bluuebunny/crossref_metadata_2025 huggingface dataset:
A Completely Bounded Noncommutative Choquet Boundary for Operator Spaces
Authors: Clouâtre Raphaël , Ramsey Christopher
Published: December 2017

We develop a completely bounded counterpart to the noncommutative Choquet boundary of an operator space. We show how the class of completely bounded linear maps is too large to accommodate our purposes. To overcome this obstacle, we isolate the subset of completely bounded linear maps admitting a dilation of the same norm that is multiplicative on the associated C*-algebra. We view such maps as analogs of the familiar unital completely contractive maps, and we exhibit many of their structural properties. Of particular interest to us are those maps that are extremal with respect to a natural dilation order. We establish the existence of extremals and show that they have a certain unique extension property. In particular, they give rise to *-homomorphisms that we use to associate to any representation of an operator space an entire scale of C*-envelopes. We conjecture that these C*-envelopes are all *-isomorphic and verify this in some important cases.
Inheritance and Allelic Relationship Among Downy Mildew Resistance Genes in Pearl Millet
Authors: Raj Chandramani , Sharma Rajan , Pushpavathi B. , Gupta S. K. , Radhika K.
Published: December 2017

Pearl millet downy mildew (DM), caused by Sclerospora graminicola, is of serious economic concern to pearl millet farmers in the major crop-growing areas of the world. To study the inheritance and allelic relationship among genes governing resistance to this disease, three DM-resistant pearl millet lines (834B, IP 18294-P1, and IP 18298-P1) and one susceptible line (81B) were selected on the basis of disease reaction under greenhouse conditions against two isolates of S. graminicola (Sg 526-1 and Sg 542-1). Three resistant parents were crossed with the susceptible parent to generate F1, F2, and backcross BC1P1 (susceptible parent × F1) and BC1P2 (resistant parent × F1) generations for inheritance study. To carry out a test for allelism, the three resistant parents were crossed with each other to generate F1 and F2 generations. The different generations of these crosses were screened for disease reaction against two isolates (Sg 526-1 and Sg 542-1) by artificial inoculation under greenhouse conditions. The segregation pattern of resistance in the F2 and corresponding backcross generations revealed that resistance to DM is controlled by a single dominant gene in 834B and IP 18294-P1 and by two dominant genes in IP 18298-P1. A test for allelism inferred that a single dominant gene for resistance in 834B is nonallelic to that which governs resistance in IP 18294-1, whereas one of the two dominant genes for DM resistance in IP 18298-P1 against the test isolates is allelic to the gene for DM resistance in 834B and a second gene is allelic to the resistance gene present in IP 18294-P1.
Disfiguring facial lesions and loss of sensation
Authors: Hundemer Marleen , Wan Claire Ramsay
Published: December 2017

Hansen disease (leprosy) continues to be prevalent in some regions of Africa, Asia, and South America, and each year 100 to 300 cases are reported in the United States, especially in immigrants and patients exposed to armadillos. Treatment depends on patient presentation. Hansen disease remains highly stigmatized, though it is now clear that it is not readily transmitted through casual physical contact.
Cystic placentomegaly on a second-trimester ultrasound
Authors: Adams Heather P. , Malloy Jennifer
Published: December 2017

Placental mesenchymal dysplasia (PMD) is a rare disorder of the placenta characterized by placentomegaly, cystic vesicles, and dilated chorionic blood vessels. Clinically and pathologically, it closely resembles partial molar pregnancy and complete hydatidiform mole with a coexistent healthy fetus, both of which are associated with malignant trophoblastic disease. PMD, however, has no risk of malignant trophoblastic disease and can result in the birth of a normal fetus, highlighting the need for clinician awareness of PMD in order to avoid unnecessary termination of a viable and potentially healthy fetus.
Are hormonal contraceptives less effective in overweight and obese women?
Authors: Patel Shriya , Carey Lawrence
Published: December 2017

Loss of efficacy of hormonal contraceptives is of particular concern for women who are overweight or obese. Only recently have clinical trials started to include overweight and obese women in their study populations, limiting the data available on which to make the best prescribing decisions for hormonal contraceptives for these patients. Other methods, such as the copper or levonorgestrel-containing intrauterine device, the etonogestrel implant, and depot medroxyprogesterone acetate, are preferred over combined oral contraceptives, the transdermal patch, and the vaginal ring.
Procalcitonin-guided treatment of lower respiratory tract infections
Authors: Watkins Elyse J. , Guerrini James
Published: December 2017

The FDA recently approved a procalcitonin assay for use in hospitals and EDs to help prescribers determine if an antibiotic should be prescribed and for what duration. This article reviews the use of procalcitonin testing and evidence-based medical decision-making for patients with sepsis or lower respiratory tract infections.
Medical Graduates, Truthful and Useful Analytics With Big Data, and the Art of Persuasion
Authors: Gorman Des , Kashner T. Michael
Published: December 2017

The authors propose that the provision of state-of-the-art, effective, safe, and affordable health care requires medical school graduates not only to be competent practitioners and scientists but also to be policy makers and professional leaders. To meet this challenge in the era of big data and cloud computing, these graduates must be able to understand and critically interpret analyses of large, observational datasets from electronic health records, third-party claims files, surveys, and epidemiologic health datasets.

