bluuebunny/crossref_metadata_2025 huggingface dataset:
THICKNESSES OF CENTRAL MACULAR, RETINAL NERVE FIBER, AND GANGLION CELL INNER PLEXIFORM LAYERS IN PATIENTS WITH HYPERTENSION
Authors: Lee Soo Hyun , Lee Woo Hyuk , Lim Hyung Bin , Jo Young Joon , Kim Jung Yeul
Published: May 2018

Purpose:

To compare retinal thickness between patients with chronic hypertension without retinopathy, hypertensive retinopathy, Keith–Wagener–Barker Grade IV status, and normal controls using spectral domain optical coherence tomography.

Methods:

In this retrospective study, we analyzed patients who visited our retinal clinic from January 2013 to February 2016. Of those included, 58 eyes of 58 patients were in the healthy control group (Group A), 37 eyes of 37 patients were in the chronic hypertension without retinopathy group (disease duration of at least 10 years; Group B), and 31 eyes of 31 patients with relieved hypertensive retinopathy (Grade IV hypertensive retinopathy a year or more ago but no longer had hypertensive retinopathy at the time of the study; Group C). The thicknesses of the central macula, retinal nerve fiber layer (RNFL), and ganglion cell inner plexiform layer (GCIPL) were measured by spectral domain optical coherence tomography in each group.

Results:

The average thicknesses of the central macula, RNFL, and GCIPL layers were lower in Group B than in Group A (P < 0.001, 0.001, and <0.001, respectively). The thicknesses of the three layers were lower in Group C than in Group B (P < 0.001, <0.001, and <0.001, respectively). Of the three groups, the average thicknesses of the central macula, RNFL, and GCIPL were lowest in the Group C (P < 0.001, <0.001, and <0.001, respectively).

Conclusion:

The central macula, RNFL, and GCIPL in Group B were significantly thinner than those of healthy eyes, and these retinal changes were more prominent in Group C. Thus, the effects of retinal changes associated with hypertension should be considered when analyzing the thicknesses of the central macular, RNFL, and GCIPL layers in patients with ocular disorders, including retinal, glaucoma, and neuro-ophthalmological diseases.
Evaluation of Clostridium Bacteremia in the Cancer Population
Authors: Hernandez Burgos Paula M. , Nanjappa Sowmya , Snyder Matthew , Bitetzakis Christopher , Greene John N.
Published: May 2018

Introduction

Clostridium species are gram-positive or gram-variable anaerobic organisms that have been known to cause different kinds of infections of varying scope and severity. Clostridium species have been associated with high in-hospital mortality rates, particularly in immunocompromised patients with malignancies. Despite the potential severity of these infections in the oncologic population, primary literature on the topic is relatively scarce.

Methods

A retrospective chart review was performed to identify all patients older than 18 years with positive Clostridium species blood cultures at the H. Lee Moffitt Cancer Center and Research Institute from April 10, 2005, to September 30, 2016. Data were analyzed to identify underlying risk factors, clinical presentation, and treatment of Clostridium bacteremia in the cancer population.

Results

A total of 18 patients had bacteremia with Clostridium species. The patients' ages ranged from 26 to 79 years (median, 62.5 years), and 6 of the patients were female (33%). The predominant Clostridium species in our sample was Clostridium perfringens, which was found in 7 patients (38%), followed by Clostridium septicum found in 4 patients (22%). A gastrointestinal source was identified in 11 patients (66%). Three patients died of the infection (16%).

Conclusions

The potential severity of Clostridium infections in the oncologic population warrants a thorough evaluation in every patient with positive blood cultures, with focus on the gastrointestinal tract as a potential source of infection. Further studies about susceptibility testing would provide valuable information and may serve to reduce mortality rates among patients with Clostridium bacteremia.
Perioperative lidocaine infusions for the prevention of chronic postsurgical pain: a systematic review and meta-analysis of efficacy and safety
Authors: Bailey Martin , Corcoran Tomas , Schug Stephan , Toner Andrew
Published: May 2018

Chronic postsurgical pain (CPSP) occurs in 12% of surgical populations and is a high priority for perioperative research. Systemic lidocaine may modulate several of the pathophysiological processes linked to CPSP. This systematic review aims to identify and synthesize the evidence linking lidocaine infusions and CPSP. The authors conducted a systematic literature search of the major medical databases from inception until October 2017. Trials that randomized adults without baseline pain to perioperative lidocaine infusion or placebo were included if they reported on CPSP. The primary outcome was the presence of procedure-related pain at 3 months or longer after surgery. The secondary outcomes of pain intensity, adverse safety events, and local anesthetic toxicity were also assessed. Six trials from 4 countries (n = 420) were identified. Chronic postsurgical pain incidence was consistent with existing epidemiological data. Perioperative lidocaine infusions significantly reduced the primary outcome (odds ratio, 0.29; 95% confidence interval, 0.18-0.48), although the difference in intensity of CPSP assessed by the short-form McGill Pain Questionnaire (4 trials) was not statistically significant (weighted mean difference, −1.55; 95% confidence interval, −3.16 to 0.06). Publication and other bias were highly apparent, as were limitations in trial design. Each study included a statement reporting no adverse events attributable to lidocaine, but systematic safety surveillance strategies were absent. Current limited clinical trial data and biological plausibility support lidocaine infusions use to reduce the development of CPSP without full assurances as to its safety. This hypothesis should be addressed in future definitive clinical trials with comprehensive safety assessment and reporting.
Systematic analysis of annual health resource utilization and costs in hospitalized patients with inflammatory bowel disease in Switzerland
Authors: Schoepfer Alain , Vavricka Stephan R. , Brüngger Beat , Reich Oliver , Blozik Eva , Bähler Caroline
Published: May 2018

Background and aims

Real-life data on health resource utilization and costs of hospitalized patients with inflammatory bowel disease are lacking in Switzerland. We aimed to assess health resource utilization and costs during a 1-year follow-up period starting with an index hospitalization.

