bluuebunny/crossref_metadata_2025 huggingface dataset:
Serum Osteocalcin Levels in Children With Nonalcoholic Fatty Liver Disease
Authors: Amin Saleh , El Amrousy Doaa , Elrifaey Shaymaa , Gamal Rasha , Hodeib Hossam
Published: October 2017

Objectives:

The aim of the study was to investigate the relationship between osteocalcin and nonalcoholic fatty liver disease (NAFLD) in children with obesity.

Method:

60 obese children with NAFLD were taken as a patient group and 60 obese children and normal liver with matching age, sex, and body mass index were taken as a control group. Anthropometric measurements, abdominal ultrasonography for diagnosis and grading of NAFLD, and laboratory investigations in the form of liver function tests, lipid profile, fasting serum glucose and insulin, and serum osteocalcin levels were done for all children. Patients with NAFLD were further divided into patients with metabolic syndrome (MS) and patients without MS.

Results:

Age of NAFLD children was (10.55 ± 2.71), 20 boys and 40 girls, whereas age of children in control group was (10.05 ± 3.51), 24 boys and 36 girls (P > 0.05). Patients with NAFLD showed significant increase in waist and hip circumference, alanine aminotransferase, alkaline phosphatase, total cholesterol, triglycerides, insulin resistance (IR), fasting serum glucose, and insulin, but lower serum osteocalcin level than control group. Serum osteocalcin level is inversely correlated with waist circumference, triglyceride, liver enzymes, fasting serum insulin, fasting serum glucose, IR, and grades of fatty liver. Increase in alanine aminotransferase, total cholesterol, triglycerides, fasting insulin, and IR went with increase in degree of hepatic steatosis. Serum osteocalcin level <44.5 ng/mL is a good predictor for severity of hepatic steatosis with sensitivity and specificity of 80%.

Conclusions:

Osteocalcin plays an important role in glucose and lipid metabolism for protection against NAFLD occurrence and progression. Moreover, it could be a useful marker for progression of NAFLD in children with obesity.
The Relation Between Malnutrition and the Exocrine Pancreas
Authors: Bartels Rosalie H. , van den Brink Deborah A. , Bandsma Robert H. , Boele van Hensbroek Michael , Tabbers Merit M. , Voskuijl Wieger P.
Published: October 2017

Objective:

The relation between malnutrition and exocrine pancreatic insufficiency (EPI) has been described previously, but it is unclear if malnutrition leads to EPI or vice versa. We systematically synthesized current evidence evaluating the association between malnutrition and EPI in children.

Methods:

Pubmed, Embase, and Cochrane databases were searched from inception until February 2017. We included cohort or case‐controlled studies in children reporting on prevalence or incidence of EPI and malnutrition. Data generation was performed independently by 2 authors. Quality was assessed by using quality assessment tools from the National Heart, Lung, and Blood Institute.

Results:

Nineteen studies were divided into 2 groups: 10 studies showing EPI leading to malnutrition, and 9 studies showing malnutrition leading to EPI. Because of heterogeneity in design, definitions, and outcome measures, pooling of results was impossible. Quality was good in 4 of 19 studies. Pancreatic insufficiency was linked to decreased nutritional status in 8 of 10 articles, although this link was not specified properly in most articles. In malnourished children, improvement was seen in pancreatic function in 7 of 9 articles after nutritional rehabilitation. The link between the 2 was not further specified. Heterogeneity exists with respect to definitions, outcome measures, and study design.

Conclusions:

There is sufficient evidence for an association between EPI and malnutrition. We could not confirm whether there is a correlation or causality between EPI or malnutrition. It was therefore not possible to draw firm conclusions from this systematic review on underlying pathophysiological mechanisms between EPI and malnutrition. More observational clinical trials are crucially needed.
Granulomatous Upper Gastrointestinal Inflammation in Pediatric Ulcerative Colitis
Authors: Queliza Karen , Ihekweazu Faith D. , Schady Deborah , Jensen Craig , Kellermayer Richard
Published: October 2017

Objectives:

Differentiating ulcerative colitis (UC) and Crohn disease (CD) can be clinically challenging, especially in children. Granulomatous inflammation has traditionally been attributed to CD. Crypt‐associated giant cells and granulomas, however, have been observed in colonic biopsies of patients with UC. This phenomenon has not been described in the upper gastrointestinal (UGI) tract with UC.

Methods:

Seven pediatric patients with UC with granulomatous UGI (gUGI) lesions were identified. Diagnosis of UC was based on symptoms, clinical course, laboratory results, imaging, and endoscopy. We compared the gUGI patients to a large cohort of pediatric patients with UC (n = 149).

Results:

All fully evaluated cases were associated with bloody diarrhea and moderate to severe pancolitis. Gastric and/or duodenal biopsies demonstrated giant cells or granulomas near gland destruction. Small bowel imaging did not reveal any involvement. The majority of cases responded to standard medical therapies, except for 2 patients (28.6%) who required total colectomy. Acute severe, refractory colitis (ie, colectomy within 1 month of presentation) was significantly more common in the gUGI group than the large pediatric UC group (28.6% vs 1.3%, Fisher exact P = 0.01).

