bluuebunny/crossref_metadata_2025 huggingface dataset:
Ultrasound-guided L5-S1 Placement of Labor Epidural Does not Improve Dermatomal Block in Parturients
Authors: Malik T. , Malas O. , Thompson A.
Published: February 2020

(Int J Obstet Anesth. 2019;38:52–58)

While epidural analgesia is safe, effective and widely used, studies have shown failure rates of 0.9% to 23% for providing sufficient analgesia to women in labor. Sacral sparing is one of the common causes of failure with labor epidural analgesia. Identification of palpable landmarks is usually used to identify lumbar interspace levels during epidural procedures. The intercristal line has commonly been used to locate the L4-L5 interspace. However, this practice may be ineffective in parturients as this landmark is more cephalad in pregnant patients. In addition, studies have reported that the epidural insertion interspace is correctly identified by palpation of landmarks in only 14% to 29% of cases. The use of preprocedural ultrasound had been reported to decrease the number of puncture attempts and catheter manipulations in parturients undergoing neuraxial procedures. It has also been suggested that placement of an epidural at a lower lumbar level might decrease the risk of sacral sparing. This study aimed to investigate the effectiveness of obtaining an adequate sacral dermatomal block when prepuncture ultrasound was used to place an epidural catheter at the L5-S1 interspace, compared with using surface landmarks to place an epidural at the L3-L4 or L2-L3 interspace.
Impact of Patient Choice for Different Postcesarean Delivery Analgesic Protocols on Opioid Consumption: A Randomized Prospective Clinical Trial
Authors: Carvalho B. , Sutton C.D. , Kowalczyk J.J. , Flood P.D.
Published: February 2020

(Reg Anesth Pain Med. 2019;44:578–585)

Pain management after cesarean delivery is typically selected by the physician without patient input. Shared decision-making between provider and patient may improve patient care. A recent study showed patients who requested a higher intrathecal morphine dose for cesarean delivery had increased opioid requirements and greater postoperative pain, regardless of the actual dose administered. This study aimed to determine whether postoperative oxycodone requirements and pain scores could be reduced and satisfaction increased when patients were given a choice for their postcesarean delivery analgesic protocol.
Incidence of Respiratory Depression After Epidural Administration of Morphine for Cesarean Delivery: Findings Using a Continuous Respiratory Rate Monitoring System
Authors: Terada S. , Irikoma S. , Yamashita A. , Murakoshi T.
Published: February 2020

(Int J Obst Anesth. 2019;38:32–36)

Epidural morphine is widely used for postcesarean analgesia. However, because of the risk of respiratory depression after neuraxial administration of morphine, the American Society of Anesthesiologists (ASA) recommends frequent respiratory rate monitoring in the 24 hours after administration. This has typically been assessed through intermittent manual counting of the respiratory rate—a practice that is prone to observer error and does not allow continuous monitoring. Using this technique has resulted in documented rates of respiratory depression after epidural or intrathecal morphine administration of 0% to 0.9%.This study aimed to estimate the incidence of respiratory depression using the Nellcor respiratory rate monitoring system, which allows continuous monitoring, in patients who received 3 mg of epidural morphine for postcesarean analgesia.
Emerging practices in onboarding programs for PAs and NPs
Authors: Morgan Perri , Sanchez Mara , Anglin Lorraine , Rana Rachel , Butterfield Rita , Everett Christine M.
Published: February 2020

Objective:

To describe administrative factors that should be considered when designing an onboarding program for physician assistants (PAs) and NPs.

Methods:

Interview study of 13 administrators of onboarding programs. Interviews were transcribed and analyzed for themes by a team of researchers, with feedback from interviewees.

Results:

Five administrative themes are summarized: goals of onboarding, critical organization factors, organizational fit, designing the program, and costs of onboarding.

Conclusions:

Careful planning and administration are essential to the success of onboarding programs. Although onboarding programs must be designed with unique institutional needs in mind, the considerations identified by our project might serve as a useful guide to PA and NP employers in the process of creating an onboarding program.
Cost–Utility Analysis of rhBMP-2 Use in Adult Spinal Deformity Surgery
Authors: Jain Amit , Yeramaneni Samrat , Kebaish Khaled M. , Raad Micheal , Gum Jeffrey L. , Klineberg Eric O. , Hassanzadeh Hamid , Kelly Michael P. , Passias Peter G. , Ames Christopher P. , Smith Justin S. , Shaffrey Christopher I. , Bess Shay , Lafage Virginie , Glassman Steve , Carreon Leah Y. , Hostin Richard A.
Published: February 2020

Study Design.

Economic modeling of data from a multicenter, prospective registry.

Objective.

The aim of this study was to analyze the cost utility of recombinant human bone morphogenetic protein-2 (BMP) in adult spinal deformity (ASD) surgery.

Summary of Background Data.

ASD surgery is expensive and presents risk of major complications. BMP is frequently used off-label to reduce the risk of pseudarthrosis.

Methods.

Of 522 ASD patients with fusion of five or more spinal levels, 367 (70%) had at least 2-year follow-up. Total direct cost was calculated by adding direct costs of the index surgery and any subsequent reoperations or readmissions. Cumulative quality-adjusted life years (QALYs) gained were calculated from the change in preoperative to final follow-up SF-6D health utility score. A decision-analysis model comparing BMP versus no-BMP was developed with pseudarthrosis as the primary outcome. Costs and benefits were discounted at 3%. Probabilistic sensitivity analysis was performed using mixed first-order and second-order Monte Carlo simulations. One-way sensitivity analyses were performed by varying cost, probability, and QALY estimates (Alpha = 0.05).

