bluuebunny/crossref_metadata_2025 huggingface dataset:
Resident Education in Complex Obstetric Procedures: Are We Adequately Preparing Tomorrow's Obstetricians?
Authors: Dotters-Katz Sarah , Gray Beverly , Heine R. Phillip , Propst Katie
Published: October 2019

PURPOSE:

Describe resident experience with surgical obstetrics and comfort in performing those procedures after graduation.

BACKGROUND:

ACGME milestones and CREOG objectives for OB/GYN residents include obstetrical technical skills. Data is limited on how often graduating residents meet these.

METHODS:

Anonymous 27-question e-survey sent to all US OB/GYN residents in 3/2018 via CREOG coordinator-listserv. Complex obstetric procedures included: forceps (FAVD), vacuum (VAVD), cerclage, breech second twin (B2T), breech delivery (BVD), perineal repairs, and cesarean hysterectomy. Technical skills questions included experience as primary surgeon (PS), comfort performing procedures independently (CPI), and for 4th year residents only-comfort performing procedures post-residency (CPPR). Descriptive statistics used to analyze responses.

RESULTS:

417 residents completed the survey. Respondents were 88% female, 75% from academic programs, and nearly 50% were post-graduate year (PGY) 3&4.

Among residents of all levels, many had been primary surgeon in operative vaginal deliveries (51%-FAVD,72%-VAVD) and cerclage (62%), fewer for BVD (21%) and B2T (34%), cesarean hysterectomy (21%), and 4th degree repairs (37%). For PGY 3&4, 85% were CPI VAVD, while only 34% were CPI FAVD. 14% and 37% were CPI BVD and 4th degree repairs respectively. Of the 95 PGY4 respondents, all felt CPPR either VAVD or FAVD. Nearly all felt CPPR a 3rd degree repair (97%), but almost 20% did not feel CPPR a 4th degree repair. 33% did not feel CPPR a cesarean hysterectomy, 28% and 74% did not feel CPPR with B2T and BVD respectively.

DISCUSSION:

Though ACGME and CREOG recommend that graduating residents are able to perform complex obstetric procedures, data suggest that for many graduating chief residents, this is not the case.
A Multimodality Imaging Evaluation of Unilateral Breast Edema: It's Not Just Cancer
Authors: Rambhia Suraj H. , Riviello Peter , McElligott Suzanne E. , Gupta Ekta
Published: October 2019

This article presents a review of the differential diagnosis and pathophysiology of benign and malignant, unilateral breast edema, including mammary, nonmammary, and systemic causes. Abnormal imaging findings related to unilateral breast edema have been described using multiple imaging modalities and a case-based approach. Accurate diagnosis of unilateral breast edema involves assessment of the clinical history, physical examination, and imaging studies.
Providing Veterans With Innovative Nursing Educational Opportunities
Authors: Wittmann-Price Ruth , Orrico Suzan , Brogdon Rhonda , Morgan Robyn D.
Published: October 2019

This funded project assisted veteran students to obtain a baccalaureate in nursing by aligning the skills learned through military training with concepts and skills valued by professional nursing and taught to nursing students. Nine concepts or skills were identified by nursing faculty that validated for course credit. The identified concepts and skills were incorporated into four simulation scenarios. Veteran students’ skills were validated through simulation experiences in place of taking a three-credit nursing course. Anecdotal data from the debriefing process were rich with students’ experiences and gratitude for being recognized for their military knowledge and service.
The admiral is a lady
Authors: Beach Patricia Ringos , White Beth E.
Published: October 2019

Promoted by President Nixon in 1972, Admiral Alene Duerk (1920-2018) was the first female admiral to serve in any navy in the world. This article highlights her accomplishments as a nurse and a military leader.
Outcomes Associated With Insertion of Indwelling Urinary Catheters by Medical Students in the Operating Room Following Implementation of a Simulation-Based Curriculum
Authors: Barnum Trevor , Tatebe Leah C. , Halverson Amy L. , Helenowski Irene B. , Yang Anthony D. , Odell David D.
Published: October 2019

Purpose

Catheter-associated urinary tract infection (CAUTI) is a priority quality metric for hospitals. The impact of placement of indwelling urinary catheter (IUC) by medical students on CAUTI rates is not well known. This study examined the impact of a simulation-based medical student education curriculum on CAUTI rates at an academic medical center.

Method

Patient characteristics, procedural data, and outcome data from all operating room IUC insertions from June 2011 through December 2016 at the Northwestern University Feinberg School of Medicine were analyzed using a multivariable model to evaluate associations between CAUTI and inserting provider. Infection data before and after implementation of a simulation-based IUC competency course for medical students were compared.

Results

A total of 57,328 IUC insertions were recorded during the study period. Medical students inserted 12.6% (7,239) of IUCs. Medical students had the lowest overall rate of CAUTI among all providers during the study period (medical students: 0.05%, resident/fellows: 0.2%, attending physicians: 0.3%, advanced practice clinicians: 0.1%, nurses: 0.2%; P = .003). Further, medical student IUC placement was not associated with increased odds of CAUTI in multivariable analysis (odds ratio, 0.411; 95% confidence interval: 0.122, 1.382; P = .15). Implementation of a simulation-based curriculum for IUC insertion resulted in complete elimination of CAUTI in patients catheterized by medical students (0 in 3,471).

