bluuebunny/crossref_metadata_2025 huggingface dataset:
Integrating poly(ADP-ribose) polymerase (PARP) inhibitors in the treatment of early breast cancer
Authors: Garber Haven R. , Litton Jennifer K.
Published: February 2019

Purpose of review

Poly(ADP-ribose) polymerase (PARP) inhibitors were recently approved for the treatment of patients with BRCA1 or BRCA2 germline pathogenic variants and metastatic breast cancer. PARP inhibitors have also demonstrated activity in early stage breast cancer, and this review discusses completed and ongoing trials of PARP inhibitors in the neoadjuvant and adjuvant setting.

Recent findings

A recent phase II trial of neoadjuvant talazoparib monotherapy in patients with BRCA1 or BRCA2 germline pathogenic variants and early stage breast cancer demonstrated a pathological complete response in 10/19 (53%) patients. Previous trials of PARP inhibition in early stage breast cancer included the I-SPY-2 and BrighTNess trials, which ultimately failed to show a benefit for adding the PARP inhibitor veliparib to standard neoadjuvant chemotherapy in patients with triple-negative breast cancer. Investigators are building on these results by designing novel clinical trials for patients with BRCA1/2-deficient tumors and/or triple-negative breast cancer.

The OlympiAD and EMBRACA trials that led to the recent approval of PARP inhibitors for metastatic breast cancer patients with BRCA1/2 germline pathogenic variants are practice changing. Investigators are now working to translate this success into the early breast cancer setting where ongoing trials incorporate new dosing schedules, PARP inhibitor monotherapy, and novel PARP combinations.
Incidence of Neonatal Neutropenia and Leukopenia After In Utero Exposure to Chemotherapy for Maternal Cancer
Authors: La Nasa Maria , Gaughan John , Cardonick Elyce
Published: February 2019

Objective:

The main purpose of this article was to report the incidence of neonatal neutropenia or leukopenia after chemotherapy exposure during pregnancy according to the time elapsed between treatment during pregnancy and birth.

Background:

A single study reports 33% of infants exposed to chemotherapy within the last month of pregnancy are born with neutropenia, which can place the newborn at risk for nosocomial infections. On the basis of this report, chemotherapy is typically stopped by 34 weeks of pregnancy to avoid maternal or neonatal myelosuppression at delivery. Such a pause in treatment may affect maternal health. Determining the true incidence of neutropenia after chemotherapy in relation to the time of this lapse in treatment is important to support this practice.

Materials and Methods:

Complete blood counts are collected for newborn whose mothers were treated for cancer during pregnancy and enrolled in the Cancer and Pregnancy Registry. Neutropenia was defined as absolute neutrophil count<1000 mm3 and leukopenia was defined as white blood cells <5000 cells/μL. Incidence of neutropenia was calculated according to the time elapsed from last chemotherapy treatment until birth. Fisher’s exact test is used to determine if neutropenia or leukopenia is related to the time elapsed between chemotherapy during pregnancy and newborn birth. A Bayesian analysis evaluated the occurrence of neutropenia and leukopenia according to the number of days between the initiation of chemotherapy and birth.

Results:

A total of 135 infants exposed to chemotherapy in utero with a complete blood count collected at birth were identified from the database. Only 7.3% and 2.9% of infants were born with neutropenia or leukopenia, respectively. The highest incidence of newborn neutropenia occurred in infants delivered 22 to 28 days after chemotherapy.

Conclusions:

The incidence of neutropenia peaks when chemotherapy is given 22 to 28 days before birth, while leukopenia is highest if delivery is <7 days from chemotherapy.
The Impact of Muscle and Adipose Tissue on Long-term Survival in Patients With Stage I to III Colorectal Cancer
Authors: Hopkins Jessica J. , Reif Rebecca L. , Bigam David L. , Baracos Vickie E. , Eurich Dean T. , Sawyer Michael B.
Published: February 2019

BACKGROUND:

Computed tomography-derived body composition parameters are emerging prognostic factors in colorectal cancer.

OBJECTIVE:

This study aimed to determine the roles of sarcopenia, myosteatosis, and obesity as independent and overlapping parameters in stage I to III colorectal cancer.

DESIGN:

This is a retrospective cohort study from a prospectively collected database. Multivariate Cox proportional hazards models were performed to assess the associations between body composition parameters and survival.

SETTINGS:

All patients were seen in a tertiary care cancer center.

PATIENTS:

Adult patients with stage I to III colorectal cancer, undergoing curative resection from 2007 to 2009, were included.

INTERVENTION:

Computed tomography-derived quantification of skeletal muscle and adipose tissues was used to determine population-specific cutoffs for sarcopenia, myosteatosis, and total adiposity.

MAIN OUTCOME MEASURES:

Primary outcome measures were overall, recurrence-free, and cancer-specific survival.

RESULTS:

In the 968 patients included, there were a total of 254 disease recurrences and 350 deaths. Body mass index and CT-derived measures of adiposity did not result in worse survival outcomes. Sarcopenia was independently predictive of worse overall (HR, 1.45; 95% CI, 1.16-1.84), recurrence-free (HR, 1.32; 95% CI, 1.00–1.75), and cancer-specific survival (HR, 1.46; 95% CI, 1.09–1.94) in a multivariate model. Myosteatosis was also independently predictive of overall survival (HR, 1.53; 95% CI, 1.19–1.97). In a model considering joint effects of sarcopenia and myosteatosis, the presence of both predicted the worst overall (HR, 2.23; 95% CI, 1.62–3.06), recurrence-free (HR, 1.53; 95% CI, 1.06–2.21), and cancer-specific survival (HR, 2.40; 95% CI, 1.69–3.42) in a multivariate model.

