bluuebunny/crossref_metadata_2025 huggingface dataset:
Temporal trends in referral patterns for invasive coronary angiography – a multicenter 10-year analysis
Authors: Gonçalves Mariana , Roque David , de Araújo Gonçalves Pedro , Borges Santos Miguel , Faustino Mariana , Campante Teles Rui , Farto e Abreu Pedro , de Sousa Almeida Manuel , Ferreira António Miguel
Published: August 2020

Aim

To assess the temporal trends in the usage pattern of non-invasive testing before invasive coronary angiography (ICA) and its diagnostic yield in patients with suspected coronary artery disease (CAD).

Methods

Cross-sectional observational multicenter study of 4805 consecutive patients (60% male, mean age 66 ± 10 years) with suspected CAD undergoing elective ICA due to angina pectoris in two centers, from 2008 to 2017. The use of noninvasive testing and the proportion of patients with obstructive CAD (defined as the presence of at least one ≥50% stenosis on ICA) were assessed.

Results

There were 4038 (84%) patients referred for ICA with positive noninvasive test, mainly SPECT (38%, n = 1828) and exercise ECG (36%, n = 1731). Obstructive CAD was found in 54.5% (n = 2621) of the patients and 37.9% (n = 1822) underwent revascularization. The prevalence of obstructive CAD was higher in patients with vs. without previous noninvasive testing (55.8% vs. 48.1%, respectively, P < 0.001) and tended to decrease during the study period (P for trend <0.001). Both the presence of obstructive CAD and revascularization rate were higher in patients who underwent anatomical evaluation with CCTA compared with noninvasive functional tests (P = 0.001 and P = 0.018, respectively). The number of patients referred after exercise testing and SPECT decreased (p for trend 0.005 and 0.006, respectively) and after CCTA and stress CMR increased (both P for trend <0.001). The proportion of patients referred without previous testing remained stable.

Conclusion

Nearly half of the patients undergoing ICA for suspected CAD did not have obstructive coronary lesions. This proportion tended to increase over the 10-year span of this study. Better clinical assessment tools and diagnostic pathways for stable CAD are warranted.
Benefits of early administration of Sacubitril/Valsartan in patients with ST-elevation myocardial infarction after primary percutaneous coronary intervention
Authors: Zhang Yi , Wu Yongbo , Zhang Kai , Ke Zili , Hu Peng , Jin Daoqun
Published: August 2020

Objective

To evaluate the effects of early administration of Sacubitril/Valsartan (Sac/Val) in patients with ST-elevation myocardial infarction after primary percutaneous coronary intervention (pPCI).

Methods

This prospective, controlled, single-center study randomized 186 ST-segment elevation myocardial infarction patients to one of the following two groups: Sac/Val group: early administration of Sac/Val within 24 hours after pPCI; control group: conventional angiotensin-converting enzyme inhibitors (ACEI) application. The creatine Kinase (CK) peak after the surgery, the incidence of acute heart failure during hospitalization, level of NT-proBNP and left ventricular ejection fraction (LVEF) measured by ultrasound before discharge and soluble suppression of tumorigenicity2 (sST2), LVEF, infarct size determined by single photon emission computed tomography (SPECT), readmission rate within 6 months were recorded and compared between two groups.

Results

Compared to the control group, Sac/Val could decrease the CK peak and the incidence of acute heart failure after pPCI; the level of NT-proBNP was lower and LVEF was higher before discharge in the Sac/Val group. After 6 months, the patients who had taken Sac/Val had a higher LVEF, a smaller infarct size determined by SPECT, lower sST2 and readmission rate.

Conclusion

Patients with ST-elevation myocardial infarction after primary percutaneous coronary intervention could benefit from early administration of Sacubitril/Valsartan, the effect was superior to conventional ACEI.
Culprit lesion morphology in patients with ST-segment elevation myocardial infarction assessed by optical coherence tomography
Authors: Hansen Kirstine Nørregaard , Antonsen Lisbeth , Maehara Akiko , Maeng Michael , Ellert Julia , Jakobsen Lars , Ahlehoff Ole , Thim Troels , Veien Karsten , Junker Anders , Fallesen Christian , Terkelsen Christian Juhl , Christiansen Evald Høj , Jensen Lisette Okkels
Published: August 2020

Aims

This study sought to evaluate the incidence of ruptured plaques and nonruptured plaques (NRP) and to compare patient characteristics and detailed plaque morphology features between the two culprit types in ST-segment elevation myocardial infarction (STEMI) patients, using optical coherence tomography (OCT).

Methods and results

Using OCT, the culprit lesions in patients with STEMI were assessed prior to stent implantation. The culprit lesion was categorized as ruptured plaques or NRP, and the plaque components were evaluated. Fifty-two patients (69.3%) presented with ruptured plaques and 23 (30.7%) with NRP. Patients with NRP were younger (58.0 ± 10.4 vs 64.7 ± 9.9 years, P = 0.01) and more often smokers (72.7% vs 37.1%, P = 0.001), compared to ruptured plaques. NRP contained significantly more fibrotic plaque (20.0% [interquartile range (IQR) 13.7–29.8] vs 11.3% [IQR 6.9–18.1], P = 0.005), but less lipidic plaque (44.0% ± 13.7 vs 59.3% ± 13.6, P < 0.001), less superficial [5.0% (IQR 2.8–7.5) vs 8.1% (IQR 5.7–11.0), P = 0.005] and profound macrophages [0.9% (IQR 0.0–1.7) vs 2.2% (IQR 0.9–4.7), P = 0.003]. The prevalence, numbers and lengths of thin-cap fibroatheroma (TCFA) were significantly lower in NRP, compared to ruptured plaques [47.8% vs 88.5%, 0 (IQR 0–1) vs 1 (IQR 1–2) and 0 mm (IQR 0–2.7) vs 4.5 mm (IQR 2.3–7.7), P < 0.001].