The authors contend that medical students need to be exposed to three components. First, students should be familiar with outcome metrics that not only are scientifically valid but also are robust, useful for the medical community, understandable to patients and relevant to their preferences and health goals, and persuasive to health administrators and policy decision makers. Next, students must interact with an inclusive set of analysts including biostatisticians, mathematical and computational statisticians, econometrists, psychometricians, epidemiologists, informaticians, and qualitative researchers. Last, students should learn in environments in which data analyses are not static with a “one-size-fits-all” solution but, rather, where mathematical and computer scientists provide new, innovative, and effective ways of solving predictable and commonplace data limitations such as missing data; make causal inferences from nonrandomized studies and/or those with selection biases; and estimate effect size when patient outcomes are heterogeneous and surveys have low response rates.
Using Relational Reasoning Strategies to Help Improve Clinical Reasoning Practice
Authors: Dumas Denis , Torre Dario M. , Durning Steven J.
Published: December 2017

Clinical reasoning—the steps up to and including establishing a diagnosis and/or therapy—is a fundamentally important mental process for physicians. Unfortunately, mounting evidence suggests that errors in clinical reasoning lead to substantial problems for medical professionals and patients alike, including suboptimal care, malpractice claims, and rising health care costs. For this reason, cognitive strategies by which clinical reasoning may be improved—and that many expert clinicians are already using—are highly relevant for all medical professionals, educators, and learners.

In this Perspective, the authors introduce one group of cognitive strategies—termed relational reasoning strategies—that have been empirically shown, through limited educational and psychological research, to improve the accuracy of learners’ reasoning both within and outside of the medical disciplines. The authors contend that relational reasoning strategies may help clinicians to be metacognitive about their own clinical reasoning; such strategies may also be particularly well suited for explicitly organizing clinical reasoning instruction for learners. Because the particular curricular efforts that may improve the relational reasoning of medical students are not known at this point, the authors describe the nature of previous research on relational reasoning strategies to encourage the future design, implementation, and evaluation of instructional interventions for relational reasoning within the medical education literature. The authors also call for continued research on using relational reasoning strategies and their role in clinical practice and medical education, with the long-term goal of improving diagnostic accuracy.
The Nicotine Content of a Sample of E-cigarette Liquid Manufactured in the United States
Authors: Raymond Barrett H. , Collette-Merrill Katreena , Harrison Roger G. , Jarvis Sabrina , Rasmussen Ryan Jay
Published: December 2017

Objectives:

Use of electronic cigarettes has dramatically increased in the United States since 2010, with a forecasted growth of 37% between 2014 and 2019. There is little research on e-liquid nicotine concentration from domestic manufacturers. However, limited research outside of the United States found wide inconsistencies between the labeled concentration of nicotine in e-liquids and the actual nicotine concentration.

Methods:

The 7 most popular online manufacturers or distributors were identified. E-liquid samples of the 5 most popular flavors from each manufacturer were purchased in nicotine concentrations of 0 and 18 mg/mL. Of the samples purchased (n = 70), all were labeled as produced in the United States of America. The researchers anonymized the samples before sending them to an independent university laboratory for testing.

Results:

The 35 e-liquid samples labeled 18 mg/mL nicotine measured between 11.6 and 27.4 mg/mL (M = 18.7, SD = 3.3) nicotine. The labeled 18 mg/mL samples measured as little as 35% less nicotine and as much as 52% greater nicotine. In the 35 samples labeled 0 mg/mL, nicotine was detected (>0.01 mg/mL) in 91.4% of the samples (range 0–23.9 mg/mL; M = 2.9, SD = 7.2). Six samples from 2 manufacturers labeled as 0 mg/mL were found to contain nicotine in amounts ranging from 5.7 to 23.9 mg/mL.

Conclusion:

This study demonstrates the nicotine labeling inaccuracies present in current e-liquid solutions produced in the United States. Incorrect labeling poses a significant risk to consumers and supports the recent regulation changes enacted by the US Food and Drug Administration. Additional routine testing of nicotine concentrations should be conducted to evaluate the effectiveness of the regulations on future e-liquid production.
Lumbar Interbody Fusion
Authors: de Kunder Suzanne L. , Rijkers Kim , Caelers Inge J.M.H. , de Bie Rob A. , Koehler Peter J. , van Santbrink Henk
Published: December 2017

In this historical study we present an overview of lumbar interbody fusion surgery, which is one of the most commonly performed instrumented spinal fusion surgeries. The present article focuses on the history of lumbar interbody fusion surgery, starting from the foundation which was laid in the 19th and 20th century until today. The development of material and techniques evolved from simple wiring to the combination of transforaminal interbody fusion with polyether ether ketone cages and pedicle screw fixation with poly axial screws. The possibilities of instrumented spinal fusion grew during the past 100 years, and a considerable increase in instrumented spinal surgery was seen over the past decades. Today, gain lies in perfection of techniques and deliberate indication and development of guidelines. Therefore, more standardized studies on instrumented spinal surgery are needed to be done and techniques should be personalized on the patients’ specific needs.

Level of Evidence: N/A
Causes and Timing of Unplanned 90-day Readmissions Following Spine Surgery
Authors: Hills Jeffrey , Sivaganesan Ahilan , Khan Inamullah , Chotai Silky , Weisenthal Benjamin , Freeman Thomas , Butler Marjorie , Wick Joseph , Daryoush Joshua , Asher Anthony , Devin Clinton J.
Published: December 2017

Study Design.

