bluuebunny/crossref_metadata_2025 huggingface dataset:
Mechanisms of immune-related adverse events during the treatment of cancer with immune checkpoint inhibitors
Authors: Weinmann Sophia C , Pisetsky David S
Published: July 2019

Immune checkpoint inhibitors are novel biologic agents to treat cancer by inhibiting the regulatory interactions that limit T cell cytotoxicity to tumours. Current agents target either CTLA-4 or the PD-1/PD-L1 axis. Because checkpoints may also regulate autoreactivity, immune checkpoint inhibitor therapy is complicated by side effects known as immune-related adverse events (irAEs). The aim of this article is to review the mechanisms of these events. irAEs can involve different tissues and include arthritis and other rheumatic manifestations. The frequency of irAEs is related to the checkpoint inhibited, with the combination of agents more toxic. Because of their severity, irAEs can limit therapy and require immunosuppressive treatment. The mechanisms leading to irAEs are likely similar to those promoting anti-tumour responses and involve expansion of the T cell repertoire; furthermore, immune checkpoint inhibitors can affect B cell responses and induce autoantibody production. Better understanding of the mechanisms of irAEs will be important to improve patient outcome as well as quality of life during treatment.
The Role of Personal Identity on Positive and Negative Symptoms in Psychosis: A Study Using the Repertory Grid Technique
Authors: García-Mieres Helena , Villaplana Anna , López-Carrilero Raquel , Grasa Eva , Barajas Ana , Pousa Esther , Feixas Guillem , Ochoa Susana
Published: July 2019

Background

People with psychosis experience disruptions in personal identity that affect positive and negative symptoms, but the complexity of these phenomena needs to be addressed in an in-depth manner. Using the Personal Construct Theory, we examined whether distinct dimensions of personal identity, as measured with the Repertory Grid Technique along with other cognitive factors, might influence psychotic symptomatology.

Method

Eighty-five outpatients with schizophrenia-spectrum disorders completed a repertory grid, an observed-rated interview of psychotic symptoms, and measures of cognitive insight, depressive symptoms, neurocognition, and theory of mind.

Results

Structural equation models revealed that interpersonal dichotomous thinking directly affected positive symptoms. Self-discrepancies influenced positive symptoms by mediation of depressive symptoms. Interpersonal cognitive differentiation and interpersonal cognitive richness mediated the impact of self-reflectivity and neurocognitive deficits in negative symptomatology.

Conclusions

This study is the first of its kind to examine the structure of personal identity in relation to positive and negative symptoms of psychosis. Results suggest interventions targeted to improving interpersonal dichotomous thinking, self-discrepancies, interpersonal cognitive differentiation, and interpersonal cognitive richness may be useful in improving psychotic symptoms.
A longitudinal analysis of albendazole treatment effect on neurocysticercosis cyst evolution using multistate models
Authors: Montgomery Michelle A , Ramos Marcel , Kelvin Elizabeth A , Carpio Arturo , Jaramillo Alexander , Hauser W Allen , Zhang Hongbin
Published: July 2019

Background

In neurocysticercosis, the larval form of the pork tapeworm Taenia solium appears to evolve through three phases—active, degenerative and sometimes calcification—before disappearance. The antihelmintic drug, albendazole, has been shown to hasten the resolution of active cysts in neurocysticercosis. Little is known about the time cysts take to progress through each phase, with or without treatment.

Methods

We reconfigured brain imaging data from patient level to cyst level for 117 patients in a randomized clinical trial of albendazole in which images were taken at baseline, 1, 6, 12 and 24 mo. Applying a multistate model, we modelled the hazard of a cyst evolving to subsequent cyst phases before the next imaging (vs no change). We examined the impact of albendazole treatment overall and by patient and cyst characteristics on the hazard.

Results

Albendazole accelerated the evolution from the active to degenerative phase (HR=2.7, 95% CI 1.3 to 6.5) and from the degenerative phase to disappearance (HR=1.9, 95% CI 1.1 to 3.9). Albendazole’s impact was stronger for patients who were male, did not have calcified cysts at baseline and who had multiple cysts in different locations.

Conclusions

This research provides a better understanding of where in the cyst trajectory albendazole has the greatest impact.
Evaluation and Management of Enterocutaneous Fistula
Authors: Bhama Anuradha R.
Published: July 2019

Case Summary:

A 36-year-old woman presents with an abscess at her midline wound 4 weeks following an ileocecectomy for Crohn’s disease. After the abscess is incised, there is purulent drainage followed by the drainage of enteric contents; the output is 750 mL per 24 hours.
Cryopreservation of Stromal Vascular Fraction Cells Reduces Their Counts but Not Their Stem Cell Potency
Authors: Solodeev Inna , Orgil Matan , Bordeynik-Cohen Mor , Meilik Benjamin , Manheim Sharon , Volovitz Ilan , Sela Meirav , Inbal Amir , Gur Eyal , Shani Nir
Published: July 2019

Background:

Adipose-derived stem cells are derived from the nonfat component of adipose tissue termed the stromal vascular fraction (SVF). The use of freshly isolated autologous SVF cells as an alternative to adult stem cells is becoming more common. Repeated SVF administration for improved clinical outcomes is complicated by the need for repeated liposuction. This can be overcome by cryopreservation of SVF cells. The current study aimed to assess whether SVF cells retain their stem cell potency during cryopreservation.

