bluuebunny/crossref_metadata_2025 huggingface dataset:
Physical Fitness and Skeletal Muscle Mass During Neoadjuvant Chemoradiotherapy in Patients with Locally Advanced Rectal Cancer: An Observational Study
Authors: Heldens Aniek F. J. M. , Bongers Bart C. , de Vos-Geelen Judith , Minis-Rutten Iris J. , Stassen Laurents P. , Buhre Wolfgang F. , van Meeteren Nico L.
Published: September 2021

Background:

Patients with locally advanced rectal cancer are often considered for neoadjuvant chemoradiotherapy before resection. This presurgical treatment can have negative effects on physical fitness, muscle mass, and treatment compliance, which can negatively influence clinical outcomes.

Objective:

The aim of this study was to evaluate physical fitness and skeletal muscle mass before and after neoadjuvant chemoradiotherapy in single subjects with locally advanced rectal cancer.

Design:

An observational longitudinal study of single subjects.

Methods:

Routine care data were retrospectively analyzed. Data consisted of tumor characteristics, clinical data (eg, side effects and toxicity of the neoadjuvant chemoradiotherapy, loss of body mass), data on performance-based physical fitness, and computed tomography–derived skeletal muscle mass. An independent-samples t test or its nonparametric equivalent was performed on outcome measures to test for significant differences between T
0 and T
1. For comparing several subgroups in this cohort, the Mann-Whitney U test was performed and correlations were studied using the Pearson or Spearman correlation coefficient, as appropriate.

Results:

Data from 25 single subjects were available. Aerobic capacity (n = 25, P = .033) and skeletal muscle mass (n = 16, P = .005) were significantly reduced after neoadjuvant chemoradiotherapy. Although not statistically significant, a large number of patients demonstrated a decrease in muscle strength and functional mobility after completing neoadjuvant chemoradiotherapy. In 14 patients (56%), adverse events, dose-limiting toxicity, or early termination of treatment occurred.

Conclusions:

Aerobic capacity and skeletal muscle mass decreased following neoadjuvant chemoradiotherapy, with large interindividual differences concerning the changes in physical fitness and muscle mass. This between-subject variability indicates the importance of a personalized treatment approach.
Predictors of Nonelective Surgery for Spinal Metastases
Authors: Khan Hammad A. , Rabah Nicholas M. , Chakravarthy Vikram , Tripathi Raghav , Krishnaney Ajit A.
Published: September 2021

Study Design.

Secondary analysis of a national all-payer database.

Objective.

Our objectives were to identify patient- and hospital-level factors independently associated with the receipt of nonelective surgery and determine whether nonelective surgery portends differences in perioperative outcomes compared to elective surgery for spinal metastases.

Summary of Background Data.

Spinal metastases may progress to symptomatic epidural spinal cord compression that warrants urgent surgical intervention. Although nonelective surgery for spinal metastases has been associated with poor postoperative outcomes, literature evaluating disparities in the receipt of nonelective versus elective surgery in this population is lacking.

Methods.

The National Inpatient Sample (2012–2015) was queried for patients who underwent surgical intervention for spinal metastases. Multivariable logistic regression models were constructed to evaluate the association of patient- and hospital-level factors with the receipt of nonelective surgery, as well as to evaluate the influence of admission status on perioperative outcomes.

Results.

After adjusting for disease-related factors and other baseline covariates, our multivariable logistic regression model revealed several sociodemographic differences in the receipt of nonelective surgery. Patients of black (odds ratio [OR] = 1.38, 95% confidence interval [CI]: 1.03–1.84, P = 0.032) and other race (OR = 1.50, 95% CI: 1.13–1.98, P = 0.005) had greater odds of undergoing nonelective surgery than their white counterparts. Patients of lower income (OR = 1.40, 95% CI: 1.06–1.84, P = 0.019) and public insurance status (OR = 1.56, 95% CI: 1.26–1.93, P < 0.001) were more likely to receive nonelective surgery than higher income and privately insured patients, respectively. Higher comorbidity burden was also associated with greater odds of non-elective admission (OR = 2.94, 95% CI: 2.07–4.16, P 
< 0.001). With respect to perioperative outcomes, multivariable analysis revealed that patients receiving nonelective surgery were more likely to experience nonroutine discharge (OR = 2.50, 95% CI: 2.09–2.98, P 
< 0.001) and extended length of stay [LOS] (OR = 2.45, 95% CI: 1.91–3.16, P < 0.001).

Conclusion.

The present study demonstrates substantial disparities in the receipt of nonelective surgery across sociodemographic groups and highlights its association with nonroutine discharge and extended LOS.

Level of Evidence: 3
Normal Anatomy of the Lumbar Sublaminar Ridge in the Lateral Recess with Potential Implications to Surgical Technique in Degenerative Spinal Stenosis
Authors: Bednar Drew A. , Son Heewon Elizabeth , Wainman Bruce
Published: September 2021

Study Design.

This is an anatomic study using cadaveric material.

Objective.

To provide anatomic descriptions of the normal lumbar sublaminar ridge in the lateral recess and its potential to impact on the exiting nerve root there, with implications to surgical technique in lumbar spinal stenosis.

Summary of Background Data.

The lateral extent of the sublaminar ridge—the bony, superior insertion site of the ligamenta flava—and its topological relationship to the nerve root are not described in the literature. In the setting of degenerative lumbar stenosis this structure can hypertrophy and impinge the nerve root within the lateral recess even after excision of the corresponding ligamentum flavum. Failure to address this may contribute to failed lateral recess decompression.

