bluuebunny/crossref_metadata_2025 huggingface dataset:
Computerized order entry, clinical decision support, and safer prescribing
Authors: Pontefract S.K. , Ferner R.E.
Published: August 2017

Unintended harms from medicines caused by adverse drug reactions and medication errors are common. The medication process is very complex, and error can occur in the development, manufacture, distribution, prescribing, dispensing, administration, and monitoring of medicines. The prescriber, to avoid error, must first make careful decisions tailored to account for numerous factors that differ from patient to patient, then communicate orders that others must execute meticulously and whose consequences must be adequately monitored.
Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women's Health Initiative Observational Study
Authors: Crandall Carolyn J. , Hovey Kathleen M. , Andrews Christopher A. , Chlebowski Rowan T. , Stefanick Marcia L. , Lane Dorothy S. , Shifren Jan , Chen Chu , Kaunitz Andrew M. , Cauley Jane A. , Manson JoAnn E.
Published: August 2017

Objective:

To determine the association between use of vaginal estrogen and risk of a global index event (GIE), defined as time to first occurrence of coronary heart disease (CHD), invasive breast cancer, stroke, pulmonary embolism, hip fracture, colorectal cancer, endometrial cancer, or death from any cause.

Methods:

For this prospective observational cohort study, we used data from participants of the Women's Health Initiative Observational Study, who were recruited at 40 US clinical centers, aged 50 to 79 years at baseline and did not use systemic estrogen therapy during follow-up (n = 45,663, median follow-up 7.2 years). We collected data regarding incident CHD, invasive breast cancer, stroke, pulmonary embolism, hip fracture, colorectal cancer, endometrial cancer, death, and self-reported use of vaginal estrogen (cream, tablet). We used Cox proportional-hazards regression models to adjust for covariates.

Results:

Among women with an intact uterus, the risks of stroke, invasive breast cancer, colorectal cancer, endometrial cancer, and pulmonary embolism/deep vein thrombosis were not significantly different between vaginal estrogen users and nonusers, whereas the risks of CHD, fracture, all-cause mortality, and GIE were lower in users than in nonusers (GIE adjusted hazard ratio 0.68, 95% confidence interval 0.55-0.86). Among hysterectomized women, the risks of each of the individual GIE components and of the overall GIE were not significantly different in users versus nonusers of vaginal estrogen (GIE adjusted hazard ratio 0.94, 95% confidence interval 0.70-1.26).

Conclusions:

The risks of cardiovascular disease and cancer were not elevated among postmenopausal women using vaginal estrogens, providing reassurance about the safety of treatment.
Associations among circulating colony-stimulating factor-1, estrogen, and bone mineral density in postmenopausal women: results from a randomized placebo-controlled trial
Authors: Haas Andrea V. , Cong Elaine , Simpson Christine A. , Sukumar Nitin , Deng Yanhong , Insogna Karl L.
Published: August 2017

Objective:

This study addresses the relationship between circulating levels of colony-stimulating factor 1 (CSF-1) and rates of postmenopausal bone loss. The purpose was to test the hypothesis that CSF-1 levels would correlate with the rate of bone loss in estrogen-deficient woman. We further hypothesized that estrogen replacement would eliminate this association.

Methods:

This was an ancillary study to the parent Kronos Early Estrogen Prevention Study (KEEPS)—a 4-year randomized placebo-controlled study that evaluated the effects of estrogen therapy on cardiovascular endpoints. Women between of the ages of 42 and 58, who had been amenorrheic for ≥6 months and ≤36 months, were enrolled in KEEPS. Participants were randomized to conjugated equine estrogen 0.45 mg daily, transdermal estradiol 50 micrograms weekly, or placebo.

Results:

There was no correlation between serum levels of CSF-1 and bone mineral density at the spine, hip, or femoral neck in estrogen-deficient women (correlation 0.0017, P = 0.99 for spine; correlation 0.0010, P = 0.0079 for hip, and correlation 0.0019, P = 0.99 for femoral neck). There was also no significant correlation in the treatment group (correlation 0.0015, P = 0.99; correlation −0.00024, P = 0.99; correlation 0.0011, P = 0.99 at spine, hip, and femoral neck respectively).

Conclusions:

This study did not demonstrate a meaningful relationship between circulating levels of CSF-1 and bone mineral density in either the placebo group or estrogen-treated group. Although CSF-1 is required for osteoclastic bone resorption, our data suggest that circulating levels of the cytokine may not reflect this process.
Resting-State Functional Connectivity in the Human Connectome Project: Current Status and Relevance to Understanding Psychopathology
Authors: Barch Deanna M.
Published: August 2017

A key tenet of modern psychiatry is that psychiatric disorders arise from abnormalities in brain circuits that support human behavior. Our ability to examine hypotheses around circuit-level abnormalities in psychiatric disorders has been made possible by advances in human neuroimaging technologies. These advances have provided the basis for recent efforts to develop a more complex understanding of the function of brain circuits in health and of their relationship to behavior—providing, in turn, a foundation for our understanding of how disruptions in such circuits contribute to the development of psychiatric disorders. This review focuses on the use of resting-state functional connectivity MRI to assess brain circuits, on the advances generated by the Human Connectome Project, and on how these advances potentially contribute to understanding neural circuit dysfunction in psychopathology. The review gives particular attention to the methods developed by the Human Connectome Project that may be especially relevant to studies of psychopathology; it outlines some of the key findings about what constitutes a brain region; and it highlights new information about the nature and stability of brain circuits. Some of the Human Connectome Project’s new findings particularly relevant to psychopathology—about neural circuits and their relationships to behavior—are also presented. The review ends by discussing the extension of Human Connectome Project methods across the lifespan and into manifest illness. Potential treatment implications are also considered.
UNILATERAL OPTIC NEURITIS AND CENTRAL RETINAL VASCULITIS DUE TO OCULAR SYPHILIS
Authors: Khan Murtaza S. , Kuruppu Dulanji K. , Popli Tanav A. , Moorthy Ramana S. , Mackay Devin D.
Published: August 2017

Purpose:

Report a case of concurrent unilateral optic neuritis and central retinal artery occlusion as the presenting signs of syphilis.

