bluuebunny/crossref_metadata_2025 huggingface dataset:
Induced Abortion in a Population Entitled to Free-of-Charge Long-Acting Reversible Contraception
Authors: Gyllenberg Frida K. , Saloranta Tuire H. , But Anna , Gissler Mika , Heikinheimo Oskari
Published: November 2018

OBJECTIVE:

To study the rate of induced abortion in a population in whom long-acting reversible contraceptive (LARC) methods are offered free of charge as part of primary health care services.

METHODS:

We conducted a register-based cohort study on females aged 15–44 years in the city of Vantaa, Finland. We assessed the rate of abortion among females entitled to LARC methods free of charge by survival analysis in four cohorts: those visiting public family planning clinics and initiating free-of-charge LARC methods during 2013–2014 (LARC cohort, n=2,035); those visiting public family planning clinics not choosing LARC methods (no LARC cohort, n=7,634); and three age-matched control participants for every LARC and no LARC participant from the general population not using the services (nonservice users, n=5,981 and 22,748). The patients were followed up by means of Finnish national registers until February 28, 2016.

RESULTS:

During the 78,500 woman-years accumulated, altogether 996 patients in Vantaa underwent an abortion (12.3 abortions/1,000 woman-years, 95% CI 11.6–13.1). Of these, 16 abortions occurred in the LARC cohort (3.9/1,000, 95% CI 2.4–6.0), 243 in the no LARC cohort (15.3/1,000, 95% CI 13.5–17.2), and 737 (12.6/1,000, 95% CI 11.7–13.5) among matched nonservice users. The adjusted abortion rate in the LARC cohort was 80% lower than in the no LARC cohort (risk ratio [RR] 0.20, 95% CI 0.11–0.32) and 74% lower than among their matched control participants (RR 0.26, 95% CI 0.15–0.43). In contrast, there was no difference in the abortion rate between the no LARC cohort and the control participants (adjusted RR 1.01, 95% CI 0.87–1.18).

CONCLUSION:

When providing a population with free-of-charge LARC methods, the abortion rate was markedly lower among patients initiating free-of-charge LARC compared with patients using the services but not initiating a LARC method. Programs of this kind could be of major importance in populations with high rates of unintended pregnancy.
An update on the nomenclature for cutaneous vasculitis
Authors: Caproni Marzia , Verdelli Alice
Published: November 2018

Purpose of review

Cutaneous vasculitis reflects a spectrum ranging from skin limited to severe systemic forms. To date, there is still no generally acknowledged nomenclature for cutaneous vasculitis. This review aims to summarize the recent advances in the nomenclature of cutaneous vasculitis.

Recent findings

The most widely adopted vasculitis classification system is the one of 2012 Revised Chapel Hill Consensus Conference (CHCC) which represent not such a classification but a nomenclature system that name vasculitis on the basis of the size of the vessel affected. The CHCC 2012 did not deal with the special features of cutaneous vasculitis and did not explicitly discuss the presence of skin-limited or skin-dominant forms of vasculitis. Therefore, a consensus group was formed to propose an Addendum to CHCC 2012, focusing on cutaneous vasculitis. The Addendum better clarify the main aspects of some single-organ vasculitis, including IgM/IgG vasculitis, nodular vasculitis, erythema elevatum et diutinum and recurrent macular vasculitis in hypergammaglobulinemia. Moreover, it differentiated normocomplementemic from hypocomplementemic urticarial vasculitis. Finally, it recognized cutaneous polyarteritis nodosa as a distinct subtype of polyarteritis nodosa.

Classification criteria are useful tools to standardize names and definitions for cutaneous vasculitis; however, they do not represent diagnostic criteria. Collaborative efforts are still needed to get a shared classification and valid diagnostic criteria for cutaneous vasculitis.
Gross Motor Function Classification System Specific Growth Charts—Utility as a Risk Stratification Tool for Surgical Site Infection Following Spine Surgery
Authors: Baranek Eric S. , Maier Stephen P. , Matsumoto Hiroko , Hyman Joshua E. , Vitale Michael G. , Roye David P. , Roye Benjamin D.
Published: November 2018

Background:

There is currently minimal evidence that preoperative malnutrition increases surgical site infection (SSI) risk in children with cerebral palsy (CP) undergoing spinal deformity surgery. Growth charts specifically for patients with CP have been created to aid in the clinical interpretation of body mass index (BMI) as a marker of nutritional status, but to our knowledge these charts have never been used to risk stratify patients before orthopaedic surgery. We hypothesize that patients with CP who have BMI-for-age below the 10th percentile (BMI≤10) on CP-specific growth charts are at increased risk of surgical site infection following spinal deformity surgery compared with patients with BMI-for-age above the 10th percentile (BMI>10).

Methods:

Single-center, retrospective review comparing the rate of SSI in patients with CP stratified by BMI-for-age percentiles on CP-specific growth charts who underwent spinal deformity surgery. Odds ratios with 95% confidence intervals and Pearson χ2 tests were used to analyze the association of the measured nutritional indicators with SSI.

Results:

In total, 65 patients, who underwent 74 procedures, had complete follow-up data and were included in this analysis. Ten patients (15.4%) were GMFCS I-III and 55 (84.6%) were GMFCS IV-V; 39 (60%) were orally fed and 26 (40%) were tube-fed. The rate of SSI in this patient population was 13.5% with 10 SSIs reported within 90 days of surgery. There was a significant association between patients with a BMI below the 10th percentile on GMFCS-stratified growth charts and the development of SSI (OR, 13.6; 95% CI, 2.4-75.4; P=0.005). All SSIs occurred in patients that were GMFCS IV-V. There was no association between height, weight, feeding method, or pelvic instrumentation and development of SSI.