LIMITATIONS:

The limitations of this study are inherent in retrospective observational studies.

CONCLUSIONS:

Sarcopenia and myosteatosis are independent predictors of worse survival in stage I to III colorectal cancer, and their joint effect is highly predictive of reduced overall, recurrence-free, and cancer-specific survival. See Video Abstract at http://links.lww.com/DCR/A923.
Predictors of Readmission Following Proctectomy for Rectal Cancer
Authors: O’Connell Emer P. , Healy Vincent , Fitzpatrick Fidelma , Higgins Caitriona A. , Burke John P. , McNamara Deborah A.
Published: February 2019

BACKGROUND:

Unplanned readmission after surgery negatively impacts surgical recovery. Few studies have sought to define predictors of readmission in a rectal cancer cohort alone. Readmission following rectal cancer surgery may be reduced by the identification and modification of factors associated with readmission.

OBJECTIVES:

This study seeks to characterize the predictors of 30-day readmission following proctectomy for rectal cancer.

DESIGN:

This study is a retrospective analysis of prospectively gathered cohort data. Outcomes were compared between readmitted and nonreadmitted patients. Multivariate analysis of factors association with readmission was performed by using binary logistic regression.

SETTINGS:

This study was conducted at Beaumont Hospital, a nationally designated, publicly funded cancer center.

PATIENTS:

Two hundred forty-six consecutive patients who underwent proctectomy for rectal cancer between January 2012 and December 2015 were selected.

MAIN OUTCOME MEASURES:

The primary outcomes measured were readmission within 30 days of discharge and the variables associated with readmission, categorized into patient factors, perioperative factors, and postoperative factors.

RESULTS:

Thirty-one (12.6%) patients were readmitted within 30 days of discharge following index rectal resection. The occurrence of anastomotic leaks, high-output stoma, and surgical site infections was significantly associated with readmission within 30 days (anastomotic leak OR 3.60, p = 0.02; high-output stoma OR 11.04, p = 0.003; surgical site infections OR 13.39, p = 0.01). Surgical site infections and high-output stoma maintained significant association on multivariate analysis (surgical site infections OR 10.02, p = 0.001; high-output stoma OR 9.40, p = 0.02). No significant difference was noted in the median length of stay or frequency of prolonged admissions (greater than 24 days) between readmitted and nonreadmitted patients.

LIMITATIONS:

The institutional database omits a number of socioeconomic factors and comorbidities that may influence readmission, limiting our capacity to analyze the relative contribution of these factors to our findings.

CONCLUSIONS:

An early postoperative care bundle to detect postoperative complications could prevent some unnecessary inpatient admissions following proctectomy. Key constituents should include early identification and management of stoma-related complications and surgical site infection. See Video Abstract at http://links.lww.com/DCR/A912.
Superior Mesenteric Artery Pseudoaneurysms in Patients With Familial Adenomatous Polyposis–Associated Intra-abdominal Desmoids: Case Series
Authors: Bolshinsky Vladimir , Xhaja Xhileta , Halleran David R. , Church James
Published: February 2019

BACKGROUND:

Rupture of a superior mesenteric artery pseudoaneurysm is a rare but potentially lethal complication in patients with familial adenomatous polyposis and desmoid disease.

OBJECTIVE:

We report our experience in the management of such patients with a rare but significant and life-threatening condition.

DESIGN:

This is a descriptive study of a small series of patients.

SETTINGS:

Data were obtained from their medical charts and from the Cologene Database of the David G. Jagelman Polyposis Registry in the Sanford R. Weiss, M.D., Center for Hereditary Colorectal Cancer at the Cleveland Clinic Foundation.

PATIENTS:

Of 227 patients with mesenteric desmoid disease, there were 4 cases of superior mesenteric artery pseudoaneurysm rupture.

MAIN OUTCOMES MEASURES:

We reviewed the patients with mesenteric desmoid tumors in our desmoid registry. The registry is approved by the institutional review board of the Cleveland Clinic.

RESULTS:

The patients were young (aged from 22 to 28 y at presentation), with otherwise minimal comorbidities. Two patients had a previous proctocolectomy and J-pouch, and 2 had a total colectomy and ileorectal anastomosis. Two patients had preemptive endoluminal stenting and fared better than the 2 who had damage control embolization. One patient died and, in the others, recovery was prolonged and complicated. Two of the 4 patients have ended up with a reasonable quality of life.

LIMITATIONS:

We acknowledge that this is a rare complication of an uncommon disease and, as such, any case series will be limited by small numbers; therefore, a tailored approach is warranted when managing such complex patients.

CONCLUSIONS:

We advocate an increased awareness of the possibility of visceral pseudoaneurysms in patients with familial adenomatous polyposis who have desmoid disease encasing the superior mesenteric artery. See Video Abstract at http://links.lww.com/DCR/A914.
Dermatologic Surgical Care for Transgender Individuals
Authors: Marks Dustin H. , Awosika Olabola , Rengifo-Pardo Monica , Ehrlich Alison
Published: February 2019

BACKGROUND

Transgender individuals experience common and unique dermatologic concerns from severe acne associated with testosterone therapy in transmen to complications due to illicit silicone injections in transwomen. Currently, 2 survey studies and 4 reviews have addressed the dermatologic care of transgender individuals. However, none of them provide a focus on the dermatologic surgeon.