Conclusions:

This is the first report of pediatric UC–associated granulomatous inflammation in the UGI tract. We speculate that these lesions represent extracolonic manifestations of intense colonic disease. These atypical findings expand the diagnostic considerations that should be incorporated during the differentiation between UC and CD in the pediatric age group.
Celiac Disease Diagnosis Without Biopsy
Authors: Previtali Giulia , Licini Lisa , D'Antiga Lorenzo , Marseglia Antonio , Ravasio Rudi , Nembrini Francesca , Greco Salvatore , Sonzogni Aurelio , Azzarà Giovanna , Ravelli Paolo , Alessio Maria G.
Published: October 2017

Objectives:

2012 European Society of Pediatric Gastroenterology, Hepatology and Nutrition guidelines allow to establish a celiac disease diagnosis without duodenal biopsy in symptomatic pediatric patients with antitissue transglutaminase (anti‐tTG) titers >10 times the upper limit of normal. For some years now, new chemiluminescence immunoassays have been made available: it is important to establish the clinical performance of anti‐tTG and to determine the cut‐off best suited to predict Marsh ≥2 to avoid gastrointestinal endoscopy not only in children, but also in the adult population.

Methods:

A total of 2565 patients performed duodenal biopsy from July 2012 to September 2016; we selected all the patients who had undergone QUANTA Flash anti‐tTG immunoglobulin A (IgA) within −3 months of duodenal biopsy and before the start of gluten‐free diet. A total of 827 patients fulfilled the criteria for selection.

Results:

Using a cut‐off of 20 chemiluminescent unit (CU; area under the curve: 0.995), sensitivity, specificity, positive, and negative predictive value were 98.2%, 98.4%, 97.9%, and 98.6%, respectively. For the correlation with Marsh ≥2, in the pediatric population, positive predictive values (PPV) were 92.1%, 99%, and 100% at 200 CU (10×), 560 CU (28×), and 1000 CU (50×), respectively. In the adult population PPV was 94.2%, 98.2%, and 100% at 200 CU (10×), 350 CU (15×), and 400 CU (20×).

Conclusions:

Sensitivity, specificity, positive, and negative predictive value of QUANTA Flash h‐tTG IgA were excellent. The cut‐off providing an optimized PPV for histological lesions compatible for celiac disease (Marsh ≥2) for the QUANTA Flash h‐tTG IgA is 350 CU (15×) in adult and 560 CU (28×) in children.
Preparing for the Chlamydia and Gonorrhea Self-Test
Authors: Peterman Thomas A. , Kreisel Kristen , Habel Melissa A. , Pearson William S. , Dittus Patricia J. , Papp John R.
Published: October 2017

New technology may soon allow individuals to test themselves for chlamydia and gonorrhea. These new self-tests might help increase screening, but they will also bring new issues for treatment, prevention, and surveillance. Providers will need to decide how to respond to patients who present after a positive screening test and how to approach partner testing and treatment. Research will be needed to identify approaches to increase screening using these tests. Laboratory-based surveillance will not capture infections if testing does not involve a laboratory, so new surveillance techniques will be needed. Self-tests are new tools that will soon be available. We should be prepared to use them.
Sender and Receiver Acceptability and Usability of an Online Partner Notification Tool for Sexually Transmitted Infection in the Netherlands
Authors: van Rooijen Martijn S. , Gotz Hannelore , Vriens Pjer , Heijman Titia , Koekenbier Rik , van Veen Maaike , Voeten Helene
Published: October 2017

Users (index patients with a verified sexually transmitted infection and notified partners) rated the health care provider–initiated Internet-based partner notification application Suggestatest.nl acceptable and usable. Both groups were less positive about Suggestatest.nl to notify/get notified of HIV than other sexually transmitted infection. An anonymous notification was perceived less acceptable.
Optimizing Screening for Sexually Transmitted Infections in Men Using Self-Collected Swabs: A Systematic Review
Authors: Yared Nicholas , Horvath Keith , Fashanu Oluwaseun , Zhao Ran , Baker Jason , Kulasingam Shalini
Published: October 2017

Background

Sexually transmitted infection (STI) rates are increasing in the United States while funding for prevention and treatment programs has declined. Sample self-collection for STI testing in men may provide an acceptable, easy, rapid, and potentially cost-effective method for increasing diagnosis and treatment of STIs.

Methods

We conducted a systematic review of articles assessing self-collection of anal, oral, or genital swab samples among adult men for detection of STIs and/or human papillomavirus–related dysplasia. We searched for English-language articles in which men 18 years or older were recruited to participate.

Results

Our literature search resulted in 1053 citations, with 20 meeting inclusion criteria. Self-collection methods were highly sensitive and comparable with clinician collection for detection of multiple STI pathogens. However, self-collected samples were less likely to be of adequate quality for anorectal cytology and less sensitive for detection of anal intraepithelial neoplasia than clinician-collected samples. Self-collection was highly acceptable. Overall, studies were small and heterogeneous and used designs providing lower levels of evidence.

Conclusions

Self-collection methods are a viable option for collecting samples for STI testing in adult men based on their high feasibility, acceptability, and validity. Implementation of self-collection procedures in STI testing venues should be performed to expand opportunities for STI detection and treatment.
Narrative Review: Assessment of Neisseria gonorrhoeae Infections Among Men Who Have Sex With Men in National and Sentinel Surveillance Systems in the United States
Authors: Weston Emily J. , Kirkcaldy Robert D. , Stenger Mark , Llata Eloisa , Hoots Brooke , Torrone Elizabeth A.
Published: October 2017

To assess trends in Neisseria gonorrhoeae among gay, bisexual, and other men who have sex with men (MSM), we reviewed existing and published gonorrhea surveillance data in the United States. Data identified in this review include the following: national gonorrhea case report data and data from 3 other surveillance programs, the Gonococcal Isolate Surveillance Project (GISP), the STD Surveillance Network (SSuN), and National HIV Behavioral Surveillance.