Methods:

A case report of a 22-year-old man with progressive unilateral vision loss.

Results:

With no known previous history of syphilis, genital lesions, or other extraocular manifestations, the patient presented with pain with eye movements and decreased color vision. His vision dramatically worsened after a course of oral steroids. Examination was remarkable for severe right optic disk edema with a macular cherry-red spot and mild posterior uveitis. Magnetic resonance imaging of the orbits with contrast revealed enhancement and enlargement of the distal right optic nerve. Fluorescein angiography demonstrated delayed filling of the right central retinal artery, suggestive of impending central retinal artery occlusion. Syphilis serologies were positive from the serum, and cerebrospinal fluid Venereal Disease Research Laboratory test was reactive, consistent with neurosyphilis. Oral steroids were discontinued and vision improved with 2 weeks of intravenous penicillin.

Conclusion:

This unusual case highlights one of the possible initial presentations of syphilis: unilateral optic neuritis and central retinal artery vasculitis with mild posterior uveitis. The worsening of vision after administration of oral steroids also highlights a potential complication of oral steroid use in the absence of a known etiology of vision loss. A thorough history and examination may be helpful in identifying risk factors for infectious causes, including syphilis, and should prompt additional evaluation.
Reproducibility of Central Corneal Thickness Measurements in Healthy and Glaucomatous Eyes
Authors: Realini Tony , Gurka Matthew J. , Weinreb Robert N.
Published: August 2017

Purpose:

The purpose of this study is to characterize intraday and interday variation in central corneal thickness (CCT) in healthy and glaucomatous subjects.

Methods:

In this prospective cohort study, 40 healthy subjects and 42 subjects with primary open-angle glaucoma underwent CCT measurements by ultrasonic pachymetry on 5 days over 1 year: first at baseline, then at 1 week and 1, 6, and 12 months after baseline. On 1visit, CCT was measured every 2 hours from 08:00 to 20:00. Intraday CCT variance was compared with interday CCT variance.

Results:

Mean CCT at all visits and time points ranged from 561 to 574 µm in healthy eyes and from 548 to 563 µm in glaucomatous eyes. The mean intraday CCT range (highest minus lowest readings) was 21±10 µm in healthy participants and 21±10 µm in glaucoma patients. The mean interday CCT range was 27±13 µm in healthy participants and 24±14 µm in glaucoma patients. Within-subject variance was significantly larger among the interday CCT measurements than the intraday CCT measurements in both healthy subjects and glaucoma patients (P<0.0001 for both) demonstrating that measurements taken on separate days are more different than measurements taken on the same day. Interday CCT differences of ≥30 µm were seen in 27.7% of normal subjects and 30% of glaucoma patients.

Conclusions:

CCT measurements exhibit intraday and interday variation, with the latter being significantly greater than the former. A single CCT assessment inadequately characterizes CCT and may impact risk assessment in patients with suspect and/or diagnosed glaucoma.
Practitioner Gender and Quality of Care in Ambulatory Cardiology Practices
Authors: Gupta Dipti , Tang Fengming , Masoudi Frederick A. , Jones Philip G. , Chan Paul S. , Daugherty Stacie L.
Published: August 2017

Background:

Some studies suggest that female practitioners are more likely to provide guideline-concordant care than male practitioners; however, little is known about the role of practitioner gender in cardiology.

Objective:

The aim of the study was to measure the association between practitioner gender and adherence to the cardiovascular performance measures in the American College of Cardiology's ambulatory Practice Innovation and Clinical Excellence Registry.

Methods:

Patients with at least 1 outpatient visit with a unique practitioner were included. Among eligible patients, adherence to 7 guideline-supported performance measures for coronary artery disease, heart failure, and atrial fibrillation over 12 months after registry entry was compared by practitioner gender using hierarchical models adjusting for practitioner type (physicians vs advance practice practitioners) and number of visits.

Results:

The study cohort included 1493 individual practitioners who saw 769 139 patients; 80% of practitioners were men. Male practitioners were more often physicians compared with female practitioners (98.2% vs 43.7%, P < .01). Accounting for practitioner category and visit frequency, guideline adherence rates were similar by practitioner gender for all measures with the exception of marginally higher rates for coronary artery disease performance measures for male practitioners compared with female practitioners (antiplatelet: rate ratio [RR] = 1.06; 95% confidence interval [CI], 1.03–1.09; β-blockers: RR = 1.06; 95% CI, 1.01–1.10; and lipid-lowering drug: RR = 1.07; 95% CI, 1.04–1.10) and atrial fibrillation (oral anticoagulants: RR = 1.05; 95% CI, 1.01–1.09).