Conclusions:

CP-specific growth charts are useful tools for identifying patients at increased risk for SSI following spinal instrumentation procedures, whereas standard CDC growth charts are much less sensitive. There is a strong association between preoperative BMI percentile on GMFCS-stratified growth charts and SSI following spinal deformity surgery.

Level of Evidence:

Level III—Retrospective Study.
Bridging Continuing Medical Education and Quality Improvement Efforts: A Qualitative Study on a Health Care System in the Kingdom of Saudi Arabia
Authors: Alsabban Wid , Kitto Simon
Published: November 2018

Introduction:

There have been initial efforts to link continuing medical education (CME), quality improvement (QI), and patient safety in North America. However, limited empirical research has been performed to characterize the relationship and integration between CME and QI/patient safety in the Kingdom of Saudi Arabia (KSA). To explore health care leaders' perceptions and experiences of collaboration between the CME department (CME-D) and the quality management administration (QMA), we conducted an exploratory qualitative study at a large governmental health care center – King Abdullah Medical City (KAMC) in Makkah, KSA.

Methods:

The health care managers at KAMC were asked to identify their perception on the state of collaboration between the CME-D and QMA. Data collection, in the form of one-to-one semistructured interviews, was directed by an interview guide. Interviews were transcribed verbatim, and the participants' perspectives were analyzed thematically using a theoretical framework.

Results:

Fifteen participants were recruited: one top manager of the CME-D, three top managers from the QMA, seven representatives from the medical board, and four representatives from the executive board. Key findings of the interviews were the presence of some shared ad hoc goals between the CME-D and QMA. However, insufficiency of other collaborative factors reflected a “potential collaboration” (level 1) based on D'Amour's model of collaboration.

Discussion:

This is the first qualitative study to explore the perceptions and experiences of CME and QI health care managers on their collaboration at one of the largest health centers in the KSA. Further research should investigate the feasibility of implementing interventions to intensify collaboration between CME and QI.
Usability Evaluation of a Dashboard for Home Care Nurses
Authors: Dowding Dawn , Merrill Jacqueline A. , Barrón Yolanda , Onorato Nicole , Jonas Karyn , Russell David
Published: November 2018

The introduction of electronic health records has produced many challenges for clinicians. These include integrating technology into clinical workflow and fragmentation of relevant information across systems. Dashboards, which use visualized data to summarize key patient information, have the potential to address these issues. In this article, we outline a usability evaluation of a dashboard designed for home care nurses. An iterative design process was used, which consisted of (1) contextual inquiry (observation and interviews) with two home care nurses; (2) rapid feedback on paper prototypes of the dashboard (10 nurses); and (3) usability evaluation of the final dashboard prototype (20 nurses). Usability methods and assessments included observation of nurses interacting with the dashboard, the system usability scale, and the Questionnaire for User Interaction Satisfaction short form. The dashboard prototype was deemed to have high usability (mean system usability scale, 73.2 [SD, 18.8]) and was positively evaluated by nurse users. It is important to ensure that technology solutions such as the one proposed in this article are designed with clinical users in mind, to meet their information needs. The design elements of the dashboard outlined in this article could be translated to other electronic health records used in home care settings.
Primary malignant melanotic melanoma and hypomelanotic melanoma of the female urethra: case series and a review of the literature in China
Authors: Yang Nianqin , Lu Jidong , Lu Yongning , Guo Jianming , Wang Hang
Published: November 2018

The incidence of primary malignant melanoma (MM) of female urethra is extremely low, leading to paucity of recommendations on management. The objectives of our study were to gain more insight into the clinical features, diagnosis, treatment, and prognosis of this rare type of tumor. We carried out a retrospective analysis of all four cases who underwent an operation in our hospital since 1980. Moreover, other 32 cases of MM that have been reported in Chinese papers were also included for further review. The age of the patients ranged from 38 to 81 years. A mass in the urethral meatus and hematuria are common presentations. The final diagnosis depends on histopathological examination. After surgery alone or combined with chemotherapy/radiotherapy/immunotherapy, all cases were followed for 1–151 months, whereas only one lived for more than 4 years after receiving the diagnosis. A timely and accurate diagnosis of MM is critical, especially for hypomelanotic and amelanotic cases. Immunohistochemical staining and electron microscopy are necessary for a precise diagnosis in some cases. Extensive resection, early chemotherapy, and immunotherapy may help to improve survival.
Mycophenolate mofetil alongside high-dose corticosteroids: optimizing the management of combination immune checkpoint inhibitor-induced colitis
Authors: Mir Romaana , Shaw Heather M. , Nathan Paul D.
Published: November 2018