Rates of reported cases of gonorrhea among men increased 54.8% in 2006 to 2015 compared with a 2.6% increase among women. Since 2012, the rate of reported gonorrhea cases among men surpassed the rate among women; the male-to-female case rate ratio increased from 0.97 in 2012 to 1.31 in 2015. The proportion of gonococcal urethral isolates collected in the Gonococcal Isolate Surveillance Project that were collected from MSM increased from 21.5% to 38.1% in 2006 to 2015. In 2009 to 2015, the percent of MSM who tested positive for rectal and oropharyngeal gonorrhea in sexually transmitted disease (STD) clinics increased by 73.4% and 12.6%, respectively. Estimated rates of gonorrhea among MSM increased by 151% in 2010 to 2015 in jurisdictions participating in the STD Surveillance Network. Data from the National HIV Behavioral Surveillance demonstrate that testing for gonorrhea among MSM increased by 23.1% between 2011 and 2014.

Together, surveillance data suggest a disproportionate burden of gonorrhea among MSM in the United States and suggest increases in both screening and disease in recent years. Because each data source has inherent limitations and biases, examining these data from different systems together strengthens this conclusion.
Complex regional pain syndrome–up-to-date
Authors: Birklein Frank , Dimova Violeta
Published: October 2017

Complex regional pain syndrome (CRPS) was described for the first time in the 19th century by Silas Weir Mitchell. After the exclusion of other causes, CRPS is characterised by a typical clinical constellation of pain, sensory, autonomic, motor, or trophic symptoms which can no longer be explained by the initial trauma. These symptoms spread distally and are not limited to innervation territories. If CRPS is not improved in the acute phase and becomes chronic, the visible symptoms change throughout because of the changing pathophysiology; the pain, however, remains. The diagnosis is primarily clinical, although in complex cases further technical examination mainly for exclusion of alternative diagnoses is warranted. In the initial phase, the pathophysiology is dominated by a posttraumatic inflammatory reaction by the activation of the innate and adaptive immune system. In particular, without adequate treatment, central nociceptive sensitization, reorganisation, and implicit learning processes develop, whereas the inflammation moderates. The main symptoms then include movement disorders, alternating skin temperature, sensory loss, hyperalgesia, and body perception disturbances. Psychological factors such as posttraumatic stress or pain-related fear may impact the course and the treatability of CRPS. The treatment should be ideally adjusted to the pathophysiology. Pharmacological treatment maybe particularly effective in acute stages and includes steroids, bisphosphonates, and dimethylsulfoxide cream. Common anti-neuropathic pain drugs can be recommended empirically. Intravenous long-term ketamine administration has shown efficacy in randomised controlled trials, but its repeated application is demanding and has side effects. Important components of the treatment include physio- and occupational therapy including behavioural therapy (eg, graded exposure in vivo and graded motor imaging). If psychosocial comorbidities exist, patients should be appropriately treated and supported. Invasive methods should only be used in specialised centres and in carefully evaluated cases. Considering these fundamentals, CRPS often remains a chronic pain disorder but the devastating cases should become rare.
Brief Report: Estimated Incidence of Perinatally Acquired HIV Infection in the United States, 1978–2013
Authors: Nesheim Steven R. , Wiener Jeffrey , Fitz Harris Lauren F. , Lampe Margaret A. , Weidle Paul J.
Published: October 2017

Background:

An incidence of perinatally acquired HIV infection less than 1:100,000 live births is one of the Centers for Disease Control and Prevention (CDC) goals of the United States. Such an estimate has only been possible in recent years because regular nationwide data were lacking.

Method:

Using previously published CDC estimates of the number of infants born with HIV infection in the United States (interpolating for years for which there was no published estimate), and census data on the annual number of live-born infants, estimated incidence was calculated for 1978–2013. Exact 95% confidence intervals (CIs) were calculated using the Poisson distribution.

Results:

Estimated incidence of perinatally acquired HIV infection peaked at 43.1 (95% CI: 41.1 to 45.1) in 1992 and declined rapidly after the use of zidovudine prophylaxis was recommended in 1994. In 2013, estimated incidence of perinatally acquired HIV infection in the United States was 1.8 (95% CI: 1.4 to 2.2), a 96% decline since the peak.

Conclusion:

Estimated incidence of perinatally acquired HIV infection in the United States in 2013 was 1.8/100,000 live births.
Inflammation-Related Morbidity and Mortality Among HIV-Positive Adults: How Extensive Is It?
Authors: Hart Brian B. , Nordell Anna D. , Okulicz Jason F. , Palfreeman Adrian , Horban Andrzej , Kedem Eynat , Neuhaus Jacqueline , Jacobs David R. , Duprez Daniel A. , Neaton James D. ,   for the INSIGHT SMART and ESPRIT Groups
Published: October 2017

Objective:

To determine the rate of grade 4, potentially life-threatening events not attributable to AIDS, cardiovascular disease (CVD), or non-AIDS cancer among participants on antiretroviral therapy and to describe associations of these events with interleukin-6 (IL-6) and D-dimer.

