bluuebunny/crossref_metadata_2025 huggingface dataset:
Precision medicine in food allergy
Authors: Arasi Stefania , Mennini Maurizio , Valluzzi Rocco , Riccardi Carla , Fiocchi Alessandro
Published: July 2018

Purpose of review

To familiarize the reader with the concept of precision medicine in food allergy through the most recent insights in the diagnosis, prognosis, and management of the disease.

Recent findings

With the advent of omics sciences, a new era is commencing. Food protein allergens characterization and quantification together with the immunoglobulin E epitope mapping will contribute to the diagnosis/prognosis of food allergy and will lead to a better safety assessment of foods. The characterization of biomarkers able to identify specific phenotypes and endotypes will improve the diagnostic accuracy. This together with a better understanding of mechanisms of action of the different therapeutic options will allow the accurate selection of the appropriate patient.

In the near future, advances in technologies and data interpretation will allow a better understanding of the pathogenesis of food allergy and the development of a personalized treatment tailored on the specific patient’ profile.
Maternal Protective Parenting Accounts for the Relationship Between Pain Behaviors and Functional Disability in Adolescents
Authors: Lynch-Jordan Anne M. , Peugh James , Cunningham Natoshia R. , Trygier Jessica R. , Kashikar-Zuck Susmita
Published: July 2018

Introduction:

A variety of factors influence parent responses to pain behaviors they observe in their adolescents with chronic pain. Certain parental responses to pain, such as attention or overprotection, can adversely impact adolescent adaptive functioning and correspond to poor clinical outcomes.

Objectives:

It was hypothesized that the relationship between adolescent pain behaviors and functional disability was mediated by maladaptive parenting (protective, monitoring, solicitousness) responses.

Materials and Methods:

Participants were 303 adolescents and their mothers presenting to a pain clinic. Adolescents completed measures of functional disability and pain intensity; mothers completed measures assessing adolescent pain behaviors, their own catastrophizing about their adolescent’s pain, and responses to pain. A path model tested the direct and indirect associations between pain behaviors and disability via 3 parenting responses, controlling for average pain intensity and parent pain catastrophizing.

Results:

Greater pain behavior was associated with increased protective responses (α path, P<0.001); greater protective behavior was associated with increased disability (β path, P=0.002). Including parenting responses in the model, the path between pain behaviors and disability remained significant (c′ path, P<0.001). The indirect path between pain behaviors and disability via parenting responses was significant for protective responses (P<0.02), controlling for pain intensity and parent pain catastrophizing. The indirect effect of protective responses explained 18% of the variance between pain behaviors and disability.

Discussion:

Observing adolescent pain behaviors may prompt parents to engage in increased protective behavior that negatively impacts adolescents’ functioning, even after controlling for the effects of parental pain catastrophizing.
Opioid Dependence and Health Care Utilization After Decompression and Fusion in Patients With Adult Degenerative Scoliosis
Authors: Sharma Mayur , Ugiliweneza Beatrice , Sirdeshpande Pooja , Wang Dengzhi , Boakye Maxwell
Published: July 2018

Study Design.

Retrospective study.

Objective.

To identify factors associated with opioid dependence after surgery for adult degenerative scoliosis (ADSc).

Summary of Background Data.

Opioid epidemic is of prodigious concern throughout the United States.

Methods.

Data was extracted using national MarketScan database (2000–2016). Opioid dependence was defined as continued opioid use or >10 opioid prescriptions for 1 year either before or 3 to 15 months after the procedure. Patients were segregated into four groups based on opioid dependence before and postsurgery: NDND (before nondependent who remain non-dependent), NDD (before nondependent who become dependent), DND (before dependent who become non-dependent) and DD (before dependent who remain dependent). Outcomes were discharge disposition, length of stay, complications, and healthcare resource utilization.

Results.

Approximately, 35.82% (n = 268) of patients were identified to have opioid dependence before surgery and 28.34% (n = 212) were identified to have opioid dependence after surgery for ADSc. After surgical fusion for ADSc, patients were twice likely to become opioid independent than they were to become dependent (13.77% vs. 6.28%, OR: 2.191, 95% CI: 21.552–3.094; P < 0.0001). Before opioid dependence (RR: 14.841; 95% CI: 9.867, 22.323; P < 0.0001) was identified as a significant predictor of opioid dependence after surgery for ADSc. In our study, 57.9%, 6.28%, 13.77%, and 22.06% of patients were in groups NDND, NDD, DND, and DD respectively. DD and NDD were likely to incur 3.03 and 2.28 times respectively the overall costs compared with patients’ ingroup NDND (P < 0.0001), at 3 to 15 months postsurgery (median $21648 for NDD; $40,975 for DD; and $ 13571 for NDND groups).

Conclusion.

Surgery for ADSc was not associated with increased likelihood of opioid dependence, especially in opioid naïve patients. Patients on regular opiate treatment before surgery were likely to remain on opiates after surgery. Patients who continued to be opioid dependent or become dependent after surgery incur significantly higher healthcare utilization at 3 and 3 to 15 months.