Methods:

SVF cells isolated from lipoaspirates (donor age: 46.1 ± 11.7 y; body mass index: 29.3 ± 4.8 kg/m2) were analyzed either immediately after isolation or following cryopreservation at −196°C. Analyses included assessment of nucleated cell counts by methylene blue staining, colony-forming unit fibroblast counts, surface marker expression using a flow cytometric panel (CD45, CD34, CD31, CD73, CD29, and CD105), expansion in culture, and differentiation to fat and bone.

Results:

While cryopreservation reduced the number of viable SVF cells, stem cell potency was preserved, as demonstrated by no significant difference in the proliferation, surface marker expression in culture, bone and fat differentiation capacity, and the number of colony-forming unit fibroblasts in culture, in cryopreserved versus fresh SVF cells. Importantly, reduced cell counts of cryopreserved cells were due, mainly, to a reduction in hematopoietic CD45+ cells, which was accompanied by increased proportions of CD45−CD34+CD31− stem cell progenitor cells compared to fresh SVF cells.

Conclusions:

Cryopreservation of SVF cells did not affect their in vitro stem cell potency and may therefore enable repeated SVF cell administrations, without the need for repeated liposuction.
History of Dose, Risk, and Compensation Assessments for US Veterans of the 1966 Plutonium Cleanup in Palomares, Spain
Authors: Beyea Jan , von Hippel Frank N.
Published: July 2019

In 1966, about 1,600 US military men—mostly Air Force—participated in a cleanup of plutonium dispersed from two nuclear bombs in Palomares, Spain. As a base for future analyses, we provide a history of the Palomares incident, including the dosimetry and risk analyses carried out to date and the compensation assessments made for veterans. By law, compensation for illnesses attributed to ionizing radiation is based on maximum estimated doses and standard risk coefficients, with considerable benefit of the doubt given to claimants when there is uncertainty. In the Palomares case, alpha activity in urine fell far faster than predicted by plutonium biokinetic excretion models used at the time. Most of the measurements were taken on-site but were disqualified on the grounds that they were “unreasonably high” and because there was a possibility of environmental contamination. Until the end of 2013, the Air Force used low dose estimates derived from environmental measurements carried out well after the cleanup. After these estimates were questioned by Congress, the Air Force adopted higher dose estimates based on plutonium concentration measurements in urine samples collected from 26 veterans after they left Palomares. The Air Force assumed that all other cleanup veterans received lower doses and therefore assigned to them maximum organ doses based on the individual among the 26 with the lowest urine measurements. These resulting maximum organ doses appear to be sufficient to justify compensation to all Palomares veterans with lung and bone cancer and early-onset liver cancer and leukemia but not other radiogenic cancers.
FOVEA-SPARING VERSUS COMPLETE INTERNAL LIMITING MEMBRANE PEELING IN VITRECTOMY FOR THE TREATMENT OF MACULAR HOLES
Authors: Morescalchi Francesco , Russo Andrea , Bahja Hassan , Gambicorti Elena , Cancarini Anna , Costagliola Ciro , Semeraro Francesco
Published: July 2019

Purpose:

To compare the anatomical and functional outcomes of vitrectomy involving complete internal limiting membrane peeling (CP) with those of vitrectomy involving fovea-sparing internal limiting membrane peeling (FSP) for the treatment of macular holes measuring >250 µm.

Methods:

This prospective, randomized, comparative study included 46 eyes with a medium or large macular hole that was randomized to undergo complete (CP group) or fovea-sparing (FSP group) internal limiting membrane peeling during vitrectomy. The main outcome measures included the foveal retinal sensitivity, visual acuity, and central retinal thickness.

Results:

Both groups showed significantly improved foveal retinal sensitivity after surgery; the mean foveal retinal sensitivity change at 12 months after surgery was +2.8 ± 2.1 dB in the CP group and +7.2 ± 2.3 dB in the FSP group. The visual acuity also showed a significant improvement in both groups, with no significant differences in values at any time point. Regarding central retinal thickness, there was a significant decrease in the CP group and no change in the FSP group. Nicks or dimples in the inner retinal layers were visible in the fovea and perifovea of nine eyes in the CP group.

Conclusion:

Our findings suggest that both CP and FSP are safe and effective treatments leading to functional and anatomical improvements in patients with all size macular holes. However, the fovea-sparing technique may provide better functional outcomes because of a greater improvement in foveal retinal sensitivity.
FOVEAL OUTER RETINAL HYPERREFLECTIVITY: A NOVEL OPTICAL COHERENCE TOMOGRAPHY FINDING IN IDIOPATHIC MULTIFOCAL CHOROIDITIS
Authors: Dolz-Marco Rosa , Kalevar Ananda , McDonald H. Richard , Cunningham Emmett T. , Freund K. Bailey
Published: July 2019

Purpose:

To describe three patients with idiopathic multifocal choroiditis (MFC) who showed foci of foveal outer retinal hyperreflectivity on optical coherence tomography.

Methods:

Retrospective review of electronic health records and multimodal imaging from three patients with MFC.

Results:

Three consecutive white patients with MFC (two male and one female) presented with unilateral foveal outer retinal hyperreflectivity in the eye with active MFC. In all cases, the lesions persisted for at least 1 month. Optical coherence tomography demonstrated finger-like projections of hyperreflectivity extending from the retinal pigment epithelium and through disrupted interdigitation and ellipsoid zones into the outer nuclear layer, with some aspects of the lesions reaching the inner limiting membrane. Visual recovery varied in the three affected eyes.

