bluuebunny/crossref_metadata_2025 huggingface dataset:
Methotrexate as an Adjuvant in Severe Thyroid Eye Disease: Does It Really Work as a Steroid-Sparing Agent?
Authors: Yong Kai-Ling , Chng Chiaw-Ling , Ming Sie Nicole , Lang Stephanie , Yang Morgan , Looi Audrey , Choo Chai-Teck , Shen Sunny , Seah Lay Leng
Published: January 2019

Purpose:

To compare the efficacy and safety of adjunctive oral methotrexate with intravenous pulsed methylprednisolone against methylprednisolone alone in the treatment of severe thyroid eye disease.

Methods:

Retrospective review of clinical data of patients with severe sight-threatening thyroid eye disease with compressive optic neuropathy treated with methylprednisolone with and without methotrexate. Eye disease outcome measures (e.g., VISA inflammatory score and vision) at 0, 3, 6, 12, and 18 months were recorded.

Results:

There were 72 subjects including 33 who had methylprednisolone alone and 39 with methylprednisolone with methotrexate. There were no statistical differences in demographics and baseline measures of disease activity or vision between the 2 treatment groups. No significant statistical differences in the cumulative dosage of methylprednisolone or occurrence of restrictive myopathy, raised intraocular pressure, proptosis, and exposure keratopathy between the groups at 0, 3, 6, 12, and 18 months were found. However, subjects who received methylprednisolone with methotrexate had better visual acuity of more than 2 lines on Snellen chart (p= 0.026) and VISA inflammatory score (p= 0.034) at 3 months, but no differences at 6, 12, and 18 months. Three patients who received methylprednisolone with methotrexate had transient worsening of liver function. No patient developed severe adverse reaction.

Conclusions:

The results demonstrated improved vision and disease activity at 3 months in the combination treatment group. This may suggest that the addition of methotrexate to methylprednisolone is beneficial for accelerating suppression of disease activity and hastens visual recovery. Addition of methotrexate to methylprednisolone did not reduce the requirement for steroids.
Collagenoma of the Eyelid
Authors: Purgert Robert J. , Blandford Alexander D. , Schowalter Michael K. , Piliang Melissa P. , Hwang Catherine J. , Perry Julian D.
Published: January 2019

The rare case of an eyelid lesion comprised of hamartomatous dermal collagen, known as a collagenoma, is presented. Collagenomas may be sporadically acquired, or inherited as part of numerous autosomal dominant syndromes. In the appropriate clinical context, their diagnosis should prompt a thorough review of systems, systemic examination, and inquiry into family history, to assess for underlying autosomal dominant syndromes. Recognition of collagenomas may thus allow diagnosis of inherited syndromes, allowing patients to obtain appropriate genetic counseling, as well as screening and treatment of associated systemic pathology.
Measurement of the Force Required by Blunt-Tipped Microcannulas to Perforate the Facial Artery
Authors: Ugradar Shoaib , Hoenig Jonathan
Published: January 2019

Purpose:

To measure the force required by blunt-tipped microcannulas of various sizes to penetrate the wall of the facial artery.

Methods:

Twenty hemifaces of 10 fresh frozen cadavers were dissected to reveal the facial artery from its origin at the external carotid artery until the angular artery was found. On the right side of each cadaver, the facial artery was removed at the nasolabial fold, while arteries on the left were kept in situ, preserved with their fascial attachments. A force-sensitive resistor (Tekscan, Boston, MA, U.S.A.) was used to measure the force required by a syringe attached to 18G, 22G, 23G, 25G, and 27G blunt-tipped microcannulas, to pierce the proximal wall of the facial arteries on the left hemiface at the nasolabial fold. The facial arteries from each right hemiface were pierced by cannulas that were attached to a horizontally mounted microtensile load cell, which included a linear motor (Ibex Engineering, Newbury Park, CA). The force required to perforate the proximal wall of the facial arteries was calculated for each cannula. A 2-tailed t test was used to compare the forces measured by the force-sensitive resistor and the microtensile load cell.

Results:

On force testing, the 18G and 22G cannulas were unable to penetrate the vessel wall in facial arteries that were both: removed from the cadavers and maintained in the cadavers. There was no statistically significant difference between the values obtained by the load motor and the force-sensitive resistor (p = 0.33). The force required to penetrate the proximal wall of the facial artery was: 0.72 kg to 0.81 kg for 23G, 0.43 kg to 0.54 kg for 25G, and 0.23 kg to 0.32 kg for 27G blunt-tipped microcannulas. There was a significant correlation between the gauge of the cannulas and the force required to penetrate the vessel walls (r = −0.970; p = <0.01).