Patients and methods

On the basis of claims data of the Helsana health insurance group, health resource utilization was assessed and costs reimbursed by mandatory basic health insurance [in Swiss Francs (CHF); 1 CHF=0.991 US$] were calculated during a 1-year follow-up period starting with an index hospitalization in the time period between 1 January 2013 and 31 December 2014.

Results

Of 202 002 patients with at least one hospitalization in 2013–2014, a total of 270 (0.13%) patients had inflammatory bowel disease as main diagnosis [112 (41.5%) ulcerative colitis (UC), 158 (58.5%) Crohn’s disease (CD), 154/270 (57.0%) females]. In comparison with patients with UC, patients with CD were significantly more frequently treated with biologics (45.6 vs. 20.5%, P<0.001) and more frequently underwent surgery during index hospitalization (27.8 vs. 9.8%, P=0.002). Compared with patients with UC, those with CD had significantly more consultations [odds ratio (OR): 1.06, 95% confidence interval (CI): 1.01–1.12, P=0.016], higher median annual total costs (OR: 1.25, 95% CI: 1.05–1.48, P=0.012), and higher outpatient costs (OR: 1.33, 95% CI: 1.07–1.66, P=0.011). In the bivariate model, median total costs for patients with CD and those with UC were 24 270 and 17 270 CHF, respectively (P=0.032).

Conclusion

When compared with patients with UC, hospitalized patients with CD have during a 1-year follow-up a higher rate of outpatient consultations and generate higher costs.
Aspirin Resistance: Cardiovascular Risk Game Changer
Authors: Yassin Ahmed S. , Abubakar Hossam , Mishra Tushar , Subahi Ahmed , Hartman Melanie , Ahmed Abdelrahman , Ibrahim Walid , Singh Manmohan , Pahuja Mohit
Published: May 2018

Background:

Aspirin (ASA) is the most used medication on the globe. ASA is a primary pillar of the secondary prevention of cardiovascular atherothromboembolic events. However, a fraction of the population does not respond to ASA as expected in a unique phenomenon called ASA resistance. Multiple mechanisms were described and studied in the literature to explain this phenomenon.

Area of Uncertainty:

ASA resistance is an interesting phenomenon that is worth studying and reviewing. Mechanisms behind this resistance are various and although the rarity of some, it is crucial for the modern health provider to be aware of such phenomenon and its possible explanations to provide more efficient preventive cardiology practice. Our study aimed to review and conclude the evidence behind ASA resistance and its implication on the cardiovascular health.

Data Sources:

We searched databases like PubMed, EMBASE, Ovid by midline, and Google Scholar for published articles and abstracts.

Results:

Our systemic search revealed more than 100 articles in relation to ASA resistance. We selected 40 articles, which were relevant for this review. Various mechanisms were described in the literature, with few of them very well documented and understood. Main mechanisms include medication nonadherence, interaction with proton pump inhibitors, esterase-mediated ASA inactivation, post-coronary artery bypass grafting (CABG) MRP-4–mediated ASA consumption, cyclooxygenase-1 (COX-1) polymorphisms, high platelet turnover–associated regeneration of platelet COX-1, and the documented platelet ability of de novo COX-1 synthesis in response to thrombin and fibrinogen.

Conclusion:

Multiple mechanisms of ASA resistance were described in the literature. Awareness of such interaction is important for medical practitioners. Bottom line, further studies and reviews are needed to further study this phenomenon and its implication on the cardiovascular health and hence reaching a valid evidence-based conclusion that might change the practice and improve the patient preventive health care.
Economic Value of Greater Access to Bariatric Procedures for Patients With Severe Obesity and Diabetes
Authors: Kim David D. , Arterburn David E. , Sullivan Sean D. , Basu Anirban
Published: May 2018

Objective:

Designing optimal insurance is important to ensure access to care for individuals that are most likely to benefit. We examined the potential impact of lowering patient cost-sharing for bariatric procedures.

Methods:

After defining 10 subgroups by body mass index (BMI) and type 2 diabetes mellitus (T2DM), we analyzed the National Health and Nutrition Examination Survey datasets to estimate the prevalence of each subgroup. The MarketScan claims database provided utilization rates and costs of bariatric procedures. Using an existing cost-effectiveness model, we estimated the economic value of bariatric procedures under various cost-sharing levels (0%–25%) with 2 frameworks: (1) a traditional cost-effectiveness analysis and (2) a new approach that incorporates utilization effects across subgroups.

Results:

The utilization rate was higher among individuals with T2DM than those without T2DM (90.4 vs. 59.1 cases per 100,000) for bariatric procedures, which were more cost-effective for those with T2DM and a higher BMI. After accounting for utilization effects, the economic value of bariatric surgery was $177 and $63 per individual from a lifetime and a 5-year time horizon, respectively. Under no patient cost-sharing for individuals with BMI≥40 and T2DM, utilization rates were expected to increase by 21 cases per 100,000, resulting in additional $2 realized value per patient and $7.07 million in returns at the US population level.