OBJECTIVE

To assess the dermatologic considerations in transgender individuals and the role of dermatologic surgeon in their care.

METHODS

The PubMed and MEDLINE databases were reviewed in June 2018 using keywords, such as transgender, procedures, hair removal, laser, and hormone therapy.

RESULTS

In total, 48 relevant publications addressing dermatologic care in transgender patients were reviewed. According to the literature, there are several critical dermatologic considerations in transgender patients, including hair growth and removal, acne vulgaris, facial procedures to masculinize and feminize the face, scar removal, and sexually transmitted infections.

CONCLUSION

As dermatologic surgeons have the privilege to improve the health care of transgender patients, they must understand the common and unique concerns of transgender individuals. Given the considerable spectrum of physical goals expressed by transmen and transwomen, individual patient preference must ultimately guide his/her/their dermatologic care.
Intake of Antioxidants in Relation to Infertility Treatment Outcomes with Assisted Reproductive Technologies
Authors: Li Ming-Chieh , Nassan Feiby L. , Chiu Yu-Han , Mínguez-Alarcón Lidia , Williams Paige L. , Souter Irene , Hauser Russ , Chavarro Jorge E.
Published: February 2019

Background:

Randomized trials of supplementation with antioxidant mixtures during infertility treatment show no benefit on pregnancy or live birth rate. However, the roles of individual antioxidants are poorly understood. We examined the association of baseline intake of vitamins A, C, E, and carotenoids with outcomes of assisted reproductive technologies (ARTs).

Methods:

We followed 349 women undergoing a total of 588 ART cycles for infertility treatment at the Massachusetts General Hospital. We assessed antioxidant intakes from food and supplements before treatment using a validated food frequency questionnaire. We used generalized linear mixed models to account for multiple ART cycles per woman while adjusting for confounding.

Results:

Mean (SD) age and body mass index were 35.1 years (4.0 years) and 24.1 kg/m2 (4.3 kg/m2), respectively. Total intake of vitamins A, C, and E was not associated with the probability of live birth. Women in the highest intake category of β-carotene from foods had a lower probability of live birth than women in the lowest intake quartile (50% vs. 22%; P trend = 0.03); for lutein and zeaxanthin, the probability for the highest intake group was 44% vs. 28% for the lowest. Intake of β-carotene from supplements and intakes of retinol and all other carotenoids were unrelated to live birth rates.

Conclusions:

We found unexpected inverse associations of β-carotene intake from foods and of lutein and zeaxanthin intake with live birth rates. Within the observed intake ranges, total consumption of vitamins A, C, and E before starting infertility treatment with ART was not associated with live birth rates.
The Impact of Unemployment on Antidepressant Purchasing
Authors: Bijlsma Maarten J. , Wilson Ben , Tarkiainen Lasse , Myrskylä Mikko , Martikainen Pekka
Published: February 2019

Background:

The estimated effect of unemployment on depression may be biased by time-varying, intermediate, and time-constant confounding. One of the few methods that can account for these sources of bias is the parametric g-formula, but until now this method has required that all relevant confounders be measured.

Methods:

We combine the g-formula with methods to adjust for unmeasured time-constant confounding. We use this method to estimate how antidepressant purchasing is affected by a hypothetical intervention that provides employment to the unemployed. The analyses are based on an 11% random sample of the Finnish population who were 30–35 years of age in 1995 (n = 49,753) and followed until 2012. We compare estimates that adjust for measured baseline confounders and time-varying socioeconomic covariates (confounders and mediators) with estimates that also include individual-level fixed-effect intercepts.

Results:

In the empirical data, around 10% of person-years are unemployed. Setting these person-years to employed, the g-formula without individual intercepts found a 5% (95% confidence interval [CI] = 2.5%, 7.4%) reduction in antidepressant purchasing at the population level. However, when also adjusting for individual intercepts, we find no association (−0.1%; 95% CI = −1.8%, 1.5%).

Conclusions:

The results indicate that the relationship between unemployment and antidepressants is confounded by residual time-constant confounding (selection). However, restrictions on the effective sample when using individual intercepts can compromise the validity of the results. Overall our approach highlights the potential importance of adjusting for unobserved time-constant confounding in epidemiologic studies and demonstrates one way that this can be done.
How Transparency Efforts Helped One System’s Financial Turnaround
Authors: Purves Stephen A.
Published: February 2019

Healthcare consumerism, costs, and price transparency are garnering unprecedented attention from hospitals and health systems in the United States. To many observers of the US healthcare delivery system, the inability to provide accurate pricing information and the variability in prices for comparable services are utter failures of the administrative infrastructure that supports patient care processes.

Price transparency and the affordability of healthcare have also become top concerns for professional and trade organizations, which are devoting significant resources to assist member institutions in facing these issues. In many states, elected officials have passed legislation requiring pricing support for consumers. When the value equation (cost divided by quality) is considered, comparisons of healthcare providers can become even more confusing.