Results.

BMP was used in the index surgery for 267 patients (73%). The mean (±standard deviation) direct cost of BMP for the index surgery was $14,000 ± $6400. Forty patients (11%) underwent revision surgery for symptomatic pseudarthrosis (BMP group, 8.6%; no-BMP group, 17%; P = 0.022). The mean 2-year direct cost was significantly higher for patients with pseudarthrosis ($138,000 ± $17,000) than for patients without pseudarthrosis ($61,000 ± $25,000) (P < 0.001). Simulation analysis revealed that BMP was associated with positive incremental utility in 67% of patients and considered favorable at a willingness-to-pay threshold of $150,000/QALY in >52% of patients.

Conclusion.

BMP use was associated with reduction in revisions for symptomatic pseudarthrosis in ASD surgery. Cost–utility analysis suggests that BMP use may be favored in ASD surgery; however, this determination requires further research.

Level of Evidence: 2
An Exploratory Analysis of Spine Patients’ Preoperative Concerns and Decision-making Process
Authors: Matthies Norah , Keshen Sam , Lewis Stephen , Webster Fiona , Perruccio Anthony V. , Rampersaud Yoga Raja
Published: February 2020

Study Design.

Cross-sectional, pre-post patient survey.

Objective.

The aim of this study was to determine what factors affect a patient's decision to undergo elective surgery following a surgical consultation.

Summary of Background Data.

The surgical consultation is an important step in selecting and preparing patients for elective surgery. Despite the proven effectiveness and low risk of complications, many spine procedure candidates may still choose to forgo surgery after an appropriate discussion and clear surgical indications.

Methods.

Survey and open-response questions regarding pre- and post-consultation surgical concerns and overall willingness to undergo surgery were collected and analyzed from 124 patients deemed surgical candidates. Demographics, surgical willingness, and patient concerns were analyzed. Open-ended response data were tallied for surgical concerns and responses were analyzed line-by-line to assess for main themes. Sub-analysis was included on patients who reconsidered their willingness post-consultation.

Results.

Qualitative thematic analysis of patient's concerns regarding surgery uncovered six major themes: Interference on quality of life (QOL), fear, physical concerns, success, risk, and concerns regarding the surgeon (CS). Success and risk were most commonly mentioned pre-consultation (27%, 26%); risk and QOL were most commonly mentioned post-consultation (22%, 21%). Of 124 patients, 103 were willing to have surgery before consultation and remained willing post-consultation; six patients became unwilling. Twenty-one patients were unwilling to consider surgery before consultation; only five remained unwilling. No differences were found between degenerative and deformity patients regarding initial willingness or changes thereafter.

Conclusion.

The decision to undergo surgery is a multifactorial and complex process with a variety of patient concerns. We grouped these concerns into six categories to aid in future discussion with patients. 87% of patients have made up their mind before attending their surgical consultation. Appropriate understanding of patient-specific willingness and concerns should help facilitate necessary discussion and aid in a more efficient and useful shared decision-making process.

Level of Evidence: 4
Long-term Results After Surgical or Nonsurgical Treatment in Patients With Degenerative Lumbar Spinal Stenosis
Authors: Burgstaller Jakob M. , Steurer Johann , Gravestock Isaac , Brunner Florian , Fekete Tamás F. , Pichierri Giuseppe , Ulrich Nils H. , Winklhofer Sebastian , Porchet François , Farshad Mazda
Published: February 2020

Study Design.

Prospective, multicenter cohort study.

Objective.

The aim of our study was to assess the course of patients over a period of 3 years undergoing surgical or nonsurgical treatments for degenerative lumbar spinal stenoses (DLSS) based on data from the Lumbar Stenosis Outcome Study (LSOS), prospectively performed in eight hospitals.

Summary of Background Data.

The optimal treatment strategy for patients with DLSS is still debated.

Methods.

The outcomes of patients with verified DLSS were quantified by Spinal Stenosis Measure (SSM) symptoms- and SSM function-scores, and EQ-5D-3L (quality of life) summary index (SI) over time (up to 36-month follow-up), and minimal clinically important difference (MCID) in SSM symptoms, SSM function, and EQ-5D-3L SI from baseline to 36-month follow-up.

Results.

For this study, 601 patients met the inclusion criteria; 430 underwent surgery, 18 of them only after more than a year after enrolment, 171 received nonsurgical treatment only. At baseline, patients in the surgical and nonsurgical groups had similar values for the SSM symptoms and SSM function scores, but patients in the surgical group suffered significantly more from buttocks pain and reported more worsening symptoms over the last 3 months before enrollment in the study. Surgically treated patients (except changers) performed significantly better in all clinical outcome measures (P < 0.001) with a plateau at 12-month follow-up staying constant until the follow-up ended. Further, two-thirds of patients in the surgical group had a relevant improvement in function, symptoms, and quality of life, compared with only about half of those in terms of symptoms and even less in terms of function and quality of life with nonsurgical treatment.

Conclusions.

Surgical treatment of DLSS results in more favorable clinical outcomes with a sustained effect over time, compared to nonsurgical treatment.

Level of Evidence: 3
Cervical Spine Endplate Abnormalities and Association With Pain, Disability, and Adjacent Segment Degeneration After Anterior Cervical Discectomy and Fusion
Authors: Harada Garrett K. , Alter Kevin , Nguyen Austin Q. , Tao Youping , Louie Philip K. , Basques Bryce A. , Galbusera Fabio , Niemeyer Frank , Wilke Hans-Joachim , An Howard S. , Samartzis Dino
Published: February 2020

Study Design.

A retrospective study with prospectively-collected data.

Objective.