Methods.

Fifteen lumbar vertebrae, not obviously degenerated, were resected en bloc from three fixed adult human cadavers and then transected through the pedicles, leaving the posterior column and neural elements intact and articulated. The shape of the sublaminar ridge in the lateral recess and its relationship to the exiting nerve root were carefully examined.

Results.

The exiting nerve root consistently crosses the sublami- nar ridge immediately inferior to the mid-pedicle, lateral to the subarticular gutter, and on the medial aspect of the true intervertebral foramen. A hypertrophic ridge can compress the exiting root by elevating the nerve root superiorly against the bony underside of the pedicle or displacing it anteriorly against the disc or vertebral body.

Conclusion.

The sublaminar ridge in the lateral recess may contribute to degenerative lumbar stenosis. Comprehensive appreciation of this anatomy may facilitate thorough lateral recess decompression.

Level of Evidence: 4
Intraoperative Ultrasound in Spine Decompression Surgery
Authors: Tat Jimmy , Tat Jessica , Yoon Samuel , Yee Albert J.M. , Larouche Jeremie
Published: September 2021

Study Design.

Systematic review.

Objective.

The aim of this study was to review the current spine surgery literature to establish a definition for adequate spine decompression using intraoperative ultrasound (IOUS) imaging.

Summary of Background Data.

IOUS remains one of the few imaging modalities that allows spine surgeons to continuously monitor the spinal cord in real-time, while also allowing visualization of surrounding soft tissue anatomy during an operation. Although this has valuable applications for decompression surgery in spinal canal stenosis, it remains unclear how to best characterize adequacy of spinal decompression using IOUS.

Methods.

We conducted a systematic search of multiple databases including: Medline, Embase, and Cochrane Central Register of Controlled Trials Strategy. Our search terms were spine, spinal cord diseases, decompression surgery, ultrasonogra-phy, and intraoperative period. We were interested in studies that used intraoperative use of ultrasound imaging in spinal decompression surgery for the cervical, thoracic, and lumbar spine. Study quality was evaluated using the Methodological Index for Non-Randomized Studies (MINORS).

Results.

Our search strategy yielded 985 of potentially relevant publications, 776 underwent title and abstract screening, and 31 full-text articles were reviewed. We found IOUS to be useful in spine surgery for decompression of degenerative cases in all regions of the spine. The thoracic spine was unique for IOUS-guided decompression of fractures, and the lumbar spine for decompressing nerve roots. Although we did not identify a universal definition for adequate decompression, there was common description of decompression that qualitatively described the ventral aspect of the spinal cord being “free floating” within the cerebrospinal fluid. Other measurable definitions, such as spinal cord diameter or spinal cord pulsatility, were not good definitions given there was insufficient evidence and/or poor reliability.

Conclusion.

The systematic review examines the current literature on IOUS and spinal decompression surgery. We identified a common qualitative definition for adequate decompression involving a “free floating” spinal cord within the cerebrospinal fluid which indicates that the spinal cord is free from contact of the anterior elements.

Level of Evidence: 1
Characteristics of Tc-MEP Waveforms for Different Locations of Intradural Extramedullary Tumors
Authors: Kobayashi Kazuyoshi , Imagama Shiro , Ando Kei , Yoshida Go , Ando Muneharu , Kawabata Shigenori , Yamada Kei , Kanchiku Tsukasa , Fujiwara Yasushi , Taniguchi Shinichirou , Iwasaki Hiroshi , Shigematsu Hideki , Tadokoro Nobuaki , Takahashi Masahito , Wada Kanichiro , Yamamoto Naoya , Funaba Masahiro , Yasuda Akimasa , Ushirozako Hiroki , Hashimoto Jun , Morito Shinji , Takatani Tsunenori , Tani Toshikazu , Matsuyama Yukihiro
Published: September 2021

Study Design.

Prospective multicenter study.

Objective.

To examine transcranial motor-evoked potential (Tc-MEP) waveforms in intraoperative neurophysiological monitoring in surgery for intradural extramedullary (IDEM) tumors, focused on the characteristics for cervical, thoracic, and conus lesions.

Summary of Background Data.

IDEM tumors are normally curable after resection, but neurological deterioration may occur after surgery. Intraoperative neurophysiological monitoring using Tc-MEPs during surgery is important for timely detection of possible neurological injury.

Methods.

The subjects were 233 patients with IDEM tumors treated surgically with Tc-MEP monitoring at 9 centers. The alarm threshold was ≥70% waveform deterioration from baseline. A case with a Tc-MEP alert that normalized and had no new motor deficits postoperatively was defined as a rescue case. A deterioration of manual muscle test score ≥1 compared to the preoperative value was defined as postoperative worsening of motor status.

Results.

The 233 patients (92 males, 39%) had a mean age of 58.1 ± 18.1 years, and 185 (79%), 46 (20%), and 2 (1%) had schwannoma, meningioma, and neurofibroma. These lesions had cervical (C1–7), thoracic (Th1–10), and conus (Th11-L2) locations in 82 (35%), 96 (41%), and 55 (24%) cases. There were no significant differences in preoperative motor deficit among the lesion levels. Thoracic lesions had a significantly higher rate of poor baseline waveform derivation (0% cervical, 6% thoracic, 0% conus, P < 0.05) and significantly more frequent intraoperative alarms (20%, 31%, 15%, P < 0.05). Use of Tc-MEPs for predicting neurological deficits after IDEM surgery had sensitivity of 87% and specificity of 89%; however, the positive predictive value was low.

