bluuebunny/crossref_metadata_2025 huggingface dataset:
The Presentation, Pace, and Profile of Infection and Sepsis Patients Hospitalized Through the Emergency Department: An Exploratory Analysis
Authors: Liu Vincent X. , Bhimarao Meghana , Greene John D. , Manickam Raj N. , Martinez Adriana , Schuler Alejandro , Barreda Fernando , Escobar Gabriel J.
Published: February 2021

Objectives:

To characterize the signs and symptoms of sepsis, compare them with those from simple infection and other emergent conditions and evaluate their association with hospital outcomes.

Design, Setting, Participants, and INTERVENTION:

A multicenter, retrospective cohort study of 408,377 patients hospitalized through the emergency department from 2012 to 2017 with sepsis, suspected infection, heart failure, or stroke. Infected patients were identified based on Sepsis-3 criteria, whereas noninfected patients were identified through diagnosis codes.

MEASUREMENTS AND MAIN RESULTS:

Signs and symptoms were identified within physician clinical documentation in the first 24 hours of hospitalization using natural language processing. The time of sign and symptom onset prior to presentation was quantified, and sign and symptom prevalence was assessed. Using multivariable logistic regression, the association of each sign and symptom with four outcomes was evaluated: sepsis versus suspected infection diagnosis, hospital mortality, ICU admission, and time of first antibiotics (> 3 vs ≤ 3 hr from presentation). A total of 10,825 signs and symptoms were identified in 6,148,348 clinical documentation fragments. The most common symptoms overall were as follows: dyspnea (35.2%), weakness (27.2%), altered mental status (24.3%), pain (23.9%), cough (19.7%), edema (17.8%), nausea (16.9%), hypertension (15.6%), fever (13.9%), and chest pain (12.1%). Compared with predominant signs and symptoms in heart failure and stroke, those present in infection were heterogeneous. Signs and symptoms indicative of neurologic dysfunction, significant respiratory conditions, and hypotension were strongly associated with sepsis diagnosis, hospital mortality, and intensive care. Fever, present in only a minority of patients, was associated with improved mortality (odds ratio, 0.67, 95% CI, 0.64–0.70; p < 0.001). For common symptoms, the peak time of symptom onset before sepsis was 2 days, except for altered mental status, which peaked at 1 day prior to presentation.

Conclusions:

The clinical presentation of sepsis was heterogeneous and occurred with rapid onset prior to hospital presentation. These findings have important implications for improving public education, clinical treatment, and quality measures of sepsis care.
Resources and Costs Associated With Repeated Admissions to PICUs
Authors: Kane Jason M. , Hall Matt , Cecil Cara , Montgomery Vicki L. , Rakes Lauren C. , Rogerson Colin , Stockwell Jana A. , Slain Katherine N. , Goodman Denise M.
Published: February 2021

Objective:

To determine the costs and hospital resource use from all PICU patients readmitted with a PICU stay within 12 months of hospital index discharge.

Design:

Cross-sectional, retrospective cohort study using Pediatric Health Information System.

Setting:

Fifty-two tertiary children’s hospitals.

Subjects:

Pediatric patients under 18 years old admitted to the PICU from January 1, 2016, to December 31, 2017.

Interventions:

None.

Measurements and Main Results:

Patient characteristics and costs of care were compared between those with readmission requiring PICU care and those with only a single PICU admission per annum. In this 2-year cohort, there were 239,157 index PICU patients of which 36,970 (15.5%) were readmitted and required PICU care during the 12 months following index admission. The total hospital cost for all index admissions and readmissions was $17.3 billion, of which 21.5% ($3.71 billion) were incurred during a readmission stay involving care in the PICU; of the 3,459,079 hospital days, 20.3% (702,200) were readmission days including those where PICU care was required. Of the readmitted patients, 11,703 (30.0%) received only PICU care, accounting for $662 million in costs and 110,215 PICU days. Although 43.6% of all costs were associated with patients who required readmission, these patients only accounted for 15.5% of the index patients and 28% of index hospitalization expenditures. More patients in the readmitted group had chronic complex conditions at index discharge compared with those not readmitted (83.9% vs 54.9%; p < 0.001). Compared with those discharged directly to home without home healthcare, patients discharged to a skilled nursing facility had 18% lower odds of readmission (odds ratio 0.82 [95% CI, 0.75–0.89]; p < 0.001) and those discharged home with home healthcare had 43% higher odds of readmission (odds ratio, 1.43 [95% CI, 1.36–1.51]; p < 0.001).

Conclusions:

Repeated admissions with PICU care resulted in significant direct medical costs and resource use for U.S. children’s hospitals.
Emerging role of multiparametric magnetic resonance imaging in identifying clinically relevant localized prostate cancer
Authors: Williams Cheyenne , Daneshvar Michael , Pinto Peter
Published: February 2021

Purpose of review

To explore the recent advances and utility of multiparametric magnetic resonance imaging (mpMRI) in the diagnosis and risk-stratification of prostate cancer.