Conclusions:

Cost-sharing is a barrier to uptake of a clinical and cost-effective treatment for severe obesity. Reducing cost-sharing for patients with severe obesity and T2DM could potentially increase the utilization of bariatric procedures and result in greater economic value to payers.
Patient Engagement in ACO Practices and Patient-reported Outcomes Among Adults With Co-occurring Chronic Disease and Mental Health Conditions
Authors: Ivey Susan L. , Shortell Stephen M. , Rodriguez Hector P. , Wang Yue (Emily)
Published: May 2018

Background:

Accountable care organizations (ACOs) have increased their use of patient activation and engagement strategies, but it is unknown whether they achieve better outcomes for patients with comorbid chronic physical and mental health conditions.

Objectives:

To assess the extent to which practices with patient-centered cultures, greater shared decision-making strategies, and better coordination among team members have better patient-reported outcomes (PROs) for patients with diabetes and/or cardiovascular and comorbid mental health diagnoses.

Research Design:

Sixteen practices randomly selected from top and bottom quartiles of a 39-item patient activation/engagement implementation survey of primary care team members (n=411) to assess patient-centered culture, shared decision-making, and relational coordination among team members. These data were linked to survey data on patient engagement and on emotional, physical, and social patient-reported health outcomes.

Subjects:

Adult patients (n=606) with diabetes, cardiovascular, and comorbid mental health conditions who had at least 1 visit at participating primary care practices of 2 ACOs.

Measures:

Depression/anxiety, physical functioning, social functioning; patient-centered culture, patient activation/engagement implementation, relational coordination.

Results:

Patients receiving care from practices with high patient-centered cultures reported better physical functioning (0.025) and borderline better emotional functioning (0.059) compared with less patient-centered practices. More activated patients reported better PROs, with higher activation levels partially mediating the relationship of patient-centered culture and better PROs.

Conclusions:

ACO patients with comorbid physical and mental health diagnoses report better physical functioning when practices have patient-centered cultures. More activated/engaged patients report better patient emotional, physical, and social health outcomes.
Demographic and Clinical Correlates of Mucosal Disaccharidase Deficiencies in Children With Functional Dyspepsia
Authors: Chumpitazi Bruno P. , Robayo‐Torres Claudia C. , Tsai Cynthia M. , Opekun Antone R. , Baker Susan S. , Nichols Buford L. , Gilger Mark A.
Published: May 2018

Background:

A subset of children with functional gastrointestinal disorders (FGIDs), which includes functional dyspepsia, may have duodenal disaccharidase deficiencies.

Objectives:

To determine the frequency, demographics, and clinical characteristics associated with duodenal disaccharidase deficiencies in children with functional dyspepsia.

Methods:

Children ages 4 to 18 years undergoing esophagogastroduodenoscopy (EGD) evaluation for dyspepsia were enrolled in either a retrospective (study 1) or prospective (study 2) evaluation. Those with histologic abnormalities were excluded. Duodenal biopsies were obtained for disaccharidase enzyme analysis. In the retrospective study, both demographic and clinical characteristics were obtained via chart review. In the prospective study, parents completed the Rome II Questionnaire on Gastrointestinal Symptoms before the EGD.

Results:

One hundred and twenty‐nine children (n = 101, study 1; n = 28, study 2) were included. Mean age was 11.2 ± 3.8 (SD) years in study 1 and 10.6 ± 3.2 years in study 2. Forty‐eight (47.5%) of subjects in study 1 and 13 (46.4%) of subjects in study 2 had at least 1 disaccharidase deficiency identified. All of those with a disaccharidase deficiency in both studies had lactase deficiency with 8 (7.9%) and 5 (17.9%) of those in studies 1 and 2, respectively, having an additional disaccharidase deficiency. The second most common disaccharidase deficiency pattern was that of pan‐disaccharidase deficiency (PDD) in both studies. In study 1 (where both race and ethnicity were captured), self‐identified Hispanic (vs non‐Hispanic, P < 0.05) and non‐white (vs white, P < 0.01) children were more likely to have lactase deficiency. Age, sex, and type of gastrointestinal symptom were not associated with presence or absence of a disaccharidase deficiency.

Conclusions:

Approximately half of children with functional dyspepsia undergoing EGD were identified as having a disaccharidase deficiency (predominantly lactase deficiency). Race/ethnicity may be associated with the likelihood of identifying a disaccharidase deficiency. Other clinical characteristics were not able to distinguish those with versus without a disaccharidase deficiency.
Recent Advances in the Classification of Low-grade Papillary-like Thyroid Neoplasms and Aggressive Papillary Thyroid Carcinomas: Evolution of Diagnostic Criteria
Authors: Guo Zhenying , Ge Minghua , Chu Ying-Hsia , Asioli Sofia , Lloyd Ricardo V.
Published: May 2018

Papillary thyroid carcinomas account for ∼80% of well-differentiated thyroid tumors. During the past decade, several new variants of papillary-like thyroid neoplasms and papillary thyroid carcinomas have been recognized. Some of these neoplasms that were previously classified as malignant have been reclassified as low-grade neoplasms, as the diagnostic criteria have evolved. Similarly, some of the papillary thyroid carcinomas that were previously classified as conventional or classic papillary thyroid carcinomas have now been recognized as more aggressive variants of papillary thyroid carcinomas. Recognizing these differences becomes more important for the proper medical, surgical, and radiotherapeutic management of patients with these neoplasms
Pediatric Carbon Monoxide Poisoning in Southern Israel
Authors: Fruchtman Yariv , Perry Zvi H. , Leibson Tom , Vered Cohen Liat , Lifshitz Matitiahu , Leibovitz Eugene
Published: May 2018

Objectives

This study aimed to describe the epidemiology and clinical burden of unintended carbon monoxide (CO) poisoning among children in the Negev region of southern Israel.