Conclusions:

Blunt-tipped microcannulas smaller than 22G penetrate the facial artery with a low amount of force.
Opioid cessation and chronic pain: perspectives of former opioid users
Authors: Goesling Jenna , DeJonckheere Melissa , Pierce Jennifer , Williams David A. , Brummett Chad M. , Hassett Afton L. , Clauw Daniel J.
Published: January 2019

Current guidelines for addressing opioid cessation in the context of chronic pain management recommend that opioids be discontinued if the risks outweigh the benefits. However, few studies have focused on understanding opioid cessation from the perspective of individuals with chronic pain. This mixed-method study included 49 former opioid users with chronic pain and used quantitative survey data and qualitative focus group data to identify themes pertaining to former opioid user's experience before, during, and after opioid cessation. Participants described several reasons for wanting to stop opioids including lack of efficacy, impact on quality of life, and concerns about addiction. Barriers to cessation included concerns about inadequate pain management and concerns about the impact of stopping opioids on mood. After opioid cessation, the sample was mixed regarding the benefit of cessation. Half of the former opioid users reported their pain to be better or the same after stopping opioids; however, 47% of the sample reported feeling worse pain since stopping their opioids. As the pendulum swings from pain control to drug control, we must ensure that the response to the opioid epidemic does not cause harm to individuals with chronic pain. Novel opioid cessation interventions are needed in combination with methods of addressing individual challenges and barriers to adequate pain relief including access to and provision of nonopioid alternatives for pain management.
Using Multisite Process Mapping to Aid Care Improvement: An Examination of Inpatient Suicide-Screening Procedures
Authors: Holleran Lori , Baker Samantha , Cheng Caleb , Wilson Jaime , Mickelson Robin , Kazana Izabela , Messinger-Rapport Barbara , Shahin Jacquelene , Cully Jeffrey , Naik Aanand D. , Godwin Kyler M.
Published: January 2019

Although most suicides occur outside of medical settings, a critical and often overlooked subgroup of patients attempt and complete suicide within general medical and inpatient units. The purpose of this quality improvement initiative was to perform a baseline assessment of the current practices for suicide prevention within medical inpatient units across eight Veterans Affairs medical centers throughout the nation, as part of the VA Quality Scholars (VAQS) fellowship training program. In conjunction with the VAQS national curriculum, the authors and their colleagues used multisite process mapping and developed a heuristic process to identify best practices and improvement recommendations with the hopes of advancing knowledge related to a key organizational priority—suicide prevention. Findings demonstrate a multitude of benefits arising from this process, both in relation to system-level policy change as well as site-based clinical care. This interprofessional and multisite approach provided an avenue for process literacy and consensus building, resulting in the identification of strengths including the improvement of prevention efforts and accessibility of supportive resources, the discovery of opportunities for improvement related to risk detection and response and the patient centeredness of current prevention efforts, and the provision of solutions that aim to achieve sustained change across a complex health system.
Moving to Another World: Understanding the Impact of Clinical Trial Closure on Research Participants Living With HIV in Uganda
Authors: Nalubega Sylivia , Cox Karen , Mugerwa Henry , Evans Catrin
Published: January 2019

Despite an increasing need for clinical trials involving people living with HIV (PLWH), little is known about how PLWH experience trial closure, particularly in low-income countries, where the majority of trials take place. We sought to explore the impact of trial closure on PLWH in Uganda. This was an interpretive, grounded theory study using in-depth interviews, conducted between October 2014 and August 2015. Adult participants (N = 23) from 3 trials were included. The findings indicated that trial closure was represented as “moving to another world” and was an emotional transition, linked to a loss of quality care in the research environment, the need to find alternative health facilities, fear of experiencing unwanted side effects, a desire to receive trial feedback, and difficulties linking to posttrial care. We concluded that PLWH leaving trials in a resource-limited setting required holistic care to facilitate their transition back to “usual care.”
Factors Associated With Depressive Symptoms in Female Victims of Intimate Partner Violence in Southern Taiwan
Authors: Hsieh Hsiu-Fen , Shu Bih-Ching
Published: January 2019

Background

Intimate partner violence (IPV) is known to cause physical suffering and psychological problems, which burden society. In addition, IPV-related psychological problems such as depressive symptoms may lead to disabilities, chronic mental illness, and an increased risk of suicide.

Purpose

This study was designed to explore the factors associated with depressive symptoms in women who were physically abused by intimate partners.

Methods

This cross-sectional study recruited 72 physically abused women from two domestic violence prevention centers in southern Taiwan. The questionnaires that were used to collect data included the Eysenck Personality Questionnaire, the Conflict Tactic Scale, and the Center for Epidemiologic Studies Depression Scale.

Results

Sixty-six of the participants (91.67%) met the inclusion criteria and completed all questionnaires. Fifty-five (83.3%) of the participants were found to have depressive symptoms. Depressive symptoms were positively associated in this sample with younger age, a lower level of extraversion, and a higher level of neuroticism. These three factors explained 59.5% of the total variance in depressive symptoms.

Conclusions/Implications for Practice

Youth and neuroticism were found to be significant risk factors for developing depressive symptoms in female victims of IPV, whereas extraversion was found to be a related protective factor. The results of this study indicate that clinical workers should provide female victims of IPV, especially relatively young victims, with services that help ameliorate neuroticism to reduce the risk of depressive symptoms.
Sport Concussion Assessment Tool: Fifth Edition Normative Reference Values for Professional Rugby Union Players
Authors: Fuller Gordon W. , Raftery Martin
Published: January 2019

Objective:

To describe distributions and establish normative ranges for new or changed subcomponents of the Sports Concussion Assessment Tool (SCAT)-5.

Design:

Cross-sectional study.

Setting and Participants:

Professional Rugby Union players performing 2017 preseason baseline SCAT-5 testing.