Conclusions

IUC insertion can be safely performed by medical students in the operating room. Simulation-based skills curricula for medical students can be effectively implemented and achieve clinically relevant improvements in patient outcomes.
Sexual Abuse and Future Mental Health Hospitalization in a Swedish National Sample of Men Who Use Opioids
Authors: Blom Nilsson Marcus , Padyab Mojgan , McCarty Dennis , Lundgren Lena
Published: October 2019

Objective:

Experiences of trauma, specifically sexual abuse, have been linked to both mental health and substance use disorders. This study used 14 years of Swedish health registry data to select a sample of adult men who reported frequent opioid use and assessed if those with a self-reported history of sexual abuse had a higher likelihood of hospitalization for a mental health disorder.

Methods:

A Swedish longitudinal (2003–2017) registry study linked Addiction Severity Index (ASI) assessments completed with individuals who sought treatment for substance use disorders with data on hospitalizations for mental health disorders, and assessed associations with self-reported histories of sexual abuse among men who reported sustained and frequent use of opioids (n = 1862). Cox regression methods tested associations and controlled for age, and the 7 ASI composite scores: family and social relationships, employment, alcohol use, drug use, legal, physical health, and mental health.

Results:

The ASI composite score for mental health (hazard ratio [HR] 16.6,P < 0.001) and a history of sexual abuse (HR 1.93,P < 0.001) were associated with an elevated risk of future mental health hospitalization.

Conclusion:

Both the ASI composite scores for mental health and self-reported history of sexual abuse reflected complex needs among men who used opioids and increased risk for mental health hospitalization. Treatment providers should strive to provide integrated care and address the negative aspects of victimization.
Comparing Reasons for Starting and Stopping Methadone, Buprenorphine, and Naltrexone Treatment Among a Sample of White Individuals With Opioid Use Disorder
Authors: Randall-Kosich Olivia , Andraka-Christou Barbara , Totaram Rachel , Alamo Jessica , Nadig Mayur
Published: October 2019

Objectives:

Despite their efficacy, medications for opioid use disorder (MOUD) are underutilized in the United States. Nonetheless, few studies have explored reasons why individuals choose to start MOUD or discontinue MOUD after starting, especially extended-release naltrexone. We sought to identify reasons why individuals start and stop MOUD, including the differences between starting and stopping the 3 most common formulations: methadone, sublingual buprenorphine, and extended-release naltrexone.

Methods:

We conducted 31 semistructured interviews over the phone with a sample of white individuals with a history of MOUD utilization. Participants were recruited using snowball sampling from 8 US states. Interviews were audio-recorded, transcribed, coded in Dedoose software, and analyzed using thematic analysis and modified event structure analysis.

Results:

Participants primarily learned about methadone and buprenorphine from other individuals with OUD. Participants primarily became interested in starting buprenorphine and methadone after seeing the medications work effectively in peers, though methadone was perceived as a last resort. In contrast, participants primarily learned about and became interested in naltrexone after receiving information from health practitioners. Participants frequently stopped MOUD to prevent medication or health service dependence. Participants also felt stigma and external pressure to stop buprenorphine and methadone, but not naltrexone. Some participants identified relapse and medication termination by health providers or the criminal justice system as reasons for stopping MOUD.

Conclusions:

Given the frequency with which participants identified informal peer education as a reason for starting methadone and buprenorphine, peers with MOUD experience may be a trusted source of information for individuals seeking OUD treatment. Further research is needed to assess whether incorporating peer support specialists with MOUD experience into formal SUD treatment would expand MOUD utilization, retain patients in treatment, and/or improve OUD treatment outcomes.
Current status of functional MRI of osteoarthritis for diagnosis and prognosis
Authors: Juras Vladimir , Chang Gregory , Regatte Ravinder R.
Published: October 2019

Purpose of review

Osteoarthritis is a major source of disability, pain and socioeconomic cost worldwide. The epidemiology of the disorder is multifactorial including genetic, biological and biomechanical components, some of them detectable by MRI. This review provides the most recent update on MRI biomarkers which can provide functional information of the joint structures for diagnosis, prognosis and treatment response monitoring in osteoarthritis trials.

Recent findings

Compositional or functional MRI can provide clinicians with valuable information on glycosaminoglycan content (chemical exchange saturation transfer, sodium MRI, T1ρ) and collagen organization (T2, T2
∗, apparent diffusion coefficient, magnetization transfer) in joint structures. Other parameters may also provide useful information, such as volumetric measurements of joint structures or advanced image data postprocessing and analysis. Automated tools seem to have a great potential to be included in these efforts providing standardization and acceleration of the image data analysis process.

Functional or compositional MRI has great potential to provide noninvasive imaging biomarkers for osteoarthritis. Osteoarthritis as a whole joint condition needs to be diagnosed in early stages to facilitate selection of patients into clinical trials and/or to measure treatment effectiveness. Advanced evaluation including machine learning, neural networks and multidimensional data analysis allow for wall-to-wall understanding of parameter interactions and their role in clinical evaluation of osteoarthritis.
Percutaneous Strain Reduction Screws—A Safe and Simple Surgical Option for Problems With Bony Union. A Technical Trick
Authors: Kothari Alpesh , Monk Paul , Handley Robert
Published: October 2019

This article describes percutaneous strain reduction screws, a technical trick, to provide effective stability in a simple manner and at low cost. Percutaneous strain reduction screws are an option when a surgeon has decided that further intervention is indicated for a fracture that has not united.
Short Versus Long InterTAN Fixation for Geriatric Intertrochanteric Hip Fractures: A Multicentre Head-to-Head Comparison
Authors: Sellan Michael , Bryant Dianne , Tieszer Christina , Papp Steven , Lawendy Abdel , Liew Allan , Viskontas Darius , MacLeod Mark , Coles Chad , Carey Tim , Gofton Wade , Trenholm Andrew , Stone Trevor , Leighton Ross , Sanders David
Published: October 2019

Objective:

To determine if geriatric intertrochanteric hip fracture patients achieve equivalent postoperative functional status after management with either a short (180-200 mm) or a long (260-460 mm) InterTAN intramedullary device.

