bluuebunny/crossref_metadata_2025 huggingface dataset:
Cervical Facet Nerve Block: Ultrasound
Authors: Siegenthaler Andreas
Published: April 2017

The cervical facet joints are well-documented sources of chronic neck pain and headache. Ultrasound may offer the advantage of visualizing the actual target nerves, which is not possible with fluoroscopy. The relevant structures are located much more superficially than in the lumbar spine, hence visibility of the potential targets with ultrasound is expected to be better than in the lumbar region. Besides the ability to perform diagnostic nerve blocks, ultrasound imaging is expected to increase precision of radiofrequency neurotomy due to the ability to localize the exact course of a facet joint supplying nerve. For practitioners with only little experience in cervical sonoanatomy, we recommend performing ultrasound-guided cervical medial branch blocks with parallel fluoroscopic control first till one gains more experience. Correct level determination with ultrasound as described may be difficult for beginners, and the parallel use of fluoroscopy will help developing a “feel” for the procedure.
Cervical Intra-Articular Facet Injection: Computed Tomography
Authors: Vydyanathan Amaresh , Gritsenko Karina , Narouze Samer N. , Brook Allan L.
Published: April 2017

Intra-articular facet joint injections commonly refer to the injection of a contrast media and local anesthetic solution, with or without corticosteroids, directly into the facet joint space. The purpose of this procedure is pain relief as well as to establish an etiological diagnosis for surgical interventions such as joint denervation or radiofrequency ablation. Medial branch block, or facet nerve block, refers to injection of local anesthetic and possible corticosteroids along the medial branch nerve supplying the facet joints. Cervical intra-articular and facet nerve block injections are often part of a work-up for general or focal neck pain, headaches, or cervical muscle spasms. There is limited evidence for short- and long-term pain relief with cervical intra-articular facet joint injections. Cervical medial branch nerve blocks with local anesthetics demonstrate moderate evidence for short- and long-term pain relief with repeat interventions, and strong evidence exists for long-term pain relief following cervical radiofrequency neurotomy.
Thoracic Epidural and Nerve Root Injections: Fluoroscopy
Authors: Cheng Jianguo
Published: April 2017

Thoracic nerve root blocks can be achieved by interlaminal epidural, transforaminal epidural, paravertebral, and selective nerve root injections. The interlaminal approach allows blocking multiple nerve roots bilaterally, while the transforaminal approach has the advantage of depositing the injectate primarily to the anterior epidural space on the side of the injection, closer to the pathology. The paravertebral approach is often used to block multiple nerve roots on the side of injection, and the selective nerve root block is used to target a specific nerve root using a small volume of injectate. Fluoroscopy-guided injection the most commonly used technique. Contrast materials are often used to confirm the appropriate needle placement and monitor the spread of the injectate. Thoracic nerve root block and transforaminal epidural block are perceived as technically demanding due to anatomic complexity of the thoracic spine, its proximity to the lungs and major vasculature, and potential complications.
Thoracic Nerve Root and Facet Injections: Computed Tomography
Authors: Vydyanathan Amaresh , Brook Allan L. , Kosharskyy Boleslav , Narouze Samer N.
Published: April 2017

Thoracic back pain patients present with associated radiculopathy, degenerative disc disease, spondylosis, stenosis, scoliosis, rib fractures, tumors, or after undergoing thoracic surgery. Thoracic transforaminal or selective nerve root blocks (SNRBs) may be both therapeutic and diagnostic. Therapeutic injections may include either local anesthetics for pain relief or corticosteroids for anti-inflammatory effects. The two types of pain amenable to therapeutic SNRBs include pain caused by irritation or direct pressure on a spinal nerve and pain originating from anatomic structures that are innervated by the sinuvertebral nerve. Although these blocks are traditionally performed under fluoroscopic guidance, computed tomography (CT) and CT fluoroscopy have been increasingly used to direct needle placement and have been advocated by experts due to superior visualization of the needle tip and the ability to clearly define spinal anatomy and adjacent soft-tissues.
Lumbar Transforaminal/Nerve Root Injections: Computed Tomography
Authors: Vydyanathan Amaresh , Shaparin Naum , Brook Allan L. , Narouze Samer N.
Published: April 2017

This chapter discusses the accuracy and safety of lumbar transforaminal or nerve root (periradicular) injections under CT guidance. To maximize procedure accuracy and minimize complications, spinal injections are best performed with image guidance. Though fluoroscopic guidance has been used for decades, greater accuracy and possibly greater safety can be achieved with CT guidance. The radiation exposure is operator dependent, and maintaining the lowest possible dose is critical in optimizing patient care. This is also true for fluoroscopic guidance, for which coning and intermittent exposure are used as well. The future may usher in ultrasound and magnetic resonance imaging guidance without the associated radiation exposure. For interventional practitioners, ensuring patient safety and efficacy goals remains a priority, and needs to evolve with advances in technology.
Lumbar Epidural Injections: Fluoroscopy
Authors: Souzdalnitski Dmitri , Tankha Pavan , Lerman Imanuel R.
Published: April 2017