Methods

This was a cross-sectional retrospective study of CO poisoning patients admitted to Soroka University Medical Center in 2011 through 2015.

Results

Overall, 43 cases of CO poisoning were recorded among children younger than 18 years. Five patients died, all upon admission. Poisoning due to smoke “per se” and due to CO emitted from heating devices were responsible for 28 (65.1%) and 14 (32.6%) cases, respectively. Eight (18.6%) patients suffered from convulsions, and 13 (43.3%) of 30 evaluable patients complained of headaches. Twenty-two (51.2%) were found unconscious in the field, and 7 (16.3%) were unconscious at examination at the emergency department. The average carboxyhemoglobin level on admission was 10.5% ± 10.4% (level ranging from 0.1% to 46.2%). Treatment included oxygen in 34 patients (79%) and hyperbaric oxygen therapy in 8 patients (19%). No differences were found between Bedouin and Jewish children in sex, age, residence area, source of CO poisoning, symptoms severity, and need for hyperbaric oxygen therapy. More patients with exposure to water heating devices were older than 4 years, lived in villages, and were diagnosed as having loss of consciousness in the field compared with those exposed to smoke inhalation.

Conclusions

Carbon monoxide poisoning in children is frequent in southern Israel. Education about prevention, implementation of safer standards for home heating systems, and government supervision are required management strategies to decrease the CO poisoning incidence in southern Israel.
Spinal Epidural Abscess in an Infant Presenting as Fever and Respiratory Distress
Authors: Gupta Katherine M. , Tay Khoon-Yen
Published: May 2018

A 9-month-old healthy female presented during winter to the emergency department with a chief complaint of fever and prominent respiratory symptoms. She was discharged on oseltamivir with a presumptive diagnosis of influenza. She returned to the emergency department 2 days later with continued fever and more upper respiratory symptoms. She was admitted for intravenous hydration to the observation unit with a diagnosis of viral illness (with viral testing that returned positive for adenovirus) and dehydration. When her high fevers continued, bloodwork that was concerning for leukocytosis, elevated inflammatory markers, and elevated alkaline phosphatase was obtained. During her workup for fever, a full body magnetic resonance imaging was performed, which revealed the diagnosis of a C3 to L5 spinal epidural abscess. This case demonstrates the difficulty of making this important diagnosis in a preverbal child presenting with a concurrent virus during winter viral season.
Exposures to Single-Use Detergent Sacs Reported to a Statewide Poison Control System, 2013–2015
Authors: Vohra Rais , Huntington Serena , Fenik Yelena , Phan Derek , Ta Nancy , Geller Richard J.
Published: May 2018

Background

Single-use detergent sacs (SUDSs) represent a relatively new household hazard to children. Brand differences and packaging changes may contribute to differential risks with accidental exposure. We sought to identify high-risk features from SUDS exposures in children and to assess whether product packaging changed trends in SUDS exposures reported to poison centers.

Methods

In this institutional review board–approved, retrospective chart review of SUDS exposures from January 2013 to August 2015, deidentified case records of a large statewide poison control system were extracted and analyzed for clinical associations and trends. Clinical and demographic data were gathered, and outcomes were analyzed for differences by brand type, presenting complaints, and occurrence in relation to SUDS packaging changes.

Results

There were 3502 SUDS exposures, with 3343 (95%) in children 5 years or younger. Metabolic, central nervous system, and pulmonary effects were significantly associated with moderate or severe outcome (P < 0.05). Forty patients received invasive procedures such as endoscopy, bronchoscopy, and/or endotracheal intubation, and more than half had mucosal lesions discovered by the diagnostic procedure. The presence of stridor, wheezing, drooling, lethargy, and exposure to the brand All Mighty Pacs were all significant predictors of moderate or severe outcome (P < 0.05). After the implementation of packaging changes, there was a transient decline in the number of exposures to the Tide Pods product.

Conclusion

Central nervous system and respiratory effects as well as certain brand types predict serious outcomes from SUDS exposures. Manufacturing changes had a brief beneficial effect on the volume of SUDS exposures reported between 2013 and 2015.
Estimating the Economic Burden Related to Older Adult Falls by State
Authors: Haddad Yara K. , Bergen Gwen , Florence Curtis S.
Published: May 2018

Objective:

Unintentional falls in older adults (persons 65 years of age and older) impose a significant economic burden on the health care system. Methods for calculating state-specific health care costs are limited. This study describes 2 methods to estimate state-level direct medical spending due to older adult falls and explains their differences, advantages, and limitations.

Design:

The first method, partial attributable fraction, applied a national attributable fraction to the total state health expenditure accounts in 2014 by payer type (Medicare, Medicaid, and private insurance). The second method, count applied to cost, obtained 2014 state counts of older adults treated and released from an emergency department and hospitalized because of a fall injury. The counts in each state were multiplied by the national average lifetime medical costs for a fall-related injury from the Web-based Injury Statistics Query and Reporting System. Costs are reported in 2014 US dollars.

Setting:

United States.

Participants:

Older adults.

Main Outcome Measure:

Health expenditure on older adult falls by state.