Design:

Retrospective review of a prospective randomized control trial.

Setting:

Four Level I Trauma Centers.

Patients/Participants:

One hundred eight patients with OTA/AO classification 31A-1 and 31A-2 intertrochanteric hip fractures were included in the study.

Intervention:

Internal fixation using an IT device.

Main Outcomes Measures:

Primary outcomes included Functional Independence Measure and Timed Up and Go. Secondary outcomes included blood loss, surgical time, length of stay, adverse events, and mortality.

Results:

Seventy-one short and 37 long IT patients met study inclusion criteria. Demographics were similar between groups. There was no difference in Functional Independence Measure or Timed Up and Go scores between the 2 IT groups at any of the time points collected. Mean operative time was lower in the short IT group than in the long IT group (60 vs. 73 minutes; P = 0.021). A higher proportion of long IT patients had reamed constructs (95% vs. 48% short IT, P < 0.001). Postoperative blood loss was significantly higher in the long IT group without a significant influence on the number of patients requiring transfusion (P = 0.582) or average units transfused (P = 0.982). There was no significant difference in the proportion of postoperative adverse events between the 2 cohorts despite a higher number of peri-implant femur fractures in the short IT group than in the long IT group (5 vs. 1, P = 0.350).

Conclusions:

Postoperative functional status was not influenced by the length of IT device in the management of geriatric intertrochanteric hip fractures.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Restoring Condylar Width: Radiographic Relationship Between the Lateral Tibial Plateau and Lateral Femoral Condyle in Normal Adult Knees
Authors: Kabirian Nima , Jiang Daniel , Fleming CAPT Mark E. , Marecek Geoffrey S.
Published: October 2019

Objectives:

We hypothesized that a constant radiographic relationship exists between the lateral tibial and femoral condyles and that no side-to-side variation exists.

Methods:

We reviewed anteroposterior x-rays of 217 uninjured adults ages 18–65, Included 109 unilateral and 108 bilateral radiographs with no or minimal osteoarthrosis (Kellgren–Lawrence grades 0–1). The perpendicular distance between the lateral-most margins of the tibial plateau articular surface (A) and the lateral femoral epicondyle (B) and the lateral femoral condyle articular surface (C) was measured in millimeters (mm). Medial and lateral measurements to point (A) were recorded as (−) and (+), respectively. First, the average of measured distances in all unilateral knees and randomly selected either right or left knees from the bilateral group (n = 217) was calculated. Comparison was made between both sexes. Next, A–B and A–C distances were compared between right and left knees in the bilateral group (n = 108) to find any significant difference (2-tailed t test, alpha = 0.05).

Results:

The average A–B distance was 0.60 ± 2.40 mm (−4.82 to +6.49 mm). The mean A–C distance was −3.96 ± 2.07 mm (−8.51 to +3.98 mm). No significant difference was found between A–B and A–C distances between males (0.40 ± 2.62 mm and −3.91 ± 2.05 mm) and females (0.70 ± 2.28 mm and −3.99 ± 2.09 mm). Similarly, no significant difference was found between A–B and A–C distances between right (1.08 ± 2.31 mm and −3.90 ± 1.73 mm) and left knees (0.90 ± 2.38 mm and −4.31 ± 1.7 mm). Concordance coefficient for interobserver and intraobserver reliability showed substantial agreement.

Conclusion:

In conclusion, this study provided a “normal” range for the relationship of the proximal lateral tibial plateau relative to the lateral femoral condyle. The lateral femoral epicondyle is generally aligned with the lateral tibial articular margin. The relationship between the lateral tibial plateau, lateral femoral epicondylar surface, and lateral femoral articular surface is constant from side to side. This technique is reproducible in the setting of fracture, and templating off of the contralateral uninjured knee may be beneficial in tibial plateau fracture surgery.
Outcomes of Expandable Prostheses for Primary Bone Malignancies in Skeletally Immature Patients: A Systematic Review and Pooled Data Analysis
Authors: Portney Daniel A. , Bi Andrew S. , Christian Robert A. , Butler Bennet A. , Peabody Terrance D.
Published: October 2019

Background:

Osteosarcoma and other primary bone malignancies are relatively common in skeletally immature patients. Current literature features case series with disparate complication rates, making it difficult for surgeons to educate patients on outcomes after limb salvage with expandable prostheses. This study aims to provide an update on complication rates, mortality, and functional outcomes in patients who undergo limb salvage with expandable prostheses for primary bone malignancies.