Conclusion.

Poor derivation of waveforms, appearance of alarms, and worse final waveforms were all significantly more frequent for thoracic lesions. Thus, amplification of the waveform amplitude, using multimodal monitoring, and more appropriate interventions after an alarm may be particularly important in surgery for thoracic IDEM tumors.

Level of Evidence: 3
Pseudarthrosis Following Lumbar and Lumbosacral Fusion Using the Antepsoas Technique
Authors: Tannoury Chadi , Bhale Rahul , Vora Molly , Saade Aziz , Kortbawi Rabih , Orlando Giuseppe , Das Avilash , Tannoury Tony
Published: September 2021

Study Design.

Retrospective case–control study.

Objective.

The aim of this study was to evaluate the prevalence of pseudarthrosis following antepsoas (ATP) lumbar and lumbosacral fusions.

Summary of Background Data.

Pseudarthrosis is a feared complication following spinal fusions and may affect their clinical outcomes. To date there are no sufficient data on the fusion rate following ATP lumbar and lumbosacral arthrodesis.

Methods.

This is a retrospective review of 220 patients who underwent lumbar minimally invasive antepsoas (MIS-ATP) fusions between January 2008 and February 2019 who have at least 1-year postoperative computed tomography (CT) follow-up scans. Fusion was graded using CT scans imaging and adopting a 1–4 grading scale (1, definitely fused; 2, likely fused; 3, likely not fused; 4, definitely not fused/nonunion). Grades 3 or 4 indicate pseudarthrosis.

Results.

A total of 220 patients (average age: 66 years, 82 males (37.2%), and 127 (57.7%) smokers) were included. Eight patients (3.6%) developed pseudarthrosis. A total of 693 discs were addressed using the ATP approach. Of those, 681 (98.3%) were considered fused (641 levels [92.5%] were “definitely fused” and 40 levels [5.8%] were “Likely fused”) and 12 discs (1.7%) developed pseudarthrosis (seven levels [1.0%] were “likely not fused” and five levels (0.7%) were “definitely not fused”). The highest rate of pseudarthrosis was found at L5-S1 (4.8%) compared to the L1-L5 discs (0–2%). Of 127 smokers, six developed pseudarthrosis (odds ratio = 2.3, P = 0.3). The fusion rates were 95.3% and 97.8% for smokers and nonsmokers, respectively. Of the eight patients who developed pseudarthrosis, only four (50%) were symptomatic, of whom two (25%) required revision surgery. Both of these patients were smokers. The overall revision rate due to pseudarthrosis was 0.9% (two of 220 patients).

Conclusion.

The MIS-ATP technique results in a high fusion rate (96.4% of patients; 98.3% of levels). Pseudarthrosis was noted mostly at the L5-S1 discs and in smokers.

Level of Evidence: 4
A Roadmap for Successful State Sepsis Regulations—Lessons From New York
Authors: Gigli Kristin Hittle , Rak Kimberly J. , Hershey Tina Batra , Martsolf Grant R. , Kahn Jeremy M.
Published: September 2021

OBJECTIVES:

New York state implemented the first state-level sepsis regulations in 2013. These regulations were associated with improved mortality, leading other states to consider similar steps. Our objective was to provide insight into New York state’s sepsis policy making process, creating a roadmap for policymakers in other states considering similar regulations.

DESIGN:

Qualitative study using semistructured interviews.

SETTING:

We recruited key stakeholders who had knowledge of the New York state sepsis regulations.

SUBJECTS:

Thirteen key stakeholders from three groups included four New York state policymakers and seven clinicians and hospital association leaders involved in the creation and implementation of the 2013 New York state sepsis regulations, as well as two members of patient advocacy groups engaged in sepsis advocacy.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

We used iterative, inductive thematic analysis to identify themes related to participant perceptions of the New York state sepsis policy, factors that influenced the policy’s perceived successes, and opportunities for improvement. We identified several factors that facilitated success. Among these were that policymakers engaged a diverse array of stakeholders in development, allowing them to address potential barriers to implementation and create early buy-in. Policymakers also paid specific attention to the balance between the desire for comprehensive reporting and the burden of data collection, narrowly focusing on “essential” sepsis-related data elements to reduce the burden on hospitals. In addition, the regulations touched on all three major domains of sepsis quality—structure, process, and outcomes—going beyond a data collection to give hospitals tools to improve sepsis care.

CONCLUSIONS:

We identified factors that distinguish the New York sepsis regulations from less successful sepsis polices at the federal level. Ultimately, lessons from New York state provide valuable guidance to policymakers and hospital officials seeking to develop and implement policies that will improve sepsis quality.
Genetic testing in patients with triple-negative or hereditary breast cancer
Authors: Bernstein-Molho Rinat , Evron Ella , Yerushalmi Rinat , Paluch-Shimon Shani
Published: September 2021

Purpose of review

In recent years there has been a dramatic evolution in the clinical utility of genetic testing with expanding therapeutic implications for individuals with breast cancer who harbor a germline mutation in BRCA1/2. As these therapeutic opportunities expand and evolve, this requires the clinical and research community to rethink the approach to genetic testing for individuals with breast cancer.