Conclusion:

Foveal outer retinal hyperreflectivity is a novel optical coherence tomography finding in eyes with active MFC. Additional studies will be required to address the prevalence and prognostic importance of foveal outer retinal hyperreflectivity.
DIMINUTIVE PARACENTRAL ACUTE MIDDLE MACULOPATHY LESION
Authors: Spaide Richard F.
Published: July 2019

Purpose:

To describe a transient positive scotoma and corresponding optical coherence tomography (OCT) structural and angiographic findings.

Methods:

The patient was evaluated with a comprehensive ophthalmic examination to include OCT structural and angiographic imaging with two different instruments, the Zeiss Plex Elite and the Optovue RTVue XR Avanti.

Results:

A 45-year-old man had a sudden onset of a positive scotoma in the visual field of the left eye. No abnormalities were noted by ophthalmoscopy or fundus photography. Optical coherence tomography angiography was performed to evaluate the macular perfusion status. With each instrument, a small hyperreflective area, 175 μm in diameter, was imaged in the inner nuclear layer. The OCT angiographic images suggested a small area of decreased perfusion in the deep capillary plexus. Except for the diminutive size, the lesion had an appearance suggestive of paracentral acute middle maculopathy. The symptoms lessened rapidly, and when examined 4 days later, the lesion was less hyperreflective. Two weeks after presentation, the positive scotoma was not present and there was no longer any hyperreflectivity in the inner nuclear layer.

Conclusion:

Detection of the lesion was aided by using OCT angiographic scans, which have a much higher scan density than conventional OCT evaluations. The diminutive abnormality was consistent with a paracentral acute middle maculopathy lesion, although smaller than those previously reported. Micro–paracentral acute middle maculopathy lesions should be considered in the differential diagnosis of positive scotomas.
Comparative Evaluation of Visual Outcomes After Bilateral Implantation of a Diffractive Trifocal Intraocular Lens and an Extended Depth of Focus Intraocular Lens
Authors: Singh Bhupesh , Sharma Sourabh , Dadia Suchit , Bharti Neha , Bharti Sudhank
Published: July 2019

Objectives:

To compare visual outcomes and clinical performance of diffractive trifocal and extended depth of focus (EDOF) intraocular lenses (IOLs).

Methods:

This prospective, consecutive, nonrandomized, comparative study of 6-month duration included assessment of 160 eyes of 80 patients (40 patients in each group). The patients had bilateral cataract surgery with implantation of a trifocal (FineVision Micro F; PhysIOL SA, Liège, Belgium) or EDOF IOL (TECNIS Symfony; Abbott Medical Optics, Inc., Abbott Park, IL) in both eyes. Ophthalmological evaluation included measurement of monocular uncorrected distance visual acuity (UDVA) and corrected distance VA (CDVA), uncorrected intermediate VA (UIVA) and distance-corrected intermediate VA (DCIVA), uncorrected near VA (UNVA) and distance-corrected near VA (DCNVA). Analysis of point-spread function and modulation transfer function was also performed postoperatively, and quality of vision and spectacle-dependence questionnaires were assessed.

Results:

There was no statistically significant difference between groups in monocular UDVA (P=0.65), CDVA (P=0.82), and binocular UDVA (P=0.81). The monocular UIVA, monocular DCIVA, and binocular UIVA were also comparable among the two groups (P=0.70, 0.74, and 0.81, respectively). Monocular UNVA, DCNVA, and binocular UNVA were statistically and significantly better for the trifocal group than for the EDOF (P=0.01, P=0.009, and P=0.001, respectively). There were no differences in visual symptoms and quality among groups.

Conclusions:

Trifocal IOL had a clear advantage over EDOF IOLs in near VA, while both IOLs showed excellent performance in distance and intermediate VA. Both IOLs provided high percentage of spectacle independence and patient satisfaction with minimal level of disturbing photic phenomena.
Woakes Syndrome: A Rare Cause of Proptosis due to Sinonasal Polyposis
Authors: Cruz Antonio Augusto V. , Chahud Fernando , Akaishi Patricia M. S. , Enz Tim J.
Published: July 2019

The authors report 2 consecutive adult male patients, aged 61 and 38 years, who presented with painless unilateral proptosis. Their past medical histories were negative for asthma, allergies, and Graves disease. On examination, the nose bridge of the eldest patient was clearly enlarged. Computed tomography scans of the orbits and paranasal sinuses showed in both patients the same radiologic pattern of hyperdense ethmoidal opacifications and expansion of the inferomedial orbital floor. Histopathological analysis of the ethmoidal cells mucosa obtained during inferomedial decompression revealed benign sinonasal polyposis. These cases demonstrate that asymptomatic sinonasal polyposis can be a rare cause of proptosis.
Association of Magnet Nursing Status With Hospital Performance on Nationwide Quality Metrics
Authors: Boylan Matthew R. , Suchman Kelly I. , Korolikova Helen , Slover James D. , Bosco Joseph A.
Published: July 2019

Introduction:

Magnet Recognition is the highest distinction a healthcare organization can receive for excellence in nursing. Although Magnet status is generally associated with superior clinical outcomes and patient satisfaction, its association with performance on nationwide quality metrics is currently unknown.