To determine how type, location, and size of endplate lesions on magnetic resonance imaging (MRI) may be associated with symptoms and clinical outcomes after anterior cervical discectomy and fusion (ACDF).

Summary of Background Data.

Structural endplate abnormalities are important, yet understudied, phenomena in the cervical spine. ACDF is a common surgical treatment for degenerative disc disease; however, adjacent segment degeneration/disease (ASD) may develop.

Methods.

Assessed the imaging, symptoms and clinical outcomes of 861 patients who underwent ACDF at a single center. MRI and plain radiographs of the cervical spine were evaluated. Endplate abnormalities on MRI were identified and stratified by type (atypical, typical), location, relation to operative levels, presence at the adjacent level, and size. These strata were assessed for association with presenting symptoms, patient-reported, and postoperative outcomes.

Results.

Of 861 patients (mean follow-up: 17.4 months), 57.3% had evidence of endplate abnormalities, 39.0% had typical abnormalities, while 18.2% had atypical abnormalities. Patients with any endplate abnormality had greater odds of myelopathy irrespective of location or size, while sensory deficits were associated with atypical lesions (P = 0.016). Typical and atypical abnormalities demonstrated differences in patient-reported outcomes based on location relative to the fused segment. Typical variants were not associated with adverse surgical outcomes, while atypical lesions were associated with ASD (irrespective of size/location; P = 0.004) and reoperations, when a large abnormality was present at the proximal adjacent level (P = 0.025).

Conclusion.

This is the first study to examine endplate abnormalities on MRI of the cervical spine, demonstrating distinct risk profiles for symptoms, patient-reported, and surgical outcomes after ACDF. Patients with typical lesions reported worsening postoperative pain/disability, while those with atypical abnormalities experienced greater rates of ASD and reoperation. This highlights the relevance of a degenerative spine phenotypic assessment, and suggests endplate abnormalities may prognosticate clinical outcomes after surgery.

Level of Evidence: 3
Comparison of Anterior Controllable Antedisplacement and Fusion With Posterior Laminoplasty in the Treatment of Multilevel Cervical Ossification of the Posterior Longitudinal Ligament
Authors: Chen Yu , Sun Jingchuan , Yuan Xiaoqiu , Guo Yongfei , Yang Haisong , Chen Deyu , Shi Jiangang
Published: February 2020

Study Design.

A prospective, randomized, controlled study.

Objective.

To compare anterior controllable antidisplacement and fusion (ACAF) with laminoplasty in the treatment of multilevel ossification of the posterior longitudinal ligament (OPLL), and evaluate the efficacy and safety of this procedure.

Summary of Background Data.

The optimal approach for the treatment of OPLL still remains controversial. Both anterior and posterior approaches have their advantages and disadvantages.

Methods.

Between September 2016 and April 2018, a total of 80 patients with multilevel OPLL were randomized in a 1:1 ratio to ACAF group and laminoplasty group. All patients were followed up at least 1 year. Clinical and radiological results were compared between ACAF group and laminoplasty group.

Results.

ACAF took a longer operation time. C5 palsy and axial pain occurred more commonly in laminoplasty group, whereas dysphagia and hoarseness appeared easily in ACAF group. At 1-year follow-up, the final Japanese Orthopedic Association (JOA) score and recovery rate were significant higher in ACAF group than those in laminoplasty group, when occupying rate (OR) was not less than 60%, or K-line was negative. ACAF was also good at preservation of cervical lordosis and sagittal balance, but range of movement of cervical spine in both groups decreased significantly.

Conclusion.

Generally speaking, ACAF is a safe and effective alternative for multilevel OPLL. Compared with laminoplasty, ACAF is more effective in the cases when OR is not less than 60%, or K-line is negative.

Level of Evidence: 2
Years of life lost due to malignant neoplasms of the digestive system in Poland during 10 years of socioeconomic transformation
Authors: Paciej-Gołębiowska Paulina , Pikala Małgorzata , Maniecka-Bryła Irena
Published: February 2020

The aim of the study was to analyse years of life lost due to selected malignant neoplasms of the digestive system (colorectum, stomach, and pancreas) in Poland, a post-communist country in Central Europe, according to socioeconomic variables: sex, age, level of education, marital status, working status, and place of residence. The study included a dataset comprising death certificates of Polish citizens from 2002 (N = 359 486) and 2011 (N = 375 501). The data on deaths caused by malignant neoplasms of the digestive system, that is, coded as C15-C26 according to International Statistical Classification of Diseases and Related Health Problems, 10th Revision, was analyzed. The standard expected years of life lost meter was used to calculate years of life lost. In 2002, malignant neoplasms of the digestive system caused 25 024 deaths among Polish citizens (7.0% of all deaths), which translated into a premature loss of 494 442.1 years of life (129.4 years per 10 000 people). In 2011, the number of deaths increased to 26 537 (7.1% of all deaths) and the number of years of life lost rose to 499 804.0 (129.7 years per 10 000). The most important causes of mortality and years of life lost were colorectal, stomach, and pancreatic cancers. In both studied years, the socioeconomic features with an adverse effect on years of life lost due to each considered malignant neoplasm of the digestive system included male gender, lower than secondary education, widowed marital status, economic inactivity, living in urban areas. Years of life lost analysis constitutes a valuable part of epidemiological assessment of health inequalities in society. It appears that the observed inequalities may have many causes; however, further research is needed to better understand their full extent.
Therapeutic Drug Monitoring Coupled With Bayesian Forecasting Could Prevent Vancomycin-Associated Nephrotoxicity in Renal Insufficiency Patients: A Prospective Study and Pharmacoeconomic Analysis
Authors: Zhang Ying , Wang Taotao , Zhang Di , You Haisheng , Dong Yuzhu , Liu Yang , Du Qian , Sun Dan , Zhang Tao , Dong Yalin
Published: February 2020

Background:

Vancomycin is a critical antibiotic used in important infections, and therapeutic drug monitoring (TDM) is recommended. Bayesian forecasting is demonstrated to provide an approach that can improve trough concentration monitoring for dose adjustment. The objective of this study was to determine whether TDM coupled with a Bayesian approach could increase trough concentration target attainment and prevent vancomycin-associated nephrotoxicity in patients with renal insufficiency.