Methods:

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An exhaustive PubMed/Medline and Cochrane search of peer-reviewed published literature from 1997 to 2017 was performed, yielding a total of 1350 studies. After multiple rounds of review for inclusion and exclusion criteria, 28 retrospective studies were included. All were level IV evidence of case series and retrospective studies. Overall, this included 634 total patients and 292 patients with individual patient data. The primary outcomes studied were complication rates, mortality, and Musculoskeletal Tumor Society (MSTS) functional score. Secondary outcomes included complication rate subtypes, number of lengthening procedures, mean amount lengthened, and prevalence of limb length discrepancies.

Results:

A total of 292 patients with individual patient data averaged 10.1 years at the surgery and had a mean follow-up of 67 months. Two hundred sixteen patients (74%) had tumors of the distal femur. MSTS scores averaged 80.3 and overall mortality was 22%. Patients with distal femur tumors averaged 4.4 lengthening procedures and 43 mm lengthened. Leg length discrepancy (LLD) was 36% overall, which increased with longer periods of follow-up (P<0.001). Overall complication and revision rate was 43%, increasing to 59% in patients with 5 to 10 years of follow-up, and 89% in patients with >10 years of follow-up. Minimally invasive prostheses had lower rates of complications than noninvasive prostheses (P=0.024), specifically mechanical complications (P=0.028), mostly because of increased rates of lengthening and device failure in the noninvasive models (21% vs. 4%, P=0.0004).

Conclusions:

Despite its limitations, which include entirely heterogenous and retrospective case series data, this systematic review provides clinicians with pooled summary data representing the largest summary of outcomes after reconstruction with expandable prostheses to date. This analysis can assist surgeons to better understand and educate their patients and their families on functional outcomes, mortality, and complication rates after limb-sparing reconstruction with expandable prostheses for primary bone malignancies.

Level of Evidence:

Level IV—retrospective case series with pooled data.
Anterior Cervical Debridement and Fusion for Cervical Pyogenic Spondylodiscitis
Authors: Kim Sung-Kyu , Park Jong-Beom , Chung Jae-Yoon , Lee Dong-Ho , Kim Young-Yul , Park Yong-Jin , Lee Nam-Hun
Published: October 2019

Study Design.

Retrospective multicenter case series.

Objective.

We sought to evaluate the safety and efficacy of anterior cervical plating in anterior cervical debridement and fusion (ACDF) for patients with cervical pyogenic spondylodiscitis (CPS).

Summary of Background Data.

Due to concerns about bacterial seeding on the foreign material after instrumentations in pyogenic infections, the safety and efficacy of anterior cervical plating for CPS are still undetermined and controversial. Little information is available about the safety and efficacy of anterior cervical plating to manage CPS.

Methods.

Twenty-three patients who underwent ACDF with (n = 12) or without (n = 11) plating for CPS were included. The mean age was 62.6 years. Medical records were reviewed and radiological parameters including segmental height, segmental angle, C2–C7 angle, and fusion status were analyzed. The mean follow-up period after surgery was 21.3 months.

Results.

After ACDF with plating, segmental height, segmental angle, and C2–C7 angle were significantly improved compared with preoperative conditions and remained well-maintained at the last follow-up. After ACDF without plating, three radiological parameters were also initially improved compared with preoperative condition, but significantly deteriorated to preoperative levels at the time of the last follow-up. The fusion rate was higher in the ACDF with plating group compared with the ACDF without plating group (90.9% vs. 63.6%; P < 0.01). One patient who received ACDF with plating and four patients who received ACDF without plating underwent revision surgery due to nonunion or bone graft dislodgement. No recurrence of pyogenic spondylodiscitis occurred in either group.

Conclusion.

ACDF with plating showed better surgical outcomes compared with ACDF without plating for CPS. We recommend the use of anterior cervical plating, which can provide biomechanical stability, for better healing of CPS. To our knowledge, this is the largest surgical case series of CPS.

Level of Evidence: 4
Survival Outcomes After Adding Stereotactic Body Radiotherapy to Metastatic Renal Cell Carcinoma Patients Treated With Tyrosine Kinase Inhibitors
Authors: He Liru , Liu Yang , Han Hui , Liu Zhuowei , Huang Sijuan , Cao Wufei , Liu Boji , Qin Zike , Guo Shengjie , Zhang Zhiling , Lin Maosheng , Jiang Xiaobo , Lin Chengguang , Li Yonghong , Yao Kai , Dong Pei , Zhou Fangjian
Published: October 2019

Objective:

Long-lasting control is rarely achieved with tyrosine kinase inhibitors (TKI) alone in metastatic renal cell carcinoma (mRCC). Our study aimed to investigate the survival outcomes of adding stereotactic body radiotherapy (SBRT) to TKI in mRCC.

Materials and Methods:

From September 2015 to September 2018, 56 patients treated with TKI received SBRT for 103 unresectable lesions. A total of 24 and 32 patients were irradiated before and after TKI failure, respectively. Overall survival (OS) was calculated from metastases. Progression-free survival (PFS) was calculated from SBRT.

Results:

Overall, 10, 32, and 12 patients had International Metastatic Renal CellCarcinomaDatabase Consortium favorable, intermediate, and poor risk. Median follow-up was 21.7 months (range, 5.1 to 110.6 mo). Median OS was 61.2 months. The median PFS was 11.5 months, while the 2-year LC rate was 94%. Sixteen (34%) lesions achieved complete response (CR) in patients irradiated before TKI failure, whereas only 4 (7%) lesions yielded CR in those irradiated after TKI failure (P=0.001). The median PFS in CR group was significantly longer than that of non-CR group (18.9 vs. 7.1 mo;P=0.003). The 5-year OS in CR group was 86%, compared with 48% in non-CR group (P=0.010). Four (7%) patients experienced Grade 3 toxicity.