Design:

Cohort study.

Methods:

HIV-infected participants on antiretroviral therapy (N = 3568) with an HIV-RNA level ≤ 500 copies/mL were followed for grade 4, AIDS, CVD, non-AIDS cancer, and all-cause mortality events. Grade 4 events were further classified masked to biomarker levels as reflecting chronic inflammation–related disease (ChrIRD) or not (non-ChrIRD). Associations of baseline IL-6 and D-dimer with events were studied using Cox models.

Results:

Over a median follow-up of 4.3 years, 339 participants developed a grade 4 event (22.9 per 1000 person-years); 165 participants developed a ChrIRD grade 4 event (10.7 per 1000 person-years). Grade 4 events were more common than AIDS (54 participants), CVD (132), and non-AIDS cancer (80) events, any of which developed in 252 participants (17.1 per 1000 person-years). Grade 4 and AIDS events were associated with similar risks of death. Higher IL-6 [hazard ratio (HR) = 1.19 per doubling of biomarker; P = 0.003] and D-dimer (HR = 1.23; P < 0.001) levels were associated with an increased risk of grade 4 events. IL-6 associations were stronger for ChrIRD (HR = 1.38; P < 0.001) than non-ChrIRD grade 4 events (HR = 1.11; P = 0.21).

Conclusions:

Morbidity and mortality associated with activation of inflammatory and coagulation pathways include conditions other than AIDS, CVD, and non-AIDS cancer events. Effective inflammation-dampening interventions could greatly affect the health of people with HIV.
Belief in Treatment as Prevention and Its Relationship to HIV Status and Behavioral Risk
Authors: Card Kiffer G. , Armstrong Heather L. , Lachowsky Nathan J. , Cui Zishan , Sereda Paul , Carter Allison , Montaner Julio S. G. , Hogg Robert S. , Roth Eric A. , Moore David M.
Published: October 2017

Background:

We evaluated attitudes toward treatment as prevention (TasP) among gay, bisexual, and other men who have sex with men (GBM) in Vancouver, Canada.

Methods:

Sexually active GBM, aged ≥16 years, were recruited between 2012 and 2015 using respondent-driven sampling. At each 6-month follow-up, participants completed a computer-administered questionnaire and nursing visit. Repeated-measures latent class analysis, grouped by self-reported serostatus, identified patterns of TasP endorsement by considering TasP-related awareness, attitudes, and behavior. Binary logistic regression identified covariates of class membership. Bivariate interactions with visit number identified factors associated with longitudinal changes in class membership.

Results:

A total of 774 men provided 2590 observations. Of these, 698 enrolled in the cohort, 575 had at least 1 follow-up visit. Among these, the median follow-up time was 1.98 years (Q1–Q2: 1.49–2.49 years). Repeated-measures latent class analysis identified 3 classes: “unaware” (64.2% HIV negative/unknown vs. 29.2% of HIV positive), “skeptical” (29.7% vs. 23.1%), and “believing” (6.1% vs. 47.7%). Membership in classes representing higher TasP endorsement was associated with greater odds of condomless anal sex and having more sexual partners. Age, sexual orientation, ethnicity, substance use, and social time spent with other GBM were also associated with class membership. Longitudinally, class membership was stable among HIV-positive men but shifted toward greater TasP endorsement among HIV-negative/unknown men. For HIV-negative/unknown men, increasing endorsement was positively associated with greater education, being employed, being in a relationship, and substance use and inversely associated with recent serodiscordant condomless anal sex or sexually transmitted infection diagnosis.

Conclusions:

Over time, disparities in TasP diffusion by HIV status have lessened, although continue to persist across other key social strata.
Commonly Prescribed Antiretroviral Therapy Regimens and Incidence of AIDS-Defining Neurological Conditions
Authors: Caniglia Ellen C. , Phillips Andrew , Porter Kholoud , Sabin Caroline A. , Winston Alan , Logan Roger , Gill John , Vandenhende Marie-Anne , Barger Diana , Lodi Sara , Moreno Santiago , Arribas José Ramón , Pacheco Antonio , Cardoso Sandra W. , Chrysos George , Gogos Charalabos , Abgrall Sophie , Costagliola Dominique , Meyer Laurence , Seng Remonie , van Sighem Ard , Reiss Peter , Muga Roberto , Hoyos Santiago Pérez , Braun Dominique , Hauser Christoph , Barrufet Pilar , Leyes Maria , Tate Janet , Justice Amy , Hernán Miguel A. ,   on behalf of the HIV-CAUSAL Collaboration
Published: October 2017

Background:

The differential effects of commonly prescribed combined antiretroviral therapy (cART) regimens on AIDS-defining neurological conditions (neuroAIDS) remain unknown.

Setting:

Prospective cohort studies of HIV-positive individuals from Europe and the Americas included in the HIV-CAUSAL Collaboration.

Methods:

Individuals who initiated a first-line cART regimen in 2004 or later containing a nucleoside reverse transcriptase inhibitor backbone and either atazanavir, lopinavir, darunavir, or efavirenz were followed from cART initiation until death, lost to follow-up, pregnancy, the cohort-specific administrative end of follow-up, or the event of interest, whichever occurred earliest. We evaluated 4 neuroAIDS conditions: HIV dementia and the opportunistic infections toxoplasmosis, cryptococcal meningitis, and progressive multifocal leukoencephalopathy. For each outcome, we estimated hazard ratios for atazanavir, lopinavir, and darunavir compared with efavirenz via a pooled logistic model. Our models were adjusted for baseline demographic and clinical characteristics.