Recent findings

Low-risk, clinically insignificant prostate cancer has a decreased risk of morbidity or mortality. Meanwhile, patients with intermediate and high-risk prostate cancer may significantly benefit from interventions like radiation or surgery. To appropriately risk stratify these patients, MRI has emerged as the imaging modality in the last decade to assist in defining prostate cancer significance, location, and biologic aggressiveness. Traditional 12-core transrectal ultrasound-guided biopsy is associated with over-detection, and ultimately over-treatment of clinically insignificant disease, and the under-detection of clinically significant disease. Biopsy accuracy is improved with MRI-guided targeted biopsy and with the use of standardized risk stratification imaging score systems. Cancer detection accuracy is further improved with combined biopsy techniques that include both systematic and MRI-targeted biopsy that aid in detection of MRI-invisible lesions.

mpMRI is an area of expanding innovation that continues to refine the diagnostic accuracy of prostate biopsies. As mpMRI-targeted biopsy in prostate cancer becomes more commonplace, advances like artificial intelligence and less invasive dynamic metabolic imaging will continue to improve the utility of MRI.
Coffee consumption and colorectal cancer risk: a multicentre case-control study from Italy and Spain
Authors: Rosato Valentina , Guercio Valentina , Bosetti Cristina , Gracia-Lavedan Esther , Villanueva Cristina M. , Polesel Jerry , Toffoluti Federica , Moreno Victor , Martin Vicente , Aragonés Nuria , Dierssen-Sotos Trinidad , Olmedo-Requena Rocío , Guevara Marcela , Amiano Pilar , Salas Dolores , Fernandez-Tardon Guillermo , Alguacil Juan , Chirlaque López María Dolores , Fernandez-Villa Tania , Pérez-Gómez Beatriz , Gomez-Acebo Ines , Jiménez-Moleón Jose J. , Moreno-Iribas Conchi , José Molina Antonio , Castaño Vinyals Gemma , Pollan Marina , Kogevinas Manolis , La Vecchia Carlo , Tavani Alessandra
Published: February 2021

Background:

Coffee contains many bioactive substances that can play a role on colorectal cancer. Epidemiological evidence of coffee intake and colorectal cancer is, however, inconsistent.

Aim:

To provide further information on the risk of colorectal cancer in relation to coffee consumption.

Methods:

Data derive from two companion case-control studies conducted in Italy and Spain within the European Union Project on Health Impacts of long-term exposure to disinfection by-products in Drinking Water and the Spanish Multi-Case Control study on Cancer. These included a total of 2289 incident cases with colorectal cancer and 3995 controls with information on coffee intake. Odds ratios (ORs) and the corresponding 95% confidence intervals (CIs) were derived from unconditional logistic regression models, adjusted for study centre, sex, age, education, smoking, and other covariates.

Results:

Compared with never coffee drinkers, the OR was 0.99 (95% CI 0.95–1.02) for total coffee consumption. There was no significant trend in risk with dose or duration, the ORs being 0.95 (95% CI 0.72–1.25) for an amount of five or more cups per day of coffee and 0.95 (95% CI 0.75–1.19) for a duration of consumption of 50 years or longer. The OR was 1.04 (95% CI 0.87–1.25) for two or more cups per day of decaffeinated coffee. There were no heterogeneity across strata of various covariates, as well as no apparent differences between various anatomical subsites.

Conclusion:

This large pooled analysis of two studies shows no association of coffee and decaffeinated coffee with colorectal cancer risk.
Inflammatory bowel disease and risk of breast cancer: a meta-analysis of cohort studies
Authors: Gong Can , Xu Renyuan , Zou Ping , Zhang Yuna , Wang Xiaodong
Published: February 2021

Inflammatory bowel disease (IBD) has been found to be correlated to increased risk of both gastrointestinal and extraintestinal malignancies. It still remains conflicting whether IBD has influence on risk of breast cancer, requesting further investigations. A systematic literature research before June 2020 was conducted in PubMed and Web of Science databases. Observational studies reporting incident breast cancer after IBD diagnosis and providing measures of association were included in the meta-analysis. The pooled odds ratio (OR) with 95% confidence interval (CI) was calculated to evaluate the associations between IBD and risk of breast cancer. Our analysis included 16 cohort studies and the overall pooled OR in patients with IBD was 0.94 (95% CI, 0.82–1.06). In further subgroup analysis, no significant association with breast cancer risk among patients with Crohn’s disease (OR, 0.91; 95% CI, 0.70–1.12) and ulcerative colitis (OR, 0.99; 95% CI, 0.90–1.08). For geographic differences, the summary OR of populations in Asia (OR, 1.01; 95% CI, 0.73–1.30) was only numerically larger than that in European populations (OR, 0.90; 95% CI, 0.75–1.06). Our findings indicated that IBD had no significant influence on breast cancer risk regardless of different IBD types and geographical areas.
Cerebral amyloid angiopathy-related inflammation: current status and future implications
Authors: Wu Juan-Juan , Yao Ming , Ni Jun
Published: February 2021

Cerebral amyloid angiopathy-related inflammation (CAA-RI) is a rare but increasingly recognized subtype of CAA. CAA-RI consists of two subtypes: inflammatory cerebral amyloid angiopathy and amyloid β (Aβ)-related angiitis. Acute or subacute onset of cognitive decline or behavioral changes is the most common symptom of CAA-RI. Rapid progressive dementia, headache, seizures, or focal neurological deficits, with patchy or confluent hyperintensity on T2 or fluid-attenuated inversion recovery sequences and evidence of strictly lobar microbleeds or cortical superficial siderosis on susceptibility-weighted imaging imply CAA-RI. The gold standard for diagnosis is autopsy or brain biopsy. However, biopsy is invasive; consequently, most clinically diagnosed cases have been based on clinical and radiological data. Other diagnostic indexes include the apolipoprotein E ε4 allele, Aβ and anti-Aβ antibodies in cerebral spinal fluid and amyloid positron emission tomography. Many diseases with similar clinical manifestations should be carefully ruled out. Immunosuppressive therapy is effective both during initial presentation and in relapses. The use of glucocorticoids and immunosuppressants improves prognosis. This article reviews the pathology and pathogenesis, clinical and imaging manifestations, diagnostic criteria, treatment, and prognosis of CAA-RI, and highlights unsolved problems in the existing research.
Unexpected pure red series aplastic anemia secondary to pembrolizumab treatment: a case report and literature review
Authors: Meri-Abad Marina , Cunquero Tomás Alberto Jacobo , Jaime Alfonso Berrocal
Published: February 2021