Immune checkpoint inhibitor (IO) induced colitis is primarily managed with corticosteroids. Most patients have a rapid resolution of symptoms and do not require additional immunosuppressants. Many patients, however, require prolonged corticosteroid courses to maintain control of toxicity. Mycophenolate mofetil (MMF) is the prodrug of mycophenolic acid; which in turn directly inhibits activated T and B lymphocytes. MMF, in addition to corticosteroids, may enable reduction of corticosteroids without precipitating resurgence of colitis. Metastatic melanoma patients between 1 January 2017 and 31 December 2017 with combination IO-induced colitis were managed with a novel treatment algorithm: upfront oral enteric-coated MMF alongside high-dose corticosteroids. Outcome measures included incidence of colitis flare, time to grade 1 colitis, time to patient-reported normal bowel habit and overall cumulative corticosteroid exposure. Thirteen patients developed high-grade combination IO-induced colitis; 11 were managed with the combination of high-dose corticosteroid and MMF. Median patient age was 59 (range: 28–73) years. Four (36%) developed flare of colitis; flares occurred at a median of 11 (interquartile range: 4.5–16.75) days. All colitis flares responded fully to infliximab (5 mg/kg). The remaining seven patients did not develop colitis flare during corticosteroid wean. All patients were successfully weaned from corticosteroids and none had a resurgence of colitis at 8 weeks following discontinuation of MMF. Concomitant enteric-coated MMF alongside high-dose corticosteroids may hasten the improvement of high-grade colitis to normal bowel habit and reduce the incidence of colitis flare.
Multiple Pilomatricomas: A Retrospective Study and Literature Review
Authors: Mesa-Álvarez Laura , Batalla Ana , Iglesias-Puzas Álvaro , Álvarez Carlos , Flórez Ángeles
Published: November 2018

Pilomatricoma is usually a single lesion. However, some patients present with more than one, a fact that has been reported in association with several systemic diseases. The aim of this analysis is to determine the prevalence of multiple pilomatricomas (MP) in our institution as well as to describe their clinical features and associated comorbidities. This is a retrospective analysis reviewing patients with a histological diagnosis of pilomatricoma registered in the database of the Pathology Department of our institution, from January 2005 to March 2017. One hundred ninety-five patients with histological criteria for pilomatricoma were registered. Fourteen (0.7%) of those patients suffered from MP. Among them, the most relevant findings were: 9 (64%) patients were women and 5 (36%) were men. The median age at diagnosis was 16 years. Seven (50%) had 2 pilomatricomas and 7 (50%) had more than 2. Two (14%) suffered from Steinert myotonic dystrophy (SMD). Regarding family background, 3 of them had relatives with pilomatricomas, one of them with pancreatic cancer, and another one with SMD. A total of 36 pilomatricomas were excised from those 14 patients with the following characteristics: The mean lesion size was 12 mm. The majority of the lesions (53%) were located on the head and neck. There was no recurrence or malignant transformation in any patient. Articles reporting on MP are scarce. We communicate 2 new familial MP without associated comorbidities. We would like to highlight that 2 of our patients with MP also developed SMD, an association previously reported. Thus, a thorough physical examination and inquiring about family history are of utmost importance for an early diagnosis of possible associated diseases.
A Rare Chest Wall Deformity after Usage of a Tissue Expander for Breast Reconstruction
Authors: Kuramoto Yukiko , Yano Tomoyuki , Sawaizumi Masayuki , Tanakura Kenta , Miyashita Hiroki
Published: November 2018

A 2-stage breast reconstruction using a breast tissue expander and prosthesis is a simple method of breast reconstruction with little donor-site morbidity and short surgery time. In this report, we present a rare case of chest wall deformity, which appeared during breast skin expansion with tissue expander. We present a case of a 31-year-old woman who underwent a 2-stage breast reconstruction with a tissue expander and breast prosthesis. She had a former history of autologous microtia reconstruction using costal cartilages to create a framework of the ear at the age of 10. During expansion, the woman developed an abnormal hollowing of the chest wall. Even though it was difficult to select an ideal size for the breast prosthesis, an excellent breast shape was obtained by measuring the actual breast projection that we needed, using ultrasound sonography. The patient was satisfied with the final result. In this case, the patient suffered from a postoperative chest wall deformity due to cartilage harvesting. This unfavorable result highlights the need for careful preoperative evaluation of risk factors that may lead to chest wall deformity when patients will have tissue expansion as a part of breast reconstruction. When thoracic deformity occurs, surgeons should realize that choosing an adequate implant becomes rather difficult. Ultrasound sonography helps surgeons in measuring the actual breast projection preoperatively.
RANIBIZUMAB 0.5 MG TREATMENT IN ADOLESCENTS WITH CHOROIDAL NEOVASCULARIZATION: SUBGROUP ANALYSIS DATA FROM THE MINERVA STUDY
Authors: Hykin Philip G. , Staurenghi Giovanni , Wiedemann Peter , Wolf Sebastian , Liew Shiao Hui Melissa , Desset-Brethes Sabine , Staines Harry , Li Jun , Lai Timothy Y. Y. ,   on behalf of the MINERVA study group
Published: November 2018

Purpose:

To evaluate the efficacy and safety of ranibizumab 0.5 mg in adolescent patients with any choroidal neovascularization etiology enrolled in the 12-month MINERVA study.

Methods:

In the open-label, non-randomized study arm, ranibizumab 0.5 mg was administered to five adolescents (aged 13–17 years). The findings were assessed descriptively as individual case reports at Month 12. Best-corrected visual acuity changes, central subfield thickness, treatment exposure, and safety were described over 12 months.

Results:

Baseline choroidal neovascularization etiologies of the study eye included choroidal neovascularization secondary to Best disease (n = 2), idiopathic chorioretinopathy (n = 2), and optic disk drusen (n = 1). At Months 2, 6, and 12, the observed mean best-corrected visual acuity changes in the study eye from baseline were +9.2, +16.6, and +16.6 letters, respectively, and the observed mean central subfield thickness change from baseline was −31.4, −87.6, and −116.4 μm, respectively. Adolescent patients received a mean of three (range, 2–5) ranibizumab injections in the study eye. No adverse events or serious adverse events related to ranibizumab were reported.