Conclusions

One-third of STEMI patients had culprit lesions without an OCT-detectable ruptured plaque. Culprit lesions with NRP contained less vulnerable plaque components, such as lipid plaque, TCFAs and macrophages compared to ruptured plaques.
Dietary protein intake and obesity-associated cardiometabolic function
Authors: Fappi Alan , Mittendorfer Bettina
Published: August 2020

Purpose of review

High-protein intake is commonly recommended to help people manage body weight. However, high-protein intake could have adverse health consequences. Here we review the latest findings concerning the effect of high-protein intake on cardiometabolic health.

Recent findings

Calorie-reduced, high-protein, low-carbohydrate diets lower plasma glucose in people with type 2 diabetes (T2D). However, when carbohydrate intake is not markedly reduced, high-protein intake often does not alter plasma glucose and increases insulin and glucagon concentrations, which are risk factors for T2D and ischemic heart disease. High-protein intake does not alter plasma triglyceride and cholesterol concentrations but promotes atherogenesis in animal models. The effect of high-protein intake on liver fat remains unclear. In population studies, high-protein intake is associated with increased risk for T2D, nonalcoholic fatty liver disease, and possibly cardiovascular diseases.

The relationship between protein intake and cardiometabolic health is complex and influenced by concomitant changes in body weight and overall diet composition. Although a high-protein, low-carbohydrate, reduced-energy diet can have beneficial effects on body weight and plasma glucose, habitual high-protein intake, without marked carbohydrate and energy restriction, is associated with increased cardiometabolic disease risk, presumably mediated by the changes in the hormonal milieu after high-protein intake.
Current mechanisms in obesity and tumor progression
Authors: Fosam Andin , Perry Rachel J.
Published: August 2020

Purpose of review

Hyperadiposity, as present in obesity, is a substantial threat to cancer risk and prognosis. Studies that have investigated the link between obesity and tumor progression have proposed several mechanistic frameworks, yet, these mechanisms are not fully defined. Further, a comprehensive understanding of how these various mechanisms may interact to create a dynamic disease state is lacking in the current literature.

Recent findings

Recent work has begun to explore not only discrete mechanisms by which obesity may promote tumor growth (for instance, metabolic and growth factor functions of insulin; inflammatory cytokines; adipokines; and others), but also how these putative tumor-promoting factors may interact.

This review will highlight the present understanding of obesity, as it relates to tumor development and progression. First, we will introduce the impact of obesity in cancer within the dynamic tumor microenvironment, which will serve as a theme to frame this review. The core of this review will discuss recently proposed mechanisms that implicate obesity in tumor progression, including chronic inflammation and the role of pro-inflammatory cytokines, adipokines, hormones, and genetic approaches. Furthermore, we intend to offer current insight in targeting adipose tissue during the development of cancer prevention and treatment strategies.
Objectively assessed disease activity and drug persistence during ustekinumab treatment in a nationwide real-world Crohn’s disease cohort
Authors: af Björkesten Clas-Göran , Ilus Tuire , Hallinen Taru , Soini Erkki , Eberl Anja , Hakala Kalle , Heikura Mikko , Jussila Airi , Koskela Ritva , Koskinen Inka , Moilanen Veikko , Nielsen Christian , Nieminen Urpo , Nuutinen Heikki , Heikkinen Markku , Suhonen Ulla-Maija , Tillonen Jyrki , Utriainen Karri , Vihriälä Ilkka , Wennerström Christina , Borsi Andras , Nissinen Riikka , Koivunen Minni R. , Sipponen Taina
Published: August 2020

Objective

Long-term evidence on ustekinumab treatment response and persistence in patients with Crohn’s disease in a real-world setting is scarce. We performed a retrospective nationwide chart review study of long-term clinical outcomes in Crohn’s disease patients treated with ustekinumab.

Methods

The study was conducted in 17 Finnish hospitals and included adult Crohn’s disease patients who received an initial intravenous dose of ustekinumab during 2017–2018. Disease activity data were collected at baseline, 16 weeks, and 1 year from health records.

Results

The study included 155 patients. The disease was stricturing or penetrating in 69 and 59% had prior Crohn’s disease-related surgeries, and 97% had a treatment history of at least one biologic agent. Of 93 patients with ≥1 year of follow-up, 77 (83%) were still on ustekinumab at 1 year. In patients with data available, from baseline to the 1-year follow-up the simple endoscopic score for Crohn’s disease (SES-CD) decreased from 10 to 3 (P = 0.033), C-reactive protein from 7  to 5 mg/L, (P < 0.001) and faecal calprotectin from 776 to 305 μg/g (P < 0.001).