Conclusion:

Male practitioners marginally outperformed their female counterparts in ambulatory practices enrolled in a voluntary cardiovascular performance improvement registry program. Overall low adherence to some performance measures suggests room for improvement among all practitioners.
Evaluation of Concurrent Oral and Long-Acting Injectable Antipsychotic Prescribing at the Minneapolis Veterans Affairs Health Care System
Authors: Dimitropoulos Erica , Drogemuller Lisa , Wong Kara
Published: August 2017

Background

Antipsychotic polypharmacy is defined as the concomitant prescribing of more than 1 antipsychotic medication for an individual patient. Despite clinical guideline recommendations, long-acting injectable antipsychotics (LAIAs) are often used together with oral antipsychotics (OAPs) to treat a variety of psychiatric illnesses. Little research exists to address this form of antipsychotic polypharmacy, and its role in therapy is poorly understood. The purpose of this evaluation was to determine the prevalence of this prescribing pattern at our facility, identify provider rationale for polypharmacy, and analyze trends. To our knowledge, this study is the first to describe the prevalence of and rationale for concomitant LAIA and OAP prescribing in the veteran population.

Methods

All patients receiving an LAIA at the time of study initiation were included. Long-acting injectable antipsychotics/oral antipsychotics polypharmacy was defined as the use of both agents outside the manufacturer's recommendations for titration and overlap. Statistical analysis was performed to further evaluate prescribing patterns by agent, dose, and indication.

Results

Long-acting injectable antipsychotics/oral antipsychotics polypharmacy occurred in 28% (22/79) of subjects. Of these, 50% (11/22) were prescribed the same antipsychotic in both dosage forms, of which 73% (8/11) were risperidone. Patients on LAIA/OAP polypharmacy were half as likely to be on a maximum dose LAIA compared with those on monotherapy (13% vs. 26%).

Conclusions

Although LAIA/OAP polypharmacy occurred less frequently than reported in previous literature, this study highlights the need for further research to better understand this prescribing practice.
Use of Selective Serotonin Reuptake Inhibitors and Bone Mineral Density Change
Authors: Ham Annelies C. , Aarts Nikkie , Noordam Raymond , Rivadeneira Fernando , Ziere Gijsbertus , Zillikens M. Carola , Tiemeier Henning , van der Velde Nathalie , Hofman Albert , Uitterlinden André G. , Visser Loes E. , Stricker Bruno H.
Published: August 2017

Background

Longitudinal studies showed conflicting results regarding the association between use of selective serotonin reuptake inhibitors (SSRIs) and bone mineral density (BMD). Therefore, we investigate the association between—duration of—SSRI use and BMD, and change in BMD (∆BMD).

Methods

Data from the population-based Rotterdam Study cohort (1991–2008) were used. In total, 4915 men and 5831 postmenopausal women, aged 45 years and older, were included, having measurement visits at 4- to 5-year intervals. Multivariable linear mixed models were applied to examine the association between SSRI use, based on pharmacy records, duration of SSRI use, and repeated measures of BMD, and changes in BMD, compared with nonuse. Femoral neck BMD (grams per centimeters squared) was measured at 4 visits, comprising 19,861 BMD measurements. Three ∆BMD periods were examined, comprising 7897 ∆BMD values. Change in BMD was expressed in the annual percentage ∆BMD between 2 consecutive visits.

Results

In men and women, we observed no association between SSRI and BMD when compared with nonuse (women: mean difference, 0.007 g/cm2; 95% confidence interval, −0.002 to 0.017; P = 0.123). We did not find an association between duration of SSRI use and ∆BMD (women: annual percentage change, −0.081; 95% confidence interval, −0.196 to 0.033; P = 0.164).

Conclusions

In conclusion, use of SSRIs is not associated with BMD or ∆BMD, after taking duration of treatment into account, in middle-aged and elderly individuals. Therefore, our results question previously raised concerns on the adverse effects of SSRIs on BMD.
Treatment of Premenstrual Breakthrough of Depression With Adjunctive Oral Contraceptive Pills Compared With Placebo
Authors: Peters Whitney , Freeman Marlene P. , Kim Semmie , Cohen Lee S. , Joffe Hadine
Published: August 2017

Purpose/Background

Two-thirds of women with depressive disorders report reemergence of depression premenstrually, or premenstrual exacerbation (PME), despite effective treatment of the underlying mood disorder during the remainder of the cycle. There is a paucity of studies that rigorously assess treatments targeting PME. Open-label data suggest that augmentation of antidepressants with the oral contraceptive pill (OCP) drospirenone and ethinyl estradiol (DRSP/EE) improves depressive symptoms that break through treatment premenstrually. We now report results of a randomized placebo-controlled OCP augmentation trial.

Methods

Women with unipolar depressive disorders in remission on stable antidepressant doses with a 30% increase in Montgomery-Åsberg Depression Rating Scale (MADRS) scores from the follicular to luteal phase were randomized to double-blind augmentation of antidepressant with either DRSP/EE or placebo for 2 months. The MADRS and Daily Record of Severity of Problems (DRSP) measures were anchored to the menstrual cycle phase.

Findings/Results

Of 32 women randomized, 25 (n = 12 DRSP/EE, n = 13 placebo) completed the trial. Premenstrual MADRS scores declined by a median of 43.6% and 38.9% (P = 0.59), and premenstrual DRSP scores declined by a median of 23.5% and 20.9% (P = 0.62) in the DRSP/EE and placebo groups, respectively. There was a trend toward greater improvement in premenstrual DRSP scores for women with fewer lifetime depressive episodes (r = −0.40, P = 0.06).