Conclusion:

Ranibizumab 0.5 mg treatment was beneficial in improving visual acuity and stabilizing or reducing central subfield thickness in five adolescents with differing choroidal neovascularization etiologies requiring infrequent injection. No new safety findings were observed over 12 months.
BULL'S EYE MACULOPATHY POSSIBLY DUE TO IRON OVERLOAD IN A CHILD WITH THALASSEMIA MAJOR: A CASE OF POSSIBLE “FERRITIN RETINOPATHY”
Authors: Abraham Anina
Published: November 2018

Purpose:

To report a case of bull's eye maculopathy probably caused by iron overload in a child with thalassemia major.

Methods:

Case report.

Results:

A 6-year-old girl with thalassemia major who was on chronic multiple blood transfusions since 2 years of age presented with blurred vision in both eyes for 2 months. Blood reports showed very high serum ferritin levels in the range 400 to 2,250 ng/mL (checked every 3 months) since 4 years of age. She was on oral iron chelator deferasirox for 2 years, which was stopped a month ago. Fundus examination of both eyes showed a characteristic bull's eye macula with a purplish hue in the outer ring probably due to iron deposition. The center of the bull's eye had a beaten bronze appearance.

Conclusion:

Careful history-taking is important in children with bull's eye maculopathy because all such retinopathies need not be hereditary fundus dystrophies. Further progression can be arrested by identifying and removing the cause vision loss.
The Influence of Trabectome Surgery on Corneal Endothelial Cells
Authors: Kasahara Masayuki , Shoji Nobuyuki , Matsumura Kazuhiro
Published: November 2018

Purpose:

The purpose of this study was to evaluate the influence of trabectome surgery on corneal endothelial cells by site.

Methods:

Retrospective observational study. Trabectome surgeries were performed on 159 eyes of 132 adult Japanese patients. Corneal endothelial cells were measured at the center (C), inferior (I), nasal inferior (NI), nasal superior (NS), superior (S), temporal superior (TS), and temporal inferior (TI) sectors at <1 month preoperatively and 3, 6, 12, 24, and 36 months postoperatively, for changes in corneal endothelial cell density (ECD), coefficient of variation (CV), and incidence of hexagonal cells (6A).

Results:

Mean preoperative ECD in all groups were 2401±451 (SD)  cells/mm2 (C), 2366±450 cells/mm2 (I), 2397±479 cells/mm2 (NI), 2476±554 cells/mm2 (NS), 2493±596 cells/mm2 (S), 2464±558 cells/mm2 (TS), and 2329±510 cells/mm2 (TI). The 12-month postoperative mean ECDs were 2344±480 cells/mm2 (C), 2312±469 cells/mm2 (I), 2325±536 cells/mm2 (NI), 2473±517 cells/mm2 (NS), 2438±607 cells/mm2 (S), 2227±578 cells/mm2 (TS), and 2193±523 cells/mm2 (TI). There was no change in ECD in all sectors before and after surgery. ECD decreased at the TS and TI in combination with cataract surgery (2620±430 and 2445±384 cells/mm2) preoperatively to 2264±501 and 2216±477 cells/mm2 at 12 months postoperatively. CV and 6A did not change at all sites in all surgical procedures before and after surgery.

Conclusions:

Trabectome surgery involves minimal effects to corneal endothelial cells, although long-term prospective studies with greater sample sizes are necessary to confirm this conclusion.
Totally Endoscopic Surgical Repair of Partial Atrioventricular Septal Defect in Children
Authors: Dang Huy Q. , Le Thanh N. , Ngo Linh T.H.
Published: November 2018

There have been few reports on the application of totally endoscopic surgery for repairing partial atrioventricular septal defect. In this report, we present two children who were successfully repaired partial atrioventricular septal defect by using totally endoscopic surgery without robotic assistance.
Minimally Invasive Ozaki Procedure in Aortic Valve Disease
Authors: Nguyen Dinh H. , Vo Anh T. , Le Khoi M. , Vu Thanh T. , Nguyen Trang T. , Vu Thien T. , Pham Chuong V. T. , Truong Binh Q.
Published: November 2018

Objective

The Ozaki procedure for aortic valve reconstruction was reported in 2014 with low mortality, a highly reproducible rate and a good midterm result. However, the procedure still requires conventional sternotomy to be accomplished. The aim of the study was to start an initial evaluation for the feasibility of the minimally invasive approach in combination with the Ozaki technique.

Methods

From January 06, 2017, to January 12, 2017, nine patients with severe aortic valve diseases underwent minimally invasive Ozaki procedure through an upper ministernotomy. The pericardium was harvested endoscopically using three trocars in different intercostal spaces. Then, a ministernotomy was performed and the Ozaki procedure was accomplished in a similar manner to the conventional technique. We analyzed the in-hospital mortality and complications of this group.

Results

The mean age was 47.4 years and 55.6% patients were female. The predominant pathology was chronic rheumatic valve disease (66.7%) and other patients were diagnosed with a bicuspid aortic valve. The mean aortic cross-clamp time was 106.8 minutes, the mean cardiopulmonary bypass time was 153.6 minutes, the mean ventilation time was 8.4 hours, and the mean intensive care unit time was 1.6 days. No mortality was recorded in our series, no conversion to full sternotomy was required, one patient experienced right hemothorax requiring drainage, and one patient required valve replacement. Intraoperative transesophageal echocardiography and predischarge transthoracic echocardiography showed five competent valves and three valves with trivial regurgitation, and no stenosis was detected.