Level of Evidence: 4
Cervical cancer screening uptake in women aged between 15 and 64 years in Mozambique
Authors: Brandão Mariana , Tulsidás Satish , Damasceno Albertino , Silva-Matos Carla , Carrilho Carla , Lunet Nuno
Published: July 2018

Cervical cancer is the most common cancer in Mozambique, reflecting the high prevalence of both human papillomavirus and HIV infections. A national screening program for cervical cancer was started in 2009, using the visual inspection with acetic acid and cryotherapy, targeting women aged 30–55 years. We aimed to estimate the self-reported prevalence and determinants of cervical cancer screening uptake in Mozambique. A cross-sectional study of a representative sample of the women aged 15–64 years (n=1888) was carried out in 2014/2015 following the WHO-Stepwise Approach to Chronic Disease Risk Factor Surveillance. The prevalence of screening uptake using visual inspection with acetic acid or cervical cytology, at least once in a lifetime, was 3.0% [95% confidence interval (CI): 2.2–4.1]; the prevalence was the lowest in the center region (1.4%) and the highest in the capital city of Maputo (11.1%). Among women aged 30–55 years, the prevalence was 3.4% (95% CI: 2.3–5.2) and the factors independently associated with a greater frequency of screening uptake were education (≥8 schooling years vs. none: prevalence ratio=5.57, 95% CI: 1.34–23.16) and use of oral contraceptives (prevalence ratio=2.33, 95% CI: 1.05–5.15). This was the first national Mozambican survey on cervical cancer screening uptake ever carried out and it showed a very low prevalence of screening, even in the more urban and affluent areas. There is an urgent need to raise public awareness of cervical cancer screening and to increase the number of screening units and trained personnel throughout the country.
Analysis of MLN4924 (pevonedistat) as a potential therapeutic agent in malignant melanoma
Authors: Olaverria Salavaggione Gonzalo N. , Duggan Megan C. , Carson William E.
Published: July 2018

The NEDD8 pathway is a known activator of the ubiquitin–protease system, a complex that is partially responsible for the degradation of proteins involved in cell-cycle regulation and neoplastic growth. In this study, we evaluated the antitumor potential of MLN4924 (pevonedistat), a potent NEDD8 inhibitor. We hypothesized that MLN4924 treatment induces apoptosis in human melanoma cells. A375 and Mel39 BRAF V600E mutant melanoma cell lines were treated in vitro with MLN4924 alone or in combination with interferon-α (IFN-α) or vemurafenib – therapeutic agents utilized on melanoma patients. Annexin/propidium iodine flow cytometry analysis showed that treatment with MLN4924 for 72 h induced apoptosis in A375 and Mel39 melanoma cells with an IC50 of 1200 and 143 nmol/l, respectively. Combination therapy of A375 cells with 104 U/ml IFN-α and 1200 nmol/l MLN4924 led to a significant increase in cell death (78.2±3.7%) compared with single-agent treatment by IFN-α (17.5±2.5%) or MLN4924 (50.7±1.0%; P<0.005). Treatment of A375 cells with 1 μmol/l vemurafenib had a notable effect on cell viability. However, the addition of MLN4924 to vemurafenib had an inhibitory effect on apoptosis. Results from MTS proliferation assays indicate that MLN4924 has antiproliferative effects on melanoma cells in vitro, with the addition of IFN-α further inhibiting proliferation. Pretreatment with MLN4924 led to A375 cell sensitization to vemurafenib treatment and immunoblot analysis of MLN4924-treated cells revealed cleavage of caspase-3, caspase-7, caspase-9, and poly-ADP-ribose polymerase. These results show that MLN4924 does have an efficacy in treating melanoma in vitro alone or in combination with IFN-α, and thus it may have potential use in patients with advanced melanoma.
Tissue Contraction—A New Paradigm in Breast Reconstruction
Authors: Becker Hilton , Zhadan Olga
Published: July 2018

Background:

Skin expansion is commonly needed in order to reconstruct the breast following modified radical mastectomy. With the advent of skin-sparing and nipple-sparing techniques, expansion is no longer necessary. The natural ability of healing tissues to contract can be advantageously used to improve the outcomes of immediate prepectoral breast reconstruction.

Methods:

A prospective analysis of the results of 20 prepectoral breast reconstructions following skin-sparing or nipple-sparing mastectomies was performed. Reconstruction was performed using the adjustable breast implant initially underfilled with air. No acellular dermal matrix or mesh support was used. Further air was added during the follow-up office visits. Air was replaced with normal saline when the desired breast size was achieved. The adjustable implants were replaced with silicone gel implants when necessary.

Results:

Contraction of the skin flap over the underfilled implant was noticed in all patients. Five patients (25%) developed a seroma, and 2 patients had hematoma of the breast pocket. Wound-edge necrosis required debridement in 2 patients (10%). Complications were all resolved without implant loss.

Conclusions:

Tissue contraction can be successfully utilized in breast reconstruction following skin-sparing and nipple-sparing mastectomy. Contraction results in thickening and elevation of the flap, eliminating the need for skin excision or the use of acellular dermal matrix. The partially filled implant functions as a spacer, preventing the flap from adhering to the underlying muscle and avoiding pressure on the skin flap.
SENSITIVITY OF 840-nm SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN DETECTING TYPE 1 NEOVASCULARIZATION ACCORDING TO THE HEIGHT OF THE ASSOCIATED PIGMENT EPITHELIAL DETACHMENT
Authors: Mrejen Sarah , Giocanti-Auregan Audrey , Tabary Sandrine , Cohen Salomon Y.
Published: July 2018

Purpose:

To evaluate the ability of optical coherence tomography angiography (OCTA) to detect abnormal vascular blood flow in Type 1 neovascularization (NV) with or without significant pigment epithelial detachment (PED).