Methods:

A prospective study was performed using propensity score matching to provide covariate balance in renal insufficiency patients with gram-positive bacterial infections treated with vancomycin. Patients were divided into non-TDM (84 cases) and TDM (84 cases) groups, and their clinical outcomes were compared. The primary endpoints were probability of trough concentration target attainment and incidence of vancomycin-associated nephrotoxicity. A decision-tree model was developed to assess the cost effectiveness of TDM to prevent vancomycin-associated nephrotoxicity.

Results:

Of the 168 eligible patients, 69 from each group (non-TDM and TDM) were matched based on propensity scores. In the matched cohort, trough concentration target attainment was higher with TDM (P = 0.003). Furthermore, reaching toxic trough concentrations was avoided (P = 0.027) in the TDM group. Multivariate logistic regression analysis confirmed that TDM practice independently reduced the incidence of vancomycin-associated nephrotoxicity in renal insufficiency patients (P = 0.021). According to this reduced nephrotoxicity, the incremental cost-effectiveness ratios of ¥22,638 per nephrotoxic episode prevented was found for vancomycin TDM.

Conclusions:

TDM coupled with Bayesian forecasting led to an increase in trough concentration target attainment and a decrease in the incidence of vancomycin-associated nephrotoxicity in renal insufficiency patients. In this high-risk population, TDM was demonstrated to be a cost-effective procedure.
Changes in Corneal Dendritic Cell and Sub-basal Nerve in Long-Term Contact Lens Wearers With Dry Eye
Authors: Liu Qiaoli , Xu Zhiqiang , Xu Yangyang , Zhang Junsong , Li Yong , Xia Jiahui , Wang Yuzhou , He Xiaoxing , Qu Jia , Hu Liang
Published: February 2020

Objectives:

To evaluate the changes of corneal sub-basal nerve (SBN) and dendritic cell (DC) in contact lens (CL) wearers with mild dry eye and their potential relationship.

Methods:

Twenty mild dry eye volunteers who had never worn CLs were recruited for long-term CL wearing. Each subject underwent ocular surface evaluations at baseline and at 1, 4, 12, and 24 weeks, including Ocular Surface Disease Index (OSDI) questionnaire, tear film break-up time (TBUT), and Schirmer I test. In vivo confocal microscopy was used to examine the density, area, number of dendrites, total dendritic length of DC, and SBN densities in central and peripheral corneas. Only right eyes were included.

Results:

The DCs were activated and peaked at week 4 after wearing CLs. The peripheral DC density increased beginning the first week, whereas the central ones increased by week 4. After 4 weeks, both began to decrease, but still higher than baseline at week 24. The central and peripheral SBN densities decreased. However, the peripheral SBN tended to increase beginning at week 12. In early period, SBN was negatively correlated with DC parameters. After 4 weeks, the correlation changed to be positive. The OSDI increased, whereas the Schirmer I test and TBUT showed no significant change.

Conclusions:

After wearing CLs, corneal DC were activated and increased, indicating ocular surface inflammation and decreased after week 4. In the early period, increases in DC may lead to decreases in SBN. Upon decrease of DC, the SBN may regenerate.
Comparison Between the eyeWatch Device and the Ahmed Valve in Refractory Glaucoma
Authors: Roy Sylvain , Villamarin Adan , Stergiopulos Constantinos , Bigler Stéphane , Stergiopulos Nikolaos , Wachtl Josephine , Mermoud André , Kniestedt Christoph
Published: February 2020

Purpose:

To assess the efficacy and safety of a glaucoma procedure to control intraocular pressure (IOP) using the adjustable eyeWatch glaucoma drainage device compared with Ahmed glaucoma valve (AGV) in refractory glaucoma.

Patients and Methods:

Monocentric, retrospective, comparative clinical trial. Patients suffering from refractory glaucoma after failed surgeries and requiring a further glaucoma procedure including an aqueous shunt were enrolled in this study. The first group AGV included patients with an AGV. The second group eW-B included patients receiving an eyeWatch used in connection with a Baerveldt glaucoma implant. The primary outcome was the success rate, defined as an IOP≤16 mm Hg and reduction of >20% from baseline, and IOP≥5 mm Hg. Secondary outcomes were mean IOP, number of antiglaucoma medications, visual acuity, number and type of complications.

Results:

Twenty-one patients were included. The mean follow-up time was 13.2±3.4 months. Mean IOP decreased from 24.8±9.0 mm Hg before surgery to 13.8±3.6 mm Hg at 12 months for group AGV, and 27.3±7.0 to 12.8±2.4 mm Hg for group eW-B, respectively (P<0.05). Mean number of glaucoma medications decreased from 3.0±0.7 before surgery to 0.3±0.7 at last control for group AGV, and 2.9±0.8 before surgery to 0.2±0.4 for group eW-B, respectively (P<0.05). The complete and overall success rates were 50% and 58% for group AGV, and 67% and 89% for group eW-B, respectively.