Results:

The estimate from the partial attributable fraction method was higher than the estimate from the count applied to cost method for all states compared, except Utah. Based on the partial attributable fraction method, in 2014, total personal health care spending for older adult falls ranged from $48 million in Alaska to $4.4 billion in California. Medicare spending attributable to older adult falls ranged from $22 million in Alaska to $3.0 billion in Florida. For the count applied to cost method, available for 17 states, the lifetime medical costs of 2014 fall-related injuries ranged from $68 million in Vermont to $2.8 billion in Florida.

Conclusions:

The 2 methods offer states options for estimating the economic burden attributable to older adult fall injuries. These estimates can help states make informed decisions about how to allocate funding to reduce falls and promote healthy aging.
Co-morbidities Associated With Early Mortality in Adults With Spina Bifida
Authors: Dicianno Brad E. , Sherman Adam , Roehmer Christian , Zigler Christina K.
Published: May 2018

Objective

The aims of this quality improvement project were to identify secondary conditions and medical co-morbidities in adult patients with spina bifida and to determine which factors were associated with an earlier age of death.

Design

Retrospective chart review of 487 patients who attended the University of Pittsburgh Medical Center Adult Spina Bifida Clinic between August 1, 2005, and June 6, 2017, was conducted.

Results

Of 487 patients who had received care at the University of Pittsburgh Medical Center Adult Spina Bifida Clinic, 48 were deceased. The most commonly reported causes of death included infection, respiratory failure, renal failure, shunt malfunction, and metastatic cancer. Underlying co-morbidities and secondary conditions included hydrocephalus, Chiari II malformation, tethered cord, scoliosis, and abnormal renal function. In deceased patients, earlier age of death was significantly associated with myelomeningocele subtype and the presence of hydrocephalus and Chiari II malformation.

Conclusions

Clinicians treating individuals with spina bifida should be aware of the potential for earlier mortality in individuals with myelomeningocele, hydrocephalus, and Chiari II malformation, especially with regard to infection, respiratory failure, renal failure, shunt malfunction, and cancer.

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CME Objectives

Upon completion of this article, the reader should be able to: (1) Discuss the importance of recognizing co-morbidities in adult individuals with spina bifida; (2) Describe secondary conditions and medical co-morbidities associated with spina bifida; and (3) Identify which conditions are associated with earlier age of death in adult individuals with spina bifida.

Level

Advanced

Accreditation

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The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
The Prevalence of Scoliosis in Spina Bifida Subpopulations
Authors: Heyns Arne , Negrini Stefano , Jansen Katrien , Moens Pierre , Schelfaut Sebastiaan , Peers Koenraad , Kiekens Carlotte
Published: May 2018

Prevalence of scoliosis within spina bifida subpopulations is important for diagnostics and therapeutic purposes. This review determined the prevalence of scoliosis within spina bifida subpopulations by means of a systematic literature review by using the following databases: Medline PubMed, Embase, Cochrane, and Pedro. All Dutch- and English-written literature using the MESH terms “spinal dysraphism,” “neural tube defects,” and “scoliosis” was analyzed using the exclusion criteria: animal studies, case reports, studies regarding the prevalence of spina bifida among patients with scoliosis, studies with inclusion of patients with scoliosis of less than 11 degrees without possibility to identify subgroups with scoliosis of greater than 10 degrees, studies without an own study group, articles comprising the same patient group as another article, neural tube defects besides spina bifida, and articles without specification of spina bifida subtype. It resulted in six articles, two concerning diastematomyelia (103 patients, 82 females and 21 males) and four about myelomeningocele (479 patients, 283 females and 196 males) with an overall weighted prevalence of scoliosis (20-degree Cobb angle cutoff) of 44.4% and 52.5%, respectively. It can be concluded that most studies have a lot of methodological flaws, so there is a need for further research with standardization of data collection to allow comparison of different data.
Development and Calibration of a Mathematical Model of Anal Carcinogenesis for High-Risk HIV-Infected Men
Authors: Burger Emily A. , Dyer Michael A. , Sy Stephen , Palefsky Joel M. , de Pokomandy Alexandra , Coutlee François , Silverberg Michael J. , Kim Jane J.
Published: May 2018

Objectives:

Men who have sex with men who are living with HIV are at highest risk for anal cancer. Our objective was to use empirical data to develop a comprehensive disease simulation model that reflects the most current understanding of anal carcinogenesis, which is uniquely positioned to evaluate future anal cancer screening strategies and provide insight on the unobservable course of the disease.

Setting:

North America.

Methods:

The individual-based simulation model was calibrated leveraging primary data from empirical studies, such as a longitudinal HIV-positive men who have sex with men cohort study [Human Immunodeficiency and Papilloma Virus Research Group (HIPVIRG); n = 247] and the North American AIDS Cohort Collaboration on Research and Design [(NA-ACCORD); n = 13,146]. We used the model to infer unobservable progression probabilities from high-grade precancer to invasive anal cancer by CD4+ nadir and human papillomavirus (HPV) genotype.

Results:

The calibrated model had good correspondence to data on genotype- and age-specific HPV prevalence; genotype frequency in precancer and cancer; and age- and nadir CD4+–specific cancer incidence. The model-projected progression probabilities differed substantially by HPV genotype and nadir CD4+ status. For example, among individuals with CD4+ nadir <200, the median monthly progression probability from a high-grade lesion to invasive cancer was 0.054% (ie, 6.28% 10-year probability) and 0.004% (ie, 0.48% 10-year probability) for men with an HPV-16 infection versus without a detectable HPV infection, respectively.