Lumbar epidural injection is most often performed for patients experiencing low back pain with radicular symptoms. The radicular symptoms can be precipitated by disc herniation or foraminal stenosis. In addition, spinal stenosis with associated neurogenic claudication is another common indication for this injection. These procedures may be effective in treatment of other syndromes that are associated with radiculopathic low back pain, including intervertebral disc degeneration without disc herniation, central spinal stenosis, spondylothesis, and failed lumbar back surgery syndrome. Lumbar epidural steroid injection (LESI) is the most commonly performed intervention. Fluoroscopically guided lumbar epidural injections led to a lower rate of complications than that reported for all lumbar epidural injections.
Caudal Epidural Steroid Injection: Ultrasound
Authors: Lerman Imanuel R.
Published: April 2017

Ultrasound guidance can facilitate caudal epidural steroid injection by providing a clear view of the sacrum, the sacral hiatus, and the needle as it is advanced through the sacrococcygeal ligament into the sacral hiatus. Using ultrasound guidance for the initial needle insertion can eliminate the exposure of the physician and patient to ionizing radiation. However, the use of ultrasound guidance as a sole imaging technique for caudal epidural steroid injection does have disadvantages. Contrast fluoroscopic guidance is necessary to visualize the needle once it passes under the apex of the sacral hiatus to confirm that the needle tip is extradural and indeed extravascular. The use of ultrasound and fluoroscopic guidance takes advantage of each imaging modality to enhance the safety and accuracy of the caudal epidural steroid injection.
Vertebral Augmentation: Fluoroscopy and CT
Authors: Vallejo Ricardo , Benyamin Ramsin
Published: April 2017

Osteoporosis, an age-related condition, is becoming a major public health problem. Vertebral compression fractures (VCFs) constitute the most frequent complication of osteoporosis. The pain and immobility caused by osteoporotic VCFs are linked to significant morbidities and impaired quality of life. Percutaneous techniques such as vertebroplasty and vertebral augmentation have emerged as viable treatments for acutely painful VCFs over the last several decades. Vertebroplasty (PV) and balloon kyphoplasty (KP) are minimally invasive vertebral augmentation procedures involving injection of polymethylmethacrylate cement under radiologic control into a fractured vertebral body. Vertebroplasty appears to offer a comparable rate of postoperative pain relief as kyphoplasty while using less bone cement, more often via a unilateral approach and without the attendant risk of adjacent level fracture.
Cervical Sympathetic Block: Fluoroscopy
Authors: Narouze Samer N.
Published: April 2017

In those patients with significant sympathetically maintained pain, repeated blocks may provide a therapeutic value and help facilitate physical therapy and rehabilitation. Cervical sympathetic blocks have been traditionally performed by using surface landmarks, however imaging-guided blocks are strongly recommended to avoid potential serious complications. Most preganglionic sympathetic efferents innervating the head, neck, and upper extremity either pass through or synapse at the stellate ganglion. This provides an ideal target for blockade of sympathetic innervation to the head, neck, and upper limbs. The stellate ganglion block can be performed at the C6 and C7 transverse processes. Fluoroscopy is a reliable method for identifying bony surfaces, which facilitates identifying the C6 and C7 transverse processes; however, this is only a surrogate marker, because the location of the cervical sympathetic trunk is defined by the fascial plane of the prevertebral fascia, which cannot be visualized with fluoroscopy.
Cervical Sympathetic Block: Ultrasound
Authors: Narouze Samer N.
Published: April 2017

To improve the safety of the stellate ganglion block (SGB), the techniques for SGB have evolved over time from the standard blind technique to fluoroscopy and more recently to ultrasound-guided technique. Ultrasound-guided SGB may also improve the safety of the procedure by direct visualization of vascular structures and soft-tissue structures. Accordingly, the risk of vascular and soft-tissue injury may be minimized. Ultrasound guidance will allow direct monitoring of the spread of the injectate and hence may minimize complications such as recurrent laryngeal nerve (RLN) palsy and intrathecal, epidural, or intravascular spread.
Cervical Sympathetic Block and Neurolysis: Computed Tomography
Authors: Kastler Adrian , Kastler Bruno
Published: April 2017

The stellate ganglion blockade technique is used to treat complex regional pain syndrome (CRPS). It is now well established that stellate blockades should be performed under imaging guidance. It has been suggested that alcohol may bring longer lasting relief in cases of severe intractable cancer-related pain arising from regional neoplasms invading the stellate ganglion, but frequent onset of Horner’s syndrome can outweigh the technique’s efficacy. Radiofrequency neurolysis (RFN) has become a common procedure in the management of chronic neuropathic pain. This chapter reviews indications of stellate ganglion procedures and describes the basic anatomical background, as knowledge of the anatomical surroundings of the stellate ganglion is a necessary prerequisite to a safe and successful procedure. Then it demonstrates how CT-guidance allows a step-by-step control of positioning the needle tip at target for either alcohol or radiofrequency thermal ablation, and discusses the results, advantages, and disadvantages of each approach.
Lumbar Sympathetic Block: Fluoroscopy
Authors: Narouze Samer N.
Published: April 2017

Lumbar sympathetic blocks (LSB) result in the interruption of the sympathetic efferent fibers to the lower extremities with sparing of the somatic nerves, thus providing a diagnostic value as to the relative sympathetic contribution to the patient’s pain syndrome. In those patients with significant sympathetically maintained pain, repeated blocks may provide a therapeutic value and help facilitate physical therapy. The original described technique is the paramedian or “classic” approach described by Mandl in 1926. A more lateral approach was later developed by Reid and colleagues. The incidence of complications related to lumbar sympathetic blockade is minimal. The complications result either from insertion and manipulation of the needle or as a direct result of the injected solution.
Lumbar Sympathetic Block and Neurolysis: Computed Tomography
Authors: Kastler Bruno , Kastler Adrian
Published: April 2017