Recent findings

Genetic testing is evolving from traditional testing models based on pretest counseling with the aim of identifying hereditary and individual risk for purposes of screening and risk reduction to contemporary models that utilize technology to improve accessibility and oncology led mainstreaming of testing where the oncologist refers for genetic testing, discloses the results and formal counseling occurs later in the process than in traditional models. The cost and accessibility to multigene panel testing have resulted in broad uptake despite the fact that clinical utility and appropriate interpretation of results are not yet well established. Furthermore, somatic testing for genomic alterations may also yield results beyond the disease with detection of germline mutations impacting the individual and their family more broadly than anticipated.

With the establishment of poly (adenosine diphosphate-ribose) polymerase inhibitors as part of the treatment armamentarium for early and advanced breast cancer, paradigms, algorithms, and resources for genetic testing need to rapidly change in order to adapt to the evolution of germline mutations from hereditary and individual risk predictors to predictive therapeutic biomarkers.
Advances in myelodysplastic syndrome
Authors: Santini Valeria
Published: September 2021

Purpose of review

In this review, the focus is on the most recent improvements in diagnosis, prognostication and therapy of myelodysplastic syndromes (MDS) and on their relevance for clinical management.

Recent findings

Analytical methods to refine cytogenetic and molecular assessment of MDS have been proposed, improving prognostic stratification obtained from integration of clinical and genomic data. Novel agents with very different mode of action, as single drugs or added to HMA backbone, show promising clinical results in LR-MDS and HR-MDS. Luspatercept has obtained approval given the fact that in transfusion-dependent erythropoietic-stimulating agent resistant/relapsed LR-MDS induced nearly 50% of transfusion independence. Another investigational agent showing efficacy and possibly disease modifying activity in the same setting is the telomerase inhibitor imetelstat. Results from phase II study with azacytidine and pevonedistat indicate the concrete possibility to enhance durable responses compared with azacitidine single drug. In the same direction are the preliminary results of other agents with different mode of action: magrolimab, venetoclax, sabatolimab, as well as the targeted therapy with enasidenib and ivosidenib. New posttransplant maintenance strategies may concur to prolong response.

Better diagnosis and prognostic stratification may allow a more precise and personalized treatment of MDS with novel agent combinations leading to improved therapeutic algorithms.
Recognizing the Trauma of Adverse Childhood Experiences
Authors: Cole Britt S.
Published: September 2021

Childhood trauma is linked to long-term negative health outcomes throughout the lifespan and is recognized as a public health crisis. Using the framework of the four main components of trauma-informed care is a beginning step in meeting the deep, unmet needs of adult patients with sensitivity and awareness. Christian nurses recognize Jesus as the first trauma-informed provider and model his relational characteristics as they promote healing from trauma.
The Most Important Question
Authors: McCroskey Diane
Published: September 2021

End-of-life (EOL) decision making in acute care often requires difficult conversations with and for family members. Planning that may seem clear and obvious to healthcare professionals can cause intense heartache and distress when a patient's needs and desires are not expressed. Nurses can play a significant role in facilitating communication among family members during the EOL.
An update on neuropsychiatric adverse effects with second-generation integrase inhibitors and nonnucleoside reverse transcriptase inhibitors
Authors: Senneker Tessa , Tseng Alice
Published: September 2021

Purpose of review

Neuropsychiatric adverse effects (NPAE) associated with integrase strand transfer inhibitors (INSTIs) and nonnucleoside reverse transcriptase inhibitors (NNRTIs) are a growing concern, with higher rates in the real-world compared to phase III trials. This paper reviews the incidence, risk factors, and management of NPAE with second-generation INSTIs, INSTI/rilpivirine dual therapy, and doravirine.

Recent findings

Recent cohort data confirm up to 8% NPAE-associated discontinuations for dolutegravir; NPAE with dolutegravir/rilpivirine therapy are higher than with dolutegravir alone, whereas bictegravir appears similar to dolutegravir. In contrast, NPAE with cabotegravir alone or with rilpivirine appears to be low. Doravirine has NPAE rates similar to rilpivirine and lower than efavirenz. Risk factors for NPAE include female gender, concurrent abacavir use, Sub-Saharan African descent, and age, whereas underlying psychiatric conditions do not appear to increase risk. Strategies to manage NPAE include changing administration time, therapeutic drug monitoring, or regimen modification including within-class INSTI changes. People experiencing NPAE with dolutegravir may tolerate bictegravir.

Overall, mild to moderate NPAE are associated with INSTIs and newer NNRTIs. Rarely, more severe symptoms may occur and lead to treatment discontinuation. Clinicians should be aware of NPAE to identify and manage drug-related adverse effects.
Accuracy of the oscillometric method for the measurement of heart rate at rest and during mild exercise
Authors: Palatini Paolo , Lazzaretto Ilaria , Fontana Umberto , Fania Claudio
Published: September 2021

Objective:

Whether oscillometric devices provide accurate measurements of heart rate (HR) is not known. Our aim was to determine the accuracy of an oscillometric device for the measurement of HR during rest and exercise.

Methods:

The Microlife WatchBP O3, a monitor previously validated for blood pressure measurement, was tested in 36 individuals from the general population (mean age, 72.9 years; 18 men). HR was measured at rest and during stress testing on a cycle ergometer in order to increase HR by 15% or more. HR was computed from the oscillometric waves recorded during the deflation phase of the blood pressure measurement and was compared with HR measured by pulse palpation by two observers.