Methods:

Within a propensity score–matched cohort, we compared performance on the Hospital-Acquired Condition Reduction Program (HACRP), Hospital Value-Based Purchasing (VBP), and Hospital Readmissions Reduction Program (RRP) initiatives.

Results:

The mean HACRP total performance score was inferior at Magnet versus non-Magnet hospitals (p < .001), and HACRP penalties were more likely to be levied against Magnet hospitals (p = .003). There was no significant difference according to Magnet status for VBP penalties after correcting for multiple comparisons (p = .049). There were no significant difference in RRP penalties according to Magnet status (p = .999).

Conclusions:

Magnet hospitals performed worse on a number of hospitalwide quality metrics tied to reimbursement by the Centers for Medicare and Medicaid Service. Although Magnet hospitals are known for superior nursing care and organizational support for safety and quality improvement, this is not captured within these composite measures of quality, which can be influenced at many levels of care. These data underscore the need for comprehensive quality improvement across multiple domains of care outside of nursing.

Level of Evidence:

Level III, retrospective study.
Workforce Competencies for Healthcare Quality Professionals: Leading Quality-Driven Healthcare
Authors: Schrimmer Karen , Williams Nidia , Mercado Stephanie , Pitts Jennifer , Polancich Shea
Published: July 2019

As healthcare delivery systems increasingly adopt models designed to reward cost-efficient and high-quality care, the demand for expertise in healthcare quality continues to grow. There has been wide variation and limited conformity in the definition of the quality competencies that are essential for healthcare professionals. To address the need for a standard, widely accepted, comprehensive definition of the competencies required for healthcare quality, the National Association for Healthcare Quality (NAHQ) made a strategic commitment to develop a comprehensive healthcare quality competency framework applicable to all practice settings across the care continuum. In this article, the authors describe the development of NAHQ's Healthcare Quality Competency Framework depicting eight competency dimensions required for success in current and future healthcare quality positions. In addition, they discuss a self-assessment survey tool to identify individual and organizational gaps in the workforce competencies of Healthcare Quality Professionals.
Bridging the Gap: Utilizing a Pediatric Trauma Care Coordinator to Reduce Disparities for Pediatric Trauma Follow-Up Care
Authors: McRoberts Christina M. , Bohlen Nie , Wills Hale E.
Published: July 2019

An American College of Surgeons–verified Level I pediatric trauma center found that some children with severe and complex injuries experienced disruptions in trauma follow-up care because of the lack of centralized care coordination after hospital discharge. A review of the literature identified little guidance to address this issue. A quality improvement project assessed the gaps in care, identified high-risk patients, and developed a novel pediatric trauma care coordinator (PTCC) nursing position to bridge the gap. Enhancements to the trauma registry software helped create a log of family and provider communication events with and interventions by the PTCC. High-risk patients were defined as those with either a traumatic brain injury plus 1 other organ system injury requiring surgical specialist follow-up, or those with 3 or more different organ system injuries requiring follow-up with a surgical specialist. Costly return to health care (CRH), which we defined as emergency department visits for 72 hr or less or unplanned readmissions of 30 day or less after hospital discharge was selected as the primary outcome measure and assessed during the pre- and postimplementation periods. In the 12-month preimplementation period, 14 patients had a CRH rate of 14%, compared with the 12-month postimplementation period in which 18 patients had a CRH rate of 0%. Patients received a mean of 21.2 communication events and 14.1 intervention events from the PTCC in the postimplementation period. This report details the process of developing and implementing a PTCC nursing position, the tasks involved, and the initial results of this novel program.
Propofol Infusion and Acute Pancreatitis: A Review
Authors: Asghar Muhammad U. , Cheema Hira A. , Tanveer Khurram , Leinwand Joshua
Published: July 2019

Background:

Propofol is a short-acting anesthetic used to induce sedation in various ambulatory and inpatient surgical procedures. It is a US Food and Drug Administration approved lipid-based intravenous hypnotic agent, which has been used clinically for the induction and maintenance of anesthesia for over 3 decades. In addition to general anesthesia, it is used to sedate patients undergoing mechanical ventilation or short procedures such as endoscopy, transesophageal echocardiogram, and abscess drainage. An infrequent but serious complication of propofol is acute pancreatitis (AP), with potentially significant morbidity and possible mortality. In this review, we will discuss the proposed mechanisms of AP secondary to propofol, a number of reported cases, studies conducted, and treatment strategies.

Areas of Uncertainty:

There are several case reports in the literature that have shown an association between propofol and pancreatitis. The exact mechanism behind propofol-induced pancreatitis is not fully understood, but proposed mechanisms include hypertriglyceridemia (HTG), hypersensitivity, or direct pancreatic toxicity of the drug. Although the association of propofol and pancreatitis has not been proven conclusively, clinicians should be aware of this possible rare complication to prevent the devastating consequences of AP.

Data Sources:

We gathered articles on previously documented case reports and up-to-date studies on propofol-induced pancreatitis by searching databases such as PubMed and Google Scholar.

Results:

Based on previous studies and case reports, we suggest that propofol should be added to a list of drugs having a direct association with AP.