Implications/Conclusions

Findings from this small randomized trial suggest that OCP augmentation of antidepressants may not be effective for treating premenstrual breakthrough of depression. Future studies should target women established to have hormonal sensitivity prior to antidepressant therapy and those with fewer lifetime depressive episodes.
The Use of Granulocyte Colony-Stimulating Factor in Clozapine Rechallenge
Authors: Lally John , Malik Steffi , Krivoy Amir , Whiskey Eromona , Taylor David M. , Gaughran Fiona P. , Flanagan Robert J. , Mijovic Aleksandar , MacCabe James H.
Published: August 2017

Purpose/Background

Clozapine is associated with hematological abnormalities, with neutropenia and agranulocytosis of most concern. Granulocyte colony-stimulating factor (G-CSF) has been used to support clozapine rechallenge after neutropenia with the aim of maintaining the neutrophil count. This study aims to explore the practice, use, safety, and efficacy of G-CSF in this context.

Methods/Procedures

We conducted a systematic review to identify all studies investigating or describing G-CSF as a prophylaxis to enable continued clozapine treatment during a rechallenge.

Findings/Results

We identified 32 reports of patients who received G-CSF either regularly (n = 23) or as required (n = 9) to support clozapine rechallenge after an episode of neutropenia necessitating discontinuation of clozapine. Seventy-five percent (n = 24) of published cases remained on clozapine with the use of continual prophylactic G-CSF or after single G-CSF administrations (n = 8). Seventy percent (n = 16) of patients in receipt of continual prophylactic G-CSF were successfully maintained on clozapine. However, 1 of the 3 episodes of rechallenge in those with a history of severe agranulocytosis (absolute neutrophil count <0.1 × 109/L) had a recurrence of agranulocytosis at week 9.

Implications/Conclusions

Our findings suggest that G-CSF can sometimes be safely used to support the maintenance of normal neutrophil counts and clozapine use after neutropenia. Publication bias is an important limitation, however. Also, few reports clearly documented the presence or absence of an independent nonclozapine cause of the index neutropenia, which may have increased success rates. Furthermore, adverse events were not systematically recorded. Prospective studies are needed to determine safety because if agranulocytosis occurs on clozapine while supported by G-CSF, there is no obvious alternate rescue therapy to promote granulopoiesis. From the available data, it is not possible to recommend this course of action for someone with a true clozapine agranulocytosis.
Nursing Management of the Patient Undergoing Focused Ultrasound: A New Treatment Option for Essential Tremor
Authors: Shaw Katherine Dale , Johnston Amy Sue , Rush-Evans Shelly , Prather Susan , Maynard Kathy
Published: August 2017

Essential tremor (ET) is among the most common neurological movement disorders that causes postural or action tremors, with an estimated prevalence nationwide of less than 3% of the population. The incidence of ET increases with age but often affects younger adults and has a familial trait association. Depending on disease progression, ET can cause significant limitations for individuals, in many cases, significantly limiting their ability to perform activities of daily living and occupational responsibilities. Until recently, treatment of ET heavily relied on medication management and invasive surgery, such as deep brain stimulation. With advances in the use of focused ultrasound (FUS) for treatment of various medical conditions, recent clinical trials have revealed positive outcomes with the use of FUS as a less invasive approach to treat patients with medication-refractory ET. In a large academic medical center in the mid-Atlantic region, the Department of Neurosurgery conducted a continued access study, recently approved by the Food and Drug Administration, to evaluate the effectiveness of transcranial FUS thalamotomy for the treatment of medication-refractory ET. One patient’s experience will be introduced, including discussion of evidence-based treatment options for ET and information on the nursing management of the patient undergoing FUS thalamotomy.
A Comparison by Meta-Analysis of Papillary Early Gastric Carcinoma to Its Tubular Counterpart for the Risk of Lymph Node Metastasis and Submucosal Invasion
Authors: Wang Xiao-Yong , Yan Jin , Wu Jia , Zhang Yi-Feng , Zhang Guo-Xin
Published: August 2017

Background and Aim:

At present, the decision to perform endoscopic resection for treating either papillary early gastric cancer (EGC) or tubular EGC is made according to identical criteria. However, there is controversy in the literature whether the risk of lymph node metastasis (LNM) and submucosal invasion for both disease modalities is equal, and this prompts investigation to clarify this issue.

Methods:

The PubMed and Web of Science databases were searched for relevant studies published up to January 2017. Data were extracted, and the pooled odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated using a random-effects or a fixed-effects model, according to heterogeneity.

Results:

A total of 13 studies were included in this analysis. Papillary EGC had a significantly higher LNM risk (OR, 1.97; 95% CI, 1.38-2.82) and submucosal invasion risk (OR, 1.44; 95% CI, 1.08-1.93), compared with tubular EGC. Stratified by geographic location, a significantly increased risk of LNM (OR, 2.28; 95% CI, 1.57-3.30) and submucosal invasion (OR, 1.52; 95% CI, 1.13-2.04) associated with papillary EGC was found in Asian studies. In addition, papillary EGC exhibited significantly more frequent elevated/flat growth patterns (OR, 7.54, 95% CI, 4.76-11.96).