Lumbar sympathetic block and neurolysis are accepted treatment procedures in patients with sympathetic mediated lower limb pain and patients with advanced peripheral arterial disease. The use of imaging guidance is highly recommended in order to achieve best possible results and to avoid complications. The high image resolution (as opposed to fluoroscopy) and high availability (as opposed to MRI) offered by CT makes it the imaging guidance technique preferred. This chapter reviews the indications of lumbar sympathetic chain blockade and neurolysis and the basic anatomical background. Then it demonstrates how CT guidance allows a step-by-step control of positioning the needle tip at the target for either lumbar blockade or alcohol neurolysis and the advantages and disadvantages of each technique are summarized.
Celiac Plexus Blockade and Neurolysis: Ultrasound
Authors: Narouze Samer N.
Published: April 2017

There has been a growing interest in ultrasound-guided celiac plexus blocks, especially neurolytic blocks, for terminally ill patients with upper abdominal malignancies. These patients are usually frail and difficult to transfer to the radiology suite. Ultrasound-guided celiac plexus neurolytic block can be performed at the bedside with appropriate monitoring. This chapter focuses on ultrasound guidance. It reviews the advantages of ultrasound compared with other imaging modalities in celiac plexus block as well as the step-by-step technique and how to avoid complications.
Celiac Plexus Blockade and Neurolysis: Computed Tomography
Authors: Narouze Samer N.
Published: April 2017

Computed tomography–guided celiac plexus interventions, especially neurolytic blocks, have become a popular technique as neurolytic blocks require precise placement of the needle into the plexus and careful monitoring of the spread of the neurolytic solution to minimize potential complications. The chapter focuses on CT guidance. It reviews the advantages of CT compared with other imaging modalities in celiac plexus blocks (CPBs) as well as the step-by-step technique and how to avoid complications.
Sacroiliac Joint Injections: Fluoroscopy
Authors: Souzdalnitski Dmitri , Kramer Adam , Guirguis Maged
Published: April 2017

Sacroiliac joint (SIJ) injections are valuable tools for diagnosing the source of low back pain and selecting patients for a radiofrequency ablation procedure, which tends to provide long-term relief for low back pain associated with SIJ dysfunction. Sacroiliac joint injections are generally safe and well-tolerated procedures. The most common complication is initial pain from distension of the joint capsule with contrast and local anesthetic. Despite adequate intra-articular needle placement, extravasation of local anesthetic may diffuse to lumbosacral nerve roots and/or the sciatic nerve, causing transient numbness and/or weakness. This chapter reviews the advantages of fluoroscopically guided SIJ injections as well as the step-by-step technique and how to avoid complications.
Hip Joint Injections: Ultrasound
Authors: Shankar Hariharan , Vardanyan Marina
Published: April 2017

Hip pain is a common presentation in medical practice, and causes include osteoarthritis, rheumatoid arthritis, congenital hip abnormalities, and trauma. Chronic hip pain significantly alters the patient’s quality of life and commonly leads to disability due to damage of structural elements of the hip joint. Ultrasound-guided hip injections are a viable alternative to fluoroscopically guided hip injections. Ultrasound imaging of the hip is a highly sensitive method for detecting joint pathology and periarticular pathology as well. This method is fast, safe, can be used in an ambulatory setting, and allows precise deposition of injectate into the hip joint.
Psoas and Quadratus Lumborum Muscle Injections: Fluoroscopy
Authors: Malik Tariq , Benzon Honorio T.
Published: April 2017

This chapter discusses the use of fluoroscopy in the performance of psoas and quadratus lumborum muscle injections. These muscles are quite often involved in the genesis of back pain. Unlike other pain syndromes, such as piriformis and thoracic outlet syndromes, that have characteristics signs and symptoms, myofascial pain involving the iliopsoas and quadratus muscles are only characterized by trigger points and/or muscle spasm. One reason for injecting the muscles is to avoid several trigger point injections using large volumes of local anesthetics.
Accuracy of Zero-Heat-Flux Cutaneous Temperature in Intensive Care Adults
Authors: Dahyot-Fizelier Claire , Lamarche Solène , Kerforne Thomas , Bénard Thierry , Giraud Benoit , Bellier Rémy , Carise Elsa , Frasca Denis , Mimoz Olivier
Published: April 2017

Objectives:

To compare accuracy of a continuous noninvasive cutaneous temperature using zero-heat-flux method to esophageal temperature and arterial temperature.

Design:

Prospective study.

Setting:

ICU and NeuroICU, University Hospital.

Patients:

Fifty-two ICU patients over a 4-month period who required continuous temperature monitoring were included in the study, after informed consent.

Interventions:

All patients had esophageal temperature probe and a noninvasive cutaneous device to monitor their core temperature continuously. In seven patients who required cardiac output monitoring, continuous iliac arterial temperature was collected. Simultaneous core temperatures were recorded from 1 to 5 days. Comparison to the esophageal temperature, considered as the reference in this study, used the Bland and Altman method with adjustment for multiple measurements per patient.