Independent Variables:

Subcomponent tests newly introduced or changed in the SCAT-5.

Main Measurements:

The 10-word immediate and delayed recall tests and the rapid neurological screen.

Results:

Thousand two hundred three players were included in complete case analyses. The 10-word immediate recall test [median score 15, interquartile range (IQR) 15-22, range 3-30] showed an asymmetrical, bimodal distribution. The delayed recall test (median score 7, IQR 5-9, range 0-10) demonstrated a left skewed distribution. The diplopia and reading/following instruction tests of the neurological screen were performed normally by virtually all participants (98.5% and 99.6%, respectively). Normative classification ranges for each SCAT-5 subcomponents of interest were determined.

Conclusions:

The increased spread of scores, with improved midrange centering, suggests that the increase to 10-word list lengths should improve the performance of immediate and delayed recall tests. Normative ranges will provide a distribution against which postinjury SCAT-5 scores can be compared and interpreted.
Integration of Safe Patient Handling and Mobility Principles in Professional Physical Therapist Education: A Case Report
Authors: Haines Jamie , Arnold Margaret
Published: January 2019

Background and Purpose.

Safe patient handling and mobility (SPHM) programs are being used across the country to safely transport and mobilize patients while at the same time reducing injury risk to caregivers, including physical therapists (PT) and physical therapist assistants (PTA). The American Physical Therapy Association has called PTs and PTAs to not only use the concepts of SPHM in clinical practice, but also be leaders in utilization, development, and implementation of SPHM programs, including training and education of other health care team members. Perlow, et al have recommended that SPHM content be integrated into Doctor of Physical Therapy (DPT) education. This case report outlines 1 current module used to deliver such content.

Case Description.

A neurologic interventions course within the DPT curriculum was selected using a framework that linked content, objectives, and learning activities with relevant Normative Model criteria and Physical Therapist Code of Ethics to improve student self-efficacy with SPHM content. Primary goals were to improve student awareness about risk and impact of work-related musculoskeletal disorders, expose students to the expected role of the PT as an advocate for and educator in SPHM programs, and provide hands-on experience with SPHM technologies. The 6-hour session was completed in 1 day with a 1-hour lecture and 5 hours with a variety of hands-on activities.

Outcomes.

Student learning was assessed through a pre–post class questionnaire, documentation/discussion of experiences, and presentations of student-generated neurologic interventions using SPHM equipment. Awareness of increased risk of injury, limits of 'good' body mechanics, and feasibility of using SPHM technologies to improve the quality of physical therapy practice dramatically increased.

Discussion.

Students should participate in a variety of learning activities threaded through the curriculum to provide sufficient hands-on opportunities to improve self-efficacy in using SPHM principles in rehabilitation. By developing a basic level of competency with SPHM principles, students may be more likely to adopt SPHM as a professional value once graduated. Improvements to this model, recommendations for SPHM integration into DPT curricula, and research opportunities are discussed.

Conclusion.

We have provided 1 model that embeds SPHM content into entry-level physical therapist education. In doing so, educators are advancing physical therapy skills needed to apply evidenced-based therapeutic principles in difficult to move patients while reducing risk of injury to students and new graduates of the profession.
The Development and Implementation of a Faculty Development Residency Within Physical Therapist Education
Authors: Salamh Paul , Roll Marcus , Figuers Carol , Covington Kyle
Published: January 2019

Background.

Over the past decade, there has been a significant proliferation of physical therapist (PT) programs within the United States. Along with these more accredited PT programs come vacant faculty positions and the need for well qualified candidates to fill core faculty rolls. The Faculty Residency Ad Hoc Group (FRAHG) of the American Board of Physical Therapy Residency and Fellowship Education was established to discuss the growing demand for qualified faculty within PT programs. A faculty development residency (FDR) was created based on the work of the FRAHG.

Method.

A 2-year full-time FDR was established at Duke University Doctor of Physical Therapy (DPT) Program. The program consists of didactic modules covering various facets of academia, teaching responsibilities, mentorship, and scholarly projects. The 2-year progressive curriculum builds on foundational knowledge and skillsets in order to move toward greater independence as a faculty member.

Discussion.

The FDR within the Duke DPT program has demonstrated the ability to identify and foster the knowledge and skills deemed valuable from the perspective of the residency directors, core faculty members, learners, and the residents themselves.

Conclusion.

Moving forward, the FDR appears to be a viable and meaningful option for the increasing demand for well-prepared core faculty within a DPT program. The model proposed has successfully led to the prior residents' ability to be competitive and successfully secure faculty positions upon completion.
The Integration of TeamSTEPPS Into Interprofessional Education Curricula at 3 Academic Health Centers
Authors: Davis Beth P. , Jernigan Stephen D. , Wise Holly H.
Published: January 2019

Background and Purpose.

The need for developing collaborative practice–ready health care providers, along with new interprofessional education (IPE) accreditation standards, highlights the importance of IPE in physical therapist education curriculum. As we strive to meet the goal of preparing students for collaborative practice and team-based care, the TeamSTEPPS system can be integrated into IPE programs to assist in the provision of quality health care and in the prevention of medical errors. Emory University (Emory), Kansas University Medical Center (KUMC), and the Medical University of South Carolina (MUSC) have integrated TeamSTEPPS into their IP classroom- and practice-based curricula. The purpose of this paper is to describe how these academic health centers have embedded TeamSTEPPS into their IP curricula, with the goal of assisting academic and clinical faculty with the development and implementation of learning activities directed toward the development of IP competency.