Conclusions:

Although, the mechanism of propofol-induced pancreatitis is not fully understood, and the causal relationship of propofol-induced hypertriglyceridemia or idiosyncratic drug reaction has remained unproven. Clinicians should be aware of the association between propofol and pancreatitis, and any patient presenting with abdominal pain after propofol infusion should be evaluated for AP and treated promptly to avoid complications.
Adherence to Home-Based Rehabilitation in Older Adults With Diabetes After Hip Fracture
Authors: Kuo Wen-Yu , Shyu Yea-Ing Lotus , Wang Jong-Shyan , Chen Min-Chi , Wu Chi-Chuan , Chen Mei-Ling
Published: July 2019

Background

Adherence to rehabilitation is beneficial to patients with hip fracture. However, the relationships between different levels of adherence and postoperative recovery among older adults after hip fracture have not been addressed thoroughly in the literature.

Objectives

The aims of this study were to explore the trajectories of adherence to home-based rehabilitation during the 12-month period after hospital discharge and to examine the effects of adhering to prescribed home-based rehabilitation on postoperative recovery of physical functions.

Methods

We employed a secondary data analysis, and 88 hip-fractured older adults with diabetes were recruited. The Chinese Barthel Index was used to measure daily physical functions, a goniometer was used to measure range of motion, and the MicroFET2 dynamometer was used to measure muscle power. Adherence was measured as the rate of adherence to the suggested frequency of home-based rehabilitation activities.

Results

Adherence to home-based rehabilitation decreased over time. The high-adherence group was more likely to recover prefracture physical functions than was the low-adherence group, and the high-adherence group had better self-care abilities, greater range of motion for ankle extension, and higher muscular strength on both adduction and abduction than did the low-adherence group.

Discussion

The results of our study suggest that patients adhere to more than 50% of prescribed rehabilitation. Future studies should continue to explore interventions to enhance rehabilitation adherence after hospital discharge.
Immunohistochemistry for ATRX Can Miss ATRX Mutations
Authors: Chami Rose , Marrano Paula , Teerapakpinyo Chinachote , Arnoldo Anthony , Shago Mary , Shuangshoti Shanop , Thorner Paul S.
Published: July 2019

Neuroblastoma is the most common extracranial solid tumor of childhood with a median age of presentation of 17 months. A common theme in high-risk neuroblastoma is maintenance of telomeres, one mechanism for which involves alternate lengthening of telomeres (ALT) associated withATRXgene mutations. Mutations are believed to result in loss of ATRX protein, and therefore immunohistochemistry is used to detect mutations. We screened 133 cases of neuroblastoma by ATRX immunohistochemistry, and found 9 cases with partial to total absence of ATRX. Sequencing forATRXmutations detected a mutation in 1 of 9 cases, suggesting immunostaining was not reliable for detecting mutations. To correlate immunostaining with ALT, fluorescence in situ hybridization (FISH) for ALT was performed in 6 of these cases and 5 (from 4 patients) showed ALT, implying impaired ATRX protein function, despite the failure to identify a mutation. Two other cases with large deletions in theATRXgene showed diffusely positive staining for ATRX protein but showed ALT by FISH. Four of the 6 patients with ALT-positive tumors were over 5 years old. Therefore, 29 additional patients 5 years old and above with ATRX-positive tumors were screened for ALT by FISH and 6 additional cases with ALT were detected, bringing the total to 29% (10/34) of children 5 years old and above, 70% of which showed positive ATRX immunohistochemistry. Patients withATRXmutations in neuroblastoma tend to have a more chronic and progressive course of disease. Screening neuroblastoma tumors at diagnosis forATRXmutations may help identify patients who might benefit from personalized therapy directed against ALT. However, relaying on negative immunohistochemistry for ATRX protein to identify ALT in neuroblastoma may miss a significant proportion of patients. The addition of FISH for ALT as part of the diagnostic workup, especially for older children (5 y old and above), would help ensure that patients are correctly identified for anti-ALT therapy.
Decreased Mortality After Establishing a Pediatric Emergency Unit at an Urban Referral Hospital in Ghana
Authors: Sylverken Justice , Robison Jeff A. , Osei-Akoto Alex , Nguah Samuel Blay , Addo-Yobo Emmanuel , Balch Alfred , Bolte Robert , Ansong Daniel
Published: July 2019

Emergently ill infants and children are often inadequately recognized and stabilized by health care facilities in low- and middle-income countries. Limited reports have shown that process improvements and prioritization of emergency care for children presenting to the hospital can improve pediatric hospital mortality.

A dedicated pediatric emergency unit (PEU) was established for nontrauma emergencies at a busy teaching and referral hospital in Kumasi, Ghana, in response to high inpatient mortality early during hospitalization. The PEU was designed to identify and separate critically ill children from more stable children on admission. Locally available hospital resources were reallocated from other areas of the hospital to prioritize staffing and supplies for the PEU.

A multiyear data set of nonnewborn inpatient mortality was analyzed with a change point model to find the point at which mortality changed the most within the Department of Child Health or the maximum likelihood estimate. Relative risk of mortality for the periods 1 and 2 years immediately before and after the implementation of the PEU and each individual year compared with its preceding year was analyzed to further establish a temporal correlation of changes in mortality rates to the PEU implementation. Individual years were also analyzed against preimplementation data to establish the durability of mortality improvements.

Patient mortality decreased over the analyzed period with the maximum change point strongly associated with implementation of the PEU. Relative risk values of mortality 1 year and 2 years immediately before and after implementation of the PEU were 0.70 (0.62–0.78) and 0.69 (0.64–0.74) respectively, representing a one-third reduction in mortality. The only other mortality improvements seen in the year-to-year analysis were between July 2004–June 2005 compared with July 2005–June 2006 with a relative risk of 0.86 (0.77–0.96).