Conclusions:

The postoperative adjustability of the eyeWatch is believed to help with getting fewer complications and better IOP management whereas AGV cannot be adjusted postoperatively.
Effect of Sodium Supplements and Climate on Dysnatremia During Ultramarathon Running
Authors: Lipman Grant S. , Burns Patrick , Phillips Caleb , Jensen Jacob , Little Colin , Jurkiewicz Carrie , Jarrett Bryan , Walker Anne , Mansfield Nicky , Krabak Brian J.
Published: February 2020

Objective:

Analyze the effect of sodium supplementation, hydration, and climate on dysnatremia in ultramarathon runners.

Design:

Prospective observational study.

Setting:

The 2017 80 km (50 mile) stage of the 250 km (150 mile) 6-stage RacingThePlanet ultramarathon in 2017 Chilean, Patagonian, and 2018 Namibian, Mongolian, and Chilean deserts.

Participants:

All race entrants who could understand English were invited to participate, with 266 runners enrolled, mean age of 43 years (± 9), 61 (36%) females, average weight 74 kg (± 12.5), and average race time 14.5 (± 4.1) hours. Post-race sodium collected on 174 (74%) and 164 (62%) participants with both the blood sample and post-race questionnaire.

Intervention:

Weight change and finish line serum sodium levels were gathered.

Main outcome measures:

Incidence of exercise-associated hyponatremia (EAH; <135 mmol·L−1) and hypernatremia (>145 mmol·L−1) by sodium ingestion and climate.

Results:

Eleven (6.3%) runners developed EAH, and 30 (17.2%) developed hypernatremia. Those with EAH were 14 kg heavier at baseline, had significantly less training distances, and averaged 5 to 6 hours longer to cover 50 miles (80 km) than the other participants. Neither rate nor total ingested supplemental sodium was correlated with dysnatremia, without significant differences in drinking behaviors or type of supplement compared with normonatremic runners. Hypernatremic runners were more often dehydrated [8 (28%), −4.7 kg (± 9.8)] than EAH [4 (14%), −1.1 kg (± 3.8)] (P < 0.01), and EAH runners were more frequently overhydrated (6, 67%) than hypernatremia (1, 11%) (P < 0.01). In the 98 (56%) runners from hot races, there was EAH OR = 3.5 [95% confidence interval (CI), 0.9-25.9] and hypernatremia OR = 8.8 (95% CI, 2.9-39.5) compared with cold races.

Conclusions:

This was the first study to show that hot race climates are an independent risk factor for EAH and hypernatremia. Sodium supplementation did not prevent EAH nor cause hypernatremia. Longer training distances, lower body mass, and avoidance of overhydration were shown to be the most important factors to prevent EAH and avoidance of dehydration to prevent hypernatremia.
Pilot Evaluation of Sheep as In Vivo Model for Cochlear Implantation
Authors: Kaufmann Christopher R. , Tejani Viral D. , Fredericks Douglas C. , Henslee Allan M. , Sun Daniel Q. , Abbas Paul J. , Hansen Marlan R.
Published: February 2020

Objectives:

The rise in the use of cochlear implants (CIs) has continued to fuel research aimed at improving surgical approaches and the preservation of residual hearing. Current in vivo models involve small animals not suitable for evaluating full-sized CIs nor are prohibitively expensive nonhuman primates. The objective of this study was to develop and evaluate an in vivo model of cochlear implantation in sheep.

Methods:

Eight adult, female sheep were implanted with full-sized CIs from three manufacturers using a retrofacial approach to the round window. Partial electrode insertions were performed to a depth of 10 to 12 mm before closure. Round window electrocochleography (ECoG) and auditory brainstem responses (ABR) were conducted during and after surgery. Following a 30-day implantation, cochleae were explanted and imaged using both x-ray microscopy and histology.

Results:

The surgery was well tolerated although limited complications were observed in three of eight sheep. Electrode insertions were up to 12 mm before insertion resistance noted. ECoG and ABR responses were reduced postimplantation, reflecting changes in cochlear mechanics due to the presence of the implant, and/or insertion trauma. Histological and radiological image analysis showed the presence of intracochlear fibrosis as well as one instance of tip fold-over.

Conclusions:

The use of sheep presents a feasible live-animal model to study cochlear implantations. Full-sized implants as well as surgical techniques can be evaluated on functional outcomes such as ABR and ECoG as well as histological markers for residual hearing including intracochlear fibrosis. Use of this model and surgical approach has potential to evaluate CIs and surgical techniques in both the acute and chronic setting.
Congenital Cholesteatoma of the Sphenoid, Occipital, and Temporal Bones: 54-Year Follow Up
Authors: Maxwell Anne K. , Muelleman Thomas , Brackmann Derald E.
Published: February 2020

Objective:

To provide long-term follow up of a unique patient with history of massive petrous apex congenital cholesteatoma.

Patient:

75-year-old man who presented at age 18 with left Gradenigo-like syndrome.

Intervention:

Staged left radical mastoidectomy and open transsphenoidal marsupialization. Followed with routine in-office cholesteatoma debridement.

Main Outcome Measures:

Bony erosion on computed tomography (CT), monitoring for new symptoms.

Results:

Interval development of sensorineural component of hearing loss due to cochlear fistulization. Very slow skull base bony erosion continues without neck destabilization. No new or recurrent cranial neuropathies have developed.