Conclusions:

Our study identifies an increased risk for submucosal invasion and LNM in papillary EGC compared with tubular EGC, indicating that papillary EGC requires more careful clinical management compared with tubular EGC.
Development of Secondary Acute Myeloid Leukemia in a Pediatric Patient Concurrently Receiving Primary Therapy for Ewing Sarcoma
Authors: McNew Brandon R. , Darbro Benjamin W. , Ma Deqin , Gordon David J.
Published: August 2017

Ewing sarcoma is a pediatric bone and soft tissue sarcoma that requires intensive therapy, which can cause secondary malignancies. We present a rare case of early, treatment-related AML in a pediatric patient concurrently receiving primary therapy for Ewing sarcoma. Despite AML-directed therapy, our patient died secondary to complications of hyperleukocytosis. Cytogenetic and mutation profiling of the leukemia cells revealed the DNA-topoisomerase-II-inhibitor-associated t(9;11)(p22;q23) translocation and clonal KRAS and BRAF mutations. This report highlights the importance of monitoring for treatment-related effects in cancer therapy, as well as the need for novel, less toxic approaches in Ewing sarcoma therapy.
Microscopic Infiltration of Cryopreserved Ovarian Tissue in 2 Patients With Ewing Sarcoma
Authors: Schifflers Stefan , Delbecque Katty , Galant Christine , Francotte Nadine , Philippet Pierre , Chantrain Christophe F.
Published: August 2017

We report the clinical history of 2 female patients with Ewing sarcoma and microscopic ovarian infiltration. In both cases, the initial workup found no metastasis. However, the examination of cryopreserved ovarian tissues revealed the presence of CD99 positive tumor cells with rearrangement of EWS gene confirmed by FISH. Both children were treated as patients with localized tumor and are currently in remission. These reports underline that, in Ewing sarcoma patients, retransplantation of cryopreserved ovarian tissue is not harmless and could lead to cancer relapse. These observations question also on the significance of ovarian dissemination on Ewing sarcoma prognosis and therapy.
Induction Methotrexate, Cisplatin, and 5-Fluorouracil Versus Cisplatin and 5-Fluorouracil Followed by Radiotherapy in Pediatric Nasopharyngeal Carcinoma: A Retrospective Analysis in a Tertiary Cancer Center
Authors: Al Mousa Abdelatif , Abu-Hijlih Ramiz , Salem Ahmed , Sultan Iyad , Mula-Hussain Layth , Ismael Taleb , Mohamad Issa
Published: August 2017

Purpose:

The purpose of this study is to compare treatment outcomes of methotrexate, cisplatin, and 5-fluorouracil (MPF) or cisplatin and 5-fluorouracil (PF) in pediatric NPC patients treated with sequential chemoradiotherapy.

Patients and Methods:

A total of 25 patients aged 18 years or below with stage II-IV NPC treated with IC using PF (n=16) or MPF (n=9) followed by radiotherapy between 2003 and 2009 were retrospectively reviewed. Radiotherapy dose was 61.2 to 66.6 Gy to the gross disease. Age, stage, radiation dose, and chemotherapy regimen were tested as prognostic factors for event-free survival (EFS) and overall survival (OS) on univariate and multivariate analyses.

Results:

The median age at diagnosis was 13.3 years. All patients completed planned chemotherapy. All patients who received MPF achieved PR whereas 15 patients (93.8%) who received PF achieved PR (P=1). There were no differences in EFS (68.75% vs. 66.67%; P=0.84) and OS (81.25% vs. 66.67%; P=0.39) at 5 years between PF and MPF, respectively. On multivariate analysis, only tumor stage (IV vs. II-III) predicted worse OS (hazard ratio, 10.3; 95% confidence interval, 1.197-88.974) but not EFS (hazard ratio, 4.805; 95% confidence interval, 0.95-24.336). Distant metastases was the predominant site of failure, seen in 5 patients (20%).

Conclusions:

Omission of methotrexate from the induction chemotherapy regimen did not affect treatment outcome.
Solid Liver Lesions in an Infant With Neonatal Cholestasis: Is it Always Malignant?
Authors: Bariş Zeren , Börcek Pelin , Haberal Kemal Murat , Özçay Figen
Published: August 2017

In this report we describe a patient with neonatal cholestasis who was found to have a liver lesion with suspicious imaging features, although ultimately it was histologically proved to be a pseudotumor. We discuss the characteristic features and imaging findings of macroregenerative nodules of the liver.
X-linked Lymphoproliferative Disease Type 1 in a Patient With the p.Gly93Asp SH2D1A Gene Mutation and Hemophagocytic Lymphohistiocytosis
Authors: de la Varga-Martínez Raquel , Mora-López Francisco , García-Cuesta Daniel , Garrastazul-Sánchez M Paz , Quintero Sebastián , Rodríguez Carmen , Sampalo Almudena
Published: August 2017

Hemophagocytic lymphohistiocytosis is characterized by uncontrolled activation of the immune system that leads to systemic hyperinflammation. Lymphoproliferative syndrome linked to the X chromosome is a hereditary immunodeficiency characterized by an inability to mount an adequate immune response to an Epstein-Barr virus infection. Hemophagocytic lymphohistiocytosis is one of the main clinical features of X-linked lymphoproliferative syndrome. We report the case of a patient who presented with primary hemophagocytic lymphohistiocytosis associated with Epstein-Barr virus infection without a familial history of immunodeficiency. A mutation in the SH2D1A gene was identified, which confirmed the diagnosis of type 1 X-linked lymphoproliferative syndrome.
A Whooping Cough Education Module for WIC Clients in Utah
Authors: Luthy Karlen E. , Anderson Alicia , Macintosh Janelle , Beckstrand Renea L. , Eden Lacey M. , Amy Ryan , Macintosh Christopher I.
Published: August 2017

Background:

Clients in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are required to complete education modules quarterly to maintain eligibility. The purposes of this project were to: (1) create a whooping cough vaccination education module for WIC clients; (2) evaluate baseline perceptions of WIC clients on the whooping cough vaccine and disease; and (3) evaluate whooping cough knowledge following completion of the module.

