pediatric cardiac intensivists.

Design:

A survey consisting of 17 questions about fluid management practices after pediatric cardiac surgery. Distribution was done by email, social media, World Federation of Pediatric Intensive and Critical Care Societies website, and World Federation of Pediatric Intensive and Critical Care Societies newsletter using the electronic survey distribution and collection system Research Electronic Data Capture.

Setting:

PICUs around the world.

Subjects:

Pediatric intensivists managing children after surgery for congenital heart disease.

Interventions:

None.

Measurements and Main Results:

One-hundred eight responses from 18 countries and six continents were received. The most common prescribed fluids for IV maintenance are isotonic solutions, mainly NaCl 0.9% (42%); followed by hypotonic fluids (33%) and balanced crystalloids solutions (14%). The majority of the respondents limit total fluid intake to 50% during the first 24 hours after cardiac surgery. The most frequently used fluid as first choice for resuscitation is NaCl 0.9% (44%), the second most frequent choice are colloids (27%). Furthermore, 64% of respondents switch to a second fluid for ongoing resuscitation, 76% of these choose a colloid. Albumin 5% is the most commonly used colloid (61%). Almost all respondents (96%) agree there is a need for research on this topic.

Conclusions:

Our survey demonstrates great variation in fluid management practices, not only for maintenance fluids but also for volume resuscitation. Despite the lack of evidence, colloids are frequently administered. The results highlight the need for further research and evidence-based guidelines on this topic.