Methods:

Consecutive age-related macular degeneration patients with either treatment-naive or anti–vascular endothelial growth factor–treated Type 1 NV were divided into 2 groups based on the PED height on structural OCT: greater than 250 μm (Group 1) versus less than 250 μm (Group 2). Two independent senior retina specialists analyzed the OCTA images (Zeiss Angioplex OCT, Carl Zeiss AG, Jena, Germany) using the automatic slabs alone (first reader) versus automatic and manual segmentation slabs (second reader).

Results:

In Group 1, 15 men and 42 women, aged from 51 years to 97 years (mean: 87.5), were included. Optical coherence tomography angiography was able to show an abnormal blood flow suggestive of Type 1 NV in 23 (40.3%) of 57 eyes for the first reader and in 32 (56.1%) of 57 eyes for the second reader. In Group 2, 7 men and 30 women, aged from 60 years to 96 years (mean: 80.2), were included. The first and second readers were able to observe an image suggestive of Type 1 NV in 33/37 (89.2%) and 37/37 (100%) of eyes, respectively.

Conclusion:

The ability of OCTA to detect an abnormal blood flow in Type 1 NV was found to highly depend on the height of the associated PED and the use of manual segmentation slabs. Our results suggest that automatic slabs of OCTA should be interpreted with caution for the diagnosis of vascularized PED. The diagnosis of Type 1 NV using OCTA requires the use of manual segmentation and a multimodal imaging approach, especially when the height of the associated PED is >250 μm.
VISUAL FUNCTION AND RETINAL CHANGES IN PATIENTS WITH BIPOLAR DISORDER
Authors: Garcia-Martin Elena , Gavin Alicia , Garcia-Campayo Javier , Vilades Elisa , Orduna Elvira , Polo Vicente , Larrosa Jose M. , Pablo Luis E. , Satue Maria
Published: July 2018

Purpose:

To evaluate visual and retinal changes in patients with bipolar disorder. To analyze the correlation between structural changes and visual function parameters.

Methods:

Thirty patients with bipolar disorder and 80 healthy controls underwent visual function evaluation with Early Treatment Diabetic Retinopathy Study charts at 100%, 2.50%, and 1.25% contrast, Pelli-Robson chart, and color vision Farnsworth and Lanthony tests. Analysis of the different retinal layers was performed using Spectralis optical coherence tomography with automated segmentation software. Correlation analysis between structural and functional parameters was conducted.

Results:

Patients with bipolar disorder presented worse color vision compared with controls (Lanthony's index, P = 0.002). Full macular thickness, the retinal nerve fiber layer (RNFL), ganglion cell layer, and inner plexiform layer were reduced in patients compared with healthy individuals (P < 0.005). The inner nuclear layer was significantly thickened in patients (P < 0.005). Peripapillary RNFL thickness was reduced in all temporal sectors (P < 0.005). Significant correlations were found between visual acuity and the RNFL thickness, the Pelli-Robson score and the inner plexiform layer, and between the Lanthony's color index and the ganglion cell layer thickness.

Conclusion:

Patients with bipolar disorder present quantifiable thinning of the macular RNFL, ganglion cell layer, and inner plexiform layer, as well as in the peripapillary RNFL thickness, and increasing thinning in the inner nuclear layer.
CONGENITAL TOXOPLASMOSIS ASSOCIATED WITH TRACTIONAL RETINAL DETACHMENT
Authors: Rassi Alessandra , Todorich Bozho , Faia Lisa J. , Trese Michael , Drenser Kimberly , Capone Antonio
Published: July 2018

Purpose:

We report a case of congenital toxoplasmosis associated with retinal detachment.

Methods:

A 9-month-old white boy presented a unilateral tractional retina detachment associated with congenital toxoplasmosis retinochoroiditis.

Results:

The diagnosis is supported by positive IgG (>400) for toxoplasmosis and intracranial calcification on magnetic resonance imaging, along with positive family history of Toxoplasma infection in the mother.

Conclusion:

Tractional retinal detachment is an infrequent and unconventional presentation of congenital Toxoplasma infection. Inflammatory interference with normal sequence of vitreous development may explain pathogenesis of tractional retinal detachments in the setting of congenital ocular toxoplasmosis.
Pharmacokinetic Evaluation of a 1-Day Treatment Initiation Option for Starting Long-Acting Aripiprazole Lauroxil for Schizophrenia
Authors: Hard Marjie L. , Wehr Angela Y. , Du Yangchun , Weiden Peter J. , Walling David , von Moltke Lisa
Published: July 2018

Background

Aripiprazole lauroxil (AL), a long-acting injectable antipsychotic for the treatment of schizophrenia, requires 21 days of oral aripiprazole supplementation upon initiation. We report findings from a phase 1 study investigating a nanocrystalline milled dispersion of AL (ALNCD) as a potential 1-day initiation regimen. The 1-day initiation regimen is designed to enable rapid achievement of plasma aripiprazole concentrations that are comparable with the 21-day oral initiation regimen. Here, a 6-month pharmacokinetic study compared 2 different initiation regimens for starting AL.