Conclusions

Ministernotomy combined with Ozaki procedure might be feasible, as well as an alternative to conventional sternotomy. This approach is associated with low mortality and morbidity and may be beneficial in younger populations.
Robotic versus Video-Assisted Thoracoscopic Surgery Pulmonary Segmentectomy
Authors: Musgrove Kelsey A. , Hayanga Jeremiah A. , Holmes Sari D. , Leung Alexander , Abbas Ghulam
Published: November 2018

Objective

Pulmonary segmentectomy using robotic assistance is often perceived as being more expensive than segmentectomy using video-assisted thoracic surgery. The robotic technique allows for meticulous dissection during segmentectomy, potentially leading to fewer parenchymal injuries, fewer air leaks, and shorter length of stay. This study compared pulmonary segmentectomy costs using video-assisted thoracic surgery versus robotic with manual staplers versus robotic with robotic staplers.

Methods

Retrospective analyses were performed evaluating our early experience with robotic pulmonary segmentectomy for 30 months compared with the video-assisted thoracic surgery approach. All 50 anatomical segmentectomies performed since introduction of robotic technique in the practice were included. Twenty-eight procedures were robotic-assisted and 22 were video-assisted thoracic surgery. Procedure-specific evaluation of direct costs was performed, including cost of robotic instruments, staplers, and average length of stay in the hospital.

Results

The mean ± SD age was 70 ± 10 years (range = 43–91 years). There were 12 males in the robotic group and eight in the video-assisted thoracic surgery group ( P = 0.642). The mean age was 69 years in the robotic group and 71 years in the video-assisted thoracic surgery group ( P = 0.367). The median length of stay was 2 (2–4) days in the robotic group (range = 1–9) and 4 (2–5) days in the video-assisted thoracic surgery group (range = 1–20, P = 0.089). The cost of robotic segmentectomy with manual staplers was less than that with robotic staplers. Both robotic techniques cost less than video-assisted thoracic surgery.

Conclusions

In this small series, cost and outcomes in our early experience with robotic-assisted segmentectomy were comparable with our video-assisted thoracic surgery approach with trends toward shorter length of stay and fewer complications. Larger series are needed to validate these results.
Factors Affecting Urinary Retention in Critically Ill Trauma Patients
Authors: Fowler Susan , Urban Stephanie , Taggart Holly
Published: November 2018

The objective of this retrospective study was to gain a better understanding of patient and care factors that may contribute to urinary retention in critically ill trauma patients. Fifty trauma patients over a 1-year period with an International Classification of Diseases, Tenth Revision (ICD-10) code for urinary retention were identified and analyzed. Most patients had an indwelling urinary catheter placed on admission, and it was reinserted in 39 patients. Male gender, orthopedic trauma, and anesthesia were possible contributing factors for urinary retention in our sample population. The use of paralytics and more than one operative intervention had a significant relationship with prescribing bladder medications. It is imperative to have protocols based on best evidence to guide management of urinary retention in this critically ill trauma patient population.
Analgesics Administered for Pain During Hospitalization Following Lower Extremity Fracture: A Review of the Literature
Authors: Griffioen Mari A. , O'Brien Grace
Published: November 2018

Effective treatment of acute pain during hospitalization following lower extremity fracture is critical to improve short-term patient outcomes including wound healing, stress response, hospital length of stay, and cost as well as minimizing long-term negative patient outcomes such as delayed return to work, disability, and chronic pain. As many patients report moderate to severe pain during hospitalization, identifying the analgesics that most effectively reduces pain is a priority to improve patient outcomes. The purpose of this review was to examine published studies describing patient response to analgesics administered orally (PO) or intravenously (IV) in the immediate hospitalization following lower extremity fracture. PubMed was queried for articles published through May 2017 that included information on type of study, population, fracture site, pain measurement tool, analgesic, and result. Of 514 articles found, eight met the inclusion criteria. Analgesics administered PO or IV were fentanyl, hydromorphone, morphine, remifentanil, diclofenac, ibuprofen, ketorolac, and etoricoxib. Five of the studies focused on comparisons between one or more analgesics and three studies compared an IV analgesic to a regional anesthetic agent. Two studies compared different nonsteroidal anti-inflammatory drugs (NSAIDs). Bupivacaine, lignocaine, and levobupivacaine administered as regional nerve blocks were superior to controlling pain compared with IV fentanyl and IV hydromorphone. IV morphine provided faster and better pain relief compared with IV ibuprofen. Based on the limited data available, regional nerve blocks provided superior pain relief compared with opioids, and opioids provided superior pain relief compared with NSAIDs. Different NSAIDs provided similar pain relief.
A Narrative Inquiry Into the Experience of Being a Victim of Gun Violence
Authors: Francis Mary
Published: November 2018