Price transparency and demonstration of cost-effective, high-quality service to patients have become strategic imperatives at Maricopa Integrated Health System (MIHS). A safety-net system and one of Arizona’s largest providers of graduate medical education and other teaching programs, MIHS faced an operating deficit of more than $74 million in fiscal year 2014. In 2015, financial concerns prompted the CEO and board to hold weekly meetings to appraise cash availability and management interventions. Over the next four years, MIHS achieved a cumulative improvement in net income of more than $150 million. Today, MIHS is reinventing itself through a major capital campaign made possible in part by a $935 million public bond referendum passed by the voters of Maricopa County. Ultimately, our ability to better serve the community involves connecting with our patients and addressing their need for price transparency.
Understanding Costs and Supporting Transparency—Keys to Quality Care
Authors: Decker Tina Freese
Published: February 2019

Demonstrating value is essential to the future success of healthcare organizations. Health systems that disrupt traditional delivery models and meet consumer demands will lead the way. However, value depends on understanding the true cost of care. Until now, determining the total cost of care has not been addressed for three primary reasons: (1) tackling such a herculean effort was not necessary; (2) a lack of effective coding, accounting, and billing tools connected to clinical systems made it next to impossible; and (3) consumers did not pay as much for their healthcare as they do now.

Diving headfirst into this challenge is Spectrum Health, a $6 billion system based in Grand Rapids, Michigan, with 14 hospitals, more than 225 service sites, a medical staff of 4,200 (about half of whom are members of its medical group), and a million-member health plan. Spectrum Health has transformed its care model and billing platform, transitioning to one electronic health record systemwide, because a high-performing, fully integrated approach ensures the highest-quality care and outcomes. At the same time, the cost of care directly correlates to what consumers pay through their insurance, and they want pricing information that can help lower their expenses. Spectrum Health’s insurance entity, Priority Health, is making significant strides in offering leading-edge price transparency tools.

This article outlines the challenges and opportunities in determining the total cost of care and ultimately reducing those costs. Equally important is translating this information into what consumers pay, as well as providing price transparency and other digital tools that engage consumers in their health and wellness.
Water Exposure and the Risk of Contact Lens–Related Disease
Authors: Arshad Memoona , Carnt Nicole , Tan Jacqueline , Ekkeshis Irenie , Stapleton Fiona
Published: February 2019

Purpose:

To describe the association of water exposure with contact lens (CL)–related disease and explore the guidelines regarding water exposure to CL wearers, provided by CL manufacturing industry, global public health, and CL–related professional associations.

Methods:

A review of the literature was conducted by searching PubMed, MEDLINE, and Web of Science databases up to September 2017 for articles published or translated in English using keywords: contact lens* AND tap water OR swimming OR showering OR water exposure AND microbial keratitis OR Acanthamoeba keratitis OR corneal infiltrate* OR ocular adverse event*. References in all relevant publications were also reviewed.

Results:

Water exposure during CL wear is associated with complications ranging from sterile corneal infiltrative events to sight-threatening infections. Despite the documented risks due to water exposure, water-related habits are common among CL wearers. This suggests a lack of awareness and understanding regarding the risks among CL wearers and potentially CL practitioners. Discrepancies exist in guidelines for CL hygiene and compliance provided by the CL manufacturing industry, global public health, and CL–related professional associations. There is also widespread use of water imagery within CL marketing and packaging materials. These factors may give rise to confusion among wearers and may contribute toward risk-taking behaviors.

Conclusions:

Consensus among stakeholders about water and CL care is needed. Guidelines should unequivocally advocate for the avoidance of any water exposure including handling CLs with wet hands, rinsing CLs or storage cases in tap water, showering while wearing CLs and swimming with CLs without wearing goggles.
Philadelphia Telemedicine Glaucoma Detection and Follow-up Study: Intraocular Pressure Measurements Found in a Population at High Risk for Glaucoma
Authors: Hark Lisa A. , Myers Jonathan S. , Pasquale Louis R. , Razeghinejad M. Reza , Maity Alisha , Zhan Tingting , Hegarty Sarah E. , Leiby Benjamin E. , Waisbourd Michael , Burns Christine , Divers Meskerem , Molineaux Jeanne , Henderer Jeffrey D. , Haller Julia A. , Katz L. Jay
Published: February 2019

Precis:

Intraocular pressure (IOP) measurements, when used during telemedicine eye screening alongside nonmydriatic fundus photography, were shown to improve the likelihood of accurate glaucoma and glaucoma-related diagnoses at the follow-up eye examination.

Purpose:

To determine if IOP measurements, used as an adjunct to nonmydriatic fundus photography, are useful in glaucoma telemedicine screening.

Materials and Methods:

A total of 902 high-risk individuals were screened for glaucoma at 7 primary care practices and 4 Federally Qualified Health Centers using telemedicine. Screening at visit 1 included fundus photography, assessing family history of glaucoma, and IOP measurements using a hand-held rebound tonometer. Participants with suspicious nerve findings for glaucoma, IOP>21 mm Hg or other ocular pathologies were invited for a follow-up appointment with an ophthalmologist (visit 2).

Results:

Of the 902 individuals screened at visit 1, 19.6% (n=177/902) had elevated IOP (>21 mm Hg). Fifteen participants were found to have an IOP>30 mm Hg at visit 1, including 2 with an IOP of >40 mm Hg. Among all who attended visit 2 (n=347), 10.9% had glaucoma and 7.2% had ocular hypertension. For participants having both suspicious nerve findings and IOP>21 mm Hg compared with those with neither, the odds ratio (OR) of being diagnosed with glaucoma was 4.48 (95% CI, 1.50-13.93; P=0.007), whereas for participants with suspicious discs and IOP≤21 mm Hg the OR was 2.04 (95% CI, 0.83-5.53; P=0.15).