Methods

Patients were randomized 1:1:1:1 to receive 1 of 4 treatments consisting of the 1-day (single ALNCD injection + one 30-mg dose of oral aripiprazole on day 1 only) or the 21-day (15-mg daily dose of oral aripiprazole for 21 days) initiation regimen, each combined with a starting AL dose of either 441 mg or 882 mg.

Results

In total, 133/161 patients completed the study. The pharmacokinetic profile of the 1-day initiation regimen was comparable to the 21-day initiation regimen; both achieved aripiprazole concentrations in the therapeutic range within 4 days and remained in a comparable concentration range during treatment initiation. Common adverse events (≥5.0%) were injection-site pain, headache, increased weight, insomnia, dyspepsia, and anxiety. Nine akathisia events occurred (4 events in 4 patients and 5 events in 2 patients in the 1-day and 21-day initiation regimen groups, respectively).

Conclusions

The 1-day initiation regimen resulted in plasma aripiprazole concentrations consistent with the 21-day initiation regimen. Therefore, a single dose of ALNCD with a single 30-mg oral dose of aripiprazole provides an alternative initiation regimen for starting AL.
Manifestations and Management of Difficult-to-Treat Psoriasis
Authors: Aldredge Lakshi M. , Higham Robert C.
Published: July 2018

Psoriasis is a common, immune-mediated skin disorder that can manifest as multiple clinical phenotypes. Although psoriasis affecting the scalp, face, nails, palms, soles, and intertriginous regions has not been studied as extensively as chronic plaque psoriasis in other body areas, these phenotypes can be associated with significant physical, psychosocial, and functional impairments, which impact quality of life. In addition, recent evidence has shown that psoriasis affecting these areas is more prevalent than traditionally thought. In this article, we discuss the clinical characteristics of these hard-to-treat areas and review newer treatment options, which have shown significant efficacy for psoriasis affecting these body regions. To provide optimal care to patients with difficult-to-treat psoriasis, nurses, nurse practitioners, and physician assistants should evaluate patients for scalp, facial, nail, palmoplantar, and inverse psoriasis to provide more effective therapeutic options.
Daylight-Mediated Photodynamic Therapy for Actinic Keratosis
Authors: Spelman Lynda , Holland Teagan , Davidson Kurt
Published: July 2018

Actinic (solar) keratoses are premalignant lesions caused by prolonged exposure to ultraviolet radiation, with the potential to progress into squamous cell carcinoma. Hence, use of appropriate therapies is critical for effective treatment. Daylight-mediated photodynamic therapy with methyl aminolevulinate cream is a convenient new option for the safe and effective treatment of actinic (solar) keratosis lesions, offering similar efficacy to conventional photodynamic therapy, nearly painless treatment, and reduced in-clinic times. Use of appropriate therapies and optimization of clinical practice are critical for safe and effective treatment. Nurses play a key role in ensuring best clinical practice and effective treatment. This article explains the practicalities and principles of daylight-mediated photodynamic therapy to ensure best practice by treating nurses.
Development of an Automatic Diagnostic Algorithm for Pediatric Otitis Media
Authors: Tran Thi-Thao , Fang Te-Yung , Pham Van-Truong , Lin Chen , Wang Pa-Chun , Lo Men-Tzung
Published: July 2018

Hypothesis:

The artificial intelligence and image processing technology can develop automatic diagnostic algorithm for pediatric otitis media (OM) with accuracy comparable to that from well-trained otologists.

Background:

OM is a public health issue that occurs commonly in pediatric population. Caring for OM may incur significant indirect cost that stems mainly from loss of school or working days seeking for medical consultation. It makes great sense for the homecare of OM. In this study, we aim to develop an automatic diagnostic algorithm for pediatric OM.

Methods:

A total of 1,230 otoscopic images were collected. Among them, 214 images diagnosed of acute otitis media (AOM) and otitis media with effusion (OME) are used as the database for image classification in this study. For the OM image classification system, the image database is randomly partitioned into the test and train subsets. Of each image in the train and test sets, the desired eardrum image region is first segmented, then multiple image features such as color, and shape are extracted. The multitask joint sparse representation-based classification to combine different features of the OM image is used for classification.

Results:

The multitask joint sparse representation algorithm was applied for the classification of the AOM and OME images. The approach is able to differentiate the OME from AOM images and achieves the classification accuracy as high as 91.41%.

Conclusion:

Our results demonstrated that this automatic diagnosis algorithm has acceptable accuracy to diagnose pediatric OM. The cost-effective algorithm can assist parents for early detection and continuous monitoring at home to decrease consequence of the disease.
Salvage Radiosurgery After Subtotal Resection for Catecholamine-secreting Jugular Paragangliomas: Report of Two Cases and Review of the Literature
Authors: Chweya Cynthia M. , Patel Neil S. , Young William F. , Pollock Bruce E. , Link Michael J. , Carlson Matthew L.
Published: July 2018

Objectives:

Catecholamine-secreting jugular paragangliomas (JPs) represent a rare subset of head and neck paragangliomas that may present with hypertension, arrhythmia, or syncopal episodes. Subtotal resection to protect critical neurovascular structures may result in persistent catecholamine excess from residual tumor. Herein, we report our experience with stereotactic radiosurgery (SRS) for salvage treatment of catecholamine-secreting JP following subtotal microsurgical resection.

Patients:

Adult patients treated with SRS after subtotal microsurgical resection of catecholamine-secreting JP.

Interventions:

SRS.