Results:

Twenty six thousand one hundred seventy-two individuals initiated efavirenz, 5858 initiated atazanavir, 8479 initiated lopinavir, and 4799 initiated darunavir. Compared with efavirenz, the adjusted HIV dementia hazard ratios (95% confidence intervals) were 1.72 (1.00 to 2.96) for atazanavir, 2.21 (1.38 to 3.54) for lopinavir, and 1.41 (0.61 to 3.24) for darunavir. The respective hazard ratios (95% confidence intervals) for the combined end point were 1.18 (0.74 to 1.88) for atazanavir, 1.61 (1.14 to 2.27) for lopinavir, and 1.36 (0.74 to 2.48) for darunavir. The results varied in subsets defined by calendar year, nucleoside reverse transcriptase inhibitor backbone, and age.

Conclusion:

Our results are consistent with an increased risk of neuroAIDS after initiating lopinavir compared with efavirenz, but temporal changes in prescribing trends and confounding by indication could explain our findings.
Scaling up Pediatric HIV Testing by Incorporating Provider-Initiated HIV Testing Into all Child Health Services in Hurungwe District, Zimbabwe
Authors: Musarandega Reuben , Mutede Blessing , Mahomva Agnes , Nyamayaro Wenceslas , Mushavi Angela , Lindan Christina , Machekano Rhoderick
Published: October 2017

Background:

Practical ways are needed to scale-up pediatric HIV testing in sub-Saharan Africa, where testing is usually limited to HIV-exposed children in maternal and child health clinics.

Methods:

We implemented an enhanced pediatric HIV testing program in 33 health facilities in Zimbabwe by integrating HIV testing into all pediatric health services. We collected individual data on children tested by having health care workers complete a program-specific child health booklet. We compared numbers of children tested before and during the program using routinely collected aggregate program data reported by health facilities.

Results:

A total of 12,556 children aged 0–5 years were recorded in child health booklets; 9431 (75.1%) had information on HIV testing, of whom 7326 (77.7%) were tested; 7167 had test results of whom 122 (1.7%) were HIV-infected. Among children seen in outpatient clinics, 82.1% were tested compared with 66.5% tested among children seen in maternal/child health clinics. Of the 122 HIV-infected children identified, 77 (63.1%) could be missed under existing pediatric testing guidelines. The number of HIV-infected children identified during the 6-month program increased by 55% compared with the prior 6-month period (RR = 1.55, 95% CI: 1.22 to 1.96). Factors independently associated with HIV infection included being malnourished (adjusted odds ratio [AOR] = 7.7, 95% CI: 2.1 to 28.6), being exposed to TB (AOR = 8.1, 95% CI: 2.0 to 32.2), and having an HIV-infected mother (AOR = 41.6, 95% CI: 15.9 to 108.8).

Conclusions:

Integrating HIV testing into all pediatric health services is feasible and can assist in identifying HIV-infected children who could be missed in current testing guidelines.
Changes in Kidney Function Associated With Daily Tenofovir Disoproxil Fumarate/Emtricitabine for HIV Preexposure Prophylaxis Use in the United States Demonstration Project
Authors: Tang Eric C. , Vittinghoff Eric , Anderson Peter L. , Cohen Stephanie E. , Doblecki-Lewis Susanne , Bacon Oliver , Coleman Megan E. , Buchbinder Susan P. , Chege Wairimu , Kolber Michael A. , Elion Richard , Shlipak Michael , Liu Albert Y.
Published: October 2017

Background:

HIV preexposure prophylaxis (PrEP) using daily oral tenofovir-disoproxil-fumarate/emtricitabine (TDF/FTC) is effective for preventing HIV acquisition, but concerns remain about its potential kidney toxicity. This study examined kidney function in individuals using PrEP in real-world clinical settings.

Setting:

Demonstration project in 2 sexually transmitted infection clinics and a community health center.

Methods:

We evaluated kidney function among men who have sex with men and transgender women taking tenofovir-disoproxil-fumarate/emtricitabine PrEP for up to 48 weeks. Serum creatinine and urine dipstick for protein were obtained at 12-week intervals. Kidney function was estimated using creatinine clearance (CrCl) (Cockcroft–Gault) and estimated glomerular filtration rate (eGFR) (CKD-EPI).

Results:

From October 2012 to January 2014, we enrolled 557 participants (median age 33). Mean creatinine increased from baseline to week 12 by 0.03 mg/dL (4.6%) (P < 0.0001); mean CrCl decreased by 4.8 mL/min (3.0%) (P < 0.0001). These changes remained stable through week 48 (P = 0.81, P = 0.71 respectively). There were 75/478 (15.7%) participants who developed worsening proteinuria at week 12 compared with baseline (P < 0.0001), and this percent remained stable through week 48 (P = 0.73). Twenty-five participants (5.1%) developed new-onset eGFR <70 mL/min/1.73 m2; independent predictors of this outcome were age ≥40 years (OR 3.79, 95% CI: 1.43 to 10.03) and baseline eGFR <90 mL/min/1.73 m2 (OR 9.59, 3.69–24.94).