Method/Model Description and Evaluation, Outcomes.

The IPE models used by Emory, KUMC, and MUSC use the TeamSTEPPS framework and are described with select evaluation measures and outcomes. The Emory and KUMC models are primarily classroom based, whereas the MUSC uses a combined classroom- and clinic-based model. Although each institution's model for IP training and assessment is different, all have shown positive results.

Discussion and Conclusion.

With new IPE accreditation standards for most health professions programs, using TeamSTEPPS is a strategy to assist in meeting the standards for IPE training and a larger goal of improving the quality and safety of patient care.
A model of successful DNP and PhD collaboration
Authors: Cowan Linda , Hartjes Tonja , Munro Shannon
Published: January 2019

Background and purpose:

Within nursing education, the existence of two graduate-level programs has created some challenges. Role confusion between the practice-focused Doctor of Nursing Practice (DNP) and the research-focused Doctor of Philosophy (PhD) is compounded by competition for similar positions. Collaboration between DNP and PhD nurses, however, benefits the health care system and patients.

Methods:

The complementary skills of these two groups of nurses are detailed, and a model for building PhD-DNP partnerships is presented based on a collaborative PhD-DNP project that resolved a negative trend in outcomes from cardiac surgery. The clinical pathway created by the project met national benchmarks, improved interprofessional staff communication, and resulted in uniform and improved patient care.

Conclusions:

Although role differentiation for doctoral nurses can be challenging, role integration is critical. Building collaborative partnerships between these groups of nurses benefits the health care system, as well as patients, and this partnership is sustainable through successful collaborative projects.

Implications for practice:

Doctoral-prepared nurses must understand each other's background and education and focus on what each can contribute. In the beginning, as with any collaborative relationship, collaborators must discuss and agree on ground rules, team roles, responsibilities, and time line for projects.
Lesbian, Gay, Bisexual, and Transgender health: Creating safe spaces and caring for patients with cultural humility
Authors: Kuzma Elizabeth K. , Pardee Michelle , Darling-Fisher Cynthia S.
Published: January 2019

Background and purpose:

This article provides foundational information about 1) the significant health disparities LGBT individuals face, which are associated with persistent discrimination, oppression, and stigmatization in both societal and healthcare settings; and 2) how cultural humility can help nurses to create safe spaces and provide optimal care for all patients.

Methods:

CINAHL, Medline, PsychInfo, and GoogleScholar databases were searched to identify theoretical and empirical literature regarding LGBT health, health disparities, barriers to accessing care, unconscious bias, cultural humility, and creating safe spaces to better meet the healthcare needs of the LGBT population.

Conclusions:

LGBT patients' health needs are not being adequately met in many healthcare settings due to inadequate education and preparation of healthcare providers, including nurses. Lack of access to safe, appropriate, and affirming healthcare services increases the risk of poor health and persistent health disparities.

Implications for practice:

As the largest professional healthcare workforce, nurses can have a significant role in reducing the health disparities LGBT patients face. When armed with the tools to care for LGBT patients with cultural humility, nurses can lead clinical change within their institutions to create safe, accepting, affirming, inclusive, and welcoming environments for all patients.
Challenges faced by Canadian primary health care nurse practitioners in chronic disease management: A qualitative study among key informants
Authors: Pelletier Jérôme , Vermette Sarah , Lauzier Sophie , Bujold Mathieu , Bujold Louise , Martin Élisabeth , Guillaumie Laurence
Published: January 2019

Background and purpose:

The increasing prevalence of chronic diseases is driving health care systems to rethink their operations. Despite numerous studies supporting the advantages of primary health care nurse practitioners (PHCNPs) in chronic disease management, implementing practices that fully use the skills of these practitioners seems impeded in the Canadian province of Québec. This study explores the views of leaders involved in primary health care regarding the contributions PHCNPs can make in chronic disease management and the challenges they face in doing so.

Methods:

Through semistructured interviews, an exploratory descriptive qualitative study was conducted with 20 key informants across Québec who hold a variety of professional positions connected to PHCNPs.

Conclusions:

Primary health care nurse practitioners were perceived to be able to improve self-management support for chronic diseases. In reality, however, PHCNPs are mainly devoting their time to clientele in acute care, and current regulations governing their practices limit their involvement in chronic disease management.

Implications for practice:

Integrating PHCNPs offers a unique opportunity for health care settings to redefine the roles of family physicians and registered nurses and to restructure practices toward a chronic disease–oriented system. A clinical manager should be designated to monitor this restructuring process and ensure its success.
Progression of Peripheral Vestibular Dysfunctions in Patients With a Mitochondrial A3243G Mutation
Authors: Inoue Aki , Iwasaki Shinichi , Fujimoto Chisato , Kinoshita Makoto , Yamasoba Tatsuya
Published: January 2019

Objective:

To evaluate the progression of peripheral vestibular dysfunction in patients with an A-to-G point mutation at nucleotide pair 3243 in mitochondrial DNA (A3243G mutation).