Main Outcome Measures:

Post-treatment catecholamine and metanephrine levels, clinical outcomes, and tumor control.

Results:

Of 85 patients with JPs treated with primary or salvage radiosurgery between 1990 and 2017, 2 (2%) harbored nonmalignant secreting tumors. Patient 1 developed catecholamine excess with elevated norepinephrine (NE) at 475 mcg/24 hours (normal < 80 mcg/24 h). Following subtotal resection, she developed catecholamine excess with radiographic evidence of tumor growth and therefore underwent SRS. Three years post-SRS and beyond, catecholamine levels remained normalized (NE 62 mcg/24 h at 10 yr) and tumor volume remained stable on serial MRI studies over the 17-year follow-up period.

Patient 2 developed symptomatic arrhythmia and was found to have a JP. Urine norepinephrine (NE) was elevated at 213 mcg/24 hours. She underwent nerve-sparing subtotal resection and upfront SRS was used to treat residual tumor. Twenty months following SRS, the area of residual JP had not enlarged in size and catecholamine levels remained normal (NE 46 mcg/24 h).

Conclusions:

Radiosurgery can be used in salvage treatment of catecholamine-secreting JP, providing durable tumor control and resolution of catecholamine excess. For patients with large catecholamine-secreting JP and normal lower cranial nerve function, aggressive nerve-sparing subtotal resection with adjuvant radiosurgery may offer a low-morbidity alternative to gross total resection. Further study of this subset of patients is warranted to substantiate these promising, yet preliminary findings.
Colorectal cancer in young African Americans: clinical characteristics and presentations
Authors: Lapumnuaypol Kamolyut , Mahmood Ejaz , Chaiwatcharayut Wikrom , Bandres Maria V. , Goyal Abhinav , Djibo Djeneba A. , Tiu Andrew
Published: July 2018

Purpose

Colorectal cancer (CRC) is the third most common cancer in the USA, and the incidence in young adults has been increasing over the past decade. We studied the clinical characteristics and presentations of CRC in young African American (AA) adults because available data on how age and ethnicity influence its pattern of presentation is limited.

Patients and methods

We conducted a retrospective study of 109 young adults (75 African Americans) below 50 years, who were diagnosed with CRC between 1 January 1997 and 31 December 2016. Proximal CRC was defined as lesions proximal to the splenic flexure. Independent t-tests and χ
2-test or Fisher’s exact test were performed where appropriate to determine the differences between AA and non-AA patients.

Results

The mean age at diagnosis was 42 years (range: 20–49 years). Compared with non-AAs, AAs had more frequent proximal CRC (38.7 vs. 14.7%, P=0.003), lower hemoglobin (10.5 vs. 12.7 g/dl, P<0.001), and more frequent weight loss (21.3 vs. 2.9% P=0.014). Non-AAs presented more frequently with rectal bleeding (52.9 vs. 32.0% P=0.037). There was no statistically significant difference in histology, stage, grade, tumor size, and carcinoembryonic antigen level between groups. When we stratified between proximal and distal disease among patients with CRC, we found larger tumor size in distal disease, which presented more with rectal bleeding and bowel habit changes. Proximal disease presented more as abdominal pain and weight loss.

Conclusion

There should be a higher index of suspicion for CRC in young AA adults presenting with anemia, abdominal pain, and weight loss. Early screening colonoscopy should be advocated in AAs because of the predominance of proximal disease.
Non-parenchymal hepatic cell lipotoxicity and the coordinated progression of non-alcoholic fatty liver disease and atherosclerosis
Authors: Peters Kia M. , Wilson Rachel B. , Borradaile Nica M.
Published: July 2018

Purpose of review

Non-alcoholic fatty liver disease (NAFLD) appears to be independently associated with the development of atherosclerosis. The biological mechanisms underlying this association are complex, and likely involve liver-resident cell types other than hepatocytes. Thus, we review recent evidence that non-parenchymal hepatic cell responses to lipid excess contribute to the pathogenesis of both NAFLD and atherosclerosis.

Recent findings

Significant independent associations between NAFLD and atherosclerosis have been identified through cross-sectional studies and meta-analyses. Mechanistic studies in cell cultures and in rodent models suggest that liver-resident macrophages, activated hepatic stellate cells (HSC) and liver sinusoidal endothelial cells (LSEC) mount lipotoxic responses under NAFLD conditions which can contribute to the progression of both NAFLD and atherosclerosis.

Non-parenchymal hepatic cell types exhibit some similarity in their responses to lipid excess, and in their pathogenic mechanisms, which likely contribute to the coordinated progression of NAFLD and atherosclerosis. In response to lipotoxic conditions, macrophages, Kupffer cells and HSC initiate robust inflammatory responses, whereas LSEC generate excess reactive oxygen species (ROS). The extent to which inflammatory cytokines and ROS produced by non-parenchymal cells contribute to the progression of both NAFLD and atherosclerosis warrants further investigation.
Eosinophilic esophagitis: short and long-term considerations
Authors: Goyal Aakash
Published: July 2018

Purpose of review

Eosinophilic esophagitis (EoE) is a relatively new disease but its understanding is evolving over a period of time. This review highlights recent advances in the understanding of pathophysiology, diagnostic modalities, short and long-term goals of therapy and novel therapeutic agents.