Conclusions:

We synthesized existing evidence into a state-of-the-art anal cancer disease simulation model that will be used to quantify the tradeoffs of harms and benefits of alternative strategies, understand critical uncertainties, and inform national anal cancer prevention policy.
Assessing Unwanted Variations in Rheumatology Clinic Previsit Rooming
Authors: Ramly Edmond , Stroik Brad , Lauver Diane R. , Johnson Heather M. , McBride Patrick , Steffen Lewicki Kristin , Arnason Jon , Bartels Christie M.
Published: May 2018

Background

Rheumatologists face time pressures similar to primary care but have not generally benefitted from optimized team-based rooming during the time from the waiting room until the rheumatologist enters the room.

Objective

The aim of this study was to assess current capacity for population management in rheumatology clinics; we aimed to measure the tasks performed by rheumatology clinic staff (medical assistants or nurses) during rooming.

Methods

We performed a cross-sectional time-study and work-system analysis to measure rooming workflows at 3 rheumatology clinics in an academic multispecialty practice during 2014–2015. We calculated descriptive statistics and compared frequencies and durations using Fisher exact test and analysis of variance.

Results

Observing 190 rheumatology clinic previsit rooming sequences (1419 minutes), we found many significant variations. Total rooming duration varied by clinic (median, 6.75–8.25 minutes; p < 0.001). Vital sign measurement and medication reconciliation accounted for more than half of rooming duration. Among 3 clinics, two of 15 tasks varied significantly in duration, and 9 varied in frequency. Findings led clinic leaders to modify policies and procedures regarding 6 high-variation tasks streamlining assessment of weight, height, pain scores, tobacco use, disease activity, and refill needs.

Conclusions

Assessing rheumatology rooming tasks identified key opportunities to improve quality and efficiency without burdening providers. This project demonstrated user-friendly methods to identify opportunities to standardize rooming and support data-driven decisions regarding rheumatology clinic practice changes to improve population management in rheumatology.
Greater Occipital Nerve Decompression for Occipital Neuralgia
Authors: Jose Anson , Nagori Shakil Ahmed , Chattopadhyay Probodh K. , Roychoudhury Ajoy
Published: May 2018

The aim of the study was to evaluate the effectiveness of greater occipital nerve decompression for the management of occipital neuralgia. Eleven patients of medical refractory occipital neuralgia were enrolled in the study. Local anaesthetic blocks were used for confirming diagnosis. All of them underwent surgical decompression of greater occipital nerve at the level of semispinalis capitis and trapezial tunnel. A pre and postoperative questionnaire was used to compare the severity of pain and number of pain episodes/month. Mean pain episodes reported by patients before surgery were 17.1 ± 5.63 episodes per month. This reduced to 4.1 ± 3.51 episodes per month (P < 0.0036) postsurgery. The mean intensity of pain also reduced from a preoperative 7.18 ± 1.33 to a postoperative of 1.73 ± 1.95 (P < 0.0033). Three patients reported complete elimination of pain after surgery while 6 patients reported significant relief of their symptoms. Only 2 patients failed to notice any significant improvement. The mean follow-up period was 12.45 ± 1.29 months. Surgical decompression of greater occipital nerve is a simple and viable treatment modality for the management of occipital neuralgia.
Dysfunction of Iron Metabolism and Iron-Regulatory Proteins in the Rat Hippocampus After Heat Stroke
Authors: Liu Jing , Wan Mingsheng , Zhang Yun , Zhang Shu , Zhang Hongying , Wu Shiwen
Published: May 2018

Heat stroke, the most serious type of heat illness, refers to the presence of hyperthermia (core temperature >40°C), accompanied by central nervous system dysfunction. The hippocampus is a particularly vulnerable region in the early stage of heat stroke. Increasing evidence suggests that dysregulation of brain iron metabolism is involved in many neurodegenerative diseases. However, whether heat stroke causes dysfunction of iron metabolism, as well as iron-regulatory proteins, in the hippocampus remains unknown. The present study was conducted to explore the effects on spatial learning and memory, as well as iron content, ferroportin 1 (Fpn1), and hepcidin expression in the hippocampus after heat stroke in rats. Compared with the Sham group, learning ability and memory declined in rats after heat stroke. Iron concentration was significantly increased in the hippocampus. Expression of Fpn1 protein significantly decreased in the hippocampus, while expression of hepcidin increased. Interestingly, Fpn1 mRNA expression in the hippocampus increased. Our data thereby indicate that heat stroke can decrease learning ability and memory in rats. The mechanism may be related to changes of iron levels, as well as Fpn1 and hepcidin expression, in the hippocampus. Furthermore, hepcidin may rapidly decrease cellular Fpn1 protein levels, even under conditions of iron loading, indicating that hepcidin is a more dominant regulator of Fpn1 than is iron.
Association Between Muscle Wasting and Muscle Strength in Patients Who Developed Severe Sepsis And Septic Shock
Authors: Borges Rodrigo Cerqueira , Soriano Francisco Garcia
Published: May 2018

Purpose:

To evaluate the association between the rectus femoris cross-sectional area (RFCSA) and the muscular strength obtained at the bedside in patients forwarded to the intensive care unit (ICU) for severe sepsis and septic shock.

Methods:

An observational study of prospective cohort. RFCSA was assessed by ultrasound on the following day of the ICU admission and monitored during hospitalization. The patients performed clinical tests of muscle strength (Medical Research Council (MRC) scale and handgrip dynamometry), when they could understand the verbal commands of the examiners.