Study Design:

Retrospective patient series.

Setting:

Tertiary referral center.

Patients:

Six unrelated patients with an A3243G mutation (four mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes; and two maternally inherited diabetes and deafness; five females and one male; average age 41 ± 11.3 yr old), who underwent repeated vestibular examinations, were included (average interval between the first and second examinations: 5.7 ± 2.1 yr).

Intervention:

Diagnostic.

Main Outcome Measure:

Results of caloric testing and cervical vestibular evoked myogenic potential testing in response to air-conducted sound were analyzed.

Results:

All the patients except one, who was already completely deaf in both ears at the first examination, showed progression of hearing loss (average 4.0 ± 6.3 dB per year). Five of the six patients had vestibular symptoms at the first examination. The other patient developed dizziness later. Caloric responses were abnormal in four patients at the first examination and in five patients at the second examination. Cervical vestibular evoked myogenic potential responses were bilaterally absent in three patients at the first examination and in five patients at the second examination.

Conclusions:

The A3243G mutation causes progression of peripheral vestibular dysfunction as well as that of hearing loss.
Long-term Changes in Musical Perception in Korean Cochlear Implant Patients
Authors: Ahn Jungmin , Ryu Gwanghui , Cho Yang-Sun
Published: January 2019

Objective:

The purpose of this study was to assess the long-term changes in music perception among cochlear implant (CI) patients using the Korean version of the Clinical Assessment of Music Perception test and questionnaires for music listening.

Methods:

Twenty-seven CI patients participated in this study. Their music perception ability was evaluated using the Korean version of the Clinical Assessment of Music Perception test, which consisted of pitch discrimination, melody, and timbre identification. The test was conducted at least twice after CI. A questionnaire was also used to quantify listening habits (LH) and level of musical experience (LE).

Results:

The participants were divided into two groups according to the average of each test result from the first test. In the pitch discrimination test, the just-noticeable-difference limen values increased as the base frequency increased, and significant differences were observed between the results of 262 and 391 Hz (p = 0.006). In the good performance group, pitch discrimination in the second test did not significantly differ from the first test, but the pitch discrimination score significantly improved in the poor performance group. Similarly, timbre test results were significantly improved in the poor performance group. Neither group exhibited changes in the second test for melody identification. The scores for LH and LE significantly decreased postoperatively and did not recover during the follow-up period.

Conclusions:

Pitch discrimination and timbre identification improved in CI listeners who exhibited poor musical performance shortly after surgery. However, melody identification did not improve over time. LH and LE scores decreased after CI surgery without time-dependent improvement.
Cochlear FLAIR Signal Changes in Hearing Preservation Vestibular Schwannoma Surgery
Authors: Tu Nathan Chin-yau , Bobarnac Dogaru Gabriela , Huang Polly , Kim Jeehong , Diegnan Bernadette , Go John Louie , Friedman Rick Adam
Published: January 2019

Objective:

Cochlear fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) signal intensity has been shown to be elevated in patients with vestibular schwannomas (VS). This study evaluated the preoperative and postoperative cochlear signal on FLAIR sequences in patients undergoing hearing preservation surgery.

Study Design:

Retrospective chart review.

Setting:

Tertiary referral center.

Patients:

All patients undergoing middle cranial fossa or retrosigmoid craniotomy for VS at a single institution from September 2013 to January 2017 were screened.

Hearing was graded according to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) hearing classification. Inclusion criteria included preoperative AAO-HNS class A or B hearing and available preoperative and postoperative FLAIR sequences.

Main Outcome Measure:

Signal intensity of cochlear FLAIR signal was measured in the affected cochlea and normalized to the contralateral cochlea. Hearing preservation was defined as AAO-HNS class A or B postoperatively.

Results:

Eighteen patients met all inclusion criteria, and 12/18 experienced hearing preservation. There was no difference in preoperative FLAIR ratio between hearing preserved and nonpreserved groups (2.02 vs 2.32, p = 0.52). Postoperatively, FLAIR ratio was lower in the hearing preserved group compared to the nonpreserved group (1.19 vs 1.87, p = 0.033).

Conclusions:

The current study is the first to examine postoperative cochlear FLAIR changes in VS patients undergoing hearing preservation surgery. In our study population, abnormal hyperintense FLAIR signal normalized in patients experiencing successful hearing preservation, while those who lost hearing maintained abnormal signal. Future studies may investigate the role of FLAIR in guiding optimal timing of operative intervention in VS patients.
Direction-Changing Positional Nystagmus in Acute Otitis Media Complicated by Serous Labyrinthitis: New Insights into Positional Nystagmus
Authors: Choi Jin Woo , Han Kyujin , Nahm Hyunjoo , Shin Jung Eun , Kim Chang-Hee
Published: January 2019

Objective:

To demonstrate characteristic nystagmus findings in acute otitis media (AOM) complicated by serous labyrinthitis and discuss the mechanism of direction-changing positional nystagmus (DCPN) in this condition.

Patients:

A patient with AOM complicated by serous labyrinthitis on the left side.

Intervention:

Video nystagmography and 3D fluid attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI).

Main Outcome Measures:

Characterize positional nystagmus in a head-roll test observing the change of nystagmus direction in process of time and compare findings of temporal bone 3D FLAIR MRI.