Retrospective cohort study.

Objective.

The aim of this study was to evaluate the causes, timing, and factors associated with unplanned 90-day readmissions following elective spine surgery.

Summary of Background Data.

Unplanned readmissions after spine surgery are costly and an important determinant of the value of care. Several studies using database information have reported on rates and causes of readmission. However, these often lack the clinical detail and actionable data necessary to guide early postdischarge interventions.

Methods.

Patients undergoing elective spine surgery for degenerative disease at a major medical center were enrolled in a prospective longitudinal registry. Patient and surgery-specific characteristics, baseline, and 3-month patient-reported outcomes were prospectively recorded. Readmissions were reviewed retrospectively to establish the reason and time to readmission. A multivariable Cox proportional hazard model was created to analyze the independent effects of several factors on readmission.

Results.

Of 2761 patients with complete 3-month follow-up, 156 had unplanned 90-day readmissions (5.6%). The most common reason was surgery-related (52%), followed by medical complications (38%) and pain (10%). Pain readmissions presented with a median time of 6 days. Medical readmissions presented at 12 days. Surgical complications presented at various times with wound complications at 6 days, cerebrospinal fluid leaks at 12 days, surgical site infections at 23 days, and surgical failure at 38 days. A history of myocardial infarction, osteoporosis, higher baseline leg and arm pain scores, longer operative duration, and lumbar surgery were associated with readmission.

Conclusion.

Nearly half of all unplanned 90-day readmissions were because of pain and medical complications and occurred with a median time of 6 and 12 days, respectively. The remaining 52% of readmissions were directly related to surgery and occurred at various times depending on the specific reason. This timeline for pain and medical readmissions represents an opportunity for targeted postdischarge interventions to prevent unplanned readmissions following spine surgery.

Level of Evidence: 3
Interactions of Propofol With Human Voltage-gated Kv1.5 Channel Determined by Docking Simulation and Mutagenesis Analyses
Authors: Kojima Akiko , Fukushima Yutaka , Ito Yuki , Ding Wei-Guang , Ueda Rika , Seto Tomoyoshi , Kitagawa Hirotoshi , Matsuura Hiroshi
Published: December 2017

Propofol blocks the voltage-gated human Kv1.5 (hKv1.5) channel by preferentially affecting in its open state. A previous mutational study suggested that several amino acids within the pore region of the hKv1.5 channel are involved in mediating the blocking action of propofol. The present investigation was undertaken to elucidate the predicted binding modes of propofol within the pore cavity of the open-state hKv1.5 channel, using computational docking and mutagenesis approaches. The docking simulation using a homology model of the hKv1.5 channel, constructed based on the crystal structure of the Kv1.2 channel, predicted that propofol was positioned at the base of the pore cavity of hKv1.5 channel, adjacent to 4 amino acids Thr479, Thr480, Val505, and Ile508, and formed arene-H interactions with Val505. The patch-clamp experiments on wild-type and mutant hKv1.5 channels constructed by site-directed mutagenesis revealed that the blocking potency of propofol was significantly reduced in T480A, V505A, and I508A but not in T479A mutants compared with wild-type hKv1.5 channel. These computational docking and experimental mutational analyses suggest that propofol is positioned at the base of the pore cavity and forms functional contact with Thr480, Val505, and Ile508 to directly block the hKv1.5 channel.
EFFICACY AND SAFETY OF INTRAVITREAL AFLIBERCEPT AND RANIBIZUMAB IN ASIAN PATIENTS WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION
Authors: Wong Tien Yin , Cheung Chui Ming Gemmy , Lai Timothy Y. Y. , Chen Shih-Jen , Lee Won Ki , Yoon Young Hee , Iida Tomohiro , Tueckmantel Claudia , Sowade Olaf , Ogura Yuichiro
Published: December 2017

Purpose:

To assess the treatment effect of intravitreal aflibercept and ranibizumab in Asian patients with neovascular age-related macular degeneration.

Methods:

We evaluated data from VIEW 1 and VIEW 2, comparing functional and morphologic outcomes at Week 96 between intravitreal aflibercept 2 mg monthly (2q4) or 2 mg bimonthly after 3 initial monthly doses (2q8) versus ranibizumab 0.5 mg monthly among Asian patients (n = 269) and between Asian and white patients (n = 2044).

Results:

In Asian patients, there were no significant differences between intravitreal aflibercept 2q4 and 2q8 compared with ranibizumab in mean gain in best-corrected visual acuity (10.23 and 8.35 vs. 8.51 letters). Reduction in central retinal thickness was greater for intravitreal aflibercept 2q4 (150.43 μm, P = 0.0075) and 2q8 (148.15 μm, P = 0.0126) than ranibizumab (119.46 μm). The proportion of dry retinas was greater for intravitreal aflibercept 2q4 (65.7%, P < 0.01) than ranibizumab (41.7%). There were no differences in outcomes between Asian and white patients. Serious treatment-emergent ocular adverse events occurred in <8% of treated eyes, evenly distributed across subgroups.

Conclusion:

In Asian patients with neovascular age-related macular degeneration, functional and morphologic outcomes were largely similar between intravitreal aflibercept and ranibizumab groups, and to results seen in white patients.
CHOROIDAL TUMOR BIOPSY
Authors: Finn Avni P. , Materin Miguel A. , Mruthyunjaya Prithvi
Published: December 2017

Purpose:

To review the indications for and the methods of obtaining biopsies in eyes with uveal melanoma. In addition, this review provides recommendations for avoiding biopsy-related complications and discusses the future directions of biopsy techniques for uveal melanoma.