Pembrolizumab is a treatment that has shown a survival benefit in patients with metastatic melanoma. Programmed death receptor 1 inhibitors are new therapeutic agents that produce clinical responses with a more manageable profile of adverse effects compared to chemotherapy. The most frequent adverse effects include fatigue, rash, myalgia, pyrexia and cough, with less frequent occurrence of immune-mediated adverse reactions such as colitis, pneumonitis, hepatitis and encephalitis. Immune-related hematological toxicities have been poorly described. Here we present the case of a patient with metastatic melanoma who develops pure red series aplasia after almost 3 years of treatment with pembrolizumab. To our knowledge, this is the first case of aplastic anemia during treatment with pembrolizumab, with some peculiarities compared to the published cases in the literature.
Tumor Necrotic Debris and High Nuclear Grade
Authors: Holloway Steven B. , Colon Glorimar R. , Zheng Wenxin , Lea Jayanthi S.
Published: February 2021

Objective:

Invasive pattern of endocervical adenocarcinomas (EACs) is known to influence lymph node metastasis and cancer recurrence. In this study we describe the prognostic significance of necrotic tumor debris (NTD) and tumor nuclear grade on recurrence risk stratification of early-stage cervical adenocarcinoma.

Methods:

Patients who underwent surgery from 2007 to 2018 for International Federation of Gynecology and Obstetrics (FIGO) stage IA1-IB2 EAC, for whom pathology was available for review were included in this study. Clinico-pathologic variables and clinical recurrence risk stratification (low, intermediate, or high risk) were correlated to intraluminal NTD and tumor nuclear grade (N3).

Results:

Among 50 patients meeting inclusion criteria, all were managed surgically and clinically risk stratified as low (n=33), intermediate (n=13), and high risk (n=4). Twenty-three patients (46%) were NTD-N3 negative and 27 (54%) were NTD-N3 positive. NTD-N3 was significantly associated with higher stage, tumor grade, larger tumor size, positive lymphovascular space invasion, and recurrence of disease (P=0.025). Patients with stage IB1 EAC who were stratified as intermediate or high-risk for recurrence were positive for NTD-N3. Lack of NTD-N3 had 100% negative predictive value for disease recurrence.

Conclusions:

NTD-N3, a novel pathologic finding, may be used to further stratify overall recurrence risk, and may play a role in individualization of patient care in early-stage EAC.
Cutaneous Keratocyst With D2-40 Immunoreactivity in Basal Cell Nevus Syndrome
Authors: Goggins Clare A. , Zerah Michele L. , Anatelli Florencia , Norton Scott A.
Published: February 2021

Although not a diagnostic criterion for basal cell nevus syndrome (BCNS, OMIM#109400), cutaneous cysts, particularly epidermoid cysts, are common in this condition. Cutaneous keratocysts, on the other hand, are extremely rare in general and have been identified in only 5 patients with BCNS. Here, we describe a BCNS patient with a cutaneous keratocyst that demonstrated D2-40 (podoplanin) immunoreactivity, which has been detected in odontogenic keratocysts but not cutaneous keratocysts. This finding suggests that cutaneous keratocysts may be developmentally homologous to odontogenic keratocysts and may behave similarly in terms of invasion and growth pattern.
Cutaneous Presentation of T-Cell Prolymphocytic Leukemia Mimicking Dermatomyositis
Authors: Ingrasci Giuseppe , Diaz-Perez Julio , Verne Sebastian , Romanelli Paolo , Yosipovitch Gil
Published: February 2021

T-cell prolymphocytic leukemia (TPLL) is a rare form of leukemia by T lymphocytes at a post-thymic intermediate stage of development with an α/β immunophenotype. Facial involvement is common in TPLL and displays significant heterogeneity of the lesions' description and location. TPLL also contains a wide array of histology findings, cell cytology, and molecular studies. Here, we describe a TPLL patient who presented with an ill-defined erythematous patch involving the right axilla progressing to the left axilla, upper back, and face that resembled dermatomyositis. The diagnosis of TPLL was established using flow cytometry of bone marrow and peripheral blood, and histopathology of the involved skin. Dermatologists should be aware of these unique features.
Cutaneous Polymer-Coating Embolism After Endovascular Procedures: Report of Two Cases and a Literature Review
Authors: Berríos-Hernández Mario , Abou-Jokh Casas Charigan , Sainz-Gaspar Laura , Ginarte-Val Javier , Fernández Redondo Virginia , López-Otero Diego , Aliste Carlos , Suárez-Peñaranda Jose M.
Published: February 2021