Measurements and Main Results:

The esophageal temperature ranged from 33°C to 39.7°C, 61,298 pairs of temperature using zero-heat-flux and esophageal temperature were collected and 1,850 triple of temperature using zero-heat-flux, esophageal temperature, and arterial temperature. Bias and limits of agreement for temperature using zero-heat-flux were 0.19°C ± 0.53°C compared with esophageal temperature with an absolute difference of temperature pairs equal to or lower than 0.5°C of 92.6% (95% CI, 91.9–93.4%) of cases and equal to or lower than 1°C for 99.9% (95% CI, 99.7–100.0%) of cases. Compared with arterial temperature, bias and limits of agreement were –0.00°C ± 0.36°C with an absolute difference of temperature pairs equal to or lower than 0.5°C of 99.8% (95% CI, 95.3–100%) of cases. All absolute difference of temperature pairs between temperature using zero-heat-flux and arterial temperature and between arterial temperature and esophageal temperature were equal to or lower than 1°C. No local or systemic serious complication was observed.

Conclusions:

These results suggest a comparable reliability of the cutaneous sensor using the zero-heat-flux method compared with esophageal or iliac arterial temperatures measurements.
Cutaneous Rosai–Dorfman Disease With Linear Lesions and Monoclonal Gammopathy
Authors: Bae Edward , White Paul , Brophy Mary , Lichtman Michael , Krathen Michael S. , Mahalingam Meera
Published: April 2017

Cutaneous Rosai–Dorfman disease (CRDD), a benign histiocytosis of unknown etiology, typically presents as a solitary or clusters of lesions. Although the histopathology is fairly distinctive, the laboratory abnormalities are not; past reports note elevated erythrocyte sedimentation rate, anemia, and polyclonal hyperglobulinemia. We describe a 61-year-old African American diabetic gentleman who presented with nodules in a linear distribution on the flank. Histopathologic examination of a biopsied nodule revealed a pandermal sheet-like infiltrate of plasma cells and histiocytes, some demonstrating elastophagocytosis and emperipolesis. The lesional histiocytes were S100 and CD68 positive and CD1a negative—findings consistent with a diagnosis of CRDD. Additional laboratory work-up performed 12 weeks after the biopsy was taken revealed an elevated serum κ light chain concentration of 37.26 mg/L (reference range: 3.30–19.40 mg/L), which correlated with an M-protein spike identified as IgG κ proteins per serum protein electrophoresis. Given the difficulty in excising a large area and preexisting diabetes, a course of low-dose methotrexate was selected for therapy with a recommendation of close follow-up for the monoclonal gammopathy. To the best of our knowledge, this is the first report of CRDD associated with a linear distribution of lesions and serum protein electrophoresis–confirmed monoclonal gammopathy.
Adverse effects of laxatives: update
Authors: Anton Christopher , Crawford Colin
Published: April 2017

Laxatives are generally well tolerated and adverse effects mild or moderate, although rarely adverse effects can be fatal. Several laxatives have recently been licensed for intractable constipation not relieved by simple laxatives, opioid-induced constipation, and irritable bowel syndrome with constipation. Like the older laxatives, the new laxatives usually cause only mild adverse effects, although some serious effects have been reported.
2, 3, 5, 4′-Tetrahydroxystilbene-2-O-β-d-glucoside prevention of lipopolysaccharide-induced depressive-like behaviors in mice involves neuroinflammation and oxido-nitrosative stress inhibition
Authors: Chen Zhuo , Huang Chao , He Haiyan , Ding Wenbin
Published: April 2017

Although numerous hypotheses have been raised in recent years, the exact mechanisms that promote the development of major depression are largely unknown. Recently, strategies targeting the process of neuroinflammation and oxidative stress in depression have been attracting greater attention. 2, 3, 5, 4′-Tetrahydroxystilbene-2-O-β-d-glucoside (TSG), a compound purified from a traditional Chinese herbal medicine polygonummultiflorum, has been widely reported to inhibit neuroinflammation and oxidative stress. In this context, we investigated whether TSG affects lipopolysaccharide (LPS)-induced depressive-like behaviors in a manner associated with neuroinflammation and oxido-nitrosative stress. Results showed that administration of ICR mice with 0.83 mg/kg of LPS-induced typical depressive-like behaviors in the experiments of the tail-suspension test, the forced-swimming test, and sucrose preference, and these behaviors were prevented by TSG treatment (30 and 60 mg/kg). Further analysis showed that TSG pretreatment at the doses of 30 and 60 mg/kg not only inhibited the production of proinflammatory cytokines induced by LPS, such as interleukin-1β, interleukin-6, and tumor necrosis factor-α, but also prevented the LPS-induced enhancement of oxido-nitrosative stress in mouse hippocampus and prefrontal cortex. The LPS-induced decreases in brain-derived neurotrophic factor levels in the hippocampus and prefrontal cortex were also prevented by TSG treatment. Generally, our data provide evidence to show that TSG could be used to cope with depressive-like symptoms by inhibition of neuroinflammation and oxido-nitrosative stress.
Comorbidities in Patients With Chronic Obstructive Pulmonary Disease and Pulmonary Rehabilitation Outcomes
Authors: Tunsupon Pichapong , Lal Ashima , Abo Khamis Mohammed , Mador M. Jeffery
Published: April 2017

Purpose:

The objective of this study was to evaluate the impact of comorbidities as potential predictors of the response to pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD).

Methods:

The study included 165 patients with COPD with exercise limitations. Comorbidity was classified as cardiac, metabolic, orthopedic, behavioral health problems, or other diseases. Number of comorbidities was grouped as 0, 1, or ≥2. Outcomes were defined as improvement in exercise capacity (maximal exercise capacity, 6-minute walk test, and constant workload cycle exercise duration) and quality of life (Chronic Respiratory Questionnaire). We assessed the effect of comorbidities on improvement in outcomes and the impact of the number of comorbidities on the percentage of patients reaching the minimal clinically important difference for each outcome.