Results:

A previously healthy 50-year-old man who complained of acute otalgia, hearing loss, and vertigo was diagnosed with AOM complicated by serous labyrinthitis on the left side. A head-roll test performed on the day when vertigo developed showed persistent geotropic DCPN. While pre- and postcontrast T1-weighted MRI showed no signal abnormality in both inner ears, 10-minute delay postcontrast 3D FLAIR image showed enhancement in the inner ear on the left side. Four-hour-delay postcontrast 3D FLAIR images showed more conspicuous enhancement of the whole cochlea, vestibule, and semicircular canals on the left side.

Conclusions:

In AOM complicated by serous labyrinthitis, density of perilymph may increase due to direct penetration of cytokines and other inflammatory mediators from the middle ear into perilymph and breakdown of blood–labyrinth barrier that causes vascular leakage of serum albumin into perilymph. The density difference between perilymph and endolymph makes the semicircular canal gravity sensitive. A buoyant force is also generated by gravity, causing indentation of endolymphatic membrane in the ampulla and cupula displacement. Thus, at the early stage of serous labyrinthitis, a head-roll test may elicit persistent geotropic DCPN, of which the direction can be changed over time.
Cochlear Implant Receiver-Stimulator Migration Using the Subperiosteal Pocket Technique: Objective Measurements of Early and Late Positioning
Authors: Maxwell Anne K. , Cass Stephen P.
Published: January 2019

Objective:

Current clinical practice for fixation of the cochlear implant receiver-stimulator (RS) may not follow recommended manufacturer's guidelines. We investigated short- and long-term RS migration using a subperiosteal pocket technique via serial objective position measurements since previous literature provided only subjective or short-term evaluation.

Study Design:

Retrospective review.

Setting:

Tertiary referral center.

Patients:

We reviewed all patients who underwent cochlear implantation by the senior author between 2012 and 2018. At least two comparison measurements were available for 73 implants in 62 patients, 72.6% adults and 27.4% children.

Interventions:

RS placement using a subperiosteal pocket technique.

Main Outcome Measure:

Distance between the pinna and RS magnet in the early (<6 mo) and late (>6 mo) postoperative period.

Results:

In the early postoperative period, mean RS distance was 57.0 mm (SD 9.4 mm) from the pinna compared with baseline intraoperative distance of 55.8 mm (SD 8.4 mm), p = 0.44. With some shifts closer and some farther from the pinna, there was a 3.0 mm mean absolute value migration (median 2 mm, SD 3.8 mm, range 0–15 mm). Fourteen implants (25.9%) migrated >5 mm in the early period, 35.7% closer, and 64.3% farther from pinna. In the late postoperative period, mean RS final distance was 56.6 mm (SD 10.1 mm), compared with its baseline of 59.0 mm (SD 9.2 mm), p = 0.29. Seven implants (19.4%) demonstrated shifts >5 mm, with a mean 3.6 mm shift (median 2 mm, SD 4.5 mm, range 0–17 mm).

Conclusion:

A subperiosteal pocket technique demonstrated objective RS migration in 20 to 25% of adult and pediatric patients, nearly all of which were not clinically apparent unless measured. Additionally, none of these patients experienced associated symptoms or device failures.
Improving Outcomes in INTERMACS Category 1 Patients with Pre-LVAD, Awake Venous-Arterial Extracorporeal Membrane Oxygenation Support
Authors: Mori Makoto , McCloskey Gerard , Geirsson Arnar , Mangi Abeel A. , Yun James J. , Jacoby Daniel , Ahmad Tariq , Bellumkonda Lavanya , Lee Forrester , Chen Michael E. , Bonde Pramod
Published: January 2019

Effective strategies to optimize Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS 1) patients are in much need. A novel awake venous-arterial extracorporeal membrane oxygenation (aVA ECMO) allows for clinical assessments while temporarily supporting biventricular function and stabilizing end-organ functions. The aim of the study was to assess outcomes of patients with aVA ECMO support before durable left ventricular assist device (LVAD) implantation. We evaluated 83 patients who received durable LVAD in 2012–2015, of whom 19 received aVA ECMO support before durable LVAD. Kaplan–Meier and Cox proportional hazards analyses were conducted to assess post-LVAD survival. No complications were observed during the mean aVA ECMO support of 2.7 days. Unadjusted survival of aVA ECMO-supported patients and non-aVA ECMO INTERMACS 1 patients at 1 year were 84.2% and 66.7%, respectively (p = 0.15). Survival of aVA ECMO patients was comparable with that of non-aVA ECMO INTERMACS 2 cohort (84.2% vs. 80.8%) at 1 year. Multivariate analysis demonstrated a significant reduction in the risk of death in aVA ECMO group compared with INTERMACS 1 non-aVA ECMO group (hazard ratio [HR]: 0.17; p = 0.035). Awake venous-arterial (VA) ECMO allows bridge to next therapy and improves outcomes in INTERMACS category 1 patients with an effect comparable with downgrading the disease severity on the INTERMACS scale.
Efficacy of robotic radical hysterectomy for cervical cancer compared with that of open and laparoscopic surgery
Authors: Zhang Sha-sha , Ding Tian , Cui Zheng-hui , Lv Yuan , Jiang Ruo-an
Published: January 2019

Background:

To perform a meta-analysis of high-quality studies comparing robotic radical hysterectomy (RRH) vs laparoscopic radical hysterectomy (LRH), and open radical hysterectomy (ORH) for the treatment of cervical cancer.