Prioritizing and redirecting limited resources toward pediatric emergency care in low- and middle-income country hospitals is associated with reductions in inpatient mortality that are both immediate and sustained.
Quality Assurance for Point-of-Care Ultrasound in North American Pediatric Emergency Medicine Fellowships
Authors: Thomas-Mohtat Rosemary , Breslin Kristen , Cohen Joanna S.
Published: July 2019

Objectives

The American Academy of Pediatrics, the Society for Academic Emergency Medicine, and the American College of Emergency Physicians released a policy statement endorsing the use of point-of-care ultrasound (POCUS) by pediatric emergency medicine (PEM) providers. This statement specifically recommends that emergency departments have a credentialing and quality assurance (QA) program for POCUS. There is limited knowledge of how QA for POCUS is currently carried out in pediatric emergency departments with PEM training programs.

Methods

We sent a cross-sectional web-based survey to all 81 PEM fellowship-training programs in the United States and Canada between June 2016 and June 2017.

Results

Sixty-six of 81 programs (81.2%) responded. Sixty-five percent of responding PEM training programs had POCUS-trained faculty or a POCUS champion at their institution. Forty-six percent had a POCUS fellowship in their institution, with 10 programs having PEM-specific POCUS fellowships. Programs with POCUS fellowships were more likely to save all images, review all scans, review scans more frequently, provide feedback, and bill compared with programs without POCUS fellowships.

Conclusions

Point-of-care ultrasound is growing in PEM fellowship-training programs, with a majority of programs now having faculty members trained or interested specifically in POCUS. Most programs prefer more frequent and thorough QA processes, and programs with POCUS fellowships are more likely to have more frequent and thorough QA processes.
Association Between Insurance and the Transfer of Children With Mental Health Emergencies
Authors: Kissee Jamie L. , Huang Yunru , Dayal Parul , Yellowlees Peter , Sigal Ilana , Marcin James P.
Published: July 2019

Objectives

This study sought to investigate the association between a patient's insurance coverage and a hospital's decision to admit or transfer pediatric patients presenting to the emergency department (ED) with a mental health disorder.

Methods

This is a cross-sectional study of pediatric mental health ED admission and transfer events using the Healthcare Cost and Utilization Project 2014 Nationwide Emergency Department Sample. Children presenting to an ED with a primary mental health disorder who were either admitted locally or transferred to another hospital were included. Multivariable logistic regression models were used to adjust for confounders.

Results

Nineteem thousand eighty-one acute mental health ED events among children were included in the analyses. The odds of transfer relative to admission were higher for children without insurance (odds ratio, 3.30; 95% confidence interval, 1.73–6.31) compared with patients with private insurance. The odds of transfer were similar for children with Medicaid compared with children with private insurance (odds ratio, 1.23; 95% confidence interval, 0.80–1.88). Transfer rates also varied across mental health diagnostic categories. Patients without insurance had higher odds of transfer compared with those with private insurance when they presented with depressive disorder, bipolar disorder, attention-deficit/conduct disorders, and schizophrenia.

Conclusions

Children presenting to an ED with a mental health emergency who do not have insurance are more likely to be transferred to another hospital than to be admitted and treated locally compared with those with private insurance. Future studies are needed to determine factors that may protect patients without insurance from disparities in access to care.
Back to the Future
Authors: Pieper Claus Christian , Hur Saebeom , Sommer Christof-Matthias , Nadolski Gregory , Maleux Geert , Kim Jinoo , Itkin Maxim
Published: July 2019

Lipiodol is an iodinated poppy seed oil first synthesized in 1901. Originally developed for therapeutic purposes, it has mainly become a diagnostic contrast medium since the 1920s. At the end of the 20th century, Lipiodol underwent a transition back to a therapeutic agent, as exemplified by its increasing use in lymphangiography and lymphatic interventions. Nowadays, indications for lymphangiography include chylothorax, chylous ascites, chyluria, and peripheral lymphatic fistula or lymphoceles. In these indications, Lipiodol alone has a therapeutic effect with clinical success in 51% to 100% of cases. The 2 main access sites to the lymphatic system for lymphangiography are cannulation of lymphatic vessels in the foot (transpedal) and direct puncture of (mainly inguinal) lymph nodes (transnodal). In case of failure of lymphangiography alone to occlude the leaking lymphatic vessel as well as in indications such as protein-losing enteropathy, postoperative hepatic lymphorrhea, or plastic bronchitis, lymphatic vessels can also be embolized directly by injecting a mixture of Lipiodol and surgical glues (most commonly in thoracic duct embolization). The aim of this article is to review the historical role of Lipiodol and the evolution of its clinical application in lymphangiography over time until the current state-of-the-art lymphatic imaging techniques and interventions.
Incidental Detection of Ovarian Thecoma by 99mTc-MDP Whole-Body Bone Scan
Authors: Zhang Linqi , He Qiao , Zhou Tao , Zhang Rusen
Published: July 2019