Methods:

This review is based on a presentation by the authors (PM and MM) at the 2017 Duke Advanced Vitreoretinal Surgery Course and an extensive literature review using PubMed.

Results:

Transscleral and transvitreal fine-needle aspiration biopsy, and transvitreal vitrectomy-assisted biopsy techniques are described. The use of 25- and 27-gauge needles and vitreous cutters through a transvitreal approach are most commonly used. Complications are uncommon but may include vitreous hemorrhage, retinal detachment, and rarely, extraocular extension. Proper technique and precautions will minimize the occurrence of these rare complications.

Conclusion:

Biopsy of uveal melanoma either using a needle or vitrectomy-assisted procedures is safe and these techniques continue to improve with new vitreoretinal surgical advances.
THE ROLE OF INTRAOCULAR GAS TAMPONADE IN RHEGMATOGENOUS RETINAL DETACHMENT
Authors: Neffendorf James E. , Gupta Bhaskar , Williamson Tom H.
Published: December 2017

Purpose:

To review the literature regarding intraocular gas tamponade after vitrectomy for rhegmatogenous retinal detachment.

Methods:

The history and evolution of the use of gas is described. The theories explaining gas tamponade are discussed, and efficacy and safety studies in human and animal models are covered.

Results:

A total of 61 articles relating to gas tamponade were cited in this review.

Conclusion:

Gas tamponade is a frequently used procedure in vitreoretinal surgery. An understanding of its mechanism of action is crucial for its safe use when determining which gas is to be used and at what concentration.
Long-Term Topical Diquafosol Tetrasodium Treatment of Dry Eye Disease Caused by Chronic Graft-Versus-Host Disease: A Retrospective Study
Authors: Yamane Mio , Ogawa Yoko , Fukui Masaki , Kamoi Mizuka , Uchino Miki , Saijo-Ban Yumiko , Kozuki Naoyuki , Mukai Shin , Mori Takehiko , Okamoto Shinichiro , Tsubota Kazuo
Published: December 2017

Objectives:

The aim of this study was to assess the safety and efficacy of long-term use of 3% diquafosol ophthalmic solution (DQS), an eye drop for mucin production and water secretion, for treating dry eye disease (DED) caused by chronic graft-versus-host disease (cGVHD).

Methods:

We retrospectively evaluated the safety and efficacy of DQS in 10 patients with mild to moderate cGVHD-induced DED. The efficacy was assessed by (1) degree of symptoms, (2) Schirmer I test value, (3) tear film breakup time (TFBUT), and (4) fluorescein and rose bengal scores.

Results:

The median duration of DQS treatment was 12.0 months (range 6–17 months). DQS was effective for relieving severe pain caused by cGVHD-related DED. Although the Schirmer I test value was enhanced only marginally, the long-term application of DQS significantly improved the corneal/conjunctival epitheliopathy and tear film stability: the fluorescein score improved from 5.9±0.6 to 1.3±1.1 points (P=1.771×10−5); rose bengal staining from 4.7±1.6 to 2.0±1.5 points (P=0.008); and TFBUT from 2.6±0.9 to 4.6±1.6 mm (P=0.009). Furthermore, the long-term DQS treatment caused no major adverse events.

Conclusions:

This study suggested that long-term DQS treatment is a safe and robust approach for alleviating cGVHD-related DED.
Secure Provider-to-Provider Communication With Electronic Health Record Messaging: An Educational Outreach Study
Authors: Walsh Kathleen E. , Secor Jessica L. , Matsumura Jon S. , Schwarze Margaret L. , Potter Beth E. , Newcomer Peter , Kim Michael K. , Bartels Christie M.
Published: December 2017

Introduction:

With increasing electronic health record (EHR) use, providers are talking less with one another. Now, many rely on EHRs, informal emails, or texts, introducing fragmentation and new data security challenges with new communication strategies. We aimed to examine the impact of a physician champion educational outreach intervention to promote electronic provider-to-provider communication in a large academic multispecialty group.

Methods:

Physician champions provided educational outreach to 16 academic departments, using 10-minute case-based presentations. Online surveys assessed communication preferences and practices. Electronic health record queries counted EHR messaging use before and after intervention. Descriptive statistics compared responses by specialty (z-test). Paired responses with pre–post data were compared using chi-square tests. Time series analysis assessed EHR messaging rates before intervention versus after intervention.

Results:

Five hundred seventeen providers responded to the postoutreach survey. Eighty-six percent were familiar with EHR messaging tool and 78% knew how to use it after intervention. Among practitioner groups, Family Medicine preferred EHR messaging the most (62%). Groups who declined outreach least preferred it (26%). Among 88 respondents with paired pre–post intervention surveys, familiarity rose (79–96%), and self-reported use increased (66–88%).