Methods:

A systematic search of PubMed, Embase, Cochrane Library, and Web of Science was performed to identify studies that compared RRH with LRH or ORH. The selection of high-quality, nonrandomized comparative studies was based on a validated tool (methodologic index for nonrandomized studies) since no randomized controlled trials have been published. Outcomes of interest included conversion rate, operation time, intraoperative estimated blood loss (EBL), length of hospital stay (LOS), morbidity, mortality, number of retrieved lymph nodes (RLNs), and long-term oncologic outcomes.

Results:

Twelve studies assessing RRH vs LRH or ORH were included for this meta-analysis. In comparison with LRH, there was no difference in operation time, EBL, conversion rate, intraoperative or postoperative complications, LOS, and tumor recurrence (P > .05). Compared with ORH, patients underwent RRH had less EBL (weighted mean difference [WMD] = −322.59 mL; 95% confidence interval [CI]: −502.75 to −142.43, P < .01), a lower transfusion rate (odds ratio [OR] = 0.14, 95% CI: 0.06–0.34, P < .01), and shorter LOS (WMD = −2.71 days; 95% CI: −3.74 to −1.68, P < .01). There was no significant difference between RRH and LRH with respect to the operation time, intraoperative or postoperative complications, RLN, and tumor recurrence (P > .05).

Conclusion:

Our results indicate that RRH is safe and effective compared to its laparoscopic and open counterpart and provides favorable outcomes in postoperative recovery.
Contrast-enhanced ultrasound for evaluating the pathologic response of breast cancer to neoadjuvant chemotherapy
Authors: Jia Kun , Li Li , Wu Xiao Jing , Hao Mei Jin , Xue Hong Yuan
Published: January 2019

Objective:

Recent reports have suggested that contrast-enhanced ultrasound (CEUS) can be used to monitor the pathologic responses of breast cancer (BC) to neoadjuvant chemotherapy (NAC); however, the diagnostic performance of CEUS in BC has yet to be confirmed. Thus, we conducted a meta-analysis of related studies to explore the relationship between CEUS and pathologic responses of BC to NAC.

Materials and methods:

We searched PubMed, Embase, Web of Science, ScienceDirect, and China National Knowledge Infrastructure databases for studies published until September 31, 2018. Study-specific odds ratios (ORs) and 95% confidence intervals (CIs) were calculated, and then ORs with 95% CIs were pooled to estimate the prognostic role of CEUS for the pathologic responses of BC to NAC.

Results:

Pooled meta-analysis of the 9 eligible studies that included 424 patients indicated the high performance of CEUS for monitoring pathologic responses to NAC (OR = 31.83, 95% CI: 16.69–60.67, P < .001), with no significant heterogeneity (I
2 = 0.0%, P = .529). The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were 87% (95% CI: 0.81–0.92), 84% (95% CI: 0.74–0.91), 5.5 (95% CI: 3.3–9.2), 0.15 (95% CI: 0.10–0.23), and 36 (95% CI: 18–70), respectively. An area under the curve of 0.92 (95% CI: 0.89–0.94) suggests a high ability for prognostic detection. Although Begg's funnel plot (P = .057) indicated the presence of publication bias among the included studies, the trim-and-fill method verified the stability of the pooled outcomes. Sensitivity analysis suggested that the pooled OR was robust.

Conclusion:

Our results suggest that CEUS has a high diagnostic performance for the pathologic responses of BC to NAC. Further and better-designed studies should be performed to verify the clinical applications of CEUS for monitoring BC responses to NAC.
The effect of surgical fecal stream diversion of the healthy colon on the colonic microbiota
Authors: van der Sluis Wouter B. , Bouman Mark-Bram , Mullender Margriet G. , Degen Malieka C. , Savelkoul Paul H.M. , Meijerink Wilhelmus J.H.J. , de Boer Nanne K.H. , van Bodegraven Adriaan A. , Budding Andries E.
Published: January 2019

Objectives

The intestinal microbiota plays an important role in intestinal health. After colonic diversion from the fecal stream, luminal nutrients for bacteria are expected to be depleted, inducing changes in microbial composition. In this study, we describe microbial changes in the healthy colon following surgical fecal stream diversion, studied in the surgically constructed sigmoid-derived neovagina.

Methods

At various postoperative times after sigmoid vaginoplasty, rectal, neovaginal, and skin microbial swabs were obtained for microbial analysis by interspacer profiling, a PCR-based bacterial profiling technique. Differences in bacterial profiles, in terms of bacterial abundance and phylum diversity, were assessed. Microbial dissimilarities between anatomical locations were analyzed with principal coordinate analysis and partial least squares discriminant analysis.

Results

Bacterial samples were obtained from 28 patients who underwent sigmoid vaginoplasty. By principal coordinate analysis, microbial profiles of samples from the sigmoid-derived neovagina were distinctively different from rectal samples. Partial least squares discriminant analysis showed that the most discriminative species derived from the phylum Bacteroidetes. The abundance and diversity of Bacteroidetes species were reduced following fecal stream diversion compared with rectal samples (median Shannon diversity index of 2.76 vs. 2.18, P<0.01). Similar abundance of Phyla Firmicutes, Actinobacteria, Fusobacteria, Verrucomicrobia, and Proteobacteria was observed.