Results:

At rest, the mean device–observer HR difference was 0.9 ± 2.1 bpm. During exercise, the average HR increase was 20.3% and the mean device–observer difference was 0.6 ± 2.6 bpm. The device–observer HR differences were all included within ±6 bpm both at rest and during exercise. Kappa statistics showed a very good agreement between device and observers both at rest (kappa scores, 0.82–0.88) and during exercise (kappa scores, 0.81 and 0.86). The device–observer HR differences were unrelated to the level of HR or to pulse pressure.

Conclusion:

The present study shows that the oscillometric technique is able to provide reliable HR measurements during rest and mild exercise. Whether evaluation of HR performance should be included during validation testing of automatic monitors should be established by regulatory bodies.
Dietary sodium intake and sodium load is associated with arterial stiffness in children and young adults
Authors: Brady Tammy M. , Horst Gilbert , Appel Lawrence J. , Khoury Philip R. , Urbina Elaine M.
Published: September 2021

Objective:

The aim of this study was to examine the association of sodium intake (g/day) and sodium load (Na-L; mg/kcal/day) on arterial stiffness in youth.

Methods:

A cross-sectional analysis of 723 youth enrolled in a study evaluating the cardiovascular effects of obesity and type 2 diabetes mellitus (T2DM). Three measures of arterial stiffness were evaluated: brachial distensibility (BrachD), carotid-femoral pulse wave velocity (PWVcf) and augmentation index (AIx). Three-day diet histories yielded mean daily sodium and calorie intake. Youth were divided into Na-L tertiles: Low (≤1.67 mg/kcal per day); Medium (1.68--1.98 mg/kcal per day) and High (>1.98 mg/kcal per day). General linear models adjusting for demographics, % body fat, T2DM and SBP z-score evaluated the independent association of Na-L with arterial stiffness

Results:

Mean age was 17.9 years (10–24 years), 35% male, 59% nonwhite and 31% T2DM. Mean (±standard deviation) dietary intake was calories = 2074 (±797) kcal/day; Na = 3.793 (±1567) g/day; Na- = 1.86 (±0.753) mg/kcal per day. With higher levels of dietary Na intake and Na-L, measures of arterial stiffness worsened: BrachD decreased (Na intake: beta = −0.09, P = 0.003; Na-L: beta = −0.28, P < 0.0001), PWVcf increased (Na intake: beta = 0.07, P = 0.007; Na-L: beta = 0.21, P < 0.0001) but AIx did not change (Na intake: beta = −0.4, P = 0.2; Na-L: beta = 0.89, P = 0.11). In multivariable analysis, High Na-L was independently associated with BrachD, PWVcf and AIx (P < 0.05 for all), with age modifying the association of High Na-L with PWVcf and AIx.

Conclusion:

Sodium intake and load are associated with arterial stiffness, a preclinical measure of CVD, among a paediatric population. Paediatricians should stress healthy dietary choices to reduce accelerated vascular ageing.
Clinical Utility of Bruch Membrane Opening–Minimum Rim Width for Detecting Early Glaucoma in Myopic Eyes
Authors: Park Do Hee , Kook Kyung Yoon , Kang Yeon Soo , Piao Helong , Sung Mi Sun , Park Sang Woo
Published: September 2021

Précis:

Bruch membrane opening–minimum rim width (BMO-MRW) is overall a useful parameter for diagnosing early glaucoma in myopic eyes.

Purpose:

The aim of this study was to determine the diagnostic value of BMO-MRW compared with peripapillary retinal nerve fiber layer (pRNFL) thickness for detecting early glaucoma in patients with moderate to severe myopia.

Methods:

One eye was randomly selected from each of the 253 subjects (127 normal controls, 82 with glaucoma suspect, and 44 with early glaucoma). All patients underwent visual acuity testing, refractive error assessment, slit-lamp inspection, intraocular pressure measurement, fundus photography, perimetry. BMO-MRW and pRNFL thickness data were obtained using spectral-domain optical coherence tomography. Area under the receiver operating characteristic curves (AUC) for global and sectoral thickness parameters were calculated.

Results:

Global analyses for the discrimination of early glaucoma in all myopic subjects showed comparable AUCs between BMO-MRW and pRNFL thickness [AUC 0.952 (95% confidence interval, 0.918-0.975) and 0.934 (95% confidence interval, 0.896-0.961), respectively, P=0.345]. However, in sectoral analysis, BMO-MRW showed significantly better diagnostic performance than pRNFL thickness except for the superotemporal sector. The AUC for discriminating early glaucoma from glaucoma suspect, BMO-MRW showed statistically better diagnostic performance in the inferotemporal, inferonasal, superonasal, and nasal sectors. When dividing the subject based on a threshold Bruch membrane opening (BMO) area of 2.5 mm2, the diagnostic power of BMO-MRW was generally lower except for the inferonasal sector in the subgroup with a large BMO area.