Different hydrophilic and hydrophobic polymers are used as lubricious coatings to reduce vascular traumas in minimally invasive percutaneous procedures. Although they are usually very safe, there is still a risk of serious complications in patients undergoing such procedures, mostly derived from the devices' coating detachment and systemic embolization. The lungs are the most common organ involved, followed by the central nervous system. Yet, cutaneous embolization is unusual, and only 19 cases are available in the literature. Most commonly, they present as asymptomatic retiform purpura on the lower legs, which tends to involve spontaneously. Correct clinical diagnosis is not suspected in most cases, being cholesterol emboly or vasculitis the preferred options. Time interval since surgical procedure and appearance of lesions vary widely but they generally start in the first few days. Histopathological identification of the embolus as bluish, amorphous intraluminal material in dermal vessels is diagnostic, but vasculitic signs are not present. We report 2 cases of skin lesions as the main manifestation of polymer embolization after endovascular surgical procedures. In both cases, biopsy allowed identification of embolized foreign material and lesions resolved without specific treatment.
Occupational Localized Cutaneous Argyria With Pseudo-Ochronosis in a Jeweler
Authors: Georgiadou Nikki , Singh Sarita , Wagner Bart , Goggin Patricia , Katsarma Effie , Singh Manuraj
Published: February 2021

A case of localized argyria in a 36-year-old female jeweler is described who presented with 2 discrete and asymptomatic bluish–black pigmented macules on the pulp of her left middle finger. A skin biopsy from both lesions demonstrated deposition of brown/black pigmented granules along the basement membrane zone of eccrine glands, blood vessels, nerves, and the dermo-epidermal junction fully in keeping with silver deposition. In addition, there was yellow–brown deposition seen within the interstitial dermis mimicking an early form of ochronosis, so called “pseudo-ochronosis.” This latter feature is rarely described in cases of argyria. Transmission electron microscopy and energy dispersive x-ray spectroscopy confirmed the presence of electron dense particles up to 150 nm in diameter and the presence of silver, respectively. On further questioning, the patient had a history of localized and chronic exposure to silver, which specifically involved holding and manipulating silver wires and rings over the left middle finger. This case highlights an unusual and rare presentation of localized argyria in a jeweler. In addition, our case showed preferential silver deposition on dermal elastic fibers which has not been previously described in the literature.
Ossifying Plexiform Tumor: A Case Report
Authors: Lau Sean K. , Koh Stephen S. , Cassarino David S.
Published: February 2021

Ossifying plexiform tumor is an exceedingly rare cutaneous neoplasm with distinctive histologic features. The typical microscopic appearance is that of a well-circumscribed dermal lesion composed of spindled and epithelioid cells in a myxoid appearing matrix with a plexiform architecture associated with areas of ossification. The present report details the clinicopathologic features of an ossifying plexiform tumor involving the lower extremity of a 69-year-old man. The cutaneous lesion exhibited characteristic morphologic features of this entity. By immunohistochemistry, the tumor was negative for most markers assessed, but notably exhibited diffuse positivity for SATB2. No lesional recurrence was observed. The present case serves to expand on the limited existing knowledge regarding the clinicopathologic features of this uncommon tumor. The histogenesis of ossifying plexiform tumor remains unclear; however, the demonstration of SATB2 expression in this case suggests osteoblastic differentiation.
Combining Reflective Confocal Microscopy and Dynamic Optical Coherence Tomography to Diagnose Melanoacanthoma: Case Report
Authors: Bressler Moshe Y. , Felice Skye , Yousefi Nyousha , Marghoob Nadeem , Alapati Usha , Gill Melissa , Markowitz Orit
Published: February 2021

Few reported cases discuss distinguishing between melanoma and melanoacanthoma, a seborrheic keratosis (SK) variant, using noninvasive imaging devices. We present a case of a 38-year-old man with Fitzpatrick skin type IV with an asymmetric black papule showing clinical and dermoscopic features of both melanoma and SK. Reflectance confocal microscopy (RCM) and dynamic optical coherence tomography (d-OCT) were used for further evaluation. RCM revealed acanthotic epidermis with a mixed honeycomb and cobblestone pattern, polycyclic bulbous rete ridges, and bright plump cells within entrapped, edged, dermal papillae, compatible with pigmented SK. Also noted were a population of fairly uniform bright dendritic cells scattered quite evenly at all levels of the epidermis and the notable absence of concomitant features of a melanocytic neoplasm (roundish Pagetoid cells, sheets of roundish or dendritic cells at the dermal–epidermal junction, junctional thickenings, and melanocytic nests), suggesting melanoacanthoma. d-OCT showed well-circumscribed, regular, epidermal acanthosis, superficial rounded hypodense structures, normal vascular flow, and notable absence of wiry or contoured vessels, features typically seen in SKs and benign lesions, respectively. Similarly, histologic examination revealed characteristics of pigmented SK containing a population of evenly dispersed dendritic melanocytes (decorated using Melan-A stain) confirming a diagnosis of melanoacanthoma. This case highlights the advantages of incorporating both RCM and d-OCT into clinical practice to noninvasively differentiate melanoma from its clinical mimickers.
Effect of Tranexamic Acid Administration on Postoperative Ecchymosis and Edema in Excision of Lipomas
Authors: Choi Young-Jun , Park Hyeon Jeong , Lee Heun Joo , Lee Ga-Young , Kim Won-Serk
Published: February 2021

BACKGROUND

Previous studies have shown that systemic tranexamic acid reduces bleeding during soft tissue surgeries and reduces postoperative ecchymosis and edema experienced by surgical patients.

OBJECTIVE

To evaluate the effect of postoperative tranexamic acid administration on the reduction of ecchymosis and edema after lipoma surgery.

MATERIALS AND METHODS

A total of 40 patients who underwent lipoma excision were included in the comparative analysis. In the tranexamic acid group (n = 20), 1 g of tranexamic acid was administered daily for 5 consecutive postoperative days. Tranexamic acid was not administered to the control group (n = 20). The severity of ecchymosis and edema at the first visit after surgery was rated on a 4-point scale by 2 blinded dermatologists.