Conclusions:

In this telemedicine vision screening setting, having a higher IOP at the screening visit increased the likelihood of receiving a final diagnosis of glaucoma. Therefore, this study supports incorporating IOP measurements, using a portable tonometer, into vision screening programs in high-risk populations.
Different Disc Characteristics Associated With High Myopia and the Location of Glaucomatous Damage in Primary Open-Angle Glaucoma and Normal-Tension Glaucoma
Authors: Lan Yu-Wen , Chang Shin-Yu , Sun Fang-Ju , Hsieh Jui-Wen
Published: February 2019

Précis:

Disc tilt is a characteristic of high myopia and related to lower wedge-shaped retinal nerve fiber layer (RNFL) defects in normal-tension glaucoma (NTG). In primary open-angle glaucoma (POAG), the direction of disc torsion corresponds to the location of wedge-shaped RNFL defects.

Purpose:

To evaluate the disc characteristics in high myopia and the relationships between disc tilt and torsion and the location of wedge-shaped RNFL defects in primary POAG and NTG.

Materials and Methods:

The differences in disc properties and clinical characteristics between POAG (n=53) and NTG (n=82), and between high myopic (<−6 D, n=77) and non–high myopic (≥−6 D, n=58) glaucoma, were investigated. The association between disc tilt and torsion and the location of wedge-shaped RNFL defects in POAG and NTG were assessed by univariate and multivariate logistic regression analyses.

Results:

In NTG, but not in POAG, high myopia eyes had significantly smaller discs, a lower tilt ratio (0.73±0.09), and more disc tilt (56.5%) than did non–high myopia eyes (0.80±0.09, 33.3%). In POAG, eyes with lower wedge-shaped RNFL defects had a significantly smaller torsion angle (−5.44±19.62 degrees, inferior disc torsion) than did eyes with upper defects (9.70±23.62 degrees, superior disc torsion;P=0.014). In NTG, a significantly decreased tilt ratio (0.74±0.93;P=0.001) and more disc tilt (55.9%,P=0.005) were found in eyes with lower wedge-shaped RNFL defects than in eyes with upper defects (0.81±0.09; 21.7%). The torsion degree and tilt ratio were the only factors associated with the location of wedge-shaped RNFL defects in POAG and NTG, respectively.

Conclusions:

In NTG, smaller and tilted discs were the characteristics of high myopia. Disc tilt was associated with lower wedge-shaped RNFL defects. In POAG, the direction of disc torsion corresponded to the location of the wedge-shaped RNFL defects.
Surgical Timing for Congenital Ptosis Should Not Be Determined Solely by the Presence of Anisometropia
Authors: Chisholm Smith Ann M. , Costakos Deborah M. , Harris Gerald J.
Published: February 2019

Purpose:

Timing of surgery in children with congenital ptosis is a critical component of care, and anisometropia is frequently cited as an indication for early intervention. The purpose of this study is to evaluate the change in refractive error following surgery for congenital ptosis to better inform decisions regarding the timing of surgery.

Methods:

A retrospective review of clinical records was performed on patients who underwent surgical correction of congenital ptosis in an academic oculoplastic surgery practice from 2002 to 2017. Patients with complete preoperative and postoperative refractive data were included in the study. Changes in refractive error following surgery were analyzed.

Results:

Among 184 pediatric patients who underwent ptosis surgery during the study period, 56 patients (71 eyes) met inclusion criteria. The mean age at surgery was 5.1 years. Mean refractive error change in all the operated eyes was a 0.82 D decrease in spherical equivalent (p = 0.1920) and a 0.40 D increase in cylinder (p = 0.0255). There were no statistically significant changes in spherical equivalent or cylinder in the control eyes.

Conclusions:

The authors data did not show movement toward normalization of refractive error following ptosis surgery. In fact, it showed a statistically significant worsening of astigmatism following surgery. Because refractive error does not improve following surgery, anisometropia should not be the sole indication for early surgery in congenital ptosis.
Giant Dermatofibrosarcoma Protuberans With Bilateral Orbital Involvement
Authors: Liou Victor , Chisholm Smith Ann , Logunova Valentina , Havlik Robert , Esmaili Neda
Published: February 2019

Dermatofibroma sarcoma protuberans (DFSP) is a rare, locally aggressive soft tissue sarcoma with a tendency for recurrence after excision. Although reports of unilateral orbital and bilateral eyelid disease exist, there have been no prior reports of DFSP with bilateral orbital involvement and no previously described cases of DFSP associated with transient optic neuropathy. The authors present a case report of a 34-year-old woman with a giant scalp DFSP involving the bilateral orbits. Despite radical resection with 5 cm margins where possible, multiple positive margins remained including deep positive margins at the bilateral superomedial retroseptal soft tissue. The patient completed adjuvant radiation for surgically unresectable disease. This case highlights the challenge of achieving local control given the disease extent and infiltration of the bilateral eyelids and orbits. This is the first reported case of DFSP with bilateral orbital involvement and associated transient optic neuropathy.
Barriers and Predictors Associated With Accessing Oral Healthcare Among Patients With Cardiovascular Disease in Australia
Authors: Sanchez Paula , Salamonson Yenna , Everett Bronwyn , George Ajesh
Published: February 2019

Background

Periodontal disease is associated with cardiovascular disease, and patients should be aware of this risk and seek dental care.

Objective

In this study, the authors sought to identify the barriers and predictors for seeking oral healthcare among patients with cardiovascular disease.