Conclusions:

BMO-MRW was overall a useful parameter for diagnosing early glaucoma in myopic eyes. However, its diagnostic performance was decreased in myopic eyes with large BMO and there were no significant differences from pRNFL thickness.
Strengthening the US Response to Resistant Gonorrhea: An Overview of a Multisite Program to Enhance Local Response Capacity for Antibiotic-Resistant Neisseria gonorrhoeae
Authors: Schlanger Karen , Learner Emily R. , Pham Cau D. , Mauk Kerry , Golden Matthew , Wendel Karen A. , Amsterdam Lori , McNeil Candice J. , Johnson Kimberly , Nguyen Trang Quyen , Holderman Justin L. , Hasty Gerald L. , St. Cyr Sancta B. , Town Katy , Nash Evelyn E. , Kirkcaldy Robert D. ,   for the SURRG Working Group
Published: September 2021

Background

In 2016, Centers for Disease Control and Prevention initiated Strengthening the US Response to Resistant Gonorrhea (SURRG) in multiple jurisdictions to enhance antibiotic resistant gonorrhea rapid detection and response infrastructure and evaluate the impact of key strategies.

Methods

Eight jurisdictions were funded to establish or enhance local gonococcal culture specimen collection in sexually transmitted disease and community clinics, conduct rapid antimicrobial susceptibility testing (AST) in local laboratories, modify systems for enhanced data collection and rapid communication of results, and initiate enhanced partner services among patients with gonorrhea demonstrating elevated minimum inhibitory concentrations (MICs) to ceftriaxone, cefixime or azithromycin.

Results

Grantees incorporated genital, pharyngeal, and rectal gonococcal culture collection from all genders at participating clinics. During 2018 to 2019, grantees collected 58,441 culture specimens from 46,822 patients and performed AST on 10,814 isolates (representing 6.8% [3412] and 8.9% [4883] of local reported cases in 2018 and 2019, respectively). Of isolates that underwent AST, 11% demonstrated elevated azithromycin MICs; fewer than 0.5% demonstrated elevated ceftriaxone or cefixime MICs. Among patients whose infections demonstrated elevated MICs, 81.7% were interviewed for partner elicitation; however, limited new cases were identified among partners and contacts.

Conclusions

As a public health model to build capacity to slow the spread of emerging resistance, SURRG successfully expanded culture collection, implemented rapid AST, and implemented an enhanced partner services investigation approach in participating jurisdictions. Findings from SURRG may enhance preparedness efforts and inform a longer-term, comprehensive, and evidence-based public health response to emerging gonococcal resistance. Continued development of innovative approaches to address emerging resistance is needed.
How the Disruption in Sexually Transmitted Infection Care Due to the COVID-19 Pandemic Could Lead to Increased Sexually Transmitted Infection Transmission Among Men Who Have Sex With Men in The Netherlands: A Mathematical Modeling Study
Authors: Xiridou Maria , Heijne Janneke , Adam Philippe , Op de Coul Eline , Matser Amy , de Wit John , Wallinga Jacco , van Benthem Birgit
Published: September 2021

Background

During the COVID-19 pandemic, the disruption in care for sexually transmitted infections (STIs) and the social distancing measures have led to reductions in STI testing and sexual behavior. We assessed the impact of these COVID-19–related changes on transmission of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) among men who have sex with men (MSM) in The Netherlands.

Methods

We developed a mathematical model for CT and NG transmission among MSM, accounting for COVID-19–related changes in sexual behavior and testing in 2020 to 2021. Changes in 2020 were estimated from data from the Dutch COVID-19, Sex, and Intimacy Survey among MSM and the National Database of STI Clinics. Because of the lack of data for 2021, we examined several scenarios covering a range of changes.

Results

A reduction of 10% and 40% in STI testing of symptomatic and asymptomatic, respectively, individuals with a 10% to 20% reduction in numbers of casual partners (according to partner status and activity level) during the second lockdown, resulted in a 2.4% increase in CT prevalence, but a 2.8% decline in NG prevalence in 2021. A 5% and 30% reduction in STI testing of symptomatic and asymptomatic, respectively, individuals with the same reduction in casual partners resulted in a 0.6% increase in CT prevalence and a 4.9% decrease in NG prevalence in 2021.

Conclusions

The disruption in STI care due to COVID-19 might have resulted in a small increase in CT prevalence, but a decrease in NG prevalence. Scaling up STI care is imperative to prevent increases in STI transmission.
Evaluating the Efficacy of Eradicating Gardnerella vaginalis Vaginal Colonization With Amoxicillin: A Randomized, Double-Blind, Phase 2 Study
Authors: McNeil Candice J. , Tan Amy , Powell Jonathan A. , Pontius Angela , Lewis Andrea , Myler Noelle , Schwebke Jane R.
Published: September 2021

Background

Research suggests that Gardnerella vaginalis (GV) is the keystone pathogen in bacterial vaginosis (BV). Knowledge gaps exist regarding the role of GV eradication in the development of BV. This study was designed to test the hypothesis that vaginal colonization with GV could be eradicated by treatment of women without BV with amoxicillin, a drug highly active against GV. If GV is necessary for the development of BV, then eradication of GV may prevent the development of BV.

Methods

We conducted a randomized control trial of amoxicillin 500 mg twice daily versus placebo for 7 days in women aged 18 to 45 years without vaginitis who screened positive for vaginal colonization with GV by quantitative polymerase chain reaction. Test-of-cure visit for GV was conducted at day 21.

Results

One hundred seventy-two women met preliminary criteria and were screened for enrollment. Ninety-seven GV-positive women were randomized to receive amoxicillin versus placebo. Eradication of GV occurred in 21% of women randomized to amoxicillin versus 16% on placebo (P = 0.757). In the 4 weeks between screening and test-of-cure visit, 16 of 92 (17%) of participants developed Nugent scores greater than 3 with 8 of 92 (9%) having BV. All of these were in participants in whom GV was not eradicated (P = 0.035).