Conclusions:

Marsupialized cholesteatoma may be followed with routine debridement and interval imaging for monitoring over many decades.
Association of lymphocyte-to-monocyte ratio with total coronary plaque burden in patients with coronary artery disease
Authors: Si Yueqiao , Liu Jingyi , Shan Weichao , Zhang Ying , Han Chao , Wang Ruijuan , Sun Lixian
Published: February 2020

Background:

Lymphocyte-to-monocyte ratio (LMR) is involved in all stages of coronary atherosclerosis and related to coronary artery disease (CAD). However, the correlation between LMR and the coronary plaque burden of CAD is not clearly elucidated. Therefore, this study aimed to investigate their correlation in patients with CAD.

Methods:

A total of 1953 consecutive eligible inpatients with suspected CAD were retrospectively included in this study. They were assigned into CAD (n = 564) and non-CAD groups (n = 1389). All patients underwent coronary computed tomographic angiography to evaluate coronary stenosis and coronary artery calcification (CAC). Spearman’s tests were used to analyze the correlation between CAC score and LMR. Multivariate logistic regression models were set up to assess the risk factors of CAD.

Results:

Patients with CAD had lower LMR value than patients without CAD (P = 0.001). LMR was negatively correlated with CAC score and was an independent risk factor of CAC score (P < 0.05). Multivariate logistic regression model showed that LMR ≤4.8 was a newly independent risk factor of CAD (all P < 0.05). Additionally, the new risk score model was compared with the Framingham model and showed that NRI was 4.9%, which proved that the new risk score model improved the prediction capability of CAD.

Conclusion:

LMR ≤4.8 is a new independent risk factor of CAD. LMR value was negatively correlated with CAC score and could be used as a new marker to evaluate the coronary plaque burden of CAD.
The utility of liver biopsy in 2020
Authors: Khalifa Ali , Rockey Don C.
Published: February 2020

Purpose of review

Over the past decade, imaging modalities and serological tests have emerged as important tools in the evaluation of liver diseases, in many cases supplanting the use of liver biopsy and histological examination. Nonetheless, the accuracy and diagnostic value of these methods may not always be conclusive and the assessment of liver histology often remains the gold standard for diagnostic evaluation. The purpose of this review is to summarize the current role of liver biopsy in contemporary hepatology practice.

Recent findings

Technical factors were found to influence the diagnostic value of liver biopsy and histological examination of the liver, including specimen number and size (preferably ≥3 nonfragmented specimens of >20 mm in length), needle diameter (1.6 mm Menghini), number of passes (mean 2.5), imaging-guidance, and operator experience. Liver biopsy was demonstrated to be diagnostically valuable in the evaluation of persistently abnormal liver tests of unclear cause, with histology pointing to a specific diagnosis in 84% of patients. Although coagulation abnormalities continue to be an important concern when performing liver biopsy, their influence on complication risk remains unclear. Implementation of less stringent preprocedural coagulation thresholds decreased preprocedural transfusions without increasing the bleeding rate. Serious complications associated with percutaneous liver-biopsy (PLB) and transjugular liver-biopsy are similar, but pain appears to be more common with PLB.

Histopathological evaluation continues to be fundamentally important in assessing hepatic disease, and liver histology remains the most accurate approach to assess fibrosis and assign prognosis.
NR1H4‐related Progressive Familial Intrahepatic Cholestasis 5
Authors: Himes Ryan W. , Mojarrad Majid , Eslahi Atieh , Finegold Milton J. , Maroofian Reza , Moore David D.
Published: February 2020

Pathogenic sequence variants in the nuclear bile acid receptor FXR, encoded by NR1H4, have been reported in a small number of children with low‐γ‐glutamyl transferase (GGT) cholestasis progressing to liver failure. We describe 3 additional children from 2 unrelated families with cholestasis and liver failure because of pathologic variants in NR1H4. One patient underwent liver transplantation and has had good clinical outcomes in 6 years of follow‐up. Although that patient has biochemical evidence of increased bile acid synthetic activity, he has not experienced post‐transplant diarrhea or allograft steatosis, as has been reported among other transplanted patients.
Differences in Management of Eosinophilic Esophagitis in Europe
Authors: Tourlamain Gilles , Garcia‐Puig Roger , Gutiérrez‐Junquera Carolina , Papadopoulou Alexandra , Roma Eleftheria , Kalach Nicolas , Oudshoorn Johanna , Sokollik Christiane , Karolewska‐Bochenek Kasia , Oliva Salvatore , Strisciuglio Caterina , Bauraind Olivia , Auth Marcus Karl‐Heinz , Thomson Mike , Otte Sebastian , Rok Orel , Dias Jorge Amil , Tzivinikos Christos , Urbonas Vaidotas , Kostovski Aco , Zevit Noam , Velde Saskia Vande ,   ESPGHAN EGID Working group
Published: February 2020

Objectives:

The aim of the study was to assess differences in the diagnosis and management of eosinophilic esophagitis (EoE) by European pediatric (PG) and adult gastroenterologists (AG), and their self‐reported adherence to guidelines.

Methods:

A multiple‐choice questionnaire gauged the diagnostic and management strategies of gastroenterologists treating children or adults in 14 European countries and the United Arab Emirates (UAE).

Results:

Questionnaires were completed by 465 PG and 743 AG. PG were significantly more likely to take biopsies in patients with symptoms of esophageal dysfunction (86.2% PG vs 75.4% AG, P < 0.001) and to perform endoscopic follow‐up (86.3% PG vs 80.6% AG, P < 0.001). After failure of proton‐pump inhibitors (PPIs), topical steroids were the preferred second‐line therapy; however, PG opted more frequently for elimination diets (47.5% PG vs 13.7% AG, P < 0.001). More PG than AG indicated having read recent guidelines (89.4% PG vs 58.2% AG, P < 0.001). Geographic differences in practice were reported, with respondents from the United Kingdom, Portugal, and Spain more often adhering to recommended biopsy protocols. Physicians in the UAE, France, Lithuania, and Poland tended to opt for steroid therapy or elimination diets as first‐line therapy, in contrast to most other countries.