Conclusions

Ustekinumab treatment in patients with highly refractory Crohn’s disease resulted in high long-term treatment persistence and significantly reduced disease activity, assessed with objective markers for intestinal inflammatory activity.
Predictive markers of nonalcoholic fatty liver disease in lean patients. A multinomial regression model and a 2k factorial analysis
Authors: Purón-González Emma , González-Cantú Arnulfo , Coronado-Alejandro Edgar Ulises , Sánchez-Dávila Oswaldo Enrique , Cobos-Aguilar Héctor , Romero-Ibarguengoitia Maria Elena
Published: August 2020

Objective

Nonalcoholic fatty liver disease (NAFLD) is associated with obesity and insulin resistance; however, there is a group of non-obese patients with NAFLD that need to be characterized. Our aim was to evaluate the factors associated with NAFLD in non-obese subjects in a third-level hospital.

Methods

A comparative cross-sectional study was performed. Participants were divided into four groups: non-obese without NAFLD (group 1), non-obese with NAFLD (group 2), obese without NAFLD (group 3), and obese with NAFLD (group 4). We evaluated the effect of clinical and biochemical characteristics with the disease by groups using a multinomial regression model and a 2K factorial analysis.

Results

We included 278 participants. Low platelet–lymphocyte ratio (PLR) as a novel parameter associated with NAFLD in non-obese subjects. Age, uric acid, alanine transaminase (ALT), high-density lipoprotein (HDL)-cholesterol, and neutrophil–lymphocyte ratio (NLR) were other related parameters (akaike information criterion = 557). NLR had the larger OR in groups with NAFLD (lean with NAFLD 7.12, obese with NAFLD 13.02). The 2k factorial design found inverse effect on PLR by NAFLD (effect –21.89, P < 0.001), which was higher than BMI (effect –1.33, P < 0.045).

Conclusion

Our study found that PLR is a novel parameter with inverse correlation with NAFLD in non-obese patients. Other related parameters are age, hyperuricemia, elevation of ALT and NLR, and low HDL-cholesterol.
Proton-pump-inhibitor use associated with lower short-term rebleeding and mortality in patients receiving esophageal variceal band ligation: a retrospective cohort study
Authors: Ghoz Hassan , Patel Payal , Stancampiano Fernando , Patel Sheetal , Fox Erin A. , Yousaf Mohammad B. , Omer Mohamed , Heckman Michael G. , Spiegel Matthew R. , Palmer William C.
Published: August 2020

Background

The impact of proton-pump inhibitor (PPI) therapy on subsequent hemorrhage and mortality after variceal hemorrhage is unclear.

Aim

Evaluate the associations of PPI use with upper gastrointestinal bleeding (UGIB) and death within 30 days of undergoing esophageal variceal band ligation (EBL) separately in inpatient and outpatient settings.

Methods

Retrospective review of cirrhotic patients with variceal hemorrhage who underwent EBL between 2005 and 2018. Endoscopic findings, PPI use at admission (inpatients only), PPI use at discharge (inpatients and outpatients), and adverse outcomes data (liver transplant, UGIB, transjugular intrahepatic portosystemic shunt, and death within 30 days of discharge or death during hospitalization) were reviewed.

Results

A total of 446 patients (164 inpatients, 282 outpatients) were included. The most commonly observed outcomes were death within 30 days of discharge in inpatients (12.8%), UGIB within 30 days of discharge in inpatients (21.3%), and UGIB within 30 days of discharge in outpatients (8.5%). For inpatients, prescription of PPI at discharge was associated with a lower risk of bleeding within 30 days (odds ratio: 0.30, P = 0.025) and death within 30 days (odds ratio = 0.16, P = 0.002). No other significant associations of PPI with death or UGIB were reported.

Conclusion

Post-EBL PPI therapy is associated with reduced risk of bleeding and death within 30 days after variceal hemorrhage in hospitalized patients.
Do Insurance-mandated Precertification Criteria and Insurance Plan Type Determine the Utilization of Bariatric Surgery Among Individuals With Private Insurance?
Authors: Gasoyan Hamlet , Soans Rohit , Ibrahim Jennifer K. , Aaronson William E. , Sarwer David B.
Published: August 2020

Background:

Access to bariatric surgery is restricted by insurers in numerous ways, including by precertification criteria such as 3–6 months preoperative supervised medical weight management and documented 2-year weight history.

Objectives:

To investigate if there is an association between the aforementioned precertification criteria, insurance plan type, and the likelihood of undergoing bariatric surgery, after controlling for potential sociodemographic confounders.

Research Design:

The study was conducted using the Pennsylvania Health Care Cost Containment Council’s data in 5 counties of Pennsylvania in 2016 and records of preoperative insurance requirements maintained by the Temple University Bariatric Surgery Program.

Privately insured bariatric surgery patients and individuals who met the eligibility criteria but did not undergo surgery were identified and 1:1 matched by sex, race, age group, and zip code (n=1054). Univariate tests and logistic regression analysis were utilized for data analysis.

Results:

The insurance requirement for 3–6 months preoperative supervised medical weight management was associated with smaller odds of undergoing surgery [odds ratio (OR)=0.459; 95% confidence interval (CI), 0.253–0.832; P=0.010], after controlling for insurance plan type and the requirement for documented weight history.

Preferred provider organization (OR=1.422; 95% CI, 1.063–1.902; P=0.018) and fee-for-service (OR=1.447; 95% CI, 1.021–2.050; P=0.038) plans were associated with greater odds of undergoing surgery, compared with health maintenance organization plans, after controlling for the studied precertification requirements. The documented weight history requirement was not a significant predictor of the odds of undergoing surgery (P=0.132).