Conclusions

The study failed to show a benefit of treatment with amoxicillin to eradicate GV. No participants in whom GV was eradicated had progression to abnormal vaginal flora during the study period.
Novel Evaluation of Submandibular Salivary Gland Tissue for Use as an Alternative Postmortem Toxicology Specimen
Authors: Morton Ernest , Prahlow Joseph A. , Ianni Julie , Jones Prentiss
Published: September 2021

The collection of blood and tissue provides an opportunity for an objective comparison of autopsy results. Occasionally, a viable tissue sample is not available during autopsy. Expanding upon collected tissues to include a tissue that is accessible, is a possible drug depot, and is amendable to various analytical techniques may complement information obtained from other specimens. Given its absorption of ions, nutrients, and likely drugs via its rich blood supply, we evaluated the use of submandibular salivary gland tissue as an alternative postmortem specimen. The submandibular salivary glands of 52 decedents were excised. The tissue was homogenized, extracted, and analyzed via liquid chromatography tandem mass spectrometry for 43 opioids and 5 nonopioids. Liquid chromatography tandem mass spectrometry salivary tissue results were compared with the decedent's blood results. Results revealed that opioids were detected in salivary gland tissue at a sensitivity and specificity of 94.4% and 94.1%, respectively. Nonopioid drugs were detected at a sensitivity and specificity of 88.2% and 100.0%, respectively. This study suggests a comparable correlation exists between salivary gland tissue and blood results for certain drugs. Further evaluation is warranted. To our knowledge, this is the first report of salivary gland tissue being used for postmortem toxicology testing in humans.
Rhabdomyosarcoma—Updated Histologic and Molecular Classification for 2021
Authors: Dashti Nooshin K. , Perry Kyle , Cates Justin M. M.
Published: September 2021

Rhabdomyosarcomas are the most common soft tissue sarcoma in children and adolescents, but some specific histologic subtypes occur in adult patients. They involve various soft tissue or visceral sites, and most follow an aggressive clinical course. Currently, rhabdomyosarcomas are classified into 4 distinct clinical and morphological subtypes: embryonal, alveolar, spindle cell/sclerosing, and pleomorphic. This article reviews the clinical, histopathologic, and updated genetic features of these rhabdomyosarcoma subtypes.
Primary Alveolar Soft Part Sarcoma Arising in the Thyroid Gland: A Rare Case Report
Authors: Aggarwal Ashna , Mansour Mena
Published: September 2021

Background

Alveolar soft part sarcoma (ASPS) is a rare aggressive soft tissue sarcoma usually involving the soft tissue of thigh and buttock region in adults. In children, head and neck presentation is more common, with orbit and tongue being the preferred sites. Alveolar soft part sarcoma primarily arising in the thyroid gland is an extremely rare clinical entity, with only two other cases being reported in the literature to date.

Case

A 16-year-old boy presented with respiratory distress and enlarged thyroid gland. Hemithyroidectomy revealed well-circumscribed nests of large cells with abundant eosinophilic cytoplasm arranged in a pseudoalveolar pattern and separated by fibrous septa containing sinusoidal blood vessels. The tumor cells showed nuclear positivity for TFE3 protein and the TFE3 gene rearrangement in 79% of the nuclei. The patient's most recent chest computed tomography revealed multiple subcentimeter nodules occupying the lung bases emphasizing the aggressiveness of the disease process and the need for constant surveillance.
Rapid Autopsy Programs and Research Support: The Pre– and Post–COVID-19 Environments
Authors: Hooper Jody E.
Published: September 2021

Each rapid autopsy is a powerful opportunity to supply multiple researchers with many valuable tissue specimens at the same time. Since the beginning of the development of rapid autopsy, the overriding organizing principle for all rapid autopsy programs has been that the samples or organs must be removed and processed as rapidly as possible. To accomplish this, some rapid autopsy programs are focused on only 1 tumor type, whereas others accept patients demonstrating all tumor types and sometimes other diseases as well. Rapid autopsy programs are logistically complicated and labor-intensive structures; therefore, the key to their success is program flexibility and maintaining a multidisciplinary focus. The necessary collaborations in the complex relationships between clinicians and researchers can be broken down into a series of thought and action steps that must be understood, accepted, and practiced by all participants. A crucial part of the precase steps (prior to death) for a rapid autopsy is the study consenting process. It is extremely important that this individualized consent is obtained for postmortem specimens and that it is written in terms general enough to be used for patients with all types of diseases and for an appropriate range of future research uses. The advent of SARS-CoV-2/COVID-19 (severe acute respiratory syndrome coronavirus 2/coronavirus disease 2019) has presented new challenges and opportunities to the field of autopsy pathology. Guidelines and practice had to be created and adapted to protect physicians and staff while maximizing diagnostic yield. However, any autopsy performed on a patient dying of or with COVID-19 represents a unique opportunity to contribute to understanding the disease mechanisms and to improve death certification, thus assisting in both clinical care and the development of health public policy.
Common Differential Diagnostic Issues in Lung Cytopathology: 3 Case Reports and a Review
Authors: Fanaroff Rachel , Legesse Teklu B. , Geisinger Kim R.
Published: September 2021