Conclusions:

Adding SBRT to TKI is safe and seems to improve survival in mRCC. Patients irradiated before TKI failure have higher CR rate, and the favorable local response might turn into survival benefit.
Women Are at Higher Risk for Concussions Due to Ball or Equipment Contact in Soccer and Lacrosse
Authors: Ling Daphne I. , Cheng Jennifer , Santiago Kristen , Ammerman Brittany , Jivanelli Bridget , Hannafin Jo , Casey Ellen
Published: October 2019

Background

There is ample evidence to suggest sex- and gender-based differences in the incidence of sports-related concussions. The mechanisms of concussion may vary between male and female athletes and contribute to this observed difference. Understanding the underlying etiology by pooling data from primary studies across different settings and sport types will inform interventions that can reduce concussion rates.

Questions/purposes

Specifically, we asked: (1) In which sports are female athletes less likely to experience concussions from player contact? (2) In which sports are female athletes more likely to experience concussions because of ball or equipment contact?

Methods

PubMed, EMBASE, and Cochrane Library databases were searched to identify articles published from January 2000 to December 2018. Ten studies met the inclusion criteria, which were studies that reported concussion incidence by mechanism for both male and female athletes. Exclusion criteria included non-English studies, conference abstracts, and studies on non-sports related concussions. The sports represented by the 10 studies included ice hockey (n = 4), soccer (n = 5), basketball (n = 4), baseball/softball (n = 4), and lacrosse (n = 5). The rate ratio was calculated as the incidence rate in female athletes/male athletes for each concussion mechanism or activity. Data were pooled using the DerSimonian-Laird random-effects model. Study quality was assessed with the Newcastle-Ottawa Scale.

Results

Female athletes were at lower risk of player-contact-induced concussions in lacrosse (pooled rate ratio 0.33 [95% CI 0.25 to 0.43]; p < 0.001), basketball (pooled rate ratio 0.86 [95% CI 0.76 to 0.97]; p = 0.01), ice hockey (pooled rate ratio 0.64 [95% CI 0.56 to 0.73]; p < 0.001), soccer (pooled rate ratio 0.70 [95% CI 0.66 to 0.75]; p < 0.001), and soccer heading (pooled rate ratio 0.80 [95% CI 0.72 to 0.90]; p < 0.001); in these sports, men were at higher risk of concussions from player contact. Female athletes were more likely to experience concussions because of ball or equipment contact in lacrosse (pooled rate ratio 3.24 [95% CI 2.10 to 4.99]; p < 0.001), soccer (pooled rate ratio 2.04 [95% CI 1.67 to 2.49]; p < 0.001), and soccer heading (pooled rate ratio 2.63 [95% CI 1.84 to 3.77]; p < 0.001).

Conclusions

The mechanism or activity underlying concussions differs between male and female athletes across different sports. This finding remains the same regardless of whether there are rule differences between the men’s and women’s games. The implementation of other interventions are required to further ensure player safety, including protective head equipment, concussion prevention training, or rules limiting player contact in the men’s game.

Level of Evidence

Level III, retrospective study.
Nail Anatomy, Nail Psoriasis, and Nail Extensor Enthesitis Theory: What Is the Link?
Authors: Perrin Christophe
Published: October 2019

The concept of the nail unit as a musculoskeletal appendage has become popular in the dermatological and rheumatological literature. However, an exact knowledge of the characteristics of mesenchyme surrounding the nail such as the composition of the collagen and elastic fibers and their arrangement is fundamental before one can propose a constitutive model. To the best of my knowledge, there is no study in the literature concerning the elastic network of the ligamentous connective tissue of the base of the distal phalanx. This study by means of elastic stains demonstrates that the so-called superficial, deep, and lateral laminae of the extensor tendon correspond to 3 different microanatomic structures: the nail dermis and its fibrous root, the subcutaneous proximal nail fold, and the periosteum. The complex fascial and adipose connective tissue of the proximal nail fold surrounds the matrical dermis and could viewed as a kind of suspensory system for the proximal nail unit. Such suspensory system protects the nail matrix epithelium from the biomechanical strain of the extensor mechanism. Near the ulnar and radial edge of the base of the phalanx, focal interconnections between the fibrous root of the apex of the matrix and the periosteum through a fascia-like structure are visible. In its most lateral zone, the matrical horns lie on a thick dermis connected to the interosseous ligament. Such lateral laminar system serves as anchoring ropes for the vault of the nail plate. The nail–extensor enthesitis theory relies on an oversimplified anatomy because the nail unit is an epidermal appendage with a specialized connection with the lateral periosteum, but not a musculoskeletal appendage. Finally, I would like to emphasize, the practical importance of recognizing the matrical hypoderm. In nail surgery, the interface between the matrical nail dermis and its submatrical loose connective tissue is potentially a new, relatively superficial, surgical cleaving plane, beside the classical deep surgical procedure usually extending to the periosteum. Recognition of this additional cleaving plane leads to an optimal nail tangential biopsy.
Identification and Management of Adolescent Depression in a Large Pediatric Care Network
Authors: Farley Alyssa M. , Gallop Robert J. , Brooks Elizabeth S. , Gerdes Marsha , Bush Morgan L. , Young Jami F.
Published: October 2019

Objective:

Primary care has been promoted as a setting to identify and manage adolescent depression. This study examined primary care–based adolescent depression identification and follow-up care when elevated symptoms were identified.