Results:

Most patients (n = 160; 96%) were elderly males (mean age 70 years) with COPD Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages II to IV. Sixty-four percent of patients had at least 1 comorbidity. The ≥2 comorbidity group (n = 29) had a higher modified Charlson index and more patients required continuous supplemental oxygen. Absolute differences in dyspnea scores in patients with cardiac disease and orthopedic problems compared with those without these comorbidities were 2.6 ± 0.87; 95% CI 0.89 to 4.32; p = .003, and −3.25 ± 1.23; 95% CI −5.69 to −0.82; p = .009, respectively. Comorbidities had no significant effect on other exercise outcomes or quality of life.

Conclusion:

Patients with cardiac disease experienced greater improvement in the dyspnea score compared with patients with no cardiac disease, whereas patients with orthopedic problems had a smaller but also clinically significant improvement in dyspnea after pulmonary rehabilitation.
Effects of Breathing-Based Meditation on Earthquake-Affected Health Professionals
Authors: Iwakuma Miho , Oshita Daien , Yamamoto Akihiro , Urushibara-Miyachi Yuka
Published: April 2017

On March 11, 2013, the Great East Japan Earthquake (magnitude 9) hit the northern part of Japan (Tohoku), killing more than 15 000 people and leaving long-lasting scars, including psychological damage among evacuees, some of whom were health professionals. Little is known about meditation efficacy on disaster-affected health professionals. The present study investigated the effects of breathing-based meditation on seminar participants who were health professionals who had survived the earthquake. This study employed a mixed methods approach, using both survey data and handwritten qualitative data. Quantitative results of pre- and postmeditation practice indicated that all mood scales (anger, confusion, depression, fatigue, strain, and vigor) were significantly improved (N = 17). Qualitative results revealed several common themes (emancipation from chronic and bodily senses; holistic sense: transcending mind-body; re-turning an axis in life through reflection, self-control, and/or gratitude; meditation into mundane, everyday life; and coming out of pain in the aftermath of the earthquake) that had emerged as expressions of participant meditation experiences. Following the 45-minute meditation session, the present study participants reported improvements in all psychological states (anger, confusion, depression, fatigue, strain, and vigor) in the quantitative portion, which indicated efficacy of the meditation. Our analysis of the qualitative portion revealed what and how participants felt during meditating.
Rates of Intraocular Pressure Elevation and Use of Topical Antihypertensive Medication After Descemet Stripping Automated Endothelial Keratoplasty
Authors: Kaleem Mona , Ridha Faisal , Shwani Zryan , Swenor Bonnielin , Goshe Jeffrey , Singh Annapurna
Published: April 2017

Purpose:

To investigate intraocular pressure (IOP) elevation and medication augmentation after Descemet stripping automated endothelial keratoplasty (DSAEK) in those with and without glaucoma.

Methods:

The records of 379 patients who underwent DSAEK at the Cleveland Clinic Foundation between January 2009 and 2014 were retrospectively reviewed. Postoperative IOP elevations were considered significant if IOP was ≥22 mm Hg on at least 1 follow-up visit or if it increased by ≥10 mm Hg from baseline.

Results:

The incidence rate of IOP elevation was 4% per person-month (confidence interval [CI], 3%–6%) in patients with preexisting glaucoma and 3% (CI, 2%–4%) in those without. Rates of medication augmentation were 4% per person-month (CI, 3%–5%) in patients with glaucoma and 1.8% (CI, 1.4%–2.4%) in those without. Incidence rates for both outcomes peaked at 1 month. Whites had nearly a 47% lower incidence of IOP elevation compared with nonwhites (P = 0.004); patients with pseudophakic bullous keratopathy had a 54% higher incidence of IOP elevation (P = 0.024); and those with Fuchs endothelial corneal dystrophy had a 36% lower incidence (P = 0.024). Patients with glaucoma had over a 2-fold higher incidence of medication augmentation compared with those without (hazard rate ratio = 2.08, P < 0.001).

Conclusions:

The incidence of post-DSAEK IOP elevation did not significantly differ by glaucoma status, although patients with glaucoma were more likely to have escalation of topical antihypertensive therapy. The incidence of IOP elevation was significantly associated with pseudophakic bullous keratopathy and nonwhite race. These patients should be followed closely in the early postoperative period, as elevated IOP can be a serious consequence of DSAEK.
Analyzing Patient Safety Culture From Viewpoints of Physicians and Nurses—A Case of a Regional Teaching Hospital in Taiwan
Authors: Lee Yii-Ching , Shieh Jiunn-I , Huang Chih-Hsuan , Wang Chieh Yu , Wu Hsin-Hung
Published: April 2017

The Chinese version of safety attitudes questionnaire is used to evaluate patient safety culture from the viewpoints of physicians and nurses of a regional teaching hospital in Taiwan in 2014. This study applies Mann–Whitney U test for two independent samples test and analysis of variance to observe if different demographic variables are perceived differently in patient safety culture in terms of eight dimensions. In addition, linear regression models are applied to take into account the confounding effects of demographic variables in eight dimensions. The results show that none of the eight dimensions is more important. Besides, supervisor/manager and experience in position are the two critical demographic variables to influence the patient safety culture. The results imply that the hospital management needs to pay much attention to the employees who are not supervisors/managers and/or more experienced in position because they are less satisfied in patient safety culture.
Imaging Criteria to Predict Surgical Difficulties During Stapes Surgery
Authors: Parra Claire , Trunet Stéphanie , Granger Benjamin , Nguyen Yann , Lamas Georges , Bernardeschi Daniele , Hervochon Rémi , Tankere Frédéric
Published: April 2017

Background and Purpose:

Stapes surgery for otosclerosis can be challenging if access to the oval window niche is restricted. The aim of this study was to determine the accuracy of the computed tomographic (CT) scan in the evaluation of anatomical distances, and to analyze its reliability in predicting surgical technical difficulties.