Methods

With the use of a cross-sectional descriptive study design, 307 patients with cardiovascular disease attending cardiac rehabilitation/outpatient cardiac clinics were surveyed between 2016 and 2017 in Sydney, Australia. Survey items included the prevalence of accessing dental services and a new “barriers to seeking frequent dental care” scale.

Results

Most respondents (81%) reported at least 1 oral health problem, yet only 10% received any oral health information and more than half (58%) saw a dentist in the preceding 12 months. The barriers to seeking frequent dental care scale was internally consistent (Cronbach's α = 0.82) with 2 subscales, identified as personal-related and system-related barriers to accessing oral healthcare. Respondents were more likely to have seen a dentist in the previous 12 months if they received oral health information (adjusted odds ratio [AOR], 5.08; 95% confidence interval [CI], 1.62–15.93), had private health insurance (AOR, 3.33; 95% CI, 1.91–5.83), reported low barriers (AOR, 2.68; 95% CI, 1.61–4.47), or were born overseas (AOR, 2.13; 95% CI, 1.25–3.63).

Conclusions

The accessibility and affordability of dental care, as well as lack of oral health awareness, are key barriers and predictors for patients with cardiovascular disease accessing dental care. Greater emphasis on oral health is needed in the cardiac setting, along with appropriate dental referral pathways.
Health Professionals Who Suffer Intimate Partner Violence: A Descriptive, Multicenter, and Cross-Sectional Study
Authors: Carmona-Torres Juan Manuel , Cobo-Cuenca Ana Isabel , Recio-Andrade Beatriz , Dios-Guerra Caridad , Lopez-Soto Pablo Jesús , Hidalgo-Lopezosa Pedro , Rodríguez-Borrego María Aurora
Published: February 2019

Objective

The purpose of this study was to know who are the people who assist women, who work as a health professional in the Spanish Public Health System, when they suffer intimate partner violence (IPV).

Methods

A descriptive, cross-sectional, multicenter study was conducted. The participants were female health professionals (N = 794) working within the Spanish Public Health System. The instrument used was Delgado, Aguar, Castellano, and Luna del Castillo's (2006) scale to measure ill-treatment of women.

Results

Two hundred seventy women suffered IPV (34%). Of the female health professionals who suffered IPV, 25.9% had spoken with someone about the violence, most commonly talking to trusted people (24.3%), a psychologist (24.3%), health professionals (20%), and others (20%). Married female health professionals living with their current or last partner/husband, residing in an urban area, and with their own salary were least likely to speak about their problem.

Conclusion

Female health professionals who suffer IPV usually speak about this problem with trusted people instead of consulting a health professional, which may leave the problem in the private sphere. This can be because of victims not wanting to report the violence for fear of their intimate partner or wanting it to remain private. This may deprive the victims of the help they need. For this reason, the health services should establish screening for IPV not only for their patients but also for their workers.
Use and Outcome of Local Anesthetic Painkilling Injections in Athletes: A Systematic Review
Authors: Gultekin Sinem , Chaker Jomaa Mohammad , Jenkin Rebekah , Orchard John W.
Published: February 2019

Background:

The use of local anesthetic painkilling injections to improve player availability is common practice in elite-level sport.

Objective:

To document the published use of local anesthetic injections in sport, according to number of injections, sites of injections, and complications reported.

Data Sources:

A systematic search of MEDLINE, Embase, CINAHL, AMED, Cochrane Database of Systematic reviews, SportDiscus, EBSCO Host, and Google Scholar.

Results:

One thousand nine hundred seventy local anesthetic injections reported on 540 athletes in 10 studies (from rugby league, American football, Australian football, and soccer) were reviewed. The most common areas of injection were as follows: the acromioclavicular (AC) joint; hand (including fingers); sternoclavicular joint (including sternum); rib injuries; and iliac crest contusions.

Discussion:

This review found some evidence of long-term safety for a limited number of injection sites (eg, AC joint) and some evidence of immediate complications and harmful long-term consequences for other sites. The quality of evidence is not high, with little long-term data and a lack of independent verification of the effects of the injections. Ideally, long-term follow-up should be conducted to determine whether these injections are safe, with follow-up undertaken independently of the treating physician and team.

Conclusions:

Based on limited publications, there is some evidence of long-term safety; however, there is a lack of clear proof of either absolute safety or long-term harm for many of these procedures. Physicians and players in professional sport should proceed with caution in using local anesthetic injections.
Long-Term Follow-Up of Intratympanic Methylprednisolone Versus Gentamicin in Patients With Unilateral Menière's Disease
Authors: Harcourt Jonny Philip , Lambert Aileen , Wong Phui Yee , Patel Mitesh , Agarwal Kiran , Golding John Foster , Bronstein Adolfo Miguel
Published: February 2019

Objectives:

To determine whether long term (>48 months) symptomatic vertigo control is sustained in patients with Menière's disease from a previous comparative trial of intratympanic methylprednisolone versus gentamicin, and if the two treatments remain nonsignificantly different at long-term follow-up.

Study Design:

Mail survey recording vertigo frequency in the previous one and six months, further intratympanic treatment received, and validated symptom questionnaires.

Setting:

Outpatient hospital clinic setting.

Patients:

Adult patients with definite unilateral refractory Menière's disease, who previously received intratympanic treatment in a comparative trial.

Intervention:

A survey of trial participants who received intratympanic gentamicin (40 mg/mL) or methylprednisolone (62.5 mg/mL).