Conclusions:

Physician champion educational outreach increased the use of the secure provider-to-provider EHR messaging tool.
Breast Cancer: Does Type of Hospital Where You Get Surgery Affect Survival?
Authors: Lin Jenny J. , Egorova Natalia , Franco Rebeca , Bickell Nina A.
Published: December 2017

Under the Affordable Care Act (ACA), more women are insured with Medicaid, which should improve healthcare access. We sought to determine whether there are survival differences among patients with breast cancer undergoing surgery at facilities with varying proportions of Medicaid patients. We used New York State (NYS) Vital Statistics death records data linked with NYS discharge inpatient and ambulatory surgery databases to examine 90-day survival after surgery from 2008 to 2013. We used all Medicaid discharges to calculate and create quintiles of facilities based on Medicaid volume. We calculated survival hazard ratios using a marginal Cox model controlling for clustering of patients within hospitals, age, race, insurance, year of surgery, and comorbidities. Women who received surgery in facilities with the highest quintile of Medicaid volume had higher 90-day mortality (2.1% vs. 0.07%, p < .001) compared with those treated in facilities with lowest Medicaid volume, even after adjusting for multiple confounders. Consequently, although the ACA may improve access, healthcare quality remains questionable because patients treated at facilities with high proportions of Medicaid volume appear to have worse 90-day survival, likely due to quality of surgical and postsurgical care. Policymakers must ensure that quality of care is not negatively impacted by programs to reduce costs.
Efficacy and Safety of Flexible Endoscopic Management of Zenker’s Diverticulum
Authors: Jain Deepanshu , Sharma Abhinav , Shah Manan , Patel Upen , Thosani Nirav , Singhal Shashideep
Published: December 2017

Zenker’s diverticulum (ZD), a pulsion diverticulum of hypopharynx is a rare but treatable cause of morbidity in geriatric population. Traditionally a surgical disease but due to its associated high morbidity, flexible endoscopy has become a lucrative option. We reviewed 997 patients from 23 original studies who underwent flexible endoscopic diverticulotomy (FED) of ZD. Composite technical and clinical success rate for the study cohort was 99.4% and 87.9%, respectively. Composite failure rate was 10.0% but close to half of them (45.3%) had success with repeat endoscopic intervention. Composite rate for symptom recurrence after long-term follow-up was 13.6% but more than half (61.8%) had success with repeat endoscopic intervention. Bleeding (6.6%) and perforation (5.3%) were 2 most common complications of FED. All bleeding events were successfully managed with observation or endoscopic therapy. Majority of perforation events (4.4%) were successfully managed with conservative care and only 0.9% required invasive management. No mortality was reported. Efficacy and safety of FED of ZD remained same irrespective of diverticulum size or prior surgical/endoscopic treatment. FED with diverticuloscope (FEDD) and FED with cap (FEDC) had comparable technical success rate (99.6% vs. 100.0%) but FEDD had higher clinical success rate compared with FEDC (86.8% vs. 75.4%). FEDD had twice the risk of symptom recurrence than FEDC (16.5% vs. 9.5%). FEDD had a comparable bleeding risk to FEDC (3.3% vs. 4.0%) but a much lower perforation rate (2.3% vs. 10.3%). Upper esophageal sphincterotomy and adequate length of septotomy are the cornerstones of FED. FED can be considered a safe and efficacious treatment modality for patients with ZD.
Effects of liver cirrhosis and patient condition on clinical outcomes in intrahepatic cholangiocarcinoma: a retrospective analysis of 156 cases in a single center
Authors: Jesper Daniel , Heyn Sabrina G. , Schellhaas Barbara , Pfeifer Lukas , Goertz Ruediger S. , Zopf Steffen , Neurath Markus F. , Strobel Deike
Published: December 2017

Objective

The incidence of intrahepatic cholangiocarcinoma (iCCA) has been increasing over the past few decades. Liver cirrhosis is an independent risk factor for the development of iCCA. This study aimed to examine the prognostic impact of liver cirrhosis and patient condition on the treatment of iCCA.

Patients and methods

We retrospectively analyzed the cases of 156 patients diagnosed with iCCA between 1990 and 2014 in our center. Patients were divided into subgroups depending on the presence and severity of liver cirrhosis and the type of treatment. Clinical data, patient characteristics, and overall survival were compared between these groups.

Results

Forty-seven (30%) of 156 patients had liver cirrhosis, predominantly with Child–Pugh scores A (n=27) and B (n=12). The median survival differed between patients receiving tumor resection (34 months), chemotherapy (10 months), and best supportive care (2 months). An Eastern Cooperative Oncology Group Performance Status score more than 1 was a predictor of poor survival in all patients (P<0.001), independent of the presence of cirrhosis. Resection could be performed less frequently in cirrhotic patients (6 vs. 31 patients; P=0.04). If resection was performed, the presence of cirrhosis A/B did not influence survival. Cirrhosis A/B did not influence the outcome in patients receiving chemotherapy either. In cirrhotic patients receiving chemotherapy, cancer antigen 19-9 levels above 129 U/ml were associated with a significantly shorter survival (22.5 vs. 3 months, P=0.0003).