RESULTS

The mean interval of the initial visit after surgery was 1.1 ± 0.5 (range: 1–4) days. Mean ecchymosis scores were significantly lower in the tranexamic acid group (0.5 ± 0.8) than in the control group (1.2 ± 1.0) (p < .05). No statistical difference was seen in mean edema scores between groups (0.5 ± 0.6 in tranexamic acid vs 0.7 ± 0.8 in control).

CONCLUSION

We observed that postoperative administration of tranexamic acid significantly decreased ecchymosis in lipoma excision.
Nicotinamide for Keratinocyte Carcinoma Chemoprevention: A Nationwide Survey of Mohs Surgeons
Authors: Desai Sheena , Olbricht Suzanne , Ruiz Emily S. , Hartman Rebecca I.
Published: February 2021

BACKGROUND

Nicotinamide has been shown to reduce keratinocyte carcinoma (KC) in high-risk patients in a randomized controlled trial setting. Data on nicotinamide's use for KC prevention are limited.

OBJECTIVE

To characterize nicotinamide prescribing patterns among Mohs surgeons.

METHODS AND MATERIALS

We surveyed 1,500 members of the American College of Mohs Surgeons regarding their demographics, use of nicotinamide, and safety perceptions. We performed multiple logistic regression analysis to evaluate correlations between physician characteristics and nicotinamide prescribing habits.

RESULTS

76.9% of survey respondents recommend nicotinamide for KC prevention. Twenty percent of respondents have recommended nicotinamide to more than 100 patients in the past year. Forty-five percent of respondents report a duration of use of 2 years or more in their patients. 63.8% of respondents had no concerns over nicotinamide's safety with long-term use. Individuals who answered “yes,” “maybe,” or “uncertain” to having safety concerns over long-term nicotinamide use and individuals in practice for more than 10 years were less likely (odds ratio [OR] 0.30, 95% confidence interval [CI] 0.13–0.71 and OR 0.20, 95% CI 0.05, 0.82, respectively) to have recommended nicotinamide to patients for KC prevention.

CONCLUSION

Given the widespread nicotinamide use among Mohs surgeons, additional studies on nicotinamide cost-effectiveness, safety, and use patterns are needed.
Willingness to Pay for Surgical Treatments for Basal Cell Carcinoma: A Population-Based Cross-Sectional Study
Authors: Kantor Jonathan
Published: February 2021

BACKGROUND

Keratinocyte carcinoma (KC) treatment accounts for approximately $5 billion in spending per year, yet no studies have evaluated the US general public's willingness to pay (WTP) for these procedures.

OBJECTIVE

To determine the monetary value of surgical KC treatments, as perceived by society, as a measure of preference.

PARTICIPANTS, METHODS AND MATERIALS

We performed an internet-based age-, sex-, and race-stratified cross-sectional survey of 425 subjects representative of the US general population. Stated WTP and desirability of electrodesiccation and curettage (EDC), excision, and Mohs micrographic surgery (MMS) for facial and extrafacial basal cell carcinoma (BCC) were assessed. A discrete choice experiment was performed using maximum likelihood estimation, and a secondary analysis was performed to determine the influence of framing MMS as the best treatment option.

RESULTS

A total of 425 subjects finished their questionnaires, yielding a completion rate of 97%. Median (interquartile range) stated WTP for EDC, excision, and MMS were $1,000 (421–2,079), $1,503 (562–3,062), and $3,006 (1,250–5,084), respectively, when MMS was framed in a standard fashion. Stated WTP for MMS increased to $3,989 (2,015–5,801) when it was framed as the best option. For BCC on the back, WTP for MMS dropped by 12%.

CONCLUSION

There is markedly higher societal WTP for MMS on both the face and trunk, regardless of whether MMS is framed as the best option. Gold-standard bias may affect WTP and desirability in medical decision-making under uncertainty, inflating the WTP of options framed as the best while decreasing the desirability of alternatives.
Positive Predictive Value of Sarcoidosis Identified in an Administrative Healthcare Registry: A Validation Study
Authors: Ceder Sylvia , Rossides Marios , Kullberg Susanna , Eklund Anders , Grunewald Johan , Arkema Elizabeth V.
Published: February 2021

Background:

International classification of disease (ICD) codes used to study sarcoidosis has previously been validated in only 1 study. We aimed to determine the accuracy of ICD codes to identify true sarcoidosis diagnoses in Sweden.

Methods:

We identified adults with at least 2 ICD codes for sarcoidosis (ICD-10 D86) at Karolinska University Hospital 2010–2013 from the National Patient Register. Of these, we randomly sampled 100 patients for validation. We collected clinical data and categorized the diagnosis of sarcoidosis as definite, probable, or unlikely. We estimated the positive predictive value for definite and probable sarcoidosis—identified with at least 2 ICD codes—with 95% confidence intervals.

Results:

We deemed 77% of the cases to be definite and 17% to be probable. The positive predictive value was 0.94 (95% confidence intervals = 0.87 to 0.98).

Conclusions:

Using at least 2 visits listing an ICD-10 code for sarcoidosis accurately identified patients with sarcoidosis from administrative health data in Sweden.
Prenatal Opioid Analgesics and the Risk of Adverse Birth Outcomes
Authors: Brogly Susan B. , Velez Maria P. , Werler Martha M. , Li Wenbin , Camden Andi , Guttmann Astrid
Published: February 2021

Background:

It is unclear whether confounding accounts for the increased risk of preterm birth and small for gestational age (SGA) birth in opioid analgesic exposed pregnancies.