Conclusions:

There is a need for consideration of insurance benefits design as a determinant of access to bariatric surgery.
Cystatin C is ready for clinical use
Authors: Ebert Natalie , Shlipak Michael G.
Published: August 2020

Purpose of review

The goal of this update is to raise awareness of clinical scenarios where cystatin C has clear and immediate benefits as an alternative glomerular filtration rate (GFR) biomarker to supplement creatinine. An additional goal is to focus the estimated GFR (eGFR) controversy onto medication prescribing for agents with narrow therapeutic windows where better GFR estimation will lead to improved medical care.

Recent findings

Equations that include cystatin C predict GFR more accurately than serum creatinine in children, adults, and older adults with larger effects among persons who are acutely ill. Numerous studies have evaluated medication dosing based on either GFR estimate; vancomycin was the most frequently studied drug and its target level and elimination were better predicted by cystatin C. Overall, approaches to medication dosing and monitoring that include cystatin C concentrations have been shown to result in a better achievement of drug trough levels. Furthermore, cystatin C offers the opportunity to avoid the race coefficient that is required for any current creatinine-based eGFR equation, which has been appropriately criticized for introducing unnecessary imprecision, assumptions and values on GFR estimation.

Hospital laboratories must make cystatin C available for clinical care to improve the safety and efficacy of medications that have narrow therapeutic windows.
Host immune interactions in chronic inflammatory gastrointestinal conditions
Authors: Caminero Alberto , Pinto-Sanchez MI
Published: August 2020

Purpose of review

We performed a literature review of the latest studies on the interactions between the host immune system and microbes in chronic intestinal inflammatory conditions.

Recent findings

The mechanisms leading to celiac disease (CeD) and inflammatory bowel disease (IBD), the most common chronic inflammatory gastrointestinal conditions, are complex. The intestinal homeostasis depends on the interactions between the microbiota, the intestinal mucosa and the host immune system. Failure to achieve or maintain equilibrium between a host and its microbiota has the potential to induce chronic conditions with an underlying inflammatory component. Mechanisms by which intestinal microbes trigger inflammation include the alteration of intestinal permeability, activation of the host immune system and digestion of dietary antigens with a consequent repercussion on tolerance to food. Therefore, therapies modulating gut microbiota, including diet, antibiotics, probiotics and faecal transplantation have a potential in CeD and IBD. Probiotics are effective to treat pouchitis and faecal transplant for ulcerative colitis, but the evidence is less clear in Crohn's disease or CeD.

Diverse regulatory mechanisms cooperate to maintain intestinal homeostasis, and a breakdown in these pathways may precipitate inflammation. The role of microbiota inducing immune dysfunction and inflammation supports the therapeutic rationale of manipulating microbiota to treat chronic inflammatory conditions.
Proton pump inhibitors: misconceptions and proper prescribing practice
Authors: Schubert Mitchell L.
Published: August 2020

Purpose of review

The current review summarizes and attempts to place in proper perspective the past year's literature regarding purported adverse effects of proton pump inhibitors (PPIs).

Recent findings

Although generally considered safe, physicians are inundated with retrospective database-driven epidemiologic studies, and meta-analyses on the same studies, claiming a panoply of serious adverse effects associated with long-term use of PPIs. The quality of the evidence underlying most of these associations is very low and cannot ascribe cause and effect. Nonetheless, these reports have stoked fears, in both prescribers and patients. As a result, patients are being harmed. Physicians are not prescribing PPIs when medically indicated and patients are stopping PPIs without consulting their caregivers. It is reassuring that a cross-sectional analysis of data from the National Ambulatory Medical Care Survey as well as a double-blinded, placebo-controlled trial report no safety concerns with PPIs, other than a possible small association with enteric infection.

Most of the publicized serious putative adverse effects attributed to PPIs have been debunked in more recent and properly designed studies. Nevertheless, PPIs should be prescribed for valid indications and, when prescribed long-term, they should be used at the lowest effective dose and their ongoing need periodically assessed.
Gastroparesis and functional dyspepsia: different diseases or different ends of the spectrum?
Authors: Cangemi David J. , Lacy Brian E.
Published: August 2020

Purpose of review

This review assesses the relationship between gastroparesis and functional dyspepsia, in light of recent research assessing cause, pathophysiology and treatment.

Recent findings

The Gastroparesis Cardinal Symptom Index (GCSI) lacks the ability to readily distinguish functional dyspepsia from gastroparesis based on symptoms. Although prior studies found that the extent of delay in gastric emptying did not accurately predict severity of symptoms, when optimally measured, delayed gastric emptying may in fact correlate with gastroparesis symptoms. Enteric dysmotility may be an important risk factor for gastroparesis. Altered central processing may play a role in symptom generation for both gastroparesis and functional dyspepsia based on functional brain MRI. Treatment directed towards reducing low-grade inflammation and improving mucosal barrier function in the duodenum may represent a novel therapeutic target for functional dyspepsia, whereas gastric peroral endoscopy myotomy (G-POEM) remains a promising intervention for refractory gastroparesis.