Conclusions:

Significant differences in general practice between PG and AG were demonstrated with notable divergence from consensus guidelines. International practice variations are also apparent. Among other strategies, educational activities to highlight current recommendations may help harmonize and optimize clinical practice.
Adherence to Gluten‐free Diet in a Celiac Pediatric Population Referred to the General Pediatrician After Remission
Authors: Sbravati Francesca , Pagano Sara , Retetangos Cristiana , Spisni Enzo , Bolasco Giulia , Labriola Flavio , Filardi Maria C. , Grondona Ana G. , Alvisi Patrizia
Published: February 2020

Objectives:

Assessment of adherence to gluten‐free diet in celiac disease (CD) is generally recommended. Few data are available about consequences of transition from the referral center to the general pediatrician (GP) once remission is achieved.

Methods:

Adherence was assessed in patients referred to the GP for an annual basis follow‐up, called back for re‐evaluation. Immunoglobulin A (IgA) antitissue transglutaminase (anti‐tTG) antibodies and the Biagi score (BS) were determined at last follow‐up at the referral center (V1), and at re‐evaluation (V2). Patients were classified as adherent (BS 3–4, IgA anti‐tTG <7 U/mL) and nonadherent (BS 0–2, IgA anti‐tTG ≥7). Scores of adherence were correlated with personal and clinical data.

Results:

We evaluated 200 patients. Overall, we found good adherence rates in 94.95% of patients at V1 and 83.5% at V2. IgA anti‐tTG were negative in 100% at V1 and 96.97% at V2. BS is 3 to 4 in 94.5% at V1 and 84% at V2. Adherence at V2 was significantly worse than V1 (P < 0.001). No significant associations were found between scores of adherence and sex, symptoms and age at diagnosis, family history of CD, comorbidity, and diagnosis by endoscopy. Age 13 years or older represents a risk factor for lack of compliance at V1 (P = 0.02) and V2 (P = 0.04), and foreign nationality at V2 (P = 0.001).

Conclusions:

The BS, serology, and a clinical interview, integrated, are reliable tools for assessing pediatric adherence to gluten‐free diet. We argue that referring patients to the GP after remission of CD is important, but the process must be improved and recommendations are required.
A Homozygous Mutation in 5′ Untranslated Region of TNFRSF11A Leading to Molecular Diagnosis of Osteopetrosis Coinheritance With Wiskott-Aldrich Syndrome
Authors: Chen Tianping , Sun Jun , Liu Guanghui , Yin Chuangao , Liu Haipeng , Qu Lijun , Fang Shijin , Shifra Ash , Gilad Gil
Published: February 2020

Wiskott-Aldrich syndrome (WAS) and osteopetrosis are 2 different, rare hereditary diseases. Here we report clinical and molecular genetics investigations on an infant patient with persistent thrombocytopenia and prolonged fever. He was clinical diagnosed as osteopetrosis according to clinical presentation, radiologic skeletal features, and bone biopsy results. Gene sequencing demonstrated a de novo homozygous mutation in 5′-untranslated region of TNFRSF11A, c.−45A>G, which is relating to osteopetrosis. Meanwhile, a hemizygous transition mutation in WAS gene, c.400G>A diagnosed the infant with WAS. This is the first clinical report for the diagnosis of osteopetrosis coinheritance with WAS in a single patient.
Clinical Characteristics of Invasive Fungal Infections in Pediatric Oncology Patients With Solid Tumors
Authors: Ruijters Veerle J. , Oosterom Natanja , van der Perk Madeleine E.M. , Wolfs Tom F.W. , Meijer Annelot J.M. , van den Heuvel-Eibrink Marry M. , van Grotel Martine
Published: February 2020

Invasive fungal infections (IFIs) are an important cause of morbidity and mortality in children with cancer. Studies on the clinical characteristics of IFI in children with solid tumors are limited. This Dutch retrospective cohort study reviewed the medical records of 61 children with solid tumors to analyze the clinical characteristics during their full treatment period. Seven IFI episodes were reported in 6/61 patients (10%), all diagnosed with intermediate-risk or high-risk Wilms tumor or neuroblastoma. Larger studies are necessary to reveal the determinants of IFI in this group of patients and the value of fungal prophylaxis.
Spanish version of the mini-BESTest: a translation, transcultural adaptation and validation study in patients with Parkinson’s disease
Authors: Bustamante-Contreras Carolina , Ojeda-Gallardo Yenifer , Rueda-Sanhueza Claudia , Rossel Pedro O. , Martínez-Carrasco Claudia
Published: February 2020

Balance is affected in numerous neurologic disorders, like stroke, multiple sclerosis and Parkinson’s disease contributing to falls, and diminishing quality of life and functionality. The mini-BESTest is one of the most recommended scales to detect balance disorders in people with Parkinson’s disease, which has solid psychometric properties. Unfortunately, this scale has not been validated in Chile and there are no other validated scales that can determine balance disorders in patients with Parkinson’s disease to date. The study objective was to validate the mini-BESTest scale in Chilean Parkinson’s disease patients. The translation and adaptation to Chilean Spanish of the mini-BESTest scale were made following a cross-cultural adaptation process, to then obtain face and content validity by an expert committee. Afterwards, the demographic data and psychometric properties of internal consistency and ceiling and floor effects were measured with a sample of 50 subjects with Parkinson’s disease. Furthermore, 10 subjects of the sample were evaluated with the purpose of measuring inter rater reliability. The scale presented a good internal consistency (Cronbach’s alpha = 0.845), and an excellent inter rater reliability (intraclass correlation coefficient = 0.97), no ceiling or floor effects were found. The results of the face and content validity and psychometric properties are adequate, achieving the validation of the mini-BESTest scale for balance in Chilean people with Parkinson’s disease.
Factors Associated With Diagnostic Error on Admission to a PICU: A Pilot Study
Authors: Cifra Christina L. , Ten Eyck Patrick , Dawson Jeffrey D. , Reisinger Heather Schacht , Singh Hardeep , Herwaldt Loreen A.
Published: February 2020