The purpose of this study was to gain a greater understanding of gun violence from the victim's personal story. The design for the study was narrative inquiry. Sixteen victims of gun violence were interviewed and asked to tell their story. The interview format comprised open-ended interview questions that encouraged participants to tell their stories. The method was narrative inquiry; the victims were encouraged to tell their story. The interview was recorded and transcribed. The transcripts of the interviews were the data for the study. Multiple readings allowed themes to emerge and provided a means of classifying the content. The data were organized by a categorical-content perspective as described by A. Lieblich, R. Tuval-Mashiach, and T. Zilber (1998). Four themes emerged that captured the study participants' experience: prevailing nature of everyday violence; feeling abandoned by the institutions of society; living in a context of reactive violence fueled by poverty; lack of employable skills and education; and evolving psychological effect following gun violence. The study provided insight into the personal experience of gun violence. Victims of gun violence experience challenges related to poverty, deficient educational preparation, and community neglect. The presence of gun violence in their neighborhoods has had an everlasting impact on their well-being. Gun violence is a major public health crisis. Thousands of people are killed or injured daily by guns. It is crucial that appropriate interventions be created. Partnerships between neighborhood leaders, health care professionals, and politicians need to be developed and fostered.
A mitochondrial neurogastrointestinal encephalomyopathy with intestinal pseudo-obstruction resulted from a novel splice site mutation
Authors: Erdogan Mehmet A. , Seckin Yuksel , Harputluoglu Muhsin M. , Karincaoglu Melih , Aladag Murat , Caliskan Ali R. , Bilgic Yilmaz , Yildirim Oguzhan , Cagin Yasir F. , Atayan Yahya , Cengiz Ayse N. , Emul Cihat , Esener Zeynep , Erbay Mehmet F. , Tekedereli Ibrahim
Published: November 2018

Mitochondrial neurogastrointestinal encephalopathy (MNGIE) is an autosomal recessive disorder characterized by gastrointestinal dysmotility, cachexia, ptosis, peripheral neuropathy and leukoencephalopathy. The diagnosis is often not made until 5–10 years after the onset of symptoms. MNGIE is caused by mutations in thymidine phosphorylase gene TYMP. Here, we present a 19-year-old boy with MNGIE who had a chronic intestinal pseudo-obstruction, and we describe his family history. Genetic analysis revealed a novel homozygous c.765+1G>C intronic mutation which is expected to disrupt splicing of TYMP in the patient. Family screening revealed that the brother was also affected and the mother was a carrier. MNGIE should be considered and genetic testing instigated if individuals with cachexia have neuromuscular complaints or symptoms of chronic intestinal pseudo-obstruction.
Influence of magnesium sulfate on hemodynamic responses during laparoscopic cholecystectomy
Authors: Zhang Juyi , Wang Yubin , Xu Hao , Yang Juan
Published: November 2018

Background:

The impact of magnesium sulfate on hemodynamic responses during laparoscopic cholecystectomy remains controversial. We conduct a systematic review and meta-analysis to explore the influence of magnesium sulfate on hemodynamic responses for laparoscopic cholecystectomy.

Methods:

We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through June 2018 for randomized controlled trials (RCTs) assessing the effect of magnesium sulfate on hemodynamic responses for laparoscopic cholecystectomy. Meta-analysis is performed using the random-effect model.

Results:

Four RCTs involving 208 patients are included in the meta-analysis. Overall, compared with control group in laparoscopic cholecystectomy, intravenous magnesium sulfate is associated with systolic blood pressure at 30 minutes [Std. MD = −1.34; 95% confidence interval (95% CI) = −1.86 to −0.82; P < .00001], diastolic blood pressure at 30 minutes (Std. MD = −1.40; 95% CI = −1.86 to −0.94; P < .00001), mean arterial pressure at 30 minutes (Std. MD = −1.19; 95% CI = −1.91 to −0.46; P = .001), systolic blood pressure at 10 minutes (Std. MD = −1.61; 95% CI = −2.08 to −1.13; P < .00001), diastolic blood pressure at 10 minutes (Std. MD = −1.54; 95% CI = −2.68 to −0.40; P = .008), heart rate at 30 minutes (Std. MD = −2.09; 95% CI = −2.87 to −1.32; P < .00001), but results in prolonged extubation time (Std. MD = 0.96; 95% CI = 0.18–1.74; P = .02).

Conclusion:

Magnesium sulfate can reduce blood pressure, but with the increase in extubation time for laparoscopic cholecystectomy.
Congenital anal atresia with rectovestibular fistula, scoliosis, unilateral renal agenesis, and finger defect (VACTERL association) in a patient with partial bicornuate uterus and distal vaginal atresia
Authors: Kang Jia , Mao Meng , Zhang Ye , Ai Fang-Fang , Zhu Lan
Published: November 2018

Rationale:

Vertebral defect, anal atresia, cardiac defect, tracheoesophageal fistula/esophageal atresia, renal defect, and limb defect (VACTERL) association and Müllerian duct anomalies are rare conditions. We present a rare condition with the co-occurrence of the VACTERL association and Müllerian duct hypoplasia to characterize patients’ clinical presentations, outcomes, and treatment.

Patient concerns:

An 11-year-old girl presented to our hospital with severe lower abdominal pain, lower vaginal atresia with enlargement of the upper vagina and a bicornuate uterus with a Y-shaped uterine cavity filled with hematometra on pelvic magnetic resonance imaging. Her medical history included congenital anal atresia with a rectovestibular fistula, congenital right renal deficiency, congenital right thumb malformation, and scoliosis.

Diagnoses:

1. Congenital genital tract malformations, a partial bicornuate uterus, and distal vaginal atresia (U3aC0V4); 2. VACTERL association (congenital anal atresia with rectovestibular fistula, scoliosis with hemi vertebra and butterfly vertebra, unilateral renal agenesis, and finger defect).

Interventions:

Colpotomy, laparoscopic exploration, pelvic adhesiolysis, and hysteroscopy were performed.