Abnormalities on functional MRI of the brain have been identified in patients with functional dyspepsia and gastroparesis. Small bowel dysmotility and duodenal barrier dysfunction have been implicated in the pathophysiology of gastroparesis and functional dyspepsia, respectively. New treatments for functional dyspepsia may target low-grade duodenal inflammation and barrier dysfunction. The pylorus remains a target in gastroparesis.
Evaluation of very early-onset inflammatory bowel disease
Authors: de Mesquita Mirjam Bueno , Shouval Dror S.
Published: August 2020

Purpose of review

Very early-onset inflammatory bowel disease (VEO-IBD) is a rare presentation defined as onset of intestinal inflammation at the age of <6 years. Some of these young children develop IBD because of inherent defects in immune or epithelial cell function resulting from deleterious mutations in genes involved in mucosal homeostasis. Here, we provide an overview of the clinical, genetic and immunologic approach in patients with VEO-IBD.

Recent findings

More than 50 different monogenic disorders directly causing IBD have been identified in the last decade; most of them present with unique clinical features in the first years of life. Such a diagnosis may facilitate the administration of targeted therapies and is important for genetic counseling. Nevertheless, a monogenic disorder is identified only in a minority of patients with VEO-IBD. Consequently, different demographic, clinical and histologic features should prompt a detailed genetic and immunologic workup in patients with IBD.

A diagnosis of monogenic IBD can have a huge impact on patient's care, enabling in some cases to provide personalized therapies. Clinicians should be aware of unique features of such disorders, and complete a detailed genetic and immune workup in selected cases, even when disease manifests beyond a young age.
New insights into IVIg mechanisms and alternatives in autoimmune and inflammatory diseases
Authors: Norris Peter A.A. , Kaur Gurleen , Lazarus Alan H.
Published: August 2020

Purpose of review

Intravenous immunoglobulin (IVIg) is an effective treatment for an increasing number of autoimmune and inflammatory conditions. However, IVIg continues to be limited by problems of potential shortages and cost. A number of mechanisms have been described for IVIg, which have been captured in newly emergent IVIg mimetic and IVIg alternative therapies. This review discusses the recent developments in IVIg mimetics and alternatives.

Recent findings

Newly emergent IVIg mimetics and alternatives capture major proposed mechanisms of IVIg, including FcγR blockade, FcRn inhibition, complement inhibition, immune complex mimetics and sialylated IgG. Many of these emergent therapies have promising preclinical and clinical trial results.

Significant research has been undertaken into the mechanism of IVIg in the treatment of autoimmune and inflammatory disease. Understanding the major IVIg mechanisms has allowed for rational development of IVIg mimetics and alternatives for several IVIg-treatable diseases.
The benefit of exercise in children with congenital heart disease
Authors: Selamet Tierney Elif Seda
Published: August 2020

Purpose of review

Children and adolescents with congenital heart disease (CHD) often have decreased exercise capacity and muscle mass. Exercise has numerous health benefits and can improve exercise capacity and muscle mass. As such, guidelines recommend 60 min of daily physical activity in the majority of pediatric CHD patients. Despite these known benefits and guidelines, children and adolescents with CHD often do not exercise regularly. The purpose of this review is to summarize the current literature on exercise in this population.

Recent findings

With recent advancements in the field, clinical focus in pediatric cardiology has expanded from improving mortality to improving long-term outcomes and quality of life. As part of this paradigm shift, there is ongoing research on safety, impact, and effective delivery of exercise to this population with the overarching goal of promoting an active lifestyle.

Exercise interventions are generally safe, feasible, and beneficial in children and adolescents with CHD. There is growing evidence demonstrating the benefits and utility of exercise as a prescription rather than restriction in pediatric CHD patients. Novel approaches are needed for effective delivery of exercise in this population. Further studies are warranted for assessment of long-term benefits of exercise in pediatric CHD patients.
Rapid Deployment of a Virtual Nurse Residency Program; Virtually No Idea Where to Start
Authors: Malone Melissa , John Elsa , Ridgeway Pamela
Published: August 2020

The disruption of the COVID-19 pandemic had a significant impact in the transition of the new graduate nurse to independent practice. This article describes the conversion of a nurse residency program from a traditional classroom to a virtual setting and the barriers the team encountered. Curriculum changes and processes are described, including ideas for future implementation. These processes may be used as a guide for other institutions.
Primary Female Urethral Carcinoma
Authors: Aron Manju , Park Sanghui , Lowenthal Brett M. , Gupta Sounak , Sahoo Debashis , Cheville John C. , Hansel Donna E.
Published: August 2020

Primary female urethral carcinoma is rare. Limited clinicopathologic information has hindered development of staging criteria in this disease. We analyzed 29 primary female urethral carcinoma resections from 3 academic medical centers to characterize histopathologic features, clinical outcomes, and applicability of current and a novel modified staging criteria. We complemented this analysis with review of fully embedded female autopsy urethras to detail anterior and posterior urethral wall histology. Primary female urethral carcinoma subtypes included urothelial carcinoma in situ (3/29, 10%), adenocarcinoma in situ (1/29; 3%), invasive urothelial carcinoma (13/29, 45%), clear cell carcinoma (5/29, 17%), adenocarcinoma not otherwise specified (4/29, 14%) and squamous cell carcinoma (3/29, 10%). Only 6/29 cases (21%) were originally assigned a stage at diagnosis. Using histologic landmarks specific to the female urethra, we modified existing eighth edition American Joint Committee on Cancer urethral staging to a histology-based female urethral carcinoma staging (UCS) system. UCS stages were defined as pTa/pTisUCS (noninvasive carcinoma), pT1UCS (subepithelial tissue invasion), pT2UCS (periurethral muscle invasion), pT3UCS (vaginal adventitia or surrounding fibrovascular tissue), and pT4UCS (anterior wall fibroadipose tissue or posterior vaginal wall). UCS staging was applicable to all cases and showed stepwise changes in disease recurrence with increasing stage and was statistically significant for disease-specific and overall survival in contrast to the American Joint Committee on Cancer staging system. This study of one of the largest cohort of primary female urethral carcinomas provides a modified histology-based staging system specific to female urethral anatomy that provides outcomes-related information, which may be further validated by larger multi-institutional studies.
Procedural Training in Pediatric Emergency Medicine Fellowship
Authors: Weiss Anna , Myers Sage , Lockman Justin L. , Posner Jill , Shaw Kathy
Published: August 2020