Conclusions:

In a demonstration setting, daily tenofovir-disoproxil-fumarate/emtricitabine PrEP leads to reduced CrCl and eGFR; however, these eGFR changes are based on very small changes in serum creatinine and seem to be nonprogressive after the first 12 weeks. Future studies are needed to understand the prognostic significance of these small changes.
Predictors of HIV, HIV Risk Perception, and HIV Worry Among Adolescent Girls and Young Women in Lilongwe, Malawi
Authors: Price Joan T. , Rosenberg Nora E. , Vansia Dhrutika , Phanga Twambilile , Bhushan Nivedita L. , Maseko Bertha , Brar Savvy K. , Hosseinipour Mina C. , Tang Jennifer H. , Bekker Linda-Gail , Pettifor Audrey
Published: October 2017

Background:

Adolescent girls and young women (AGYW) in sub-Saharan Africa have high HIV prevalence and incidence. We sought to understand which HIV risk factors individually and in combination contribute to risk, and whether these factors are associated with HIV worry and risk perception.

Setting:

This study is ongoing at 4 public health centers in Lilongwe, Malawi (2016–2017).

Methods:

AGYW of 15–24 years old were recruited to participate in a study assessing 4 models of service delivery. At each health center, participants completed a baseline survey assessing socioeconomic, behavioral, biomedical, and partnership characteristics; self-reported HIV status; and, if HIV-uninfected, HIV risk perception (high versus low or none) and HIV worry (any versus none). We analyzed associations between baseline characteristics and HIV prevalence, risk perception, and worry.

Results:

Among 1000 AGYW, median age was 19 years (IQR: 17–21). Thirty-three participants reported being HIV-infected. Fifteen characteristics were associated with HIV infection. Having more risk factors was associated with higher HIV prevalence (≤4 factors, 0.5%; 5–8 factors, 6%; >8 factors, 21%). Having more risk factors was also associated with higher risk perception (P < 0.001) and higher worry (P < 0.001). However, among those with ≥8 risk factors, 52% did not consider themselves to be at high risk and 21% did not report any HIV worry.

Conclusions:

Most AGYW perceive little risk of HIV acquisition, even those at highest risk. As a critical gap in the HIV prevention cascade, accurate risk perception is needed to tailor effective and sustained combination prevention strategies for this vulnerable population.
Using Discrete-Event Simulation to Promote Quality Improvement and Efficiency in a Radiation Oncology Treatment Center
Authors: Famiglietti Robin M. , Norboge Emily C. , Boving Valentine , Langabeer James R. , Buchholz Thomas A. , Mikhail Osama
Published: October 2017

Background:

To meet demand for radiation oncology services and ensure patient-centered safe care, management in an academic radiation oncology department initiated quality improvement efforts using discrete-event simulation (DES). Although the long-term goal was testing and deploying solutions, the primary aim at the outset was characterizing and validating a computer simulation model of existing operations to identify targets for improvement.

Methods:

The adoption and validation of a DES model of processes and procedures affecting patient flow and satisfaction, employee experience, and efficiency were undertaken in 2012-2013. Multiple sources were tapped for data, including direct observation, equipment logs, timekeeping, and electronic health records.

Results:

During their treatment visits, patients averaged 50.4 minutes in the treatment center, of which 38% was spent in the treatment room. Patients with appointments between 10 am and 2 pm experienced the longest delays before entering the treatment room, and those in the clinic in the day's first and last hours, the shortest (<5 minutes). Despite staffed for 14.5 hours daily, the clinic registered only 20% of patients after 2:30 pm. Utilization of equipment averaged 58%, and utilization of staff, 56%.

Conclusion:

The DES modeling quantified operations, identifying evidence-based targets for next-phase remediation and providing data to justify initiatives.
The Affordable Care Act and Its Effects on Physician Leadership: A Qualitative Systematic Review
Authors: Sterbenz Jennifer M. , Chung Kevin C.
Published: October 2017

Objectives:

The Affordable Care Act (ACA) shifted the focus in medical care from quantity to quality. This qualitative systematic review aimed to determine the key skills necessary for effective physician leaders after the implementation of the ACA, and to compare them with key skills identified prior to its implementation.

Methods:

A qualitative systematic review was conducted. A systematic literature search on leadership skills for physicians returned 26 articles published between 2009 and 2016. Thematic analysis was used to categorize the data presented in each article. The results from the thematic analysis were then compared with a similar article published before the implementation of the ACA.

Results:

Teamwork and team-building, communication, and self-awareness skills were mentioned most often. The percentage of articles mentioning teamwork and team-building skills (61.5%) was significantly greater than the percentage (25%) reported before the implementation of the ACA (P ≤ .04).

Conclusion:

With the shift toward quality of patient care, health care workers at all levels should strive to work as a team to provide the best quality of care at all stages of patient care.
Does Hospital Size Affect Patient Satisfaction?
Authors: McFarland Daniel C. , Shen Megan Johnson , Parker Patricia , Meyerson Sandra , Holcombe Randall F.
Published: October 2017

Background:

Centers for Medicare & Medicaid Services reimbursement is now contingent on quality measures such as patient satisfaction as determined by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). In providing patient-centered care that is guided by patient satisfaction measures, it is critical to understand system-level factors that may influence how patients assess their care experiences. One important system-level influence to consider is hospital size.

Methods:

HCAHPS scores, number of hospital beds, and nursing magnet status were obtained from publically available Hospital Compare, American Hospital Directory, and Magnet Hospitals Web sites, respectively. An aggregate score for patient satisfaction was created across all domains of the HCAHPS. Multilevel regression modeling was performed to examine the associations between hospital size and HCAHPS aggregate and individual dimensions.