Material and Methods:

A total of 96 patients (101 ears) were enrolled in a prospective study between 2012 and May 2015. During surgery, we evaluated the distance D1 between the stapes and the facial nerve, distance D2 between the promontory and the facial nerve after ablation of the superstructure, and the intraoperative discomfort of the surgeon. On preoperative CT scans, we measured the width and depth of the oval window niche, and the angle formed by two axes starting from the center-point of the footplate, the first tangential to the superior wall of the promontory, and the second tangential to the inferior wall of the fallopian canal.

Results:

Intraoperative distances D1 and D2 were correlated with the width of the oval window and with the facial-promontory angle measured on imaging. CT scan measurements of the facial-promontory angle and width of the oval window were associated with the degree of discomfort of the surgeon. The cut-off threshold for intraoperative subjective discomfort was computed as 1.1 mm for the width of the oval window niche, with a sensibility of 71% and a specificity of 84%.

Conclusion:

Preoperative imaging analysis of the oval window width and the facialpromontory angle can predict operative difficulty in otosclerosis surgery.
Improved oxygen uptake efficiency slope in acute myocardial infarction patients after early phase I cardiac rehabilitation
Authors: Tsai Yun-Jeng , Li Min-Hui , Chen Chia-Hsin , Tuan Sheng-Hui , Chen Yi-Jen , Lin Ko-Long
Published: April 2017

A predischarge submaximal exercise test is often recommended after acute myocardial infarction (AMI) as part of phase I cardiac rehabilitation. In this study, a submaximal exercise parameter, oxygen uptake efficiency slope (OUES), was used to monitor the benefit of early mobilization within 48 h after AMI. An early mobilization protocol within 48 h after AMI has been initiated since 1 September 2012 in our center. Patients with onset time of AMI within 1 year before and 1 year after initiation of the early mobilization protocol were recruited for comparisons. Sixty patients were analyzed on the basis of this criterion, and were subjected to predischarge submaximal exercise tests. The OUES calculated with 100% exercise duration (OUES100) and calculated with the first 50% of exercise duration (OUES50) were obtained and analyzed. Both OUES100 and OUES50 of the AMI patients with early mobilization were significantly higher than those without early mobilization (P=0.025 and 0.007, respectively). The OUES100 and OUES50 were also highly correlated (r=0.891, P<0.001). The subgroup analysis using patients within 3 months before and 3 months after initiation of the protocol also showed a significant difference. OUES could be used to measure the exercise capacity and monitor the effect of phase I cardiac rehabilitation in patients soon after AMI. Early mobilization within 48 h following AMI significantly enhanced the patient’s exercise capacity.
Change of Uncertainty in Illness and Unmet Care Needs in Patients With Recurrent Hepatocellular Carcinoma During Active Treatment
Authors: Shun Shiow-Ching , Chou Yun-Jen , Chen Chien-Hung , Yang Jyh-Chin
Published: April 2017

Background:

Uncertainty about or related to cancer-related treatment and prognosis is commonly experienced by patients with hepatocellular carcinoma and might be associated with unmet care needs. However, their dynamic associations have not been examined in this population.

Objective:

The aim of this study was to explore change in unmet care needs and uncertainty under different levels of uncertainty (low vs high) before discharge and the significant factors related to change of uncertainty in patients with recurrent hepatocellular carcinoma after treatment.

Methods:

A set of questionnaires was used to collect data including symptom distress, supportive care needs, and uncertainty of illness before discharge (T0), 1 month after discharge (T1), and 2 months after discharge (T2). The significant factors related to uncertainty were identified by generalized estimating equations.

Results:

The patients with high uncertainty, who were younger in age, had significantly higher levels of symptom distress and unmet care needs. Before discharge, the patients’ highest levels of unmet needs were psychological in the high-uncertainty group. Patients with jobs, higher unmet care needs, and high uncertainty before discharge had higher levels of uncertainty over time.

Conclusions:

The changes in uncertainty were significantly associated with unmet care needs over time, and the baseline level of uncertainty was a significant factor related to the change of uncertainty.

Implications for Practice:

Healthcare providers should take into account each individual’s age, levels of psychological need, and symptom distress and should offer personalized information related to psychological needs and symptom management to decrease levels of uncertainty before discharge.
Fluid Overload and Kidney Injury Score: A Multidimensional Real-Time Assessment of Renal Disease Burden in the Critically Ill Patient*
Authors: Akcan-Arikan Ayse , Gebhard Daniel J. , Arnold Megan A. , Loftis Laura L. , Kennedy Curtis E.
Published: April 2017

Objective:

Interruptive acute kidney injury alerts are reported to decrease acute kidney injury–related mortality in adults. Critically ill children have multiple acute kidney injury risk factors; although recognition has improved due to standardized definitions, subtle changes in serum creatinine make acute kidney injury recognition challenging. Age and body habitus variability prevent a uniform maximum threshold of creatinine. Exposure of nephrotoxic medications is common but not accounted for in kidney injury scores. Current severity of illness measures do not include fluid overload, a well-described mortality risk factor. We hypothesized that a multidimensional measure of renal status would better characterize renal severity of illness while maintaining or improving on correlation measures with adverse outcomes, when compared with traditional acute kidney injury staging.