Methods:

Data came from a large pediatric care network with an organizational recommendation to screen for depression at age 16 well-visits using an electronic health record (EHR)-integrated standardized measure. Analyses examined rates of screening and elevated symptoms, pediatricians' initial responses to elevated scores, and types of follow-up care received over 1 year using retrospective EHR data extraction and manual chart reviews.

Results:

Across program sites, 76.3% (n = 6981) of patients attending their age 16 well-visits were screened. About one-quarter had an elevated score (6.7% mild and 19.2% moderate-to-severe), many of whom received active follow-up on their well-visit date. Over 1 year, three-fourths of patients with scores in the moderate-to-severe range and 40.0% of patients with scores in the mild range received follow-up care (e.g., antidepressant prescriptions) as per EHR extraction. Follow-up rates were higher as per manual chart reviews.

Conclusion:

Routine adolescent depression screening is feasible across diverse primary care sites. Most patients with elevated scores were not already receiving behavioral health services, suggesting screening identified previously undetected concerns. In turn, many adolescents with elevated scores initiated treatment after screening, which indicates providing screen results at the point of care may facilitate pediatrician actions. Still, gaps in follow-up care demonstrate the need for greater investment in primary care–based behavioral health services to support high-quality treatment and ultimately decrease the burden of adolescent depression.
Critical analysis of methods for assessing genitourinary syndrome of menopause used in clinical trials
Authors: Lima Sônia M.R.R. , Honorato Juliana V.
Published: October 2019

Objective:

The aim of the study was to determine the most used methods for assessing genitourinary syndrome of menopause by the latest studies on the subject, and to critically assess their differences and comparability.

Methods:

A narrative review of the literature was conducted, employing the terms genitourinary syndrome, vaginal atrophy, urogenital atrophy, and atrophic vaginitis, to analyze methods used to assess treatment efficacy. Only controlled randomized clinical trials assessing improvement of genitourinary syndrome of menopause, conducted in the last 5 years, and considering all types of treatment, were selected.

Results:

Of the 37 studies included, 24 combined both objective and subjective methods thereby ensuring reproducibility and efficacy of symptom relief of the treatment analyzed. The vaginal maturation index was the most used objective method, followed by vaginal pH. One study used histological and immunohistochemistry tests. Regarding subjective methods, the “Most bothering Symptom” and other questionnaires as the Female Sexual Function Index for sex life, the Verbal Rating Scale, among others, were used.

Conclusions:

Despite the heterogeneity observed, particularly for subjective assessment of symptoms, there was a tendency to standardize methods and to use an objective method together with a subjective, which seems to be fundamental to guarantee reproducibility and comparability of results of each treatment analyzed. Histological and immunohistochemistry tests may be an option as an objective method in further studies, to better assess thickness, vascularization, among other parameters.
Long-term impact of adolescent chronic pain on young adult educational, vocational, and social outcomes
Authors: Murray Caitlin B. , Groenewald Cornelius B. , de la Vega Rocio , Palermo Tonya M.
Published: October 2019

Despite evidence of broad impact on daily functioning in adolescence, little is known regarding the life course effects of childhood chronic pain. This is the first nationally representative study to characterize the disruptive impact of chronic pain in adolescence on key educational, vocational, and social outcomes in young adulthood (12 years later). Data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) were used, including 3174 youth with chronic pain and 11,610 without chronic pain. Multivariate regression analyses controlling for sociodemographic factors and adolescent depression found that chronic pain in adolescence was associated with long-term risk of a constellation of impairments indicative of socioeconomic disparities. Specifically, adolescent chronic pain was subsequently associated with reduced educational attainment (eg, lower odds of attaining a high school diploma and bachelor's degree), poor vocational functioning (eg, lower odds of receiving employer-provided benefits and higher odds of receiving public aid), and social impairments (eg, early parenthood, lower self-reported romantic relationship quality) in young adulthood. These findings provide a window into the future of adolescents with chronic pain, contributing to the limited knowledge base of the scope of adverse long-term outcomes during the transition to adulthood. However, several questions remain. Increased research attention is needed to understand the life course impact of pediatric chronic pain, including early risk factors and underlying mechanisms that drive adverse outcomes as they unfold across the lifespan.
Barriers and Solutions to the Inclusion of Broader Benefits in Biopharmaceutical Value Assessments
Authors: Wamble David , Ciarametaro Mike , Dubois Robert
Published: October 2019

Objective:

The aim of this was to evaluate how institutional barriers prevent the inclusion of broader individual and societal benefits associated with new health care innovations from being considered when assessing the value of medical treatments and making health care coverage determinations.

Methods:

A survey of health insurance providers, pharmacy benefit managers, employee benefit consultancies, and employer group representatives in the United States queried respondents’ opinions regarding the feasibility of evaluating indirect treatment benefits in four domains: absenteeism, presenteeism, caregiver burden, and quality of life.

Results:

Inclusion of indirect benefits (including absenteeism and presenteeism) in the assessment of a treatment's value was of low importance to payers, but higher importance to employer stakeholders.