Recent findings

The prevalence of EoE is increasing. Upper endoscopy and biopsy remains the gold standard for diagnosing EoE but less invasive and more cost-effective testing has been under investigation. Scoring systems to assess symptoms, histology and endoscopic findings can distinguish between active and inactive disease. Step up therapy with 2–4–6 food elimination can result in early identification of triggering foods and reduce frequency of endoscopies. The term proton pump inhibitor (PPI) responsive eosinophilia should be avoided and PPI should be considered a therapeutic modality. Oral viscous budesonide has been more effective than fluticasone in achieving remission. Adrenal suppression should be looked for patients on swallowed steroids. IL-13 antagonists can be a promising therapy for EoE and dilation is a safe and effective treatment modality in patients with EoE but as is expected, does not decrease inflammation.

EoE has been increasingly recognized as a cause of food impactions and dysphagia. Less invasive methods for diagnosis and to monitor treatment response have been studied but need validation in children. Short-term treatment goals include symptomatic and histological improvement, with prevention of fibrostenotic disease the primary long-term goal. Elemental diet and empiric elimination diet appear to be successful in inducing remission. PPI and swallowed steroids cause symptomatic improvement and histological remission but relapse is common after discontinuation of therapy.
Walking endurance and perceived symptom severity after a single maximal exercise test in persons with mild disability because of multiple sclerosis
Authors: Moumdjian Lousin , Gervasoni Elisa , Van Halewyck Florian , Eijnde Bert O. , Wens Inez , Van Geel Fanny , Van Wijmeersch Bart , Feys Peter , Van Asch Paul
Published: July 2018

People with multiple sclerosis (PwMS) are less physically active compared with the general population. This might also be because of the perception of temporary worsening of symptoms during physical activity. Forty-two PwMS with a mild level of disability underwent a maximal exercise test on a bicycle ergometer. Fifteen minutes before and 15 and 75 min after the maximal exercise test, the 6-minute walking test was conducted and the rate of perceived exertion was recorded. Twice before and three times after the maximal exercise test, participants rated the symptom inventory, including symptom domains of general fatigue, muscle fatigue, balance, gait pattern, muscle weakness, spasticity, pain, sensory disturbance, dizziness, and visual impairment. The visual analogue scale was used to rate the perceived symptoms from 0 (no intensity) to 10 (maximal intensity). The 6-minute walking test distance increased significantly over time, whereas the rate of perceived exertion increased temporarily after the maximal exercise test. Immediately after the maximal exercise test, significant temporary increases were found in balance, gait pattern, muscle weakness, and visual impairment. General and muscle fatigue were elevated, compared with the baseline, till 15 and 75 min after the maximal exercise test, respectively. A short-term impact of a single maximal exercise test was considered as the temporary worsening of perceived symptoms, especially (muscle) fatigue and the gait pattern, in PwMS with a mild level of disability. However, a recovery was observed after 75 min. Walking endurance was not affected by the maximal exercise test.
Epithelial Inclusions in Gallbladder Specimens Mimic Parasite Infection
Authors: Swanson Eric A. , March Jordon K. , Clayton Frederic , Couturier Marc R. , Arcega Ramir , Smith Richard , Evason Kimberley J.
Published: July 2018

Recent publications have described epithelial cytoplasmic vacuoles and inclusions incidentally noted within gallbladder epithelium and concluded that they represent coccidian parasite infection, in particular, Cystoisospora belli. We identified 8 gallbladder specimens from our institution in the past 3 years in which this diagnosis was suggested or in which similar epithelial alterations were prominent. Molecular analysis was performed on the 8 gallbladder specimens and on 3 positive control specimens: small bowel biopsies from acquired immunodeficiency syndrome patients with diarrhea. Polymerase chain reaction using primers designed to amplify an internal transcribed spacer (ITS2) in the C. belli ribosomal gene cluster was performed on the DNA samples. All 8 gallbladder specimens were negative for amplification, while a product consistent with C. belli was amplified from all 3 positive controls. Histologically, the gallbladder cytoplasmic inclusions stained diffusely positive for Grocott-Gomori’s methenamine silver and Periodic acid–Schiff with diastase. In contrast, sections from a positive control small bowel biopsy demonstrated organisms that were negative for Grocott-Gomori’s methenamine silver and showed a distinct capsular and punctate internal staining on Periodic acid–Schiff with diastase in various parasite forms. Together, the lack of molecular evidence of C. belli and the distinct morphologic and special staining patterns in these gallbladders compared with positive control small bowel suggest that these epithelial changes do not represent true C. belli infection. Our results suggest that gallbladders of immunocompetent patients may occasionally show epithelial changes that can morphologically mimic C. belli infection. Pathologists should be aware of this histologic variant to minimize unnecessary treatment, testing, and patient anxiety.
Elevated Heart Rate and Risk of Revisit With Admission in Pediatric Emergency Patients
Authors: Daymont Carrie , Balamuth Fran , Scott Halden F. , Bonafide Christopher P. , Brady Patrick W. , Depinet Holly , Alpern Elizabeth R.
Published: July 2018

Objective

The aim of this study was to identify emergency department (ED) heart rate (HR) values that identify children at elevated risk of ED revisit with admission.