Background

Life-saving procedures are rarely performed on children in the emergency department, making it difficult for trainees to acquire the skills necessary to provide proficient resuscitative care for children. Studies have demonstrated that residents in general pediatrics and emergency medicine lack exposure to procedures in the pediatric context, but no studies exist regarding procedural training in pediatric emergency medicine (PEM). Although the Accreditation Council for Graduate Medical Education (ACGME) provides a list of procedures in which PEM fellows must be competent, the relevance of this procedure list to actual PEM practice has not been studied.

Objectives

This study sought to determine whether PEM fellowships currently provide sufficient exposure to the skills most relevant for practicing PEM physicians.

Study Design

Data were collected via anonymous electronic survey from physicians who graduated from PEM fellowship between 2012 and 2016. Survey items measured respondents' comfort with performing critical procedures, and their perceptions of the necessity of knowing how to perform each procedure in their current practice environment.

Results

A total of 133 individuals responded to the survey. Respondents unanimously agreed that 18 of the 36 procedures required by the ACGME are necessary to know in their current practice environment. For the remaining 18 mandated procedures, there was significant disagreement among respondents both as to the necessity of the procedure in current practice and respondents' degree of comfort with performing each procedure.

Conclusions

Among recent PEM fellowship graduates, there is significant variation in comfort with performing ACGME-mandated procedures. These data highlight important opportunities for curricular enhancement in the procedural training of PEM physicians.
Are Complex Skull Fractures Indicative of Either Child Abuse or Major Trauma in the Era of 3-Dimensional Computed Tomography Imaging?
Authors: Metz James B. , Otjen Jeffrey P. , Perez Francisco A. , Done Stephen L. , Brown Emily C. B. , Wiester Rebecca T. , Jenny Carole , Kelton Megan C. , Ganti Sheila N. , Feldman Kenneth W.
Published: August 2020

Objective

The aim of the study was to determine whether complex skull fractures are more indicative of child abuse or major trauma than simple skull fractures.

Design

This is a retrospective chart and imaging review of children diagnosed with a skull fracture. Subjects were from 2 pediatric tertiary care centers. Children younger than 4 years who underwent a head computed tomography with 3-dimensional rendering were included. We reviewed the medical records and imaging for type of skull fracture, abuse findings, and reported mechanism of injury. A complex skull fracture was defined as multiple fractures of a single skull bone, fractures of more than 1 skull bone, a nonlinear fracture, or diastasis of greater than 3 mm. Abuse versus accident was determined at the time of the initial evaluation with child abuse physician team confirmation.

Results

From 2011 to 2012, 287 subjects were identified by International Classification of Diseases, Ninth Revision, code. The 147 subjects with a cranial vault fracture and available 3-dimensional computed tomography composed this study's subjects. The average age was 12.3 months. Seventy four (50.3%) had complex and 73 (49.7%) had simple fractures. Abuse was determined in 6 subjects (4.1%), and a determination could not be made for 5 subjects. Adding abused children from 2013 to 2014 yielded 15 abused subjects. Twelve of the abused children (80%) had complex fractures; more than the 66 (48.5%) of 136 accidentally injured children (P = 0.001; relative risk = 1.65 [1.21–2.24]). However, among children with a complex fracture, the positive predictive value for abuse was only 7%.

Conclusions

Complex skull fractures frequently occur from accidental injuries. This study suggests that the presence of complex skull fractures should not be used alone when making a determination of abuse.
Radiologic Assessment of Skull Fracture Healing in Young Children
Authors: Harper Nancy S. , Eddleman Sonja , Shukla Khushbu , Narcise Maria Veronica , Padhye Laura J. , Peterson Loralie J. , Murati Michael A. , George Caroline L. S.
Published: August 2020

Background

Skull fractures are commonly seen after both accidental and nonaccidental head injuries in young children. A history of recent trauma may be lacking in either an accidental or nonaccidental head injury event. Furthermore, skull fractures do not offer an indication of the stage of healing on radiologic studies because they do not heal with callus formation as seen with long bone fractures. Thus, a better understanding on the timing of skull fracture resolution may provide guidance on the medical evaluation for accidental or nonaccidental head injury.

Objective

The aim of the study was to determine the time required for radiographic skull fracture resolution in children younger than 24 months.

Methods

This was a retrospective observational analysis of children younger than 24 months referred with skull fractures between January 2008 and December 2012. Analysis included children with accidental head injuries with a known time interval since injury and a negative skeletal survey who underwent serial radiographic studies. Complete healing of a skull fracture was defined as resolution of fracture lucency by radiograph.