Results:

Hospital size was significantly associated with patient satisfaction such that larger size was associated with lower satisfaction (β = −.312, P < .001). Hospital size was most strongly associated with less patient satisfaction on the following HCAHPS items: “receiving help as soon as needed” (β = −.441, P < .001), “room and bathroom cleanliness” (β = −.286, P < .001), and doctor communication (β = −.213, P < .001), whereas nurse communication (β = .194, P < .001) was the one modifiable dimension that was associated with more favorable ratings in larger hospitals. Magnet nursing designation was significantly associated with larger hospital size (P < .001).

Conclusion:

Patient satisfaction scores may be lower in large hospitals because of patients' perceptions of hospital cleanliness, receiving help on time, and doctor communication. Focusing on improving these factors may improve patient satisfaction scores for larger hospitals.
Gap Between Clinical Practice and Guidelines: A National Survey of the Knowledge of Recommended Heart Failure Guidelines Among Chinese Physicians
Authors: Gan Tianyi , Zhang Yuhui , Liu Nini , Huang Yuhui , Liang Tuo , Zhao Xuemei , Zhang Jian
Published: October 2017

Objective:

We investigated the current level of knowledge of Chinese heart failure (HF) guidelines among physicians, as a reference for the promotion and transformation of HF knowledge.

Methods and Results:

Physicians from 88 hospitals in 27 provinces of China completed our survey between July and December 2014. The questions covered the main points included in the Chinese HF diagnosis and treatment guidelines (2014). A total of 2146 physicians, aged 20 to 62 years (35.6 ± 7.6 years), completed the survey. The correctness rate of their answers to the 15 multiple-choice questions in the HF questionnaire was generally low (mean 32.6%). The mean correctness rate for 10 blank-filling questions about the target doses of angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists, and β-blockers was 42.5%. On the basis of their responses, physicians whose knowledge of the guidelines was “excellent,” “good,” “medium,” and “bad” accounted for 1.1%, 11.4%, 14.2%, and 73.4%, respectively. Physicians who possessed a higher level of qualifications had significantly greater awareness of HF guidelines than those with relatively low qualifications (P < .001). A statistically significant association was found between hospital level and adherence to treatment guidelines (P < .001). A significant difference was also observed among physicians in different practice scopes (P < .001).

Conclusions:

The survey found an obvious deficiency in physicians' mastery of fundamental knowledge about HF. There is a need to improve physicians' education about HF in China.
Management of Traumatic Brain Injury in the Emergency Department: Guideline Adherence and Patient Safety
Authors: Vedin Tomas , Edelhamre Marcus , Karlsson Mathias , Bergenheim Michael , Larsson Per-Anders
Published: October 2017

Background:

Traumatic brain injury is a common reason not only for emergency visits worldwide but also for significant morbidity and mortality. Several clinical guidelines exist but adherence is generally low.

Aim:

To study attitudes toward computed tomography of the head among emergency department Change to physicians throughout the article who manage patients with trauma to the head and doctors' adherence to guidelines.

Methods:

Quantitative questionnaire study with questionnaires collected over 3 months before introduction of new guidelines. After introduction, intermission of 8 months passed when information and education were given. Thereafter, questionnaires were collected for another 3 months.

Results:

A total of 694 patients were registered at the emergency department. A total of 161 questionnaires were analyzed; 50.9% did not use guidelines, 39% before intermission, and 60.5% after. When Canadian CT Head Rule was applied, 30.4% of patients with no loss of consciousness were referred to computed tomography, violating guideline recommendation.

Conclusion:

Guidelines are designed to improve performance but are not always applied correctly or as frequently as intended. Information and education did not increase guideline adherence. To improve guideline adherence, more innovative measures than formal guidelines must be undertaken. To find out what these measures are, we suggest qualitative studies to elucidate interventions that will have bigger impact on performance.
Clinically Acceptable Optimized Dose Reduction in Computed Tomographic Imaging of Necrotizing Pancreatitis Using a Noise Addition Software Tool
Authors: Jaffe Tracy A. , Tian Xiaoyu , Bashir Mustafa R. , Marin Daniele , Patel Bhavik N. , Ho Lisa M. , Samei Ehsan
Published: October 2017

Objective

This study aimed to determine potential radiation dose reduction of contrast-enhanced computed tomography (CECT) for imaging necrotizing pancreatitis (NP) using a noise addition tool.

Methods

Eighty-four patients were identified with at least 1 abdominopelvic CECT for NP within a 2-year period. Sixty consecutive scans were selected as reference radiation dose data sets. A noise addition software was used to simulate 4 data sets of increased noise. Readers rated confidence for identifying (i) anatomic structures, (ii) complications of NP, and (iii) diagnostic acceptability. Noise and dose levels were identified at acceptability threshold where observer scores were statistically indistinguishable from full-dose computed tomographies.

Results

Observers' perception of image tasks decreased progressively with increasing noise (P < 0.05). Acceptability and statistical analysis indicated that noise can be increased from 10 to 25 HU corresponding to an 84% reduction in dose without change in observer perception (P < 0.05).