Ovarian thecoma is a benign and rare neoplasm that accounts for 0.5% to 1% of all ovarian tumors. A 55-year-old woman with known breast cancer underwent a metastatic workup before surgery. The 99mTc-MDP whole-body bone scan revealed intense uptake in the left pelvic region. Hybrid SPECT/CT imaging showed that the elevated 99mTc-MDP activity was in a tumor with calcification in the left adnexa. Dynamic enhanced MRI revealed marked enhancement of the tumor. Resection of the tumor was subsequently performed, and pathologic analysis confirmed the diagnosis of an ovarian thecoma.
Integration of 68Ga-PSMA-PET/CT in Radiotherapy Planning for Prostate Cancer Patients
Authors: Onal Cem , Torun Nese , Akyol Fadil , Guler Ozan Cem , Hurmuz Pervin , Yildirim Berna Akkus , Cağlar Meltem , Reyhan Mehmet , Ozyigit Gokhan
Published: July 2019

Purpose

To assess the role of 68Gallium-labeled-prostate-specific membrane antigen PET/CT (68Ga-PSMA-PET/CT) in risk group definition and radiotherapy planning in the initially planned definitive radiotherapy (RT) for prostate cancer patients.

Methods

The clinical data of 191 prostate cancer patients treated with definitive intensity-modulated RT were retrospectively analyzed. All patients were initially staged with thoracoabdominal CT and bone scintigraphy, and the second staging was performed using 68Ga-PSMA-PET/CT. Both stages were evaluated for the decision making of RT and any change in RT target volumes.

Results

After staging with 68Ga-PSMA-PET/CT, 26 patients (13.6%) had risk group changes, 16 patients (8.4%) had an increase in risk group, and 10 patients (5.2%) had a decrease in risk group. Down-staging occurred in 22 patients (11.5%), and upstaging was observed in 30 patients (15.7%). A total of 26 patients (13.6%) had nodal stage changes. After the 68Ga-PSMA-PET/CT scans, the number of metastatic patient increased to 17 (8.9%), with 4 of them moving from oligo- to polymetastatic disease. An additional irradiation of pelvic lymphatics and metastatic site was performed in 13 patients (6.8%) and 6 patients (3.2%), respectively. The RT was aborted in 4 patients (2.1%) because of parenchymal or distant site metastasis observed in the 68Ga-PSMA-PET/CT.

Conclusions

We found that 68Ga-PSMA-PET/CT causes considerable migration in stage, risk group, and RT field arrangements, especially in high-risk patients regardless of the GS and baseline prostate-specific antigen values alone. 68Ga-PSMA-PET/CT seems to have a great influence on RT decision making in prostate cancer patients.
Focal Immunotherapy-Induced Pancreatitis Mimicking Metastasis on FDG PET/CT
Authors: Das Jeeban Paul , Halpenny Darragh , Do Richard K. , Ulaner Gary A.
Published: July 2019

A 46-year-old man with metastatic lung adenocarcinoma was treated with pembrolizumab. FDG PET/CT was performed after 3 cycles of treatment and revealed a focal region of pancreatic tail enlargement with an SUVmax value of 7. Following treatment with corticosteroids and discontinuation of pembrolizumab, radiological resolution was observed, and a diagnosis of focal immunotherapy-induced pancreatitis was made. A unique spectrum of FDG-avid adverse events can develop in patients treated with immune-checkpoint inhibitors that may mimic metastatic disease. Knowledge of the radiologic features of these potential imaging pitfalls is crucial among those interpreting FDG PET/CT to allow prompt and decisive treatment.
Thymic Tuberculosis Shown on FDG PET/CT Despite Coexisting Pulmonary Tuberculosis With No Increased FDG Activity
Authors: Li Hongyan , Long Yu , Shao Fuqiang , Lan Xiaoli
Published: July 2019

Extrapulmonary tuberculosis could involve multiple organs. However, thymic tuberculosis is relatively rare. We report a 21-year-old man who was referred for an 18F-FDG PET/CT imaging to assess his newly detected pulmonary nodule. The images showed the pulmonary nodule had minimal activity uptake. Unexpectedly, the thymus with elevated FDG accumulation was noted. The pulmonary nodule and thymic lesion were confirmed as tuberculosis by pathology.
Recovery of Renal Function Under PSMA Mediated Radioligand Therapy of Advanced Metastasized Castration Resistant Prostate Cancer
Authors: Ries Martin , Khreish Fadi , Berchem Guy , Ezziddin Samer
Published: July 2019

Radioligand therapy targeting prostate specific membrane antigen (PSMA-RLT) is becoming increasingly important in palliative care of metastasized castration resistant prostate cancer (mCRPC) as a highly effective and low toxicity therapy option. In addition to its overexpression in prostate cancer cells, PSMA is also physiologically expressed in the kidneys which is raising concerns over dose related nephrotoxicity of PSMA-RLT. We describe potential positive short-term effects of PSMA-RLT on renal function with marked recovery of a pretreatment compromised kidney.
FDG PET/CT of Mediastinal Epithelioid Hemangioendothelioma
Authors: Hod Nir , Anconina Reut , Levin Daniel , Delgado Bertha , Dudnik Julia , Lantsberg Sophie
Published: July 2019