Methods:

Using universal coverage health data for Ontario, we assembled a cohort of mother–infant pairs without opioid use disorder (627,172 pregnancies and 509,522 women). We estimated risk ratios (RRs) between opioid analgesics and preterm birth, SGA birth, and stillbirth; neonatal abstinence syndrome was a secondary outcome. We used high-dimensional propensity scores and sensitivity analyses for confounding adjustment.

Results:

4% of pairs were exposed, mainly to codeine (2%), morphine (1%), and oxycodone (1%). Compared with unexposed, the adjusted risk of preterm birth was higher with any (1.3, 95% confidence interval [CI] = 1.2, 1.3), first- (RR: 1.2, 95% CI = 1.2, 1.3), and second-trimester (RR: 1.3, 95% CI = 1.2, 1.4) opioid analgesic exposure. Preterm birth risk was higher for first- and second-trimester codeine, morphine, and oxycodone exposure, and for third-trimester morphine. There was a small increase in SGA with first-trimester exposure to any opioid analgesic or to codeine. Exposed pregnancies had an elevated stillbirth risk with any (RR: 1.6, 95% CI = 1.4, 1.8), first- and second-trimester exposure. Few infants had neonatal abstinence syndrome (N = 143); the risk was higher in exposed (RR: 3.6, 95% CI = 2.1, 6.0). In sensitivity analyses of unmeasured confounding, an elevated risk in exposed pregnancies persisted for preterm birth but not SGA.

Conclusions:

Opioid analgesic-exposed pregnancies had a small increased risk of preterm birth and possibly stillbirth after accounting for confounding by indication and sociodemographic factors.
Urinary phthalate metabolite concentrations and adolescent sleep duration
Authors: Sears Clara G. , Braun Joseph M.
Published: February 2021

Background:

Some environmental chemicals, such as phthalates, are capable of disrupting endocrine function related to the development and regulation of sleep patterns. However, the contribution of phthalate exposure to inadequate sleep during adolescence is unknown. We aim to evaluate the association between phthalate exposure and short sleep duration during adolescence.

Methods:

We used data from participants 16–17 years of age in the 2005–2010 cycles of the National Health and Nutrition Examination Survey. Participants reported typical sleep duration during weekdays, which we categorized into short sleep duration (less than 8 hours per night) and adequate sleep duration (8 or more hours) based on consensus guidelines. We used weighted logistic regression to evaluate the association between log10-transformed urinary phthalate metabolite concentrations and odds of short sleep duration.

Results:

An interquartile range increase in di(2-ethylhexyl) phthalate metabolites, monocarboxynonyl phthalate, monocarboxyoctyl phthalate, and mono-isobutyl phthalate was associated with 1.48 (95% confidence interval [95% CI] = 1.02, 2.16), 1.64 (95% CI = 1.17, 2.32), 1.46 (95% CI = 0.99, 2.16), and 1.92 (95% CI = 1.08, 3.43) times the odds of short sleep duration, respectively. Furthermore, we observed monotonic dose-response relations between some phthalate metabolites and odds of short sleep duration.

Conclusions:

Our results suggest that higher urinary concentrations of several phthalate metabolites are associated with short sleep duration during adolescence. Understanding the contribution of modifiable environmental factors to inadequate sleep duration is of great public health importance because inadequate sleep can have substantial health implications.
Risk of mortality and suicide associated with substance use disorder among healthcare professionals
Authors: Rodrigues Joao Vitor da Silva , Pereira José E. Guimarães , Passarelli Luisa Almeida , Guatura Gabrielle M.G.B. , El Dib Regina
Published: February 2021

BACKGROUND

Previous studies have suggested that healthcare professionals may be susceptible to substance use disorders, and among the medical specialties, anaesthesia providers appear to be overrepresented.

OBJECTIVE

We aimed to compare the prevalence of substance use-related mortality and suicides between anaesthesia and nonanaesthesia professionals.

DESIGN

Systematic review of observational studies with meta-analyses. We defined anaesthesia providers as any healthcare professionals belonging to the specialty, regardless of age and duration of employment. Other healthcare professionals served as the control group.

DATA SOURCES

Ovid Medline, EMBASE, Web of Science, Scopus, Scielo, LILACS and ProQuest databases up to March 2020.

RESULTS

Thirty-nine studies were included, 31 cross-sectional studies involving 13 819 participants and eight cohorts with a total 129 811 participants proved eligible. Results suggested a higher rate of drug-related mortality with odds ratio (OR) 2.69 [95% confidence interval (CI), 1.80 to 4.00; P < 0.001; I
2 = 0%, P = 0.55; high-certainty evidence] and suicide (OR 2.18, 95% CI, 1.33 to 3.58; P = 0.002; I
2 = 0%, P = 0.68; moderate-certainty evidence) for anaesthesia providers compared with other healthcare professionals.

CONCLUSION

High-to-moderate-certainty evidence shows that there is more than a two-fold increased rate of substance use-related mortality and suicide among anaesthesia providers compared with other healthcare professionals. Investigations examining substance abuse between healthcare professionals, with particular attention to working conditions and exposure are essential to further develop preventive strategies.
Treatment of spinal anaesthesia-induced hypotension with cafedrine/theodrenaline versus ephedrine during caesarean section
Authors: Kranke Peter , Geldner Götz , Kienbaum Peter , Gerbershagen Hans Jürgen , Chappell Daniel , Wallenborn Jan , Huljic Susanne , Koch Tilo , Keller Thomas , Weber Stephan , Kunitz Oliver , Linstedt Ulf , Eberhart Leopold H.J.
Published: February 2021

BACKGROUND

In Germany, hypotension induced by spinal anaesthesia is commonly treated with a combination of cafedrine hydrochloride (C, 200 mg) and theodrenaline hydrochloride (T, 10 mg) in 2 ml. We compared the effectiveness of C/T with ephedrine.