Conclusion

By analyzing the microbiome of sigmoid-derived neovaginas, we studied the effects of fecal diversion on the microbial composition of the healthy intestine. Most changes were observed in the phylum Bacteroidetes, indicating that these bacteria are likely part of the diet-dependent (butyrate-producing) colonic microbiome. Bacteria of other phyla are likely to be part of the diet-independent microbiome.
Efficacy of Sacubitril/Valsartan in Hypertension
Authors: Malik Aaqib H. , Aronow Wilbert S.
Published: January 2019

Background:

Sacubitril/valsartan (LCZ696) has progressed to be one of the most promising medication since its approval for chronic heart failure with reduced ejection fraction. Recent data have suggested a superior blood pressure control with LCZ696.

Study Question:

What is the antihypertensive efficacy and safety profile of sacubitril/valsartan?

Data Sources:

Randomized controlled trials (RCTs) comparing the efficacy and safety of LCZ696 against a placebo or angiotensin receptor blocker (ARB). RCTs were identified from a comprehensive search in PubMed, Embase, Cochrane library, and clinicaltrials.gov.

Study Design:

We used a change in systolic and diastolic blood pressures, both sitting as well as ambulatory, to calculate relevant effect sizes with their standard errors from the available change in mean and SD data. In addition, we also collected categorical data for the reported adverse effects from these trials. We performed a series of pairwise meta-analyses between LCZ696 versus an active comparator or a placebo.

Results:

Eleven RCTs with a total of 6028 participants had the relevant data available. Our meta-analysis showed that LCZ696 is an effective and a safe treatment for hypertension. It outperformed ARBs in every category, and the results are consistent across the different dosages of LCZ696. Compared with ARBs, 200 mg of LCZ696 reduced systolic blood pressure and diastolic blood pressure (DBP) by 4.62 mm Hg (95% confidence interval, 3.33–5.90, P < 0.001) and 2.13 mm Hg (95% confidence interval, 1.69–2.57, P < 0.001), respectively. Similarly, 400 mg of LCZ696 reduced systolic blood pressure and diastolic blood pressure by 5.50 mm Hg (2.94–8.07, P < 0.001) and 2.51 mm Hg (1.80–3.21, P < 0.001), respectively, in comparison with ARBs. The adverse effects with LCZ696 were not significantly higher compared with ARBs or placebo.

Conclusions:

Sacubitril/valsartan is more effective for the management of hypertensive patients, compared with an ARB. Long-term prospective studies are required to identify whether this result translates into morbidity and mortality benefits.
Missing Data in Marginal Structural Models
Authors: Liu Shao-Hsien , Chrysanthopoulou Stavroula A. , Chang Qiuzhi , Hunnicutt Jacob N. , Lapane Kate L.
Published: January 2019

Background:

The use of marginal structural models (MSMs) to adjust for time-varying confounding has increased in epidemiologic studies. However, in the setting of MSMs, recommendations for how best to handle missing data are contradictory. We present a plasmode simulation study to compare the validity and precision of MSMs estimates using complete case analysis (CC), multiple imputation (MI), and inverse probability weighting (IPW) in the presence of missing data on time-independent and time-varying confounders.

Materials and Methods:

Simulations were based on a cohort substudy using data from the Osteoarthritis Initiative which estimated the marginal causal effect of intra-articular injection use on yearly changes in knee pain. We simulated 81 scenarios with parameter values varied on missing mechanisms (MCAR, MAR, and MNAR), percentages of missing (10%, 20%, and 30%), type of confounders (time-independent, time-varying, either or both), and analytical approaches (CC, IPW, and MI). The performance of CC, IPW, and MI methods was compared using relative bias, mean squared error of the estimates of interest, and empirical power.

Results:

Across scenarios defined by missing data mechanism, extent of missing data, and confounder type, MI generally produced less biased estimates (range: 1.2%–6.7%) with better precision (range: 0.17–0.18) compared with IPW (relative bias: −5.3% to 8.0%; precision: 0.19–0.53). Empirical power was constant across the scenarios using MI.

Conclusions:

Under simple yet realistically constructed scenarios, MI seems to confer an advantage over IPW in MSMs applications.
Quality assurance in head and neck cancer surgery: where are we, and where are we going?
Authors: Simon Christian , Dietz Andreas , Leemans C. René
Published: January 2019

Purpose of review

The scope of this review is to summarize current efforts in quality assurance for head and neck cancer surgery. National and international initiatives are summarized and progress in terms of identification of process indicators and outcome indicators delineated.

Recent findings

Massive efforts have been made in order to improve quality of head and neck cancer surgery. New guidelines for quality assurance of head and neck cancer surgery in clinical trials have recently been proposed by EORTC.

Quality assurance programs can be tested within the clearly defined environment of prospective clinical trials. If positive, such programs could be rolled out within national healthcare systems, if feasible. Testing quality programs in clinical trials could be a versatile tool to help head neck cancer patients benefit from such initiatives on a global level.