Problem:

A decline in vaccination rates among infants and children using WIC services was reported by a local WIC program director who requested whooping cough vaccination education materials. This quality improvement project included development of a whooping cough education module and evaluation of learning.

Methods:

Learning was evaluated using a pre- and posttest design. Client feedback was solicited via open-ended questions. Quantitative analysis was performed on visual analog-type questions with paired t-tests and a Cohen's d. Content analysis was conducted on open-ended items.

Interventions:

The module was designed by a team of vaccination experts and included general definitions, signs and symptoms during the three stages of disease, recommendations to prevent whooping cough, and vaccination recommendations. Learning of users of the module was then evaluated.

Results:

After using the module, clients indicated they were significantly more likely to vaccinate themselves and their child against whooping cough, and to recommend the vaccination to their family members. The greatest concern of participants about whooping cough was how it affected infants. Participants reported they learned new information on disease seriousness, recognition of symptoms, and treatment options but still requested additional information on the whooping cough disease and vaccine.

Conclusions:

A whooping cough education module is an effective strategy to improve whooping cough knowledge and promote the whooping cough vaccine.
Autologous Blood Transfusion for Postpartum Hemorrhage
Authors: Greenawalt Julia A. , Zernell Denise
Published: August 2017

Postpartum hemorrhage (PPH) is a leading contributor to maternal morbidity and mortality in the United States and globally. Although the rate of PPH is generally decreasing nationally, severity of PPH appears to be increasing, potentially related to the various comorbidities associated with women of childbearing age. There is increasing evidence of risks associated with allogeneic blood transfusion, which has historically been the classic therapeutic approach for treatment to PPH. Pregnant women are particularly susceptible to the implications of sensitization to red cell antigens, a common sequela to allogenic blood transfusion. Autologous blood transfusion eliminates the potential of communicable disease transmission as well as the conceivable threat of a blood transfusion reaction. Recent technological advances allow cell salvage coupled with the use of a leukocyte filter to be used as an alternative approach for improving the outcome for women experiencing a PPH. Modest changes in standard operating procedure and continued training in use and application of cell salvaged blood may assist in minimizing negative outcomes from PPH. Salvaged blood has been demonstrated to be at least equal and often superior to banked blood. We discuss nursing implications for application of this technology for women with PPH. Continued research is warranted to evaluate the impact that application of cell salvage with filtration has on the patient experiencing a PPH.
Replacing Smartphones With Mini Tablet Technology
Authors: Maneval Rhonda , Mechtel Marci
Published: August 2017

Handheld technology allows students to access point-of-care resources throughout the clinical experience. To assess the viability of replacing student smartphones with tablets, an evaluation project was undertaken. Overall, students were equally dissatisfied with the 2 types of tablets that were evaluated. Students saw the potential usefulness of tablets to manage clinical assignments, interact with the learning management system, and communicate with faculty, but not for retrieving information currently accessible on their phones.
Mediterranean Diet and Prevention of Chronic Diseases
Authors: Romagnolo Donato F. , Selmin Ornella I.
Published: August 2017

A large body of research data suggests that traditional dietary habits and lifestyle unique to the Mediterranean region (Mediterranean diet, MD) lower the incidence of chronic diseases and improve longevity. These data contrast with troubling statistics in the United States and other high income countries pointing to an increase in the incidence of chronic diseases and the projected explosion in cost of medical care associated with an aging population. In 2013, the MD was inscribed by UNESCO in the “Representative List of the Intangible Cultural Heritage of Humanity.” The 2015–2020 Dietary Guidelines for Americans included the MD as a healthy dietary pattern. Therefore, specific objectives of this article are to provide an overview of the nutritional basis of this healthful diet, its metabolic benefits, and its role in multiple aspects of disease prevention and healthy aging. Whereas recommendations about the MD often focus on specific foods or bioactive compounds, we suggest that the eating pattern as a whole likely contributes to the health promoting effects of the MD.
Differences in Tear Film Biochemistry of Symptomatic and Asymptomatic Lens Wearers
Authors: Masoudi Simin , Stapleton Fiona J. , Willcox Mark D. P.
Published: August 2017

SIGNIFICANCE

The concentration of selected proteins and inflammatory mediators in tears of symptomatic and asymptomatic contact lens wearers were quantified. The level of leukotriene B4 was higher in the symptomatic group. This may suggest that inflammation can be the cause of discomfort sensation at the end of day.

PURPOSE

The present study aims to quantify the concentration of selected tear lipids and proteins in symptomatic and asymptomatic contact lens wearers.

METHODS

Unstimulated evening tears were collected using glass capillary tubes from 45 healthy, adapted contact lens wearers. Twenty-two had self-described symptoms of dryness and discomfort with contact lenses and 23 were asymptomatic. Tear proteins were assayed using selected reaction monitoring mass spectrometry. Enzyme immunoassay kits were used to measure prostaglandins, leukotriene B4, and cysteinyl leukotrienes. Ocular comfort was rated on a scale of 1 to 100 at the time of tear collection.