Methods

We performed a retrospective cohort study of patients 0 to 18 years old discharged from a tertiary-care pediatric ED from January 2013 to December 2014. We created percentile curves for the last recorded HR for age using data from calendar year 2013 and used receiver operating characteristic (ROC) curves to characterize the performance of the percentiles for predicting ED revisit with admission within 72 hours. In a held-out validation data set (calendar year 2014 data), we evaluated test characteristics of last-recorded HR-for-age cut points identified as promising on the ROC curves, as well as those identifying the highest 5% and 1% of last recorded HRs for age.

Results

We evaluated 183,433 eligible ED visits. Last recorded HR for age had poor discrimination for predicting revisit with admission (area under the curve, 0.61; 95% confidence interval, 0.58–0.63). No promising cut points were identified on the ROC curves. Cut points identifying the highest 5% and 1% of last recorded HRs for age showed low sensitivity (10.1% and 2.5%) with numbers needed to evaluate of 62 and 50, respectively, to potentially prevent 1 revisit with admission.

Conclusions

Last recorded ED HR discriminates poorly between children who are and are not at risk of revisit with admission in a pediatric ED. The use of single-parameter HR in isolation as an automated trigger for mandatory reevaluation prior to discharge may not improve revisit outcomes.
Practice Variation in Emergency Department Management of Children With Sickle Cell Disease Who Present With Fever
Authors: Eisenbrown Katherine , Ellison Angela M. , Nimmer Mark , Badaki-Makun Oluwakemi , Brousseau David C.
Published: July 2018

Objectives

Urgent medical evaluation is recommended for patients with sickle cell disease (SCD) and fever. Clear recommendations exist regarding certain aspects of treatment, but other areas lack evidence. We determined practice variation for children with SCD presenting with fever to the emergency department (ED).

Methods

Retrospective chart review of children ages 3 months to 21 years with SCD presenting to the ED with fever greater than or equal to 38.5°C in the ED or preceding 24 hours. Visits from 3 sickle cell centers were included. Outcomes included blood culture, complete blood count, antibiotic treatment, chest x-ray, urinalysis, electrolytes, and hospital disposition. Differences greater than 10% were considered clinically meaningful.

Results

The population included 14,454 visits, of which 4143 (29%) were febrile and met all inclusion criteria. A complete blood count and blood culture were obtained at 94% of visits, and antibiotics were given at 91%, with no differences among sites. Meaningful differences existed for disposition, with 52%, 43%, and 99% of patients admitted to the inpatient units at hospitals A, B, and C, respectively. Differences were seen in obtaining a urinalysis (33%, 17%, and 21%), electrolytes (2%, 50%, and 12%), and chest x-rays for patients 2 years and older (78%, 77%, 64%) for hospitals A, B, and C, respectively.

Conclusions

Significant variation exists in the proportion of children who receive a urinalysis, electrolytes, chest x-ray, and, most importantly, admission to the hospital. These examples of practice variation represent potential opportunities to define best care practices for children with SCD presenting to the ED for fever.
Congenital Vallecular Cyst as a Cause of Neonatal Stridor and Apnea
Authors: Oelsen J. Marshall , Hewett Kathryn M. , Discolo Christopher M. , Jackson Benjamin F.
Published: July 2018

An infant who presents with stridor and apnea constitutes a challenge for emergency physicians in terms of diagnosis and management. Among the rarest of causes for these symptoms, congenital vallecular cysts can cause devastating outcomes if left undiagnosed. Reported here is a case of intermittent episodes of stridor and apnea in a 4-day-old neonate with a previously undiagnosed vallecular cyst. The process by which the infant was stabilized, correctly diagnosed, and successfully treated for a life-threatening airway obstruction is explained. After a discussion of vallecular cysts, methods for preparing for and executing proper airway management in an infant who presents with apnea and stridor are considered.
Targeted Muscle Reinnervation in the Lower Leg: An Anatomical Study
Authors: Fracol Megan E. , Janes Lindsay E. , Ko Jason H. , Dumanian Gregory A.
Published: July 2018

Background:

Targeted muscle reinnervation reroutes the ends of cut nerves to reinnervate small motor nerves of nearby muscles, with the goal of reducing neuroma pain and/or improving prosthesis function. Anatomical roadmaps for targeted muscle reinnervation have been established in the upper extremity and thigh, but not for the lower leg.

Methods:

The major branch points of motor nerves and the motor entry points to muscles of the leg were dissected in five cadaver specimens. Leg length was defined as distance from the lateral femoral condyle to the lateral malleolus. The distances from the lateral femoral condyle to major branch points and motor entry points were recorded as percentages of leg length to identify targets for targeted muscle reinnervation.

Results:

The tibialis anterior and extensor digitorum longus were both acceptable targets in the anterior compartment, with an average 4.4 motor entry points within 10 to 80 percent and 3.0 motor entry points within 20 to 80 percent leg length, respectively. The peroneus longus was the best target in the lateral compartment, with an average 5.8 motor entry points within 20 to 70 percent leg length. The gastrocnemius and soleus were both acceptable targets in the superficial posterior compartment, with an average 4.4 motor entry points within 0 to 40 percent and 6.2 motor entry points within 20 to 80 percent leg length, respectively for each muscle. The flexor digitorum longus was the best target in the deep posterior compartment, with an average 6.0 motor entry points within 30 to 90 percent leg length.