The diagnosis and staging of lung malignancies increasingly rely on the use of cytologic sampling techniques, particularly endobronchial ultrasound-guided transbronchial needle aspiration. Endobronchial ultrasound-guided transbronchial needle aspiration is minimally invasive and cost-effective and, most significantly, has been shown to be equivalent to conventional sampling methods. As the role of endobronchial ultrasound-guided transbronchial needle aspiration and other cytologic sampling methods, including transthoracic fine-needle aspiration and bronchoalveolar lavage, expands, diagnostic dilemmas arise that may pose a challenge to the cytopathologist. This review discusses 3 cases that illustrate 3 differential diagnoses, with an emphasis on distinguishing lung carcinoma from benign entities.
Neuroendocrine Neoplasms of the Lung
Authors: Burke Allen , Stashek Kristin
Published: September 2021

In this review, we discuss the clinical and pathologic aspects of epithelial neuroendocrine neoplasms of the lung and compare the current classification with that of gastrointestinal (GI) neuroendocrine neoplasms. Endocrine neoplasms can be broken down into 2 major categories, which, as currently believed, are not part of a continuum, but rather distinct pathogenetic entities. Well-differentiated neuroendocrine tumors (NETs) are low-grade malignancies. In the lung, the term “carcinoid” is still applied for these, which are classified as typical or atypical. In the pancreas and GI tract, well-differentiated NETs are graded based on Ki-67 proliferative index into 3 numeric categories. Poorly differentiated neuroendocrine carcinomas (NECs) are classified in both organ systems into small cell carcinoma and large cell NEC. In this review, “NET” is used interchangeably with “well-differentiated NET.” Although often used in the GI tract, “poorly differentiated NEC” is not a term used in the lung, where the distinction between small cell carcinoma and LCNEC is more clear-cut than in the GI tract.
Squamous Cell Carcinoma of the Thymus Arising in a Spindle Cell Thymoma With Prominent Langerhans Cell Infiltrate
Authors: Legesse Teklu , Fanaroff Rachel , Burke Allen
Published: September 2021

The authors present a case of mixed thymoma and thymic squamous carcinoma. Pleural metastases from the thymoma, which was of the spindled phenotype (type A) were identified in the radical resection specimen. Lymph node metastasis from the carcinoma element was also identified. The thymoma was unique in that there was a prominent Langerhans cell background, a feature previously associated with micronodular thymoma.
Providing a Routine Medical Necessity Letter to Improve Access to Care for Our Patients
Authors: Feldman Joseph , DeBofsky Mark , Plakun Eric M. , Potts Cheryl
Published: September 2021

This column explains the value of developing routine medical necessity letters to help patients maximize the likelihood of securing insurance approval for medically necessary services for the treatment of mental and substance use disorders, including psychotherapeutic treatment. The structure proposed for such medical necessity letters is based on the terms of the Mental Health Parity and Addiction Equity Act and the landmark verdict in the federal class action known as Wit v. United Behavioral Health/Optum.
Treatment of Cannabinoid Hyperemesis With Olanzapine: A Case Series
Authors: Hsu Jennifer , Herrmann Zachary , Kashyap Saurabh , Claassen Cynthia
Published: September 2021

The use and availability of cannabis for recreational and medical purposes has become more widespread with increased legalization. Adverse health outcomes of this increased use include cannabinoid hyperemesis syndrome (CHS), which is underrecognized in medical settings. Cessation of substance use is the recommendation of choice for the complete resolution of CHS. However, interventions that provide rapid relief may be necessary in treatment-refractory cases. Little evidence is available to guide care in these cases. Here we report 4 cases of treatment-refractory CHS, all of which remitted after treatment with olanzapine. Olanzapine is known to block multiple neurotransmitter receptors involved in nausea and vomiting in chemotherapy-induced nausea and vomiting. Outcomes of the cases reported here suggest that off-label use of olanzapine may be effective in the symptomatic treatment of refractory CHS and may be the preferred treatment in cases in which comorbid psychotic symptoms or agitation are present.
Automated Segmentation of Fetal Ultrasound Images Using Feature Attention Supervised Network
Authors: Liu Pengfei , Zhao Huaici , Li Peixuan
Published: September 2021

Segmentation of anatomical structures from ultrasound images requires the expertise of an experienced clinician, but developing a machine automated segmentation process is complicated because of the existence of characteristic artifacts. In this article, we present a novel end-to-end network that enables automated measurements of the fetal head circumference (HC) and fetal abdomen circumference (AC) to be made from 2-dimensional (2D) ultrasound images during each pregnancy trimester. These measurements are necessary, because the HC and AC are used to predict gestational age and to monitor fetal growth. Automated HC and AC assessments are valuable for providing independent and objective results and are particularly useful for application in developing countries where trained sonographers are in short supply. We propose a scale attention expanding network that builds a feature pyramid inside the network, and the intermediate result of each scale is then concatenated to the feature with a fusion scheme for the next layer. Furthermore, a scale attention module is proposed for selecting the most useful scale and for reducing scale noise. To optimize the network, a deep supervision method based on boundary attention is employed. Results of experiments show that the scale attention expanding network obtained an absolute difference, Hausdorff distance, and dice similarity coefficient of 1.81 ± 1.69%, 1.22 ± 0.77%, and 97.94%, respectively, which were top results in the HC18 data set, and respective results on the abdomen set were 2.23 ± 2.38%, 0.42 ± 0.56%, and 98.04%. The experiments conducted demonstrate that our method provides a superior performance to existing fetal ultrasound segmentation methods.