Results:

In 37 patients hospitalized for sepsis there was a significant decline in RFCSA of 5.18 (4.49–5.96) cm2 on the 2nd day of ICU for 4.37 (3.71–5.02) cm2 at hospital discharge. Differently, the handgrip strength showed an increase from the awakening of 12.00 (7.00–20.00) Kgf to 19.00 (14.00–26.00) Kgf until hospital discharge. Patients in mechanical ventilation had a greater tendency to decline in the RFCSA compared with patients who did not receive mechanical ventilation, however without being significant (P = 0.08). There was a negative association between RFCSA delta (2nd day of ICU–ICU discharge) and handgrip strength (r = 0.51, P < 0.05), and a male and Sepsis-related Organ Failure Assessment score positive association with the RFCSA delta.

Conclusion:

There was an association of RFCSA with clinical muscle strength tests. In addition, it has been shown that sepsis can lead to short-term muscle degradation, regardless of whether they are submitted to mechanical ventilation or not.
ISHLT Primary Graft Dysfunction Incidence, Risk Factors, and Outcome: A UK National Study
Authors: Avtaar Singh Sanjeet Singh , Banner Nicholas R. , Rushton Sally , Simon Andre R. , Berry Colin , Al-Attar Nawwar
Published: May 2018

Background

Heart transplantation (HTx) remains the most effective long-term treatment for advanced heart failure. Primary graft dysfunction (PGD) continues to be a potentially life-threatening early complication. In 2014, a consensus statement released by International Society for Heart and Lung Transplantation (ISHLT) established diagnostic criteria for PGD. We studied the incidence of PGD across the United Kingdom.

Methods

We analyzed the medical records of all adult patients who underwent HTx between October 2012 and October 2015 in the 6 UK heart transplant centers Preoperative donor and recipient characteristics, intraoperative details, and posttransplant complications were compared between the PGD and non-PGD groups using the ISHLT definition. Multivariable analysis was performed using logistic regression.

Results

The incidence of ISHLT PGD was 36%. Thirty-day all-cause mortality in those with and without PGD was 31 (19%) versus 13 (4.5%) (P = 0.0001). Donor, recipient, and operative factors associated with PGD were recipient diabetes mellitus (P = 0.031), recipient preoperative bilateral ventricular assist device (P < 0.001), and preoperative extracorporeal membranous oxygenation (P = 0.023), female donor to male recipient sex mismatch (P = 0.007), older donor age (P = 0.010), and intracerebral haemorrhage/thrombosis in donor (P = 0.023). Intraoperatively, implant time (P = 0.017) and bypass time (P < 0.001) were significantly longer in the PGD cohort. Perioperatively, patients with PGD received more blood products (P < 0.001). Risk factors identified by multivariable logistic regression were donor age (P = 0.014), implant time (P = 0.038), female: male mismatch (P = 0.033), recipient diabetes (P = 0.051) and preoperative ventricular assist device/extracorporeal membranous oxygenation support (P = 0.012).

Conclusions

This is the first national study to examine the incidence and significance of PGD after HTx using the ISHLT definition. PGD remains a frequent early complication of HTx and is associated with increased mortality.
T Follicular Regulatory Cells and Antibody Responses in Transplantation
Authors: Wallin Elizabeth F.
Published: May 2018

De novo donor-specific antibody (DSA) formation is a major problem in transplantation, and associated with long-term graft decline and loss as well as sensitization, limiting future transplant options. Forming high-affinity, long-lived antibody responses involves a process called the germinal center (GC) reaction, and requires interaction between several cell types, including GC B cells, T follicular helper (Tfh) and T follicular regulatory (Tfr) cells. T follicular regulatory cells are an essential component of the GC reaction, limiting its size and reducing nonspecific or self-reactive responses.

An imbalance between helper function and regulatory function can lead to excessive antibody production. High proportions of Tfh cells have been associated with DSA formation in transplantation; therefore, Tfr cells are likely to play an important role in limiting DSA production. Understanding the signals that govern Tfr cell development and the balance between helper and regulatory function within the GC is key to understanding how these cells might be manipulated to reduce the risk of DSA development.

This review discusses the development and function of Tfr cells and their relevance to transplantation. In particular how current and future immunosuppressive strategies might allow us to skew the ratio between Tfr and Tfh cells to increase or decrease the risk of de novo DSA formation.
Revascularization Time in Liver Transplantation: Independent Prediction of Inferior Short- and Long-term Outcomes by Prolonged Graft Implantation
Authors: Buchholz Bettina M. , Gerlach Undine A. , Chandrabalan Vishnu V. , Hodson James , Gunson Bridget K. , Mergental Hynek , Muiesan Paolo , Isaac John R. , Roberts Keith J. , Mirza Darius F. , Perera M. Thamara P. R.
Published: May 2018

Background

Strategies for successful transplantation are much needed in the era of organ shortage, and there has been a resurgence of interest on the impact of revascularization time (RT) on outcomes in liver transplantation (LT).

Methods

All primary LT performed in Birmingham between 2009 and 2014 (n = 678) with portal reperfusion first were stratified according to RT (<44 minutes vs ≥44 minutes) and graft quality (standard liver graft [SLG], Donor Risk Index < 2.3 vs marginal liver graft [MLG], Donor Risk Index ≥ 2.3).