Results

Of the 26 children who met inclusion criteria, 11 (42.3%) demonstrated resolution of skull fracture(s) on follow-up imaging. Fracture resolution on radiologic studies ranged from 2 to 18 weeks. Twelve fractures in 10 children demonstrated fracture resolution at 10 or more weeks after injury.

Conclusions

Healing or resolution of a skull fracture can take months in children younger than 24 months. With the high variability in skull fracture presentation and large window to fracture resolution, unexplained or multiple skull fractures in children younger than 24 months may be the result of a single or multiple events of head trauma.
Point-of-Care Ultrasound Used to Diagnose Sternal Fractures Missed by Conventional Imaging
Authors: Khalil Paul Adeeb , Benton Carleigh , Toney Amanda Greene
Published: August 2020

Sternal fractures have often been associated with high-impact thoracic trauma. In children, this is not always the case. X-ray and even computed tomography can miss subtle sternal fractures. Point-of-care ultrasound has been shown to be more sensitive and specific for detecting subtle sternal fractures as compared with plain X-ray. The following 2 cases describe sternal fractures that were missed by traditional imaging modalities, including a fracture missed by chest computed tomography. They also highlight other potential causative mechanisms for sternal fractures in children, including hyperflexion injuries and low-mechanism motor vehicle accidents.
Innovating Pediatric Emergency Care and Learning Through Interprofessional Briefing and Workplace-Based Assessment
Authors: Steiner Isabelle , Balsiger Audrey , Goldszmidt Mark , Huwendiek Sören
Published: August 2020

Background

Managing pediatric emergencies can be both clinically and educationally challenging with little existing research on how to improve resident involvement. Moreover, nursing input is frequently ignored. We report here on an innovation using interprofessional briefing (iB) and workplace-based assessment (iWBA) to improve the delivery of care, the involvement of residents, and their assessment.

Methods

Over a period of 3 months, we implement an innovation using iB and iWBA for residents providing emergency pediatric care. A constructivist thematic analysis approach was used to collect and analyze data from 4 focus groups (N = 18) with nurses (4), supervisors (5), and 2 groups of residents (4 + 5).

Results

Residents, supervisors, and nurses all felt that iB had positive impacts on learning, teamwork, and patient care. Moreover, when used, iB seemed to play an important role in enhancing the impact of iWBA. Although iB and iWBA seemed to be accepted and participants described important impacts on emergency department culture, conducting of both iB and iWBA could be sometimes challenging as opposed to iB alone mainly because of time constraints.

Conclusions

Interprofessional briefing and iWBA are promising approaches for not only resident involvement and learning during pediatric emergencies but also enhancing team function and patient care. Nursing involvement was pivotal in the success of the innovation enhancing both care and resident learning.
Scrub typhus: a reemerging infection
Authors: John Rebecca , Varghese George M.
Published: August 2020

Purpose of review

Scrub typhus, caused by Orientia tsutsugamushi, is a widely neglected disease which is gaining global momentum because of its resurgence patterns. The disease is now being reported in newer regions as well as areas previously endemic areas. In this review, we aim to comprehensively review the data available to assist physicians in making an accurate diagnosis and appropriate management of the disease.

Recent findings

Several diagnostic tests have been developed for confirming scrub typhus. However, there is lack of clarity on which tests are most appropriate in a given clinical scenario. A recent study has demonstrated that in early disease (<7 days) when serological tests remain negative, the quantitative polymerase chain reaction is the most sensitive test. Among the serological tests, both IgM enzyme-linked immunosorbent assay as well as rapid diagnostic tests revealed excellent sensitivities and specificities.

With the reemergence of scrub typhus, a high degree of clinical suspicion is required to appropriately diagnose this disease which presents as an acute febrile illness. It can progress to develop various complications leading to multi-organ dysfunction syndrome. Mild illness responds well to antibiotic treatment with doxycycline and azithromycin. Further studies are required to determine the most optimal therapy in severe scrub typhus infections and superiority of one drug over the other.
Subarachnoid neurocysticercosis: emerging concepts and treatment
Authors: Nash Theodore E. , O’Connell Elise M.
Published: August 2020

Purpose of review

Subarachnoid neurocysticercosis (SUBNCC) is caused by a morphologically unique proliferative form of Taenia solium involving the subarachnoid spaces. Prolonged therapy based upon the pathophysiology of SUBNCC and long-term follow-up have shed light on the course of disease and led to highly improved outcomes.

Recent findings

SUBNCC has a prolonged incubation period of between 10 and 25 years characterized by cyst proliferation and growth and invasion of contiguous spaces leading to mass effect (Stage 1). With induction of the host-immune responses, cysts degenerate leading to a predominately inflammatory arachnoiditis (Stage 2) causing hydrocephalus, infarcts, and other inflammatory based neurological manifestations. Inactive disease (Stage 3) may occur naturally but mostly is a result of successful treatment, which generally requires prolonged intensive anthelminthic and antiinflammatory treatments. Cerebral spinal fluid cestode antigen or cestode DNA falling to nondetectable levels predicts effective treatment. Prolonged treatment with extended follow-up has resulted in moderate disability and no mortality. Repeated short intensive 8–14-day courses of treatment are also used, but long-term outcomes and safety using this strategy are not reported.