Outcomes:

Two months after surgery, a pelvic examination showed an unobstructed vagina which was 10 cm long and 2 fingers wide, without adhesion or constriction.

Lessons:

Clinicians should have a high index of suspicion when evaluating patients with genital malformations associated with VACTERL. Early diagnosis of distal vaginal atresia with appropriate surgical intervention decreases long-term morbidity.
Learning curves for robotic pancreatic surgery-from distal pancreatectomy to pancreaticoduodenectomy
Authors: Shyr Bor-Uei , Chen Shih-Chin , Shyr Yi-Ming , Wang Shin-E.
Published: November 2018

This study sought to identify the learning curves of console time (CT) for robotic pancreaticoduodenectomy (RPD) and robotic distal pancreatectomy (RDP). Perioperative outcomes were compared between the early group of surgeries performed early in the learning curve and the late group of surgeries performed after the learning curve.

Pancreaticoduodenectomy (PD) is a technically demanding and challenging procedure carrying a high morbidity.

Data for RDP and RPD were prospectively collected for analysis. The learning curve was assessed by cumulative sum (CUSUM). Based on CUSUM analyses, patients were divided into the early group and the late group.

There were 70 RDP and 61 RPD cases. It required 37 cases to overcome the learning curve for RDP and 20 cases for RPD. The median console time was significantly shorter in the late group for both RDP (112 minutes vs 225 minutes, P < .001) and RPD (360 minuntes vs 520 minutes, P < .001). Median blood loss was significantly less in the late group for both RDP (30 cc vs 100 cc, P = .003) and RPD (100 cc vs 200 cc, P < .001). No surgical mortality occurred in either group. Clinically relevant pancreatic fistula rate was 22.9% for RDP (32.4% in the early group vs 12.1% in the late group, P = .043), and 11.5% for RPD (0 in early group vs 17.1% in late group, P = .084).

This study demonstrates that the RPD learning curve is 20 cases with prior experience of RDP and confirms the safety and feasibility of both RPD and RDP. Practice and familiarity with the robotic platform are likely to contribute to significant shortening of the learning curve in robotic pancreatic surgery, while knowledge and experience, in addition to practical skills, are also essential to minimize the potential surgical risks of RPD.
Propranolol eye drops in patients with corneal neovascularization
Authors: Filippi Luca , de Libero Cinzia , Zamma Gallarati Barbara , Fortunato Pina , Piozzi Elena
Published: November 2018

Rationale:

Studies performed in animal models of corneal neovascularization suggested the possible efficacy of a treatment with propranolol. Corneal neovascularization is one of the most feared complications of Stevens–Johnson syndrome that frequently involves ocular surface. We report the first 2 patients with severe ocular neo-vascularization treated with different degrees of success, with propranolol eye drops.

Patient concerns:

Two patients with corneal neovascularization complicating the Stevens–Johnson syndrome, not responsive to steroids and cyclosporine, were treated with propranolol eye drops.

Diagnoses:

Corneal neovascularization was detected by ophthalmoscopic evaluation.

Interventions:

Topical treatment with propranolol eye drops at different concentrations.

Outcomes:

Both patients reported dramatic subjective benefits (reduction of photophobia and discomfort) without adverse effects, and in the patient with a less advanced disease, an objective reduction of neovascularization and an improved visual acuity was observed.

Lessons:

This experience suggests that propranolol might be an inexpensive, safe and effective treatment in counteracting the progression of corneal neovascularization.
Spontaneous complete regression of large uterine fibroid after the second vaginal delivery
Authors: Kim Myounghwan
Published: November 2018

Rationale:

Fibroids are common, hormone-dependent, benign uterine tumors. It is estimated that they occur in 20% to 40% of women during their reproductive years. The prevalence of fibroids among pregnant women is 10.7%. Most fibroids do not increase in size during pregnancy. Pregnancy has a variable and unpredictable effect on fibroid growth. The influence of pregnancy on uterine fibroid size still remains unclear. Researchers evaluating fibroids have reported an inverse association between parity and fibroids, suggestive of a protective effect. Pregnancies that occur while fibroids are small would be protective; whereas pregnancies occurring before fibroid development or after the tumors reach some critical size would not be protective. Herein, the case of a woman with a large uterine fibroid that was spontaneously regressed after a second successful vaginal delivery is reported. To our knowledge, the complete regression of a large fibroid after delivery has not yet been reported.

Patient concerns:

A 35-year-old gravida 1 para 0 woman was referred from a private clinic with a history of pelvic mass, adnexal mass and 19 weeks of amenorrhea.

Diagnosis:

Ultrasonographic examination indicated a solid mass at the uterine fundus (12.1 × 8.3 cm) suggestive of a uterine fibroid and complex echogenic mass at the right adnexa (7.7 × 6.0 cm).

Interventions:

Usually, cesarean sections are performed after myomectomy due to the risk for rupture when attempting vaginal delivery. So, the patient decided against the myomectomy, because she did not have any myoma-related symptoms after the first vaginal delivery and wanted to have more children via vaginal birth.

Outcomes:

Six months postpartum she becomes pregnant again. The patient had another vaginal birth. Four years after second delivery, the large myoma completely regressed.