Conclusions:

Therapies that improve physical or mental function accrue benefits both directly and indirectly and can only be adequately assessed if measurement standards for indirect benefits and quantifiable measures are established.
The Influence of preterm birth beyond infancy: Umbrella review of outcomes of adolescents and adults born preterm
Authors: Kelly Michelle M. , Griffith Patricia B.
Published: October 2019

Background and purpose:

In recent decades, increased neonatal survival has enabled research of long-term outcomes of those born preterm. The purpose of this article is to present the findings of an umbrella review, an examination of published systematic reviews and meta-analyses, to examine the outcomes of adolescents and adults born preterm.

Methods:

The research was guided by the Joanna Briggs Institute methodology for umbrella reviews. A systematic search of PubMed, CINAHL, and PsycINFO databases with the search years 2010 through September 2018 yielded 16 reviews for inclusion.

Conclusions:

The 16 reviews included in this umbrella review represent five clinical outcomes: neurodevelopmental (3 reviews), mental/behavioral health (5 reviews), cardiovascular (4 reviews), pulmonary (3 reviews), and life experience outcomes (4 reviews). One review included data for multiple clinical outcomes. This umbrella review highlights the adolescent and adult risks related to cognitive scores, executive function, anxiety, depression, attention-deficit hyperactivity disorder, long-term effects on systolic blood pressure, low-density lipoproteins and cholesterol levels, pulmonary symptoms, including asthma, pulmonary function, radiographic changes in the lungs, sports and leisure participation, and educational attainment and employment.

Implications for practice:

There is a preponderance of evidence that supports targeted screening for a history of preterm birth by all health care providers. This screening should facilitate the promotion of healthy lifestyles and improving psychosocial and neurodevelopmental difficulties through early and continued support services. Curricular and practice standards are advocated to support this change.
Quality of Life in Vestibular Schwannoma Patients: A Longitudinal Study
Authors: Miller Lauren E. , Brant Jason A. , Naples James G. , Bigelow Douglas C. , Lee John Y. K. , Ruckenstein Michael J.
Published: October 2019

Objective:

To examine differences in quality of life in patients with vestibular schwannoma following a single treatment modality: observation, stereotactic radiosurgery (SRS), or microsurgery.

Study design:

Retrospective review.

Setting:

Tertiary academic medical center.

Patients:

Patients diagnosed with sporadic vestibular schwannoma who had completed at least 2 Penn Acoustic Neuroma Quality of Life (PANQOL) surveys.

Interventions:

Treatment via SRS, microsurgery, or observation.

Main Outcome Measures:

PANQOL total survey and subdomain scores.

Results:

One hundred and thirty-four patients (94 observations, 24 SRS, 16 microsurgeries) were included. The mean number of PANQOL surveys completed was 2.8 (range 2–5). The total PANQOL scores were significantly lower in the SRS group, but not the microsurgery group, compared with observation at the time of diagnosis (observation 550.4 ± 58.4; SRS 471.4 ± 37.4; microsurgery 492.6 ± 40.7; p = 0.03). Over time, there were no significant differences in the change of PANQOL scores across the 3 groups (SRS PANQOL score worsened 6.8/year compared with observation, p = 0.3; microsurgery PANQOL score worsened 7.8/year compared with observation, p = 0.5). Anxiety was the only subdomain that significantly worsened over time in the microsurgery group (microsurgery PANQOL score worsened 3.8/year compared with observation; p = 0.009).

Conclusion:

Despite differences in PANQOL scores at baseline, changes in total PANQOL score over time were not found to be statistically significant, regardless of the treatment group chosen. Overall, these results hold implications for patient counseling when considering treatment choice and quality of life predictions.
The impact of comorbidities on severe asthma
Authors: Rogliani Paola , Sforza Maurizia , Calzetta Luigino
Published: October 2019

Purpose of review

Severe asthma is often associated with numerous comorbidities that complicate disease management and affect patient's outcomes. They contribute to poor disease control and mimic asthma symptoms. Although some comorbidities such as obstructive sleep apnea, bronchiectasis, and chronic obstructive pulmonary disease are generally well recognized, many other may remain undiagnosed but may be detected in an expert specialist setting. The management of comorbidities seems to improve asthma outcomes, and optimizes therapy by avoiding overtreatment. The present review provides recent knowledge regarding the most common comorbidities which are associated with severe asthma.

Recent findings

Comorbidities are more prevalent in severe asthma than in mild-to-moderate disease or in the general population. They can be grouped into two large domains: the pulmonary domain and the extrapulmonary domain. Pulmonary comorbidities include upper respiratory tract disorders (obstructive sleep apnea, allergic and nonallergic rhinitis, chronic rhinosinusitis, nasal polyposis) and middle/lower respiratory tract disorders (chronic obstructive pulmonary disease, allergic bronchopulmonary aspergillosis and fungal sensitization, bronchiectasis, dysfunctional breathing). Extrapulmonary comorbidities include anxiety, depression, gastro-esophageal reflux disease, obesity, cardiovascular, and metabolic diseases.

The identification of comorbidities via multidimensional approach is needed to initiate appropriate multidisciplinary management of patients with severe asthma.
Comparison of prognostic ability of perioperative myocardial biomarkers in acute type A aortic dissection
Authors: Gong Ming , Wu Zining , Guan Xinliang , Jiang Wenjian , Zhang Hongjia
Published: October 2019

Stanford type A aortic dissection (AD) is a lethal disease requiring surgery. Evidence regarding the prognostic ability of perioperative myocardiac markers on long-term outcome is limited.