OBJECTIVES

The primary objectives were to assess the speed of onset and the ability to restore blood pressure without an increase in heart rate. Secondary objectives were to evaluate maternal/foetal outcomes and the number of required additional boluses or other additional measures.

DESIGN

HYPOTENS was a national, multicentre, prospective, open-label, two-armed, noninterventional study comparing C/T with ephedrine in two prospectively defined cohorts. This study relates to the cohort of patients receiving spinal anaesthesia for caesarean section.

SETTING

German hospitals using either C/T or ephedrine in their routine clinical practice.

PATIENTS

Women aged at least 18 years receiving spinal anaesthesia for caesarean section.

INTERVENTIONS

Bolus administration of C/T or ephedrine at the discretion of the attending anaesthesiologist.

MAIN OUTCOME MEASURES

Endpoints within 15 min after initial administration of C/T or ephedrine were area under the curve between the observed SBP and the minimum target SBP; and incidence of newly occurring heart rate of at least 100 beats min−1.

RESULTS

Although effective blood pressure stabilisation was achieved with both treatments, this effect was faster and more pronounced with C/T (P < 0.0001). The incidence of tachycardia and changes in heart rate were higher with ephedrine (P < 0.01). Fewer additional boluses (P < 0.01) were required with C/T. Although favourable neonatal outcomes were reported in both groups, base deficit and lactate values were greater with ephedrine (P < 0.01). Physician satisfaction was higher with C/T.

CONCLUSIONS

After C/T, tachycardia was not a problem, providing an advantage over ephedrine. Fewer additional boluses were required with C/T, suggesting greater effectiveness. An increased base deficit with ephedrine suggests reduced oxygen supply or increased demands in foetal circulation.

TRIALS REGISTRATION

Clinicaltrials.gov: NCT02893241, German Clinical Trials Register: DRKS00010740.
Perspectives of Women Who Forgo Post-mastectomy Breast Reconstruction: A Mixed Methods Analysis
Authors: Singh Tanvee , Goparaju Lakshmi , Giladi Aviram M. , Aliu Oluseyi , Song David H. , Fan Kenneth L.
Published: February 2021

Background:

Despite a growing body of evidence suggesting improved psychosocial well-being and survival after post-mastectomy breast reconstruction (PMBR), rates remain stagnant at approximately 40%. Although PMBR access and utilization have been well reported, there is much less known from the point of view of women who decide not to undergo PMBR. This study uses a mixed methods approach to fill that gap by investigating the patient-level decisions that lead to foregoing PMBR.

Methods:

A concurrent triangulation model under mixed methods research (MMR) was employed using in-depth qualitative interviews and the BREAST-Q questionnaire. Interviews were conducted until data saturation was reached and were analyzed using iterative methodologies under the grounded-theory framework. Reliability checks included inter-rater reliability using Cohen’s kappa statistic (mean kappa = 0.99) and triangulation.

Results:

Interviews with 8 patients who declined PMBR revealed (1) lack of trust in plastic surgeons; (2) reliance on self-developed support; (3) desire to resume normal life; (4) perceived lack of equivalency between reconstructed and natural breasts. Concurrent triangulation between the data revealed dissonance between the BREAST-Q scores for psychosocial well-being and reported levels of satisfaction.

Conclusions:

Women in this study highlighted certain deficits in the current pathway to reconstruction: lack of trust, resources, and counseling. Such feelings of suspicion and reported opposition to PMBR are at odds with low scores for satisfaction with breasts and sexual well-being. These findings can be used to guide efforts that engender confidence, provide support, empower vulnerable patient groups, and increase utilization of PMBR.
Treating Striae Distensae Albae in Asians: Efficacy and Safety of Combined MFU-V and CaHA
Authors: Lim Joyce Teng Ee
Published: February 2021

Background:

This study evaluated the efficacy and safety of a single treatment combining microfocused ultrasound with visualization (MFU-V) and subdermal diluted calcium hydroxylapatite with lidocaine (CaHA+) for Striae Distensae Albae (SDA).

Methods:

Ten prospectively enrolled women with abdominal, back or thigh SDA were treated with MFU-V at 3 focal depths (4.5, 3.0, and 1.5 mm), followed by 3–6 mL of diluted CaHA+ (1:1 ratio) in the same session. Outcomes were assessed at 1 month, 3 months, and 5 months postprocedure using a 5-point quartile grading scale, an SDA scoring scale, a 10-point visual analog score, and a global aesthetic improvement scale.

Results:

All patients exhibited improvement in SDA at 3 months, with further improvement at 6 months. Physicians’ assessment with the quartile grading scale showed that 8 patients improved moderately, whereas 2 had good improvement at 6 months. The mean overall SDA score was 11.6 at baseline, 11.1 (not significant) at 1 month, 7.9 (P = 0.005) at 3 months, and 6.2 (P = 0.005) at 6 months. All patients had improved global aesthetic improvement scale at 3 and 6 months, with 4 patients being much improved, and 3 patients being very much improved at 6 months. At the end of the study, all patients were less bothered with their SDA compared with baseline with a mean reduction of 2.7 in visual analog score, and all patients were satisfied or very satisfied with the treatment. No adverse events occurred.