Conclusions

Higher image noise levels may be tolerated in CECT in patients with NP.
Vertical Maxillary Measurements using a Virtual External Reference Point in Orthognathic Surgery: Technical Innovation
Authors: Espinosa S Sebastián
Published: October 2017

It is extremely important to achieve vertical position of the upper jaw in orthognathic surgery. A common method used is measuring distances at surgery using external reference points. Unfortunately, surgeons have been making mistakes when calculating the goal distance of our external reference systems. A possible explanation is that when the author measure the baseline and goal vertical distances, the author usually do not consider the variations produced by the triangulation effect generated due the horizontal or/and transverse movements of the maxilla. A method is proposed to fix this phenomenon in an easy way through the virtual customization of the ERP in computer-assisted surgical simulation. The technique entails creating, in the planning software, the same reference system one will use at surgery. In this virtual system, one measures the difference between the baseline and target distances, and then uses them at surgery.
A Novel Presentation of Bladder Mass: Self-palpation by a Patient With Cystocele
Authors: Feloney Michael , Wu Jocelyn A. , Brush Thomas , Dietz Nick
Published: October 2017

Introduction

This case describes diagnosis of a T2 transitional cell carcinoma in an 89-year-old woman with known cystocele and urinary retention managed with clean intermittent self-catheterization.

Case

While self-catheterizing, the patient noted a palpable mass in her cystocele. She eventually pursued urologic evaluation of this mass, which ultimately led to her diagnosis. This is the first reported case of transitional cell carcinoma being found on self-examination by palpating a cystocele.
Gut Permeability and Glucose Absorption Are Affected at Early Stages of Graft Rejection in a Small Bowel Transplant Rat Model
Authors: Stringa Pablo , Romanin David , Lausada Natalia , Papa Gobbi Rodrigo , Zanuzzi Carolina , Martín Pedro , Abate Juan Cruz , Cabanne Ana , Arnal Nathalie , Vecchio Leandro , Milesi Verónica , Portiansky Enrique , Gondolesi Gabriel , Rumbo Martin
Published: October 2017

Background

Intestinal transplantation (ITx) faces many challenges due to the complexity of surgery and to the multiple immunological reactions that lead to the necessity of rigorous follow-up for early detection of acute cellular rejection (ACR). Our aim was to determine the kinetics of ACR using an experimental ITx model, with emphasis in the characterization of the process using different approaches, including the use of functional assays of absorptive and barrier function.

Methods

ITx in rats conducting serial sampling was performed. Clinical monitoring, graft histology, proinflammatory gene expression, and nitrosative stress determination were performed. Also, glucose absorption, barrier function using ovalbumin translocation, and contractile function were analyzed.

Results

The model used reproduced the different stages of ACR. Allogeneic ITx recipients showed signs of rejection from postoperative day (POD) 5, with increasing severity until 12 POD. Histological evaluation showed mild rejection in early sampling and severe rejection at late stages, with alterations in all graft layers. IL-6, CXCL 10, IFNg, and nitrite plasmas levels showed behavior coincident with histopathology. Remarkably, allogeneic grafts showed a marked alteration of glucose absorptive capacity from POD 5 that was sustained until endpoint. Coincidently, barrier function alteration was evidenced by luminal ovalbumin translocation to serum. Contractile function was progressively impaired along ACR.

Conclusions

Glucose absorption and barrier function are altered at early stages of ACR when histological alterations or gene expression changes were much subtle. This observation may provide simple evaluation tools that could be eventually translated to the clinics to contribute to early ACR diagnosis.
Hypothesis: Potential Utility of Serum and Urine Uromodulin Measurement in Kidney Transplant Recipients?
Authors: Bostom Andrew G. , Steubl Dominik , Friedman Allon N.
Published: October 2017

Seventy years after its discovery, studies of the myriad properties, and potential disease associations of uromodulin are now burgeoning. Although normative ranges for serum/plasma uromodulin concentrations were established over 30 years ago, their external validation occurred only in very recent, larger studies. As tubular function indices, serum and urinary uromodulin may be more sensitive indicators of kidney graft dysfunction undetected by glomerular filtration markers, or proteinuria. Moreover, 2 sizable, just published longitudinal reports revealed that lower serum uromodulin levels were associated with cardiovascular disease (CVD) outcomes, total mortality, and infectious disease deaths, in patients with known or suspected coronary heart disease. Preliminary longitudinal studies have reported that reduced levels of plasma or serum uromodulin were linked to progression to end-stage renal disease in chronic kidney disease patients, and graft failure in kidney transplant recipients (KTRs). Conflicting data on the associations, or lack thereof, between lower urinary uromodulin concentrations and accelerated loss of renal function, or renal failure, in nontransplant chronic kidney disease patients, are perhaps due, in part, to analytical limitations in determining urine uromodulin. Potential longitudinal associations between serum and urinary uromodulin concentrations, and CVD outcomes, graft failure, and all-cause mortality, await validation in large, diverse cohorts of chronic KTRs. Taking advantage of an efficient case-cohort design scheme, we demonstrate how the completed FAVORIT clinical trial cohort might be ideally suited to evaluate these associations. Using available case-cohort sample data, statistical power simulations are provided to detect relative risk estimates of 1.50 for CVD (n = 309 events), 1.56 for graft failure (n = 223 events) or 1.50 for death from any cause (n = 320 events), comparing values below the median, to values equal to or above the median for serum uromodulin values. Edifying data such as these would advance our understanding of the hypothetical utility of uromodulin measurement in KTRs considerably.