Outcome measures:

Primary: number of vertigo attacks in the 6 months prior to receiving this survey compared with the 6 months before the first trial injection. Secondary number of vertigo attacks over the previous 1 month; validated symptom questionnaire scores of tinnitus, dizziness, vertigo, aural fullness, and functional disability.

Results:

Forty six of the 60 original trial patients (77%) completed the survey, 24 from the gentamicin and 22 from the methylprednisolone group. Average follow-up was 70.8 months (standard deviation 17.0) from the first treatment injection. Vertigo attacks in the 6 months prior to receiving the current survey reduced by 95% compared to baseline in both drug groups (intention-to-treat analysis, both p < 0.001). No significant difference between drugs was found for the primary and secondary outcomes. Eight participants (methylprednisolone = 5 and gentamicin = 3) required further injections for relapse after completing the original trial.

Conclusion:

Intratympanic methylprednisolone treatment provides effective long-lasting relief of vertigo, without the known inner-ear toxicity associated with gentamicin. There are no significant differences between the two treatments at long term follow-up.
Risk Factors for Tinnitus in 37,692 Patients Followed in General Practices in Germany
Authors: Kostev Karel , Alymova Svetlana , Kössl Manfred , Jacob Louis
Published: February 2019

Background:

Tinnitus is frequently associated with a major hearing handicap, which has a significant impact on the quality of life of patients.

Aims:

The goal was to analyze risk factors for tinnitus in patients followed in general practices in Germany.

Methods:

Patients who had received a first tinnitus diagnosis in one of 928 general practices between January 2014 and December 2017 were included in this study. Controls without a tinnitus diagnosis were matched (1:1) to tinnitus cases by age, sex, index year, and physician. In total, 18,846 patients with tinnitus and 18,846 matched controls without tinnitus were included in the present study. Potential risk factors for tinnitus included in the present study were diseases of the ear, diseases of the upper respiratory tract, mental disorders, diseases of the nervous system, endocrine diseases, diseases of the circulatory system, and hemolytic anemias. A multivariate logistic regression with stepwise selection was used to analyze the association between defined diagnoses and tinnitus.

Results:

A total of 20 diseases were significantly associated with tinnitus. The five diagnoses displaying the strongest effect were vestibular neuronitis (odds ratio [OR] = 3.29, 95% confidence interval [CI]: 1.56–6.90), Menière's disease (OR = 3.23, 95% CI: 1.78–5.86), Eustachian salpingitis and obstruction (OR = 2.51, 95% CI: 1.72-3.67), presbycusis (OR = 2.27, 95% CI: 1.93-2.67), and otalgia and ear effusion (OR = 1.99, 95% CI: 1.56–2.53).

Conclusions:

Tinnitus was associated with a wide range of conditions, in particular disorders of the ear.
Poor Health Literacy and Medication Burden Are Significant Predictors for Inadequate Bowel Preparation in an Urban Tertiary Care Setting
Authors: Kunnackal John George , Thuluvath Avesh J. , Carrier Hairong , Ahuja Nitin K. , Gupta Ekta , Stein Ellen
Published: February 2019

Goals:

The goal of this study was to identify factors impacting the quality of bowel preparation in an urban tertiary care setting.

Background:

Inadequate bowel preparation is encountered in 17% to 32% of colonoscopies performed in the United States. Suboptimal colonic visualization reduces the yield of screening colonoscopies and increases healthcare costs because of longer procedure times and aborted procedures.

Study:

We performed a cross-sectional survey in patients undergoing outpatient colonoscopy within the Johns Hopkins Health System. A Boston Bowel Preparation Score (BBPS) score of <5 was considered inadequate. Fisher’s exact, χ2 tests and univariate and multivariate binary logistic regression were performed to assess the strength of the association for selected factors with a BBPS<5.

Results:

In total, 467 patients (76.3% response rate) completed the survey between August 2017 and October 2017. The median BBPS score was 7, and 81.4% of patients had an adequate bowel preparation (BBPS≥5). There was significant association between bowel preparation adequacy and level of education, health literacy, functional status, income, and medication burden. When adjusted for other factors, poor confidence in filling forms (OR, 24.1; P<0.001), multiple daily prescription medications (OR, 12.49; P=0.02) and poor functional status (OR, 2.82; P=0.03) had the highest odds of predicting inadequate bowel preparation.

Conclusions:

Inadequate bowel preparation is a significant problem accounting for reduced yield of screening and increased health care costs. Poor health literacy, functional status, and number of daily medications are significant factors predicting inadequate bowel preparation in the tertiary care setting.
Antioxidants for Pancreatic Functions in Chronic Pancreatitis
Authors: Singh Namrata , Ahuja Vineet , Sachdev Vikas , Upadhyay Ashish D. , Goswami Ravinder , Ramakrishnan Lakshmy , Dwivedi Supriya , Saraya Anoop
Published: February 2019

Background:

Antioxidants (AO) supplementation in chronic pancreatitis (CP) has been evaluated for pain. But it is not clear whether AO in CP have an effect on pancreatic functions and other clinical outcomes. We evaluated effect of AO on endocrine function in CP.

Materials and Methods:

Double-blind placebo (PL)-controlled randomized pilot study on 107 patients with CP assigned to receive daily combined AO or PL for 6 months. Primary outcome was: improvement in endocrine function (Homeostasis Model Assessment-Insulin Resistance). Secondary outcome measures were: improvement in C-peptide, Qualitative Insulin Sensitivity Check Index, exocrine pancreatic function (fecal elastase), surrogate markers of fibrosis (platelet-derived growth factor BB, transforming growth factor-β1, α-smooth muscle actin), quality of life (QOL), pain, nutritional status, markers of oxidative stress (OS), AO status, and inflammation.