Design:

A novel, real-time, multidimensional, renal status measure, combining acute kidney injury, fluid overload greater than or equal to 15%, and nephrotoxin exposure, was developed (Fluid Overload Kidney Injury Score) and prospectively applied to all patient encounters. Peak Fluid Overload Kidney Injury Score values prior to discharge or death were used to measure correlation with outcomes.

Setting:

Quarternary PICU of a freestanding children’s hospital.

Patients:

All patients admitted over 18 months.

Intervention:

None.

Results:

Peak Fluid Overload Kidney Injury Score ranged between 0 and 14 in 2,830 PICU patients (median age, 5.5 yr; interquartile range, 1.3–12.9; 55% male), 66% of patients had Fluid Overload Kidney Injury Score greater than or equal to 1. Fluid Overload Kidney Injury Score was independently associated with PICU mortality and PICU and hospital length of stay when controlled for age, Pediatric Risk of Mortality-3, ventilator, pressor, and renal replacement therapy use (p = 0.047). Mortality increased from 1.5% in Fluid Overload Kidney Injury Score 0 to 40% in Fluid Overload Kidney Injury Score 8+. When urine output points were excluded, Fluid Overload Kidney Injury Score was more strongly correlated with mortality than fluid overload or acute kidney injury definitions alone.

Conclusion:

A multidimensional score of renal disease burden was significantly associated with adverse PICU outcomes. Further studies will evaluate Fluid Overload Kidney Injury Score as a warning and decision support tool to impact patient-centered outcomes.
Investigating Clinical Benefits of a Novel Sleep-Focused Mind-Body Program on Gulf War Illness Symptoms: A Randomized Controlled Trial
Authors: Nakamura Yoshio , Lipschitz David L. , Donaldson Gary W. , Kida Yuri , Williams Samuel L. , Landward Richard , Glover Don W. , West Gavin , Tuteja Ashok K.
Published: April 2017

Objective

Mind-Body Bridging (MBB) has been shown to be effective for improving disturbed sleep. In this prospective randomized controlled trial, we evaluated the efficacy of sleep-focused MBB compared with sleep education control (SED) for improving sleep in previously deployed Gulf War veterans.

Methods

US military service members with sleep and physical health complaints who were deployed in 1990–1991 were randomized to receive three weekly sessions of either MBB (n = 33) or SED (n = 27) between 2012 and 2015. The primary outcome of Medical Outcomes Study Sleep Scale was completed at baseline, weekly during treatment, postintervention, and 3-month follow-up. Secondary outcome measures for posttraumatic stress disorder, depression, fatigue, quality of life, symptom severity, and mindfulness were completed at baseline, postintervention and 3-month follow-up. Salivary samples were collected at five time points per day at each visit for cortisol and α-amylase assessment. Clinician-administered assessments of sleep and co-occurring conditions were conducted at baseline and postintervention.

Results

MBB was significantly more efficacious than SED in reducing disturbed sleep at follow-up (F(1,180.54) = 4.04, p = .046). In addition, self-reported posttraumatic stress disorder (F(1,56.42) = 4.50, p = .038) for the treatment effect, depression (F(1,93.70) = 4.44, p = .038), and fatigue symptoms (F(1,68.58) = 3.90, p = .050) at follow-up improved in MBB compared with those in SED. Consistently higher percentages of veterans in MBB reported improvements of sleep, pain, and composite sleep/general co-occurring symptoms at the postclinical evaluation, as compared with veterans in SED. Finally, the mean waking level of salivary α-amylase in the MBB declined to a greater extent than that in the SED, at follow-up (F(1,88.99) = 3.78, p = .055), whereas no effects were found on cortisol.

Conclusions

Sleep-focused MBB can improve sleep and possibly also co-occurring symptoms in Gulf War veterans.

Clinical Trial Registration

Clinicaltrials.gov, NCT01543997.
Causal analyses, statistical efficiency and phenotypic precision through Recall-by-Genotype study design
Authors: Corbin Laura J. , Tan Vanessa Y. , Hughes David A. , Wade Kaitlin H. , Paul Dirk S. , Tansey Katherine E. , Butcher Frances , Dudbridge Frank , Howson Joanna M. , Jallow Momodou W. , John Catherine , Kingston Nathalie , Lindgren Cecilia M. , O’Donavan Michael , O’Rahilly Steve , Owen Michael J. , Palmer Colin N.A. , Pearson Ewan R. , Scott Robert A. , Heel David A. van , Whittaker John , Frayling Tim , Tobin Martin D. , Wain Louise V. , Evans David M. , Karpe Fredrik , McCarthy Mark I. , Danesh John , Franks Paul W. , Timpson Nicholas J.
Published: April 2017