Conclusion

The presence of liver cirrhosis in iCCA has been underestimated. There was no difference in survival between noncirrhotic patients and patients with compensated cirrhosis. Patients’ general condition seems to be of more prognostic value in the treatment of iCCA than the presence of cirrhosis. Therefore, the presence of cirrhosis A/B should not prevent patients with a good Eastern Cooperative Oncology Group Performance Status score from receiving tumor resection or chemotherapy.
Liver transplantation for hepatocellular carcinoma within the Milan criteria versus the University of California San Francisco criteria: a comparative study
Authors: Abdelfattah Mohamed R. , Elsiesy Hussien , Al-Manea Hadeel , Broering Dieter C.
Published: December 2017

Background

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide. Currently, liver transplantation (LT) for HCC is the only hope for cure from the tumor and from end-stage liver disease (ESLD). The organ pool shortage in deceased donor LT and the donor-related ethical concerns in living-donor LT necessitate the use of rigorous criteria for LT for HCC. In this respect, two main criteria for LT for HCC were implemented with good outcome, namely, the Milan and the University of California San Francisco criteria. Comparison of the outcome of LT for HCC using either of the two criteria has seldom been reported in the literature.

Patients and methods

Eighty-eight patients underwent LT between August 2003 and end of July 2013 for the presence of pathologically proven pure HCC lesions at our institution. Cases of pediatric LT or liver retransplantation were excluded from this study. Cases with mixed HCC and cholangiocarcinoma were excluded from this study.

Results

Eighty-eight patients underwent LT between August 2003 and July 2013 for the presence of pathologically proven pure HCC lesions at our institution. The mean follow-up duration was 45±30.9 months. HCC recurrence was related significantly to the presence of vascular invasion and degree of differentiation of HCC lesion (P value of 0.0001 and 0.001, respectively).

Conclusion

Patient and tumor free survival did not differ significantly between patients within Milan or University of California San Francisco criteria or beyond both criteria. Vascular invasion and poor differentiation are still the most influential factors for post-transplant long-term outcomes in HCC patients.
Dietary Nitrate and Nitrite Concentrations in Food Patterns and Dietary Supplements
Authors: Keller Rosa M. , Beaver Laura , Prater M. Catherine , Hord Norman G.
Published: December 2017

Inorganic nitrate and nitrite are plant nutrients, legally mandated additives to processed meats, and components of foods and dietary supplements associated with blood pressure–lowering and performance-enhancing effects. Controversy around dietary nitrate and nitrite consumption exists because of the potential for increased risk of certain cancers in adults and methemoglobinemia (ie, blue baby syndrome) in infants. However, more recent evidence suggests that dietary nitrate, as an exogenous source for endogenous nitric oxide production via the human nitrate–nitrite–nitric oxide pathway, exerts blood pressure–lowering effects and athletic performance–enhancing activities in humans. Nitrate and nitrite content in foods is lacking from nutrient databases, which limits the ability to study health-related epidemiological associations. Therefore, we estimated human nitrate and nitrite intakes from cultural meal patterns, foods, and dietary supplements in order to determine the potential exposure range from available foods. Examination of prototypical daily meal patterns from 4 cultures showed that meal patterns with the greatest nitrate and nitrite concentrations were those with an abundant amount of leafy greens and root vegetables, such as the Japanese and Chinese diet, whereas concentrations in the American and Indian diet were considerably lower. Furthermore, consumption of 1 serving of a nitrate-rich food or supplement can exceed the World Health Organization acceptable daily intake for nitrate (0-3.7 mg/kg body weight per day or 222 mg/d for a 60-kg adult). Given the potential health benefits and risks for dietary nitrate and nitrite intakes, there is a need for rational dietary guidance regarding nitrate- and nitrite-containing foods in order to achieve optimal cardiovascular health and athletic performance, while taking into account the potential negative health risks.
Bivariate Genome-Wide Association Study of Depressive Symptoms With Type 2 Diabetes and Quantitative Glycemic Traits
Authors: Haljas Kadri , Amare Azmeraw T. , Alizadeh Behrooz Z. , Hsu Yi-Hsiang , Mosley Thomas , Newman Anne , Murabito Joanne , Tiemeier Henning , Tanaka Toshiko , van Duijn Cornelia , Ding Jingzhong , Llewellyn David J. , Bennett David A. , Terracciano Antonio , Launer Lenore , Ladwig Karl-Heinz , Cornelis Marylin C. , Teumer Alexander , Grabe Hans , Kardia Sharon L.R. , Ware Erin B. , Smith Jennifer A. , Snieder Harold , Eriksson Johan G. , Groop Leif , Räikkönen Katri , Lahti Jari
Published: December 2017

Objective

Shared genetic background may explain phenotypic associations between depression and Type 2 diabetes (T2D). We aimed to study, on a genome-wide level, if genetic correlation and pleiotropic loci exist between depressive symptoms and T2D or glycemic traits.

Methods

We estimated single-nucleotide polymorphism (SNP)–based heritability and analyzed genetic correlation between depressive symptoms and T2D and glycemic traits with the linkage disequilibrium score regression by combining summary statistics of previously conducted meta-analyses for depressive symptoms by CHARGE consortium (N = 51,258), T2D by DIAGRAM consortium (N = 34,840 patients and 114,981 controls), fasting glucose, fasting insulin, and homeostatic model assessment of β-cell function and insulin resistance by MAGIC consortium (N = 58,074). Finally, we investigated pleiotropic loci using a bivariate genome-wide association study approach with summary statistics from genome-wide association study meta-analyses and reported loci with genome-wide significant bivariate association p value (p < 5 × 10−8). Biological annotation and function of significant pleiotropic SNPs were assessed in several databases.