Results

Revascularization time of 44 minutes or longer resulted in significantly greater incidence of early allograft dysfunction (EAD) (29% vs 47%, P < 0.001), posttransplant acute kidney injury (AKI) (39% vs 60%, P < 0.001), and new-onset AKI (37% vs 56%, P < 0.001), along with poor long-term outcome (3-year graft survival 92% vs 83%, P = 0.001; 3-year patient survival 87% vs 79%, P = 0.004). On multivariable analysis, RT ≥ 44 was a significant independent predictor of EAD, renal dysfunction, and overall graft survival, but not patient survival. The cumulative effect of prolonged revascularization in marginal grafts (MLGRT ≥ 44) resulted in the worst transplant outcome compared with all other groups, which could be mitigated by rapid revascularization (SLGRT < 44, SLGRT ≥ 44, MLGRT < 44 vs MLGRT ≥ 44; EAD 24%, 39%, 39% vs 69%; AKI 32%, 46%, 51% vs 70%; 3-year graft survival 94%, 87%, 88% vs 70%, respectively; each P < 0.001). Factors associated with lack of abdominal space, larger grafts, and surgical skills were predictive of RT ≥ 44.

Conclusions

Shorter graft revascularization is a protective factor in LT, particularly in the setting of graft marginality. Careful graft-recipient matching and emphasis on surgical expertise may aid in achieving better outcomes in LT.
Detection of Complement-binding Donor-specific Antibodies, Not IgG-antibody Strength Nor C4d Status, at Antibody-mediated Rejection Diagnosis Is an Independent Predictor of Kidney Graft Failure
Authors: Malheiro Jorge , Santos Sofia , Tafulo Sandra , Dias Leonídio , Martins La Salete , Fonseca Isabel , Almeida Manuela , Pedroso Sofia , Beirão Idalina , Castro-Henriques António , Cabrita António
Published: May 2018

Background

Antibody-mediated rejection (AMR) remains associated with reduced kidney graft survival and no clear prognostic marker is available.

Methods

We investigated whether donor-specific antibodies (DSA) ability to bind C1q in comparison with AMR C4d status, both indirect signs of complement activation, improve risk stratification at time of AMR. Hence, among 467 patients in whom 1 or more graft biopsies were performed between 2008 and 2015, we included 56 with AMR according to Banff '15 criteria. Using concurrent sera, we prospectively identified DSA by single-antigen beads (IgG and C1q) assays.

Results

Antibody-mediated rejection C4d (+) (n = 28) was associated with preformed DSA (P = 0.007), whereas DSA C1q (+) (n = 25) cases had stronger IgG-DSA (P < 0.001). At AMR, graft function was similar between DSA C1q groups, but in the first year after, it improved in DSA C1q (−), whereas a steady decline was observed in DSA C1q (+) cases, remaining significantly lower from 1 year until 4 years after AMR. DSA C1q (+) was significantly associated with reduced graft survival (P = 0.021), whereas AMR C4d (+) was not (P = 0.550). Importantly, a similar negative impact of DSA C1q (+) on graft survival was observed within AMR C4d (+) (P = 0.040) and (−) (P = 0.036), cases. In multivariable analysis, DSA C1q (+) (hazard ratio, 3.939, P = 0.005) and de novo DSA (hazard ratio, 4.409, P = 0.033) were independent predictors of graft failure, but stronger IgG-DSA was not. Similar results were obtained considering C1q-DSA and IgG-DSA strength as continuous variables.

Conclusions

C1q-DSA assessment at AMR can be a valuable tool in detecting patients with higher risk of graft failure.
A Novel Technique in the Treatment of Lymphoceles After Renal Transplantation: C-Arm Cone Beam CT-Guided Percutaneous Embolization of Lymphatic Leakage After Lymphangiography
Authors: Yildirim İsmail Okan , Pişkin Turgut , Duman Enes , Firat Ali , Dogan Murat , Taskapan Hülya , Sahin Idris , Sarac Kaya
Published: May 2018

Background

We aimed to evaluate the efficacy of percutaneous embolization after lymphangiography using C-arm cone-beam computed tomography (CBCT) performed at the site of lymphatic leakage in patients with postrenal transplant lymphocele.

Methods

Between July 2014 and August 2017, 13 patients not responding to percutaneous ethanol sclerotherapy and conservative treatment for recurrent lymphocele after renal transplant were included. The mean age of the patients was 56.38 ± 9.91 (range, 36-70) years, and it comprised 9 men and 4 women. All patients underwent intranodal lymphangiography. C-arm CBCT-guided percutaneous embolization was performed in patients with confirmed lymphatic leakage. Patients who had no lymphatic leakage underwent drainage with fibrin glue injection.

Results

Lymphatic leakage was observed in 9 patients after lymphangiography, and they underwent CBCT-guided percutaneous N-butyl-2-cyanoacrylate embolization. The volume of lymphatic drainage reduced to less than 10 mL in 8 patients. One patient who was not responding to embolization was treated surgically, after percutaneous drainage and fibrin glue injection. Lymphatic leakage was not observed in 4 patients after lymphangiography. Of these, 3 patients showed a reduction in the amount of lymphatic drainage after lymphangiography. All 4 patients underwent percutaneous drainage and fibrin glue injection. One patient did not respond to the treatment and was treated surgically. Prelymphangiography and postlymphangiography and embolization, the volume of lymphatic drainage was 113.07 ± 21.75 mL, and 53.84 ± 30.96 mL, respectively, and statistically significant decrease was detected (P < 0.005).

Conclusions

Lymphangiography and CBCT-guided percutaneous embolization procedures might be an effective treatment method for patients with lymphocele refractory to treatment.