Conclusions:

Targeted muscle reinnervation is technically feasible in the lower leg. This cadaveric study provides a roadmap for incision placement and identification of motor nerve targets.
Influence of Repaired Cleft Lip and Palate on Layperson Perception following Orthognathic Surgery
Authors: Lin Lawrence O. , Zhang Rosaline S. , Mazzaferro Daniel M. , Hoppe Ian C. , Pearl Rebecca L. , Swanson Jordan W. , Bartlett Scott P. , Taylor Jesse A.
Published: July 2018

Background:

Facial scarring and disharmony caused by clefting are associated with psychosocial stress, which may be improved by orthognathic surgery. The authors examine how clefting influences change in layperson perception of a patient following orthognathic surgery.

Methods:

One thousand laypersons were recruited through Mechanical Turk to evaluate patient photographs before and after orthognathic surgery. Nineteen patients—five with unilateral and five with bilateral clefting—were included. Respondents assessed six personality traits, six emotional expressions, and likelihood of seven interpersonal experiences on a scale from 1 to 7.

Results:

Changes in all aspects of social perception after the procedure differed significantly between cleft versus noncleft cohorts (p < 0.01 for all). Respondents evaluated the change for the cleft cohort compared with the noncleft cohort as more trustworthy, friendly, sad, and afraid; more likely to feel lonely, be teased or bullied by others, or feel anxious around others; less angry, disgusted, threatening, dominant, intelligent, happy, and attractive; and less likely to have romantic relationships, friends, or be praised by others. For unilateral versus bilateral cleft cohorts, change in social perception was significantly different in four of the 19 items (p < 0.05 for all). Social perception change for the unilateral cohort was less surprised, sad, dominant, or happy compared with the bilateral cohort (p < 0.05 for all).

Conclusions:

Despite significant improvements in social perception following orthognathic surgery, cleft patients benefit less than noncleft patients. These findings may be useful to counsel postsurgical expectations for cleft patients undergoing orthognathic surgery.
Correlation between Quantity of Transferred Lymph Nodes and Outcome in Vascularized Submental Lymph Node Flap Transfer for Lower Limb Lymphedema
Authors: Gustafsson Jonas , Chu Sung-Yu , Chan Wen-Hui , Cheng Ming-Huei
Published: July 2018

Background:

Vascularized lymph node transfer has shown promising results in the treatment of lower limb lymphedema, but little is known about the number of lymph nodes needed for the transfer to achieve optimal results. This study investigated the correlation between number of transferred lymph nodes in submental vascularized lymph node transfer and outcomes regarding limb circumference reduction and cellulitis incidence.

Methods:

Thirty-five patients who had received vascularized submental lymph node transfer to an ankle for lower limb lymphedema following gynecologic cancer treatment were included in the study. Limb circumference was determined by means of tape measurement preoperatively and postoperatively and was used to calculate the circumferential difference. Ultrasonography was performed postoperatively to determine the number of lymph nodes within the transferred flap. Patients were divided into groups A through C depending on the number of transferred lymph nodes: 1 or 2 (n = 10), 3 or 4 (n = 14), and 5 to 8 (n = 11), respectively.

Results:

The mean age of the patients was 60.0 ± 9.2 years. All flaps survived. The mean improvement of circumferential difference for the whole cohort was 19.8 ± 9.2 percent. Groups B and C both had significantly higher improvements in the circumferential difference than group A (p = 0.04 and p = 0.02, respectively), but when compared to each other, the difference was nonsignificant. All groups had significant reductions in the incidence of cellulitis postoperatively.

Conclusions:

Submental vascularized lymph node transfer for lower limb lymphedema reduced the incidence of cellulitis, regardless of the number of transferred lymph nodes. The transfer of three or more lymph nodes provided significantly better outcome regarding limb circumference reduction than the transfer of two or fewer lymph nodes.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Incidents of Mandibular Distraction Osteogenesis for Hemifacial Microsomia
Authors: Wang Xuan , Feng Shi , Tang Xiaojun , Shi Lei , Yin Lin , Liu Wei , Yin Hongyu , Yang Yinan , Zhang Zhiyong
Published: July 2018

Background:

This study focused mainly on the safety and unexpected incidents of mandibular distraction osteogenesis in treating patients with hemifacial microsomia.

Methods:

Records of 71 patients with hemifacial microsomia treated by mandibular distraction osteogenesis from February of 2010 to March of 2015 were examined in this retrospective study. The modified mandibular osteotomy was conducted under the assistance of three-dimensional reconstruction, computer-aided design, and rapid prototyping technique. Distraction was conducted 4 to 7 days postoperatively at a frequency of 1 mm/day; moreover, the distractor was kept in place for 4 to 13 months after the first operation before it was removed. The scope of distraction ranged from 20 to 40 mm. All incidents encountered during and after the mandibular distraction process were documented in the medical records of patients. The patients were followed up for an average of 34.4 months after the second-stage operation.

Results:

The overall rate of incidents was 36.6 percent. Of them, minor incidents, which could be resolved with or without noninvasive therapy, were observed in 18.3 percent of all procedures in this series. Meanwhile, the rate of moderate incidents necessitating invasive therapy was reported to be 12.7 percent, whereas that of major incidents that could not be resolved with invasive therapy was 5.6 percent.

Conclusions:

Mandibular distraction osteogenesis is a widely used procedure for treating patients with hemifacial microsomia. It is extremely important to be fully aware of a variety of incidents occurring during and after the surgical procedure to minimize the frequency of occurrence of such incidents.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.