Results

The SNP-based heritability ranged from 0.04 to 0.10 in each individual trait. In the linkage disequilibrium score regression analyses, depressive symptoms showed no significant genetic correlation with T2D or glycemic traits (p > 0.37). However, we identified pleiotropic genetic variations for depressive symptoms and T2D (in the IGF2BP2, CDKAL1, CDKN2B-AS, and PLEKHA1 genes), and fasting glucose (in the MADD, CDKN2B-AS, PEX16, and MTNR1B genes).

Conclusions

We found no significant overall genetic correlations between depressive symptoms, T2D, or glycemic traits suggesting major differences in underlying biology of these traits. However, several potential pleiotropic loci were identified between depressive symptoms, T2D, and fasting glucose, suggesting that previously established phenotypic associations may be partly explained by genetic variation in these specific loci.
Ultrasound-Guided Peripheral Intravenous Catheters to Reduce Central Venous Catheter Use on the Inpatient Medical Ward
Authors: Galen Benjamin T. , Southern William N.
Published: December 2017

Purpose:

The traditional technique of placing a peripheral intravenous (IV) catheter is successful in most cases on inpatient wards. However, when the traditional method fails, a central venous catheter may be placed to maintain IV access. These catheters are associated with risks including central line–associated bloodstream infection.

Methods:

We evaluated the effectiveness and acceptability of an ultrasound-guided peripheral IV service to reduce the number of newly placed central venous catheters on an inpatient ward. Central venous catheters were counted daily on intervention and control wards using a standard protocol, and rates of newly placed catheters were compared using a Poisson regression model. Nurses were surveyed to assess acceptability and perceived benefit.

Results:

We found a reduction in the rate of newly placed central venous catheters on the intervention unit compared with the control unit at 90 days: mean 0.47 versus 0.67 newly placed central venous catheters/day, but the difference was not significant (P = .08). Nurses were in favor of the ultrasound-guided IV service, with perceived benefit to their patients.

Conclusion:

Ultrasound-guided peripheral IV might reduce unnecessary central venous catheters on general inpatient wards. A portable ultrasound used for this purpose was found to be acceptable by nursing staff.
Measuring Organizational Capacity to Accelerate Health Care Innovation in Academic Health Centers
Authors: Lombardi Marilyn M. , Spratling Regena G. , Pan Wei , Shapiro Susan E.
Published: December 2017

In an era of rising clinical costs and shrinking federal research dollars, the survival of the academic health center may depend on its capacity to cultivate high-impact innovations in care delivery on an accelerated basis. Yet, the health sciences literature offers little guidance regarding the key organizational determinants most likely to facilitate such innovation. We report on the conceptualization, development, and preliminary testing of a new 21-item Accelerated Healthcare Innovation Capacity scale for addressing that knowledge gap. Instrument development followed a standardized process, including expert panel testing of the new scale's content relevance validity. A sample (N = 53) of academic health center administrators, clinicians, and faculty affiliated with a single organization volunteered to complete the Accelerated Healthcare Innovation Capacity scale in survey form. Data were analyzed to evaluate scale reliability, internal consistency, and construct validity. High-expert agreement (overall S-CVI of 0.91) was obtained on content relevance validity. Cronbach α for the scale was 0.941. Exploratory factor analysis confirmed the theoretical soundness of the scale's conceptual framework, which showed high-impact health care innovation support to be a complex, multidimensional concept involving key facilitating factors across 3 major constructs—that is, Culture, Structure, and Policy—with implications for future research and managerial practice, particularly for staff development educators engaged in evaluating quality management and organizational change strategies.
Expanding the Presence of Primary Services at Rapid Response Team Activations: A Quality Improvement Project
Authors: Gallo de Moraes Alice , O'Horo John C. , Sevilla-Berrios Ronaldo A. , Iacovella Gina , Lenhertz Andrea , Schmidt Julie , Elmer Jennifer , Oeckler Richard , Caples Sean , Jensen Jeffrey B.
Published: December 2017

Rapid response teams (RRTs) were implemented to provide critical care services for deteriorating patients outside of intensive care units. To date, research on RRT has been conflicting, with some studies showing significant mortality benefit and reduction in cardiac arrest events and others showing no benefit. However, studies have consistently showed improved outcomes when RRTs work closely with primary services. Baseline data analysis at our institution found that primary services were present only on 50% of RRT activations. This quality improvement project aimed to improve the presence of primary services during RRT activations by 25%. With a survey, the main barrier that prevented primary services to be present was identified as the primary services' failure to recognize them as a crucial part of the RRT. Education tools and in-person sessions were implemented reinforcing the importance of primary services presence during RRT activations. The intervention leads to increasing presence of primary services at RRT activations, transfers to higher level of care, and changes in code status. However, there was no difference in hospital or intensive care unit length of stay or in survival.
Use of Scribes for Documentation Assistance in Rheumatology and Endocrinology Clinics
Authors: Danila Maria I. , Melnick Joshua A. , Curtis Jeffrey R. , Menachemi Nir , Saag Kenneth G.
Published: December 2017

Background/Objective

The aim of this study was to examine the impact of utilizing medical scribes on clinic workflow, physician professional satisfaction, and patient satisfaction in rheumatology and endocrinology clinics.