RESULTS

The average evening comfort level was above 70 for the asymptomatic (83.96 ± 9.51, mean ± SE) and equal or below 70 for the symptomatic group (57.28 ± 12.38) (P < .001). LTB4 was significantly higher in symptomatic than asymptomatic contact lens wearers (0.32 ± 0.06 ng/mL vs. 0.17 ± 0.04 ng/mL, respectively; P = .03). Lysozyme was slightly but not significantly lower in symptomatic subjects (symptomatic 0.58 ± 0.10 mg/mL vs. asymptomatic 1.73 ± 0.46 mg/mL; P = .10). The levels of lactoferrin, lipocalin 1, proline-rich 4, prolactin-induced protein, prostaglandins, and cysteinyl leukotrienes were unchanged (P > .1) between symptomatic and asymptomatic subjects.

CONCLUSIONS

The LTB4 concentration was significantly higher in symptomatic contact lens wearers compared to the asymptomatic group, and this may partly mediate the discomfort response during lens wear in the symptomatic lens wearers. No other differences were found in the level of tear factors of interest between the two groups.
Comparison of Consent Models in a Randomized Trial of Corticosteroids in Pediatric Septic Shock*
Authors: Menon Kusum , O’Hearn Katharine , McNally James Dayre , Acharya Anand , Wong Hector R. , Lawson Margaret , Ramsay Tim , McIntyre Lauralyn , Gilfoyle Elaine , Tucci Marisa , Wensley David , Gottesman Ronald , Morrison Gavin , Choong Karen
Published: August 2017

Objectives:

To describe the use of deferred and prior informed consent models in the context of a low additional risk to standard of care, placebo-controlled randomized controlled trial of corticosteroids in pediatric septic shock.

Design:

An observational substudy of consent processes in a randomized controlled trial of hydrocortisone versus placebo.

Setting:

Seven tertiary level PICUs in Canada.

Patients:

Children newborn to 17 years inclusive admitted to PICU with suspected septic shock between July 2014 and March 2016.

Interventions:

None.

Measurements and Main Results:

Information on the number of families approached, consent rates obtained, and spontaneously volunteered reasons for nonparticipation were collected for both deferred and informed consent. The research ethics board of five of seven centers approved a deferred consent model; however, implementation criteria for use of this model varied across sites. The consent rate using deferred versus prior informed consent was significantly higher (83%; 35/42 vs 58%; 15/26; p = 0.02). The mean times from meeting inclusion criteria to randomization (1.8 ± 1.8 vs 3.6 ± 2.1 hr; p = 0.007) and study drug administration (3.4 ± 2.7 hr vs 4.8 ± 2.1 hr; p = 0.05) were significantly shorter with the use of deferred consent versus prior informed consent. No family member or research ethics board expressed concern following use of deferred consent.

Conclusions:

Deferred consent was acceptable in time-sensitive critical care research to most research ethics boards, families, and healthcare providers and resulted in higher consent rates and more efficient recruitment. Larger studies on deferred consent and consistency interpreting jurisdictional guidelines are needed to advance pediatric acute care.
Effect of Group Exercising and Adjusting the Brace at Shorter Intervals on Cobb Angle and Quality of Life of Patients With Idiopathic Scoliosis
Authors: Hedayati Zahra , Ahmadi Amir , Kamyab Mojtaba , Babaee Taher , Ganjavian Mohammad Saleh
Published: August 2017

Objective

The aim of the study was to evaluate the effect of group exercise with brace adjustment at shorter intervals than used in routine practice in late-onset idiopathic scoliosis patients.

Design

This was a quasi-experimental study. Thirty patients with progressive scoliosis curves of 15–50 degrees and a prescription for a brace were divided into experimental and control groups, both of which participated in an 11-wk treatment program. Those in the experimental group underwent brace adjustment twice per week and performed group exercise, whereas those in the control group received a routine protocol. The quality of life and Cobb angle of patients in both groups were evaluated based on baseline and final results of the 22-item Scoliosis Research Society questionnaire and primary and secondary radiographs.

Results

In the experimental group, the improvement in Cobb angle and patient satisfaction was greater than that in the control group (P < 0.05). Moreover, in patients with Cobb angles of less than 30 degrees, the self-image and satisfaction domains and the total scores of patients in the experimental group were significantly different from those in the control group at the final assessment (P < 0.05).

Conclusions

Brace adjustment at shorter intervals combined with group exercise increases patient satisfaction and reduces scoliosis Cobb angles.
Racial Inequities in HIV Prevalence and Composition of Risk Networks Among People Who Inject Drugs in HIV Prevention Trial Network 037
Authors: Momplaisir Florence , Hussein Mustafa , Tobin-Fiore Danielle , Smith Laramie , Bennett David , Latkin Carl , Metzger David S.
Published: August 2017

Background:

HIV prevention interventions in the United States have failed to eliminate racial inequities. Here, we evaluate factors associated with racial inequities in HIV prevalence among people who inject drugs using HIV Prevention Trial Network 037 data.

Methods:

We measured racial homophily (ie, all members share the same race), being in an HIV+ network (network with ≥1 HIV+ member), and drug and sex risk behaviors. A 2-level logistic regression with a random intercept evaluated the association between being in an HIV+ network and race adjusting for individual-level and network-level factors.

Results:

Data from 232 index participants and 464 network members were included in the analysis. Racial homophily was high among blacks (79%) and whites (70%); 27% of all-black, 14% of all-white, and 23% of racially mixed networks included HIV+ members. Sex risk was similar across networks, but needle sharing was significantly lower in all-black (23%) compared with all-white (48%) and racially mixed (46%) networks. All-black [adjusted odds ratio (AOR), 3.6; 95% confidence interval (CI), 1.4 to 9.5] and racially mixed (AOR, 2.0; 95% CI: 1.1 to 3.7) networks were more likely to include HIV+ network members; other factors associated with being in HIV+ network included homelessness (AOR, 2.0; 95% CI, 1.2 to 3.2), recent incarceration (AOR, 0.4; 95% CI, 0.2 to 0.7), and cocaine injection (AOR, 1.7; 95% CI, 1.0 to 2.7). Risk behaviors were not associated with being in an HIV+ network.