Results:

There was an increase in levels of serum selenium (107.2±26.9 to 109.7±26.9 vs. 104.1±28.6 to 124.0±33.6 μg/L, P=0.022) and serum vitamin E [0.58 (range, 0.27-3.22) to 0.66 (range, 0.34-1.98) vs. 0.63 (range, 0.28-1.73) to 1.09 (range, 0.25-2.91) mg/dL, P=0.001] in the AO than the PL group. However, no significant differences were observed between groups in any of the primary or secondary outcome measures.

Conclusions:

Supplementation with AO to patients with CP causes a sustained increase in blood levels of AO; however, it has no addition benefit over PL on endocrine and exocrine functions, markers of fibrosis, OS and inflammation, nutritional status, pain and QOL. Further larger studies with adequate sample size are required.
More Severe Deficits in Performance Status at Time of Liver Transplant is Associated With Significantly Higher Risk of Death Following Liver Transplantation
Authors: McCabe Patrick , Gish Robert G. , Cheung Ramsey , Wong Robert J.
Published: February 2019

Goal:

To evaluate the impact of Karnofsky Performance Status score (KPSS) at the time of liver transplantation (LT) on post-LT survival.

Background:

While the Model for End-Stage Liver Disease (MELD) score is used to prioritize individuals for LT, it does not specifically incorporate functional status into patient assessment for LT.

Methods:

Using 2005 to 2016 United Network for Organ Sharing data, all adults (age 18 y and above) undergoing LT were identified. The association of KPSS at the time of LT (KPSS 1: functional status 80% to 100%, KPSS 2: 60% to 70%, KPSS 3: 40% to 50%, KPSS 4: 10% to 30%) with post-LT survival was evaluated using Kaplan-Meier methods and adjusted multivariate logistic regression models.

Results:

Among 66,397 LT recipients (68% male, 72% non-Hispanic white, 22% hepatocellular carcinoma, median age: 55 to 57), women were more likely to be KPSS 4 at the time of LT compared with men (27.95% vs. 22.79%; P<0.001) and African Americans (25.43% vs. 23.03%; P<0.001) and Hispanics (31.69% vs. 23.03%; P<0.001) were more likely to be KPSS 4 than non-Hispanic whites. Worse KPSS at LT correlated with higher post-LT mortality [compared with KPSS 1: Hazard Ratio (HR) for KPSS 2: 1.16, 95% confidence interval (CI): 1.10-1.22; HR for KPSS 3: 1.40; 95% CI: 1.32-1.49; HR for KPSS 4: 1.67; 95% CI: 1.55-1.79]. This increased mortality seen with worse KPSS was observed among all liver disease etiologies and in patients with and without hepatocellular carcinoma.

Conclusions:

Worse functional status at the time of LT is strongly associated with higher risk of mortality following LT, emphasizing the importance of optimizing performance status in the preoperative period.
Has Increased Rollout of Direct Acting Antiviral Therapy Decreased the Burden of Late Presentation and Advanced Liver Disease in Patients Starting Hepatitis C Virus Therapy in Germany?
Authors: Bischoff Jenny , Boesecke Christoph , Ingiliz Patrick , Berger Florian , Simon Karl-Georg , Lutz Thomas , Schewe Carl K. , Schulze zur Wiesch Julian , Hueppe Dietrich , Christensen Stefan , Mauss Stefan , Baumgarten Axel , Rockstroh Jürgen K.
Published: February 2019

Goals and Background:

International guidelines recommend prioritized treatment initiation in hepatitis C virus (HCV)-infected patients with advanced liver disease. We aimed to evaluate whether the widespread usage of direct acting antivirals (DAAs) has led to a decrease in late presentation for care.

Study:

Data derived from the multicenter German Hepatitis C Cohort (GECCO) was analyzed. Treatment naive HCV-infected patients initiating DAA-based treatment between January 2014 and September 2017 were included. Advanced liver disease was defined by aspartate aminotransferase to platelet ratio index score ≥1.5, METAVIR≥F3, or FibroScan ≥9.5 kPa. Period prevalence and risk factors for late presentation were evaluated.

Results:

Six hundred fifty-three HCV-monoinfected and 210 HIV/HCV-coinfected patients (mean age, 48.6±12.7 y; 65.5% male) were included. Overall 32.5% of patients had advanced liver disease. In 2014 39.4% of patients presented with advanced liver disease, decreasing to 30.1%, 34.4%, and 26.4% in the years 2015, 2016, and 2017 (P=0.057), respectively. Patients with and without advanced liver disease differed in age (P<0.0001), CD4+ ≤350/µL (P=0.027), genotype (P=0.005), transmission route (P=0.047), body mass index (P<0.001), and time since diagnosis (P=0.007). In the multivariable binary logistic regression analysis GT3, age above 45 years and being diagnosed >2 years ago were positively and HCV transmission through men who have sex with men was negatively associated with advanced liver disease.

Conclusions:

Overall 32.5% of patients presented with advanced liver disease. We observed a trend toward a lower proportion of patients starting treatment late.

GT3, age, years since HCV diagnosis and HCV transmission route were identified as risk factors for presentation with advanced liver disease.