Epithelioid hemangioendothelioma is a rare low- to intermediate-grade malignant vascular neoplasm with a variable clinical course and currently no standardized treatment. We present a case of a 65-year-old woman diagnosed as having mediastinal epithelioid hemangioendothelioma, a location which is very exceptional. FDG PET/CT was more sensitive than CT for staging, revealing intense FDG uptake in the primary tumor and in the metastatic disease. Despite high FDG uptake, the disease was stable with no further specific treatment. Only few reports utilizing FDG PET/CT are available; review of the literature on this subject is included.
The Mandibular Ramus: An Alternative Donor Site for Secondary Alveolar Bone Grafting in Clefts of the Alveolus
Authors: Blatter Jeannine , May Laurence , De Buys Roessingh Anthony , Medinger Laurent , Broome Martin
Published: July 2019

The authors describe the use of the mandibular ramus as an autologous bone graft material for secondary alveolar bone grafting in cleft patients. This technique represents a safe and effective alternative to currently used donor sites. Furthermore, it allows to minimize patient discomfort, so that they can be treated as outpatients.
Metabolic Systems Analysis of Shock-Induced Endotheliopathy (SHINE) in Trauma
Authors: Henriksen Hanne H. , McGarrity Sarah , SigurÐardóttir Rósa S. , Nemkov Travis , D’Alessandro Angelo , Palsson Bernhard O. , Stensballe Jakob , Wade Charles E. , Rolfsson Óttar , Johansson Pär I.
Published: July 2019

Objective:

Investigate the endothelial cell phenotype (s) that causes Shock-Induced Endotheliopathy in trauma.

Background:

We have studied more than 2750 trauma patients and identified that patients with high circulating syndecan-1 (endothelial glycocalyx damage marker) in plasma have an increased mortality rate compared with patients with lower levels. Notably, we found that patients suffering from the same trauma severity could develop significantly different degrees of endothelial dysfunction as measured by syndecan-1.

Methods:

Prospective observational study of 20 trauma patients admitted to a Level 1 Trauma Centre and 20 healthy controls. Admission plasma syndecan-1 level and mass spectrometry were measured and analyzed by computational network analysis of our genome-scale metabolic model of the microvascular endothelial cell function.

Results:

Trauma patients had a significantly different endothelial metabolic profile compared with controls. Among the patients, 4 phenotypes were identified. Three phenotypes were independent of syndecan-1 levels. We developed genome-scale metabolic models representative of the observed phenotypes. Within these phenotypes, we observed differences in the cell fluxes from glucose and palmitate to produce Acetyl-CoA, and secretion of heparan sulfate proteoglycan (component of syndecan-1).

Conclusions:

We confirm that trauma patients have a significantly different metabolic profile compared with controls. A minimum of 4 shock-induced endotheliopathy phenotypes were identified, which were independent of syndecan-1level (except 1 phenotype) verifying that the endothelial response to trauma is heterogeneous and most likely driven by a genetic component. Moreover, we introduced a new research tool in trauma by using metabolic systems biology, laying the foundation for personalized medicine.
Trends of Burn Injury in the United States
Authors: Crowe Christopher S. , Massenburg Benjamin B. , Morrison Shane D. , Naghavi Mohsen , Pham Tam N. , Gibran Nicole S.
Published: July 2019

Objective:

The aim of this study is to report patterns of burn injury within the United States from 1990 to 2016 with regard to age, sex, geography, and year.

Summary Background Data:

Advances in the management of burn injuries as well as successful public health efforts have contributed to reductions in the annual incidence and mortality of burns. However, several studies suggest that these reductions are not equally distributed throughout the US population.

Main Outcomes and Measures:

The Global Burden of Disease Study 2016 was utilized to collect incidence, mortality, disability-adjusted life years (DALYs), and years lived with disability (YLD) from 1990 to 2016. All measures were computed with 95% uncertainty intervals (UI).

Results:

The overall incidence of burn injury in the United States has decreased from 215 (95% UI, 183–246) to 140 (95% UI, 117–161) per 100,000. However, the relative mortality of burn injury has been fixed over the 26-year study period. Alaska had the highest rates of burn incidence in 1990 and 2016, closely followed by southeastern states. When adjusted for incidence, relative mortality in 1990 was highest in Alabama and Mississippi and the mortality–incidence ratio increased for these states in 2016. In addition, 35 states also demonstrated an increase in the relative mortality of burn injury during the study period.

Conclusions:

Regional trends of burn incidence and mortality are highly variable and are likely due to a multitude of factors. Addressing these disparities will require close examination of the contributing factors of burn injury and severity.
Desensitization in the Era of Precision Medicine: Moving From the Bench to Bedside
Authors: Habal Marlena V , Farr Maryjane , Restaino Susan , Chong Anita
Published: July 2019

Patients with antibodies to HLA wait longer for transplant and are at increased risk of adverse outcomes. For more than a decade, drug therapy approaches have been tested to modulate the immune system to prevent or reduce donor-specific antibody levels. Despite some studies reporting success in facilitating transplant, many patients do not respond or experience donor-specific antibody rebound, highlighting the diversity of the individual patient’s immune response. While advances in immunomodulatory therapies have resulted in escalating efforts to successfully treat highly sensitized patients, further insight into the human immune system has uncovered its enormous complexity and diversity calling for a personalized approach. Yet, even defining the sensitized transplant candidate can be troublesome and much remains to be understood about the interaction between an individual’s immune system as a whole and their response to our current desensitization strategies. The shift toward a personalized approach calls for a reevaluation of what we know and what remains to be determined; a process that will require iterative translational approaches. This review will focus on new insights into how the interaction between immune risk assessment, the patient’s immunological history, and the clinical context can be reconciled to develop a precision-based approach to pretransplant management.