Conclusion:

Despite having lower drug risk behavior, all-black networks disproportionately included HIV+ members. HIV prevention interventions for people who inject drugs need to go beyond individual risk and consider the composition of risk networks.
Brief Report: Drop in CD4+ Counts Below 200 Cells/μL After Reaching (or Starting From) Values Higher than 350 Cells/μL in HIV-Infected Patients With Virological Suppression
Authors: Gianotti Nicola , Marchetti Giulia , Antinori Andrea , Saracino Annalisa , Gori Andrea , Rizzardini Giuliano , Lichtner Miriam , Bandera Alessandra , Mussini Cristina , Girardi Enrico , d'Arminio Monforte Antonella , Cozzi-Lepri Alessandro ,   on behalf of the ICONA Foundation Study Group
Published: August 2017

Background:

The aim of the study was to quantify the risk of a drop in CD4+ counts below 200 cells/μL after reaching values >350 cells/μL on antiretroviral therapy (ART) (or after starting ART with CD4+ count >350 cells/μL) in the absence of virological failure.

Setting:

Ambulatory care services, Italy.

Methods:

Prospective cohort study of patients enrolled in the ICONA Foundation Study cohort who started ART with >350 CD4+/μL or with ≤350 CD4+/μL and reached values >350 cells/μL after virological suppression (VS, defined by 2 consecutive viral loads ≤50 copies/mL). The date of CD4 count >350 was the baseline for the analysis and those with ≥1 viral load and CD4+ count after baseline were included. The primary end point was the cumulative risk (estimated using the Kaplan–Meier method) of a CD4+ drop below 200 cells/μL over follow-up, which was censored at the date of virological failure (confirmed HIV-RNA >50 copies/mL), death, or last visit.

Results:

Six thousand six hundred sixty-three patients were included. A confirmed CD4+ drop below 200 cells/μL was never observed over a median follow-up of 45 (Q1: 21, Q3: 89) months, as long as VS was maintained. Upper limits of the 97.5% confidence interval of rates of confirmed CD4+ drop below 200 cells/μL were 0.28 and 0.38/1000 person-years of follow-up for patients with ≤350 and >350 CD4+ cells/μL at starting ART.

Conclusions:

In patients who started ART in Italy with >350 CD4+ cells/μL or reached >350 CD4+ cells/μL after VS, the risk of a CD4+ drop below 200 cells/μL in those maintaining VS was negligible.
Alternatively Activated Macrophages Drive Browning of White Adipose Tissue in Burns
Authors: Abdullahi Abdikarim , Auger Christopher , Stanojcic Mile , Patsouris David , Parousis Alexandra , Epelman Slava , Jeschke Marc G.
Published: August 2017

Objective:

The aim of this study was to uncover the mediators and mechanistic events that facilitate the browning of white adipose tissue (WAT) in response to burns.

Background:

In hypermetabolic patients (eg, burns, cancer), the browning of WAT has presented substantial clinical challenges related to cachexia, atherosclerosis, and poor clinical outcomes. Browning of the adipose tissue has recently been found to induce and sustain hypermetabolism. Although browning appears central in trauma-, burn-, or cancer-induced hypermetabolic catabolism, the mediators are essentially unknown.

Methods:

WAT and blood samples were collected from patients admitted to the Ross Tilley Burn Centre at Sunnybrook Hospital. Wild type, CCR2 KO, and interleukin (IL)-6 KO male mice were purchased from Jax laboratories and subjected to a 30% total body surface area burn injury. WAT and serum collected were analyzed for browning markers, macrophages, and metabolic state via histology, gene expression, and mitochondrial respiration.

Results:

In the present study, we show that burn-induced browning is associated with an increased macrophage infiltration, with a greater type 2 macrophage profile in the fat of burn patients. Similar to our clinical findings in burn patients, both an increase in macrophage recruitment and a type 2 macrophage profile were also observed in post burn mice. Genetic loss of the chemokine CCR2 responsible for macrophage migration to the adipose impairs burn-induced browning. Mechanistically, we show that macrophages recruited to burn-stressed subcutaneous WAT (sWAT) undergo alternative activation to induce tyrosine hydroxylase expression and catecholamine production mediated by IL-6, factors required for browning of sWAT.

Conclusion:

Together, our findings uncover macrophages as the key instigators and missing link in trauma-induced browning.
Fatal Cerebral Edema, Seizures, and Hyponatremia After Trazodone Overdose
Authors: Avila Jose David
Published: August 2017

Trazodone is a serotonin antagonist and reuptake inhibitor that is widely used for the treatment of depression and insomnia. Fatal overdose is rare and usually occurs when combined with other drugs or alcohol. Only a few lethal cases of pure trazodone overdose have been reported, all attributed to cardiotoxicity. We reported a 37-year-old woman who presented after ingesting 6.45 g of trazodone in a suicidal attempt. She was hyponatremic because of the syndrome of inappropriate antidiuretic hormone secretion and, shortly after, had a seizure and developed fatal cerebral edema. Others have described seizures and hyponatremia after pure trazodone overdose, but this is the first report of cerebral edema and death from a neurological complication. Careful monitoring and correction of sodium levels may be necessary in these patients.