Conclusion:

A single combination treatment of MFU-V and diluted CaHA+ improves SDA without side effects and may be considered for patients seeking to minimize SDA.
The Anatomic Features of Müller’s Muscle: A Histology Study in Chinese
Authors: Zhang Minchen , Zhou Rong , Wu Jun , Chen Lulu , Ren Zijian , Gao Weicheng
Published: February 2021

Background:

The purpose of this article is to clarify the character of Müller’s muscle in Chinese specimens.

Methods:

Ten upper eyelids of 10 formalin-fixed Chinese cadavers (9 elderly people, from 68 to 86 years of age; 1 male child, 10 years old) were examined. Full-thickness sagittal sections of the central part of the upper eyelids were microscopically examined using hematoxylin-eosin, Masson trichrome, and anti–smooth muscle actin antibodies staining.

Result:

In 9 elderly specimens, Müller’s muscle inserted onto tarsus via fibers, and the smooth muscle components decreased gradually and even faded away from the originated inferior branch of levator palpebrae superioris muscle to the upper margin of tarsus, although, in 1 child specimen, Müller’s muscle inserted directly onto tarsus rather than connective fibrous structure, and smooth muscle components did not decrease obviously. Both in elderly and young specimens, the aponeurotic structure that originated from Müller’s muscle extended to the tarsal plate.

Conclusion:

This study suggests that Müller’s muscle inserts onto the tarsus via fibrous tissue or smooth muscle, and also indicates that the smooth components of Müller’s muscle may decrease gradually in elderly people.
Assessment of the Academic Productivity of Plastic Surgeons in Saudi Arabia Using the h-index
Authors: Shah Mardan Qutaiba N. M. , Mrad Mohamed Amir , Alhumsi Taghreed R. , Almarghoub Mohammed A. , Alsavaf Mohammad B. , Alsaghier Ruah M. , Kattan Abdullah E.
Published: February 2021

Background:

Hirsch-index (or h-index) is a bibliometric measure calculated for researchers based on number of publications and their citations. This study examined the h-index of board-certified plastic surgeons in Saudi Arabia and the different factors that may influence it.

Method:

In this cross-sectional study, an electronic questionnaire was sent to 156 board-certified plastic surgeons practicing in Saudi Arabia. Using their names, we conducted an online search on Scopus, Semantic scholar, and Google scholar to calculate their h-index. Bivariate and multiple regression analyses were conducted to determine the relationship of those factors with the index.

Results:

A total of 84 surgeons participated in this study, of whom 83.3% were men. Our sample scored a mean index of 1.7 and published a mean of 5 articles. More publications and a higher academic rank predicted a higher h-index, (β = 0.79, P < 0.001) and (β = 0.14, P 0.017), respectively. On the other end of the spectrum, the country of residency training (P 0.33), the year of training completion (P 0.95), attaining fellowship training (P 0.95), the number of fellowships (P 0.20), interest in research (P 0.74), working in an academic hospital (P 0.44), or attaining a higher degree (P 0.61) were not significant independent predictors of the index.

Conclusions:

More publications and a higher rank predicted increased academic productivity among the plastic surgeons in Saudi Arabia. Despite its limitations, h-index is a useful measure that can be considered in promotions and applications to prestigious plastic surgery centers in adjunct to other factors.
Service Lines: Working Toward a Value-Based Future
Authors: Lutz John A. , Zalucki Paula M. , Finarelli Maria
Published: February 2021

The primary drivers for service line development have historically been market differentiation and profitable growth. In the current transition to value-based care, however, several other factors are now driving service line strategy. Specifically, in a value-based world, service lines must be patient centric, not provider centric; they must focus on more than hospitals; and they must be market facing.

To build the operating model of the future and succeed in a value-based world, health systems need to reimagine the clinical, operational, and financial features of today’s service lines. In working toward this future state, a coordinated, evidence-based care model with a multidisciplinary care team must replace today’s episodic care. Easy access to prompt solutions and a seamless, low-stress experience for both patients and providers will be new competitive differentiators, along with cost transparency. Outcomes, patient convenience, and the total cost of care will drive future service line relationships between health systems and physicians. The criteria for selecting physician partners will be materially different, too.

In implementing this future-state model, healthcare organizations will need to reconcile several opposing forces and tear down structural and operational silos. Health systems that can navigate through these challenges can realize numerous benefits.
Clinical approach to genetic testing in amyloid cardiomyopathy: from mechanism to effective therapies
Authors: Alreshq Rabah , Ruberg Frederick L.
Published: February 2021

Purpose of review

To highlight the evolving understanding of genetic variants, utility of genetic testing, and the selection of novel therapies for cardiac amyloidosis.

Recent findings

The last decade has seen considerable progress in cardiac amyloidosis recognition given the advancement in cardiac imaging techniques and widespread availability of genetic testing. A significant shift in the understanding of a genetic basis for amyloidosis has led to the development of disease-modifying therapeutic strategies that improve survival.

The systemic amyloidoses are disorders caused by extracellular deposition of misfolded amyloid fibrils in various organs. Immunoglobulin light-chain or transthyretin amyloidosis are the most common types associated with cardiac manifestations. Genetic testing plays a central role in the identification of genotypes that are associated with different clinical phenotypes and influence prognosis. Given the emergence of effective therapies, a systematic approach to the diagnosis of cardiac amyloidosis, with the elucidation of genotype when indicated, is essential to select the appropriate treatment.