Methods

We conducted a within-practice pilot study of medical scribes that included a 6-week intervention phase (documentation assistance by medical scribes) followed by a control phase (usual documentation with no assistance) in outpatient rheumatology and endocrinology clinics at an academic medical center. We evaluated the following outcomes: physician professional satisfaction (range, 5–25, with higher values denoting higher satisfaction), autonomy (range, 4–16, with higher values denoting higher autonomy), perception of clinic workflow (range, 1 = calm, 5 = chaotic), and patient satisfaction (5-point Likert item, anchors: strongly agree, strongly disagree).

Results

Six physicians, including 3 rheumatologists and 3 endocrinologists, and 496 patients nested within their practices participated. The use of a medical scribe was not associated with physician professional satisfaction (18.17 [SD, 2.9] vs. 17.83 [SD, 1.94], not statistically significant), perception of clinic workflow (2.50 [SD, 0.84] vs. 3.17 [SD, 0.75], not statistically significant), or autonomy (8.67 [SD, 3.44] vs. 8.83 [SD, 3.06], not statistically significant). Physicians had an overall favorable view of the medical scribes program and perceived that documentation support provided by scribes was useful and easy to use and had a positive impact on their clinic workflow. Patient satisfaction was high during the intervention phase (99.4% strongly agree/agree) but not significantly different than in the control phase.

Conclusions

Rheumatologists, endocrinologists, and their patients had consistently positive views regarding the use of a medical scribe without an observed negative effect on clinic workflow in outpatient clinics.
Contemporary Utilization of Resuscitative Thoracotomy: Results From the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Multicenter Registry
Authors: DuBose Joseph , Fabian Timothy , Bee Tiffany , Moore Laura J. , Holcomb John B. , Brenner Megan , Skarupa David , Inaba Kenji , Rasmussen Todd E. , Turay David , Scalea Thomas M.
Published: December 2017

Introduction:

Several reviews of resuscitative thoracotomy (RT) use over the last five decades have been conducted, most recently the evidence-based practice management guideline (PMG) of the Eastern Association for the Surgery of Trauma (EAST). The present study was designed to examine contemporary RT utilization and outcomes compared with historical data (n = 10,238) from the EAST PMG review from published series 1974 to 2013.

Methods:

The American Association for the Surgery of Trauma Aortic Occlusion for Trauma and Acute Care Surgery (AORTA) registry was utilized to identify patients undergoing RT in the emergency department (ED) from November 2013 to December 2016. Demographics, injury data, physiologic presentation, and outcomes were reviewed and compared with those of the EAST PMG review.

Results:

Three-hundred ten RT patients from 16 contributing AORTA centers were identified. The majority were injured by penetrating mechanisms (197/310, 64% [gunshot (163/197, 83%)]). Signs of life (SOL) (organized electrical activity, pupillary response, spontaneous movement, or appreciable pulse/blood pressure) were present on arrival in 47% (147/310). When compared with the EAST PMG results, there was no difference in either hospital survival (5% vs. 8%) or neurologically intact survival between historical controls or AORTA registry patients in any category combination of mechanism/anatomic location/presenting signs of life. Blunt injuries W/O SOL on admission continue to constitute 14% (45/310) of RTs in the ED, without documented survivors.

Conclusion:

Comparison of historical RT controls to more contemporary patients from the AORTA registry suggests that practices and outcomes following RT have not changed. Despite a wealth of accumulated data over several decades, RT continues to be performed for patients after blunt mechanisms of injury who present W/O SOL despite lack of demonstrated hope for survival benefit.
Are Informal Caregivers of Persons With Dementia Open to Extending Medical Aid in Dying to Incompetent Patients? Findings From a Survey Conducted in Quebec, Canada
Authors: Bravo Gina , Rodrigue Claudie , Arcand Marcel , Downie Jocelyn , Dubois Marie-France , Kaasalainen Sharon , Hertogh Cees M. , Pautex Sophie , Van den Block Lieve
Published: December 2017

Euthanasia is a controversial and complex issue, especially when involving incompetent patients. On December 10, 2015, Quebec became the first Canadian province to give access to medical aid in dying (MAiD) (ie, euthanasia performed by a physician) to competent patients who satisfy strictly defined criteria. Less than 2 years later, Quebec is considering extending MAiD to incompetent patients who made an advance request. With the objective of contributing scientific data to current societal debates, we conducted a survey among 471 informal caregivers of persons with dementia, reached through Alzheimer Societies. We used a series of vignettes featuring a person with Alzheimer disease to investigate respondents’ attitudes towards MAiD. The response rate was 69%. Two-thirds [68%; 95% confidence interval, 63%-73%] found it acceptable to extend MAiD to an incompetent patient at an advanced stage of Alzheimer disease who had made a written request while competent, and 91% (95% confidence interval, 87%-94%) found it acceptable at the terminal stage. Self-determination was the most widely endorsed argument in favor of access to MAiD for incompetent patients. Findings suggest strong support among informal caregivers for extending MAiD to incompetent patients, provided they are terminally-ill and had made a written request before losing capacity.
Optic Nerve Avulsion After Finger-Poke Injury
Authors: Patel Tapan P. , Archer Erica L. , Trobe Jonathan D.
Published: December 2017

We present a case of optic nerve avulsion as a result of finger-poke injury to the eye. Spectral domain optical coherence tomography demonstrated a plunging cup indicative of the avulsion, a finding not previously described. Optic nerve avulsion is a form of anterior indirect traumatic optic neuropathy evoked by a sudden severe rotation at the junction of the optic nerve and globe induced, in this case, by penetration of the finger into the nasal orbit.