Lessons:

Fibroids can regress with postpartum involution. Even though fibroid-related pregnancy complication is 10% to 30%, prophylactic myomectomy is not recommended. In addition, given the protective effect of parity, conception and delivery are reasonable option and could allow treatment to be deferred in women planning a pregnancy.
Goal-directed fluid therapy does not reduce postoperative ileus in gastrointestinal surgery
Authors: Zhang Xiongxin , Zheng Wei , Chen Chaoqin , Kang Xianhui , Zheng Yueying , Bao Fangping , Gan Shuyuan , Zhu Shengmei
Published: November 2018

Background:

Perioperative goal-directed fluid therapy (GDFT) aiming to maintain individual fluid balance based on sensitive parameters was prevalent in major surgery, especially in enhanced recovery after surgery (ERAS) pathway. This meta-analysis was conducted for the purpose of evaluating whether GDFT impacts on occurrence of postoperative ileus and whether its application is worthwhile in gastrointestinal surgery.

Methods:

A systematic search of RCTs compared GDFT with other fluid management in patients undergoing gastrointestinal surgery from the PubMed, Web of Science, Embase, Cochrane Library databases was implemented. The primary outcome is incidence of postoperative ileus. Other outcome measures were length of hospital stay (LOS), postoperative morbidity and mortality. Subgroup analysis was planed a prior to verify the definite role of GDFT.

Results:

12 trials consisted of 1836 patients were included in the final analysis. GDFT did not influence the occurrence of postoperative ileus (relative risk, RR 0.71, 95% confidence interval, CI 0.47–1.07, P = .10), with moderate heterogeneity (I

2
 = 29%, P = .16). No difference was found between GDFT and control groups in LOS (mean difference –0.17 days, 95% CI –0.73 to 0.39, P = .55), total complication rate (RR 0.92, 95% CI 0.81–1.05, P = .23), and 30-day mortality (RR 0.91, 95% CI 0.47–1.75, P = .77). In other secondary outcomes, only wound infection rate was lower in the GDFT group (RR 0.68, 95% CI 0.50–0.93, P = .02). When performed subgroup analysis, GDFT was superior in reduction ileus only when compared with standard therapy or in those outside ERAS.

Conclusions:

It is possible that GDFT dose not affect the occurrence of postoperative ileus in gastrointestinal surgery. It scarcely influences postoperative morbidity and mortality as well. However, lower incidence of ileus is observed in GDFT group either outside ERAS or compared with standard fluid therapy. Probably, GDFT may not be necessary in the ERAS pathway or if a hybrid approach is adopted.
Long-term safety and immunogenicity of the M72/AS01E candidate tuberculosis vaccine in HIV-positive and -negative Indian adults
Authors: Kumarasamy Nagalingeswaran , Poongulali Selvamuthu , Beulah Faith Esther , Akite Elaine Jacqueline , Ayuk Leo Njock , Bollaerts Anne , Demoitié Marie-Ange , Jongert Erik , Ofori-Anyinam Opokua , Van Der Meeren Olivier
Published: November 2018

Objectives:

To assess the long-term safety and immunogenicity of the M72/ Adjuvant System (AS01E) candidate tuberculosis (TB) vaccine up to 3 years post-dose 2 (Y3) in human immunodeficiency virus (HIV)-positive (HIV+) and HIV-negative (HIV−) Indian adults.

Methods:

This phase II, double-blind, randomised, controlled clinical trial (NCT01262976) was conducted at YRG CARE Medical Centre, in Chennai, India, between January 2011 and June 2015.

Three cohorts (HIV+ participants stable on antiretroviral therapy [ART; HIV+ART+], HIV+ ART-naïve [HIV+ART-], and HIV− participants) were randomised (1:1) to receive 2 doses of M72/AS01E (M72/AS01E groups) or saline (control groups) 1 month apart and were followed up toY3. Latent TB infection was assessed at screening using an interferon-gamma (IFN-γ) release assay (IGRA). Safety and immunogenicity results up to Y1 post-vaccination were reported elsewhere. Here, we report serious adverse events (SAEs), humoral and cell-mediated immune (CMI) responses to M72 recorded at Y2 and Y3.

Results:

Of 240 enrolled and vaccinated participants, 214 completed the long-term follow-up part of the study.

In addition to SAEs previously described, between Y1 and Y2 1 M72/AS01E recipient in the HIV+ART+ cohort reported 2 SAEs (sinus cavernous thrombosis and gastroenteritis) that were not considered as causally related to the study vaccine.

Vaccination elicited persistent humoral immune responses against M72. At Y3, seropositivity rates were 97.1%, 66.7%, and 97.3% and geometric mean concentrations (GMCs) were 22.0  ELISA units (EU)/mL, 4.9 EU/mL, and 24.3 EU/mL in the HIV+ART+, HIV+ART-, and HIV− cohorts, respectively. Humoral immune response was lowest in the HIV+ART- cohort.

In M72/AS01E recipients, no notable decrease in the frequency of M72-specific CD4+ T-cells expressing ≥2 immune markers among interleukin-2 (IL-2), IFN-γ, tumour necrosis factor alpha (TNF-α) and CD40 ligand (CD40L) was observed at Y3 post-vaccination. Median values (interquartile range) of 0.35% (0.13–0.49), 0.05% (0.01–0.10), and 0.15% (0.09–0.22) were recorded in the HIV+ART+, HIV+ART- and HIV− cohorts, respectively. CD4+ T-cell response was lowest in the HIV+ART- cohort.

No CD8+ T-cell response was observed.

Conclusion:

The cellular and humoral immune responses induced by M72/AS01E in HIV+ and HIV− adults persisted up to Y3 post-vaccination. No safety concerns were raised regarding administration of M72/AS01E to HIV+ adults.

Clinical Trial Registration:

NCT01262976 (www.clinicaltrials.gov).