Genome-wide association studies have been useful in identifying common genetic variants related to a variety of complex traits and diseases; however, they are often limited in their ability to inform about underlying biology. Whilst bioinformatics analyses, studies of cells, animal models and applied genetic epidemiology have provided some understanding of genetic associations or causal pathways, there is a need for new genetic studies that elucidate causal relationships and mechanisms in a cost-effective, precise and statistically efficient fashion. We discuss the motivation for and the characteristics of the Recall-by-Genotype (RbG) study design, an approach that enables genotype-directed deep-phenotyping and improvement in drawing causal inferences. Specifically, we present RbG designs using single and multiple variants and discuss the inferential properties, analytical approaches and applications of both. We consider the efficiency of the RbG approach, the likely value of RbG studies for the causal investigation of disease aetiology and the practicalities of incorporating genotypic data into population studies in the context of the RbG study design. Finally, we provide a catalogue of the UK-based resources for such studies, an online tool to aid the design of new RbG studies and discuss future developments of this approach.
Can Zika account for the missing babies?
Authors: Coelho Flávio Codeço , Armstrong Margaret , Saraceni Valeria , Lemos Cristina
Published: April 2017

The Zika virus (ZIKV) spread rapidly in Brazil in 2015 and 2016. Rio de Janeiro was among the Brazilian cities which were hit the hardest, with more that a hundred thousand confirmed cases up to the end of 2016. Given the severity of the neurological damage caused by ZIKV on fetuses, we wondered whether it would also cause an increase in the number of miscarriages, especially very early ones. As early miscarriages are unlikely to be recorded as a health event, this effect – if it occurred – would only show up as a reduction in the number of live births. In this paper we show that there was a 15% drop in live births between September and December 2016 compared to the previous year, and that this sharp drop from epidemiological week 33 onward is strongly correlated with the number of recorded cases of Zika about 40 weeks earlier. We postulate that ZIKV is directly responsible for this drop in the birth rate. Further work is required to ascertain whether other factors such the fear of having a microcephaly baby or the economic crisis are having a significant effect.
An organ-on-a-chip approach for investigating root-environment interactions in heterogeneous conditions
Authors: Stanley Claire E. , Shrivastava Jagriti , Brugman Rik , van Swaay Dirk , Grossmann Guido
Published: April 2017

Plants adapt their root morphology in response to changing environmental conditions, yet it remains largely unknown to what extent developmental adaptations are based on systemic or cell-autonomous responses. We present the dual-flow-RootChip (dfRootChip), a microfluidic organ-on-a-chip platform for asymmetric perfusion of Arabidopsis roots to investigate root-environment interactions under simulated environmental heterogeneity. Applications range from root guidance, monitoring of physiology and development under asymmetric conditions, tracing molecular uptake and selective drug treatments to local inoculation with microbes. We measured calcium responses in roots treated with biotic and abiotic elicitors and observed elicitor-specific signal propagation across the root from treated to untreated cells. We provide evidence for non-autonomous positive regulation of hair growth across the root upon exposure to unfavourable conditions on the opposite side. Our approach sheds light on lateral coordination of morphological adaptation and facilitates studies on root physiology, signalling and development in heterogeneous environments at the organ level.
Human Missense Variation is Constrained by Domain Structure and Highlights Functional and Pathogenic Residues
Authors: MacGowan Stuart A. , Madeira Fábio , Britto-Borges Thiago , Schmittner Melanie S. , Cole Christian , Barton Geoffrey J.
Published: April 2017

Human genome sequencing has generated population variant datasets containing millions of variants from hundreds of thousands of individuals1-3. The datasets show the genomic distribution of genetic variation to be influenced on genic and sub-genic scales by gene essentiality,1,4,5protein domain architecture6and the presence of genomic features such as splice donor/acceptor sites.2However, the variant data are still too sparse to provide a comparative picture of genetic variation between individual protein residues in the proteome.1,6Here, we overcome this sparsity for ∼25,000 human protein domains in 1,291 domain families by aggregating variants over equivalent positions (columns) in multiple sequence alignments of sequence-similar (paralagous) domains7,8. We then compare the resulting variation profiles from the human population to residue conservation across all species9and find that the same tertiary structural and functional pressures that affect amino acid conservation during domain evolution constrain missense variant distributions. Thus, depletion of missense variants at a position implies that it is structurally or functionally important. We find such positions are enriched in known disease-associated variants (OR = 2.83,p≈ 0) while positions that are both missense depleted and evolutionary conserved are further enriched in disease-associated variants (OR = 1.85,p= 3.3×10-17) compared to those that are only evolutionary conserved (OR = 1.29,p= 4.5×10-19). Unexpectedly, a subset of evolutionary Unconserved positions are Missense Depleted in human (UMD positions) and these are also enriched in pathogenic variants (OR = 1.74,p= 0.02). UMD positions are further differentiated from other unconserved residues in that they are enriched in ligand, DNA and protein binding interactions (OR = 1.59,p= 0.003), which suggests this stratification can identify functionally important positions. A different class of positions that are Conserved and Missense Enriched (CME) show an enrichment of ClinVar risk factor variants (OR = 2.27,p= 0.004). We illustrate these principles with the G-Protein Coupled Receptor (GPCR) family, Nuclear Receptor Ligand Binding Domain family and In Between Ring-Finger (IBR) domains and list a total of 343 UMD positions in 211 domain families. This study will have broad applications to: (a) providing focus for functional studies of specific proteins by mutagenesis; (b) refining pathogenicity prediction models; (c) highlighting which residue interactions to target when refining the specificity of small-molecule drugs.