In this cohort study, we measured perioperative myocardiac markers level in 583 surgical patients with type A AD in our hospital between 2015 and 2017. All patients were followed up after surgery for a median period of 864 days to determine short- and long-term mortality.

About one-fifth of patients has a positive preoperative myocardial markers, which was increased significantly after operation. Increase log10 post-creatine kinase MB isoenzyme (CK-MB) (hazard ratio [HR], 4.64; 95% confidence interval [CI] 1.89–11.43; P = .0008), log10 post-TnI (HR, 3.11; 95% CI 1.56–6.21; P = .0013), log10 post-Mb (HR, 3.00; 95% CI 1.40–6.43; P = .0048), log10 pre-CK-MB (HR,1.82; 95% CI 1.03–3.21; P = .0377), and upper tertile of post-CK-MB (HR,1.52; 95% CI 1.05–2.20; P = .0261) were the independent risk factor for 30 days mortality adjusted for potential confounders. None of cardiac markers was significantly associated with long-term outcome independent of other factors.

Perioperative myocardiac predicts early outcome in type A AD patients undergoing surgery. Increasing perioperative myocardial markers do not appear to be a predictor for long-term all-cause mortality.
Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair in patients with liver cirrhosis accompanied by ascites
Authors: Wang Haiyang , Fu Jian , Qi Xiaotong , Sun Jianming , Chen Yikuan
Published: October 2019

To investigate the feasibility, efficacy, and safety of laparoscopic totally extraperitoneal (TEP) repair in patients with inguinal hernia accompanied by liver cirrhosis.

Between October 2015 and May 2018, 17 patients with liver cirrhosis who underwent TEP repair were included in this study. The baseline characteristics, perioperative data, and recurrence were retrospectively reviewed.

Seventeen patients with a mean duration of 18.23 ± 16.80 months were enrolled. All TEP repairs were successful without conversion to trans-abdominal pre-peritoneal (TAPP) surgery or open repair, but 4 patients had peritoneum rupture during dissection. The mean operation time was 54.23 ± 10.51 minutes for unilateral hernia and 101.25 ± 13.77 minutes for bilateral hernias. We found 2 cases with contralateral inguinal hernia and 2 cases with obturator hernia during surgery. The rate of complication was 17.65% (3/17), 2 of 3 cases were Child-Turcotte-Pugh C with large ascites. During a follow-up of 19.29 ± 9.01 months, no patients had recurrence and chronic pain, but 2 patients died because of the progression of underlying liver disease.

Early and elective inguinal hernia repair is feasible and effective for patients with liver cirrhosis. TEP is a feasible and safe repair option for cirrhotic patients in experienced hands.
Steroid therapy and outcome of parapneumonic pleural effusions (STOPPE): Study protocol for a multicenter, double-blinded, placebo-controlled randomized clinical trial
Authors: Fitzgerald Deirdre B. , Waterer Grant W. , Read Catherine A. , Fysh Edward T. , Shrestha Ranjan , Stanley Christopher , Muruganandan Sanjeevan , Lan Norris S. H. , Popowicz Natalia D. , Peddle-McIntyre Carolyn J. , Rahman Najib M. , Gan Seng Khee , Murray Kevin , Lee Yun Chor Gary
Published: October 2019

Background:

Community-acquired pneumonia (CAP) is a major global disease. Parapneumonic effusions often complicate CAP and range from uninfected (simple) to infected (complicated) parapneumonic effusions and empyema (pus). CAP patients who have a pleural effusion at presentation are more likely to require hospitalization, have a longer length of stay and higher mortality than those without an effusion. Conventional management of pleural infection, with antibiotics and chest tube drainage, fails in about 30% of cases. Several randomized controlled trials (RCT) have evaluated the use of corticosteroids in CAP and demonstrated some potential benefits. Importantly, steroid use in pneumonia has an acceptable safety profile with no adverse impact on mortality. A RCT focused on pediatric patients with pneumonia and a parapneumonic effusion demonstrated shorter time to recovery. The effects of corticosteroid use on clinical outcomes in adults with parapneumonic effusions have not been tested. We hypothesize that parapneumonic effusions develop from an exaggerated pleural inflammatory response. Treatment with systemic steroids may dampen the inflammation and lead to improved clinical outcomes. The steroid therapy and outcome of parapneumonic pleural effusions (STOPPE) trial will assess the efficacy and safety of systemic corticosteroid as an adjunct therapy in adult patients with CAP and pleural effusions.

Methods:

STOPPE is a pilot multicenter, double-blinded, placebo-controlled RCT that will randomize 80 patients with parapneumonic effusions (2:1) to intravenous dexamethasone or placebo, administered twice daily for 48 hours. This exploratory study will capture a wide range of clinically relevant endpoints which have been used in clinical trials of pneumonia and/or pleural infection; including, but not limited to: time to clinical stability, inflammatory markers, quality of life, length of hospital stay, proportion of patients requiring escalation of care (thoracostomy or thoracoscopy), and mortality. Safety will be assessed by monitoring for the incidence of adverse events during the study.

Discussion:

STOPPE is the first trial to assess the efficacy and safety profile of systemic corticosteroids in adults with CAP and pleural effusions. This will inform future studies on feasibility and appropriate trial endpoints.

Trial registration:

ACTRN12618000947202

Protocol version:

version 3.00/26.07.18