SUBNCC gives rise to a chronic arachnoiditis. Its unique ability to proliferate and induce inflammatory responses requires long-term anthelmintic and antiinflammatory medications.
Brain calcification because of neurocysticercosis: a vast field to be explored
Authors: Bustos Javier A. , Coyle Christina M.
Published: August 2020

Purpose of review

Neurocysticercosis is the most common helminthic infection of the central nervous system caused by the larval stage of the pork tapeworm, Taenia solium. Endemic regions include Latin American countries, sub-Saharan Africa, and large regions of Asia, including the Indian subcontinent and is a global health problem. Seizures are the most common manifestation and approximately 30% of adult-onset seizures in endemic regions are attributable to NCC. Calcifications because of neurocysticercosis is the most common finding on imaging in endemic regions and are important seizure foci contributing to the burden of epilepsy.

Recent findings

After treatment with antiparasitics for multiple viable parenchymal disease, approximately 38% of cysts that resolved after 6 months of therapy will result in residual calcifications, which represents a significant burden of residual disease. Calcified disease has been referred to as ‘inactive disease’, but there is accumulating evidence to suggest that calcified granulomas are actually dynamic and substantially contribute to the development and maintenance of seizures.

Calcified parenchymal neurocysticercosis contributes significantly to the development and maintenance of seizures in endemic regions. Understanding the pathogenesis of the role of calcified NCC in seizure development and risk factors for development of calcifications after treatment is critical to decreasing the burden of symptomatic disease in endemic regions.
Localization of Foramen Ovale According to Bone Landmarks of the Splanchnocranium: Help for Transforaminal Surgical Approach to Trigeminal Neuralgia
Authors: Gibelli Daniele , Cellina Michaela , Oliva Giancarlo , Sforza Chiarella
Published: August 2020

Trigeminal neuralgia is a painful condition, usually treated through surgical procedures focusing on the foramen ovale (FO). A detailed localization of FO relative to reference landmarks is therefore crucial to avoid possible complications.

The present study aims at assessing the position of FO according to the surrounding bone structures: 100 CT-scans of patients, equally divided between sexes, aged between 18 and 86 years were examined. From each subject, the 3D models of FO and the maxillary bones, the zygomatic bones and the zygomatic process of the temporal bones were segmented through ITK-SNAP software. The distance between the center of the FO and subnasale, zygion, and the upper edge of the zygomatic bone at the origin of the frontal process were measured on 3D models. On CT-scans three cranial measurements were taken as well (distance between anterior and posterior nasal spine, upper facial height and bizygomatic breadth).

Statistically significant differences in the three distances according to side and sex were assessed through two-way ANCOVA test, using the three cranial measurements (ANS-PNS, NP, ZZ) as covariates (P < 0.05).

Distances between the centre of FO and subnasale, zygion and the upper edge of the zygomatic bone were on average 82.3 ± 3.4 mm, 41.9 ± 2.6 mm and 48.8 ± 3.5 mm in males, 77.3 ± 3.9 mm, 38.2 ± 2.5 mm and 45.5 ± 3.1 mm in females, with a significant difference according to sex (P < 0.05).

Results provide innovative data for the localization of FO and will be useful for the management of transforaminal procedures in case of trigeminal neuralgia.
Captain America's Shield Genioplasty
Authors: Ramieri Valerio , Vellone Valentino , Marianetti Sara , Marianetti Tito M.
Published: August 2020

The chin represents one of the most important determinants of the facial aesthetics. Like many aesthetic parameters, the “ideal” chin has changed in history regarding projection and prominence. From the retrusive profiles of the Renaissance, stronger and more defined mandibular contour are nowadays desired both by masculine and feminine population.

This change in the ideal references plays an important role in diagnosis and treatment planning. Various techniques for chin augmentation have been described, using both alloplastic materials and osteotomies.

An interesting osteotomy variant, so-called chin shield osteotomy, has been described by Triaca et al to avoid a deep mentolabial fold. The authors describe herein the use of a shield plate, very similar in his form to Captain America's shield, that can at the same time provide bone fixation and soft tissues sustain in the mentolabial fold region, preventing the invasion of the gap between the bone fragments by the connective tissue, as it happens in a guided bone regeneration procedure.
Sublingual Gland and Mylohyoid Muscle Advancement: A Novel Combined Local Soft Tissue Reconstruction
Authors: Benech Rodolfo , Bowen Luke , Handley Thomas
Published: August 2020

Here the authors present the surgical management of a 78-year-old female with a superficial squamous cell carcinoma of the mucosa overlying her edentulous mandibular alveolus with no evidence of bony invasion.

Combining the superficial nature of the lesion, patient age and substantial medical comorbidities, a limited intra-oral resection was planned, to avoid the need for free flap reconstruction. The operation required a wide local excision with clear clinical margins and a mandibular rim resection.

All of the currently available reconstructions would result in prolonged surgical time, donor site morbidity, and possible secondary procedures. To overcome these pitfalls, a sublingual gland and mylohyoid muscle advancement flap was designed and executed. By combining the mylohyoid muscle and sublingual gland tissue as an advancement flap in a tension-free manner, secured to the remaining circumferential mucosa, a watertight closure was achieved.

After an uneventful recovery without complication the patient was discharged the following day. Complete epithelialization was observed on day 25. Adjuvant radiotherapy was offered to reduce the risk of recurrence and progression. To date, no bony exposure and no pathological fractures have occurred.

In conclusion, the entire procedure is simple and innovative. There is minimal donor site morbidity, with an immediate return to oral diet and tolerable surgical risks. It requires a small amount of surgical time compared to other reconstructive options and an overall reduced inpatient stay.