Objectives:

Diagnostic errors can harm critically ill children. However, we know little about their prevalence in PICUs and factors associated with error. The objective of this pilot study was to determine feasibility of record review to identify patient, provider, and work system factors associated with diagnostic errors during the first 12 hours after PICU admission.

Design:

Pilot retrospective cohort study with structured record review using a structured tool (Safer Dx instrument) to identify diagnostic error.

Setting:

Academic tertiary referral PICU.

Patients:

Patients 0–17 years old admitted nonelectively to the PICU.

Interventions:

None.

Measurements and Main Results:

Four of 50 patients (8%) had diagnostic errors in the first 12 hours after admission. The Safer Dx instrument helped identify delayed diagnoses of chronic ear infection, increased intracranial pressure (two cases), and Bartonella encephalitis. We calculated that 610 PICU admissions are needed to achieve 80% power (α = 0.05) to detect significant associations with error.

Conclusions:

Our pilot study found four patients with diagnostic error out of 50 children admitted nonelectively to a PICU. Retrospective record review using a structured tool to identify diagnostic errors is feasible in this population. Pilot data are being used to inform a larger and more definitive multicenter study.
The Evolution of Breast Satisfaction and Well-Being after Breast Cancer: A Propensity-Matched Comparison to the Norm
Authors: Mundy Lily R. , Rosenberger Laura H. , Rushing Christel N. , Atisha Dunya , Pusic Andrea L. , Hollenbeck Scott T. , Hyslop Terry , Hwang E. Shelley
Published: February 2020

Background:

Breast cancer survival continues to improve, with women living longer after treatment. It is not well understood how long-term satisfaction and well-being differ following treatment or how types of reconstruction differ when compared to the norm.

Methods:

In a propensity-matched sample, the authors compared patient-reported outcomes in breast cancer patients at various time intervals from surgery with normative BREAST-Q data. All data were obtained using the Army of Women, an online community fostering breast cancer research. Breast cancer patients were stratified by surgical treatment and reconstruction type. Regression lines were estimated and differences in slope tested between cancer patients and noncancer controls.

Results:

The authors compared normative (n = 922) and breast cancer (n = 4343) cohorts in a propensity-matched analysis. Among the breast cancer patients, 49.4 percent underwent lumpectomy, 17.0 percent underwent mastectomy, 21.7 percent underwent implant reconstruction, and 11.9 percent underwent autologous reconstruction. Median time since surgery was 4.7 years, with 21.1 percent more than 10 years after surgery. At the time of survey, breast cancer patients reported higher Satisfaction with Breasts and Psychosocial Well-being scores compared to noncancer controls (p < 0.01), with the cohorts undergoing lumpectomy and autologous reconstruction both reporting higher scores than the normative controls. After mastectomy, scores averaged lower than the noncancer controls, but improved over time. However, all breast cancer groups reported significantly lower Physical Well-being scores than the noncancer cohort (all p < 0.01).

Conclusions:

Breast cancer patients undergoing lumpectomy or autologous reconstruction reported higher psychosocial well-being compared to noncancer controls. These differences were influenced both by time since treatment and by choice of surgical procedure.
Obesity and Breast Reconstruction: Complications and Patient-Reported Outcomes in a Multicenter, Prospective Study
Authors: Srinivasa Dhivya R. , Clemens Mark W. , Qi Ji , Hamill Jennifer B. , Kim Hyungjin M. , Pusic Andrea L. , Wilkins Edwin G. , Butler Charles E. , Garvey Patrick B.
Published: February 2020

Background:

The authors’ purpose was to evaluate the effects of body mass index, as defined by World Health Organization criteria, on complications and patient-reported outcomes in implant-based and autologous breast reconstruction.

Methods:

Complications and BREAST-Q patient-reported outcomes were analyzed 2 years after breast reconstruction for women from 11 participating sites. Separate mixed-effects regressions were performed to assess body mass index effects on outcomes.

Results:

A total of 2259 patients (1625 implant-based and 634 autologous) were included. Women with class II/III obesity had higher risks of any complication in both the implant (OR, 1.66; p = 0.03) and autologous (OR, 3.35; p < 0.001) groups, and higher risks of major complications in both the implant (OR, 1.71, p = 0.04) and autologous (OR, 2.72; p = 0.001) groups, compared with underweight/normal weight patients. Both class I (OR, 1.97; p = 0.03) and class II/III (OR, 3.30; p = 0.001) obesity patients experienced higher reconstructive failures in the implant cohort. Class I obesity implant patients reported significantly lower Satisfaction with Breasts scores (mean difference, –5.37; p = 0.007). Body mass index did not significantly affect patient-reported outcomes for autologous reconstruction patients.

Conclusions:

Obesity was associated with higher risks for complications in both implant-based and autologous breast reconstruction; however, it only significantly affected reconstruction failure and patient-reported outcomes in the implant reconstruction patients. Quality-of-life benefits and surgical risk should be presented to each patient as they relate to her body mass index, to optimize shared decision-making for breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, I.