bluuebunny/crossref_metadata_2025 huggingface dataset:
Ocular surface lubricants
Authors: Bielory Leonard , Wagle Preeti
Published: August 2017

Purpose of review

The purpose of this article is to provide an overview of the ocular lubricants currently available, consider the components of the various formulations and highlight the status of preservative use in the treatment of anterior ocular surface diseases.

Recent findings

The primary components of ocular surface lubrication have been, in the past, based on various cellulose formulations that increase hydration. Advances in lubrication have come from areas of the human body requiring lubrication such as the skeletal joints as well as examining the use of natural components of the tear fluid. These have resulted in novel modifications of existing tear components, for example, thiolated carboxymethyl hyaluronic acid which creates crosslinking to mechanically increase retention time for ocular surface hydration. Other proteoglycans such as lubricin, having one of the lowest coefficients of friction in nature, to a lipopolysaccharide derivative of tamarind seed, may provide a unique delivery system for lubricants and medications.

The present state of ocular surface lubrication is slowly advancing from the routine use of cellulose-based solutions and gels to more advanced replacement with natural tear components. The advances that are occurring on other lubricating surfaces of the musculoskeletal system are also providing some insights into potential use on the ocular surface.
Association of Hospital Volume and Quality of Care With Survival for Ovarian Cancer
Authors: Wright Jason D. , Chen Ling , Hou June Y. , Burke William M. , Tergas Ana I. , Ananth Cande V. , Neugut Alfred I. , Hershman Dawn L.
Published: August 2017

OBJECTIVE:

To assess whether strict adherence to quality metrics by hospitals could explain the association between hospital volume and survival for ovarian cancer.

METHODS:

We used the National Cancer Database to perform a retrospective cohort study of women with ovarian cancer from 2004 to 2013. Hospitals were stratified by annual case volume into quintiles (2 or less, 2.01–5, 5.01–9, 9.01–19.9, 20 cases or greater) and by adherence to ovarian cancer quality metrics into quartiles. Hospital-level adjusted 2- and 5-year survival rates were compared based on volume and adherence to the quality metrics.

RESULTS:

A total of 100,725 patients at 1,268 hospitals were identified. Higher volume hospitals were more likely to adhere to the quality metrics. Both 2- and 5-year survival increased with hospital volume and with adherence to the measured quality metrics. For example, 2-year survival increased from 64.4% (95% CI 62.5–66.4%) at low-volume to 77.4% (95% CI 77.0–77.8%) at high-volume centers and from 66.5% (95% CI 65.5–67.5%) at low-quality to 77.3% (95% CI 76.8–77.7%) at high-quality hospitals (P<.001 for both). For each hospital volume category, survival increased with increasing adherence to the quality metrics. For example, in the lowest volume hospitals (two or less cases annually), adjusted 2-year survival was 61.4% (95% CI 58.4–64.5%) at hospitals with the lowest adherence to quality metrics and rose to 65.8% (95% CI 61.2–70.8%) at the hospitals with highest adherence to the quality metrics (P<.001). However, lower volume hospitals with higher quality scores still had survival that was lower than higher volume hospitals.

CONCLUSION:

Although both hospital volume and adherence to quality metrics are associated with survival for ovarian cancer, low-volume hospitals that provide high-quality care still have survival rates that are lower than high-volume centers.
Delivery After 40 Weeks of Gestation in Pregnant Women With Well-Controlled Human Immunodeficiency Virus
Authors: Scott Rachel K. , Chakhtoura Nahida , Burke Margaret M. , Cohen Rachel A. , Kreitchmann Regis
Published: August 2017

OBJECTIVE:

To evaluate whether there is increased mother-to-child transmission of human immunodeficiency virus (HIV)-1 associated with deliveries at 40 weeks of estimated gestational age (EGA) or greater in pregnant women with HIV-1 viral loads of 1,000 copies/mL or less.

METHODS:

We performed a secondary analysis of the Eunice Kennedy Shriver National Institute of Child Health and Human Development International Site Development Initiative Perinatal and Longitudinal Study in Latin American Countries and International Maternal Pediatric Adolescent AIDS Clinical Trials P1025 cohorts. We included pregnant women with HIV-1 with recent viral loads of 1,000 copies/mL or less at the time of delivery and compared delivery outcomes at between 38 and less than 40 weeks EGA with delivery outcomes at 40 weeks EGA or greater, the exposure of interest. Our primary outcome of interest was mother-to-child transmission, and secondary outcomes included indicators of maternal and neonatal morbidity. We examined the association between EGA and mother-to-child transmission using Poisson distribution. Associations between EGA and secondary outcomes were examined through bivariate analyses using Pearson χ2 and Fisher exact test or the nonparametric Mann-Whitney U test.

RESULTS:

Among the 2,250 eligible neonates, eight neonates were infected with HIV-1 (overall transmission rate 0.4%, 95% CI 0.2–8.1%, 40 weeks EGA or greater 0.5% [3/621, 95% CI 0.2–1.4%], less than 40 weeks EGA 0.3% [5/1,629, 95% CI 0.1–0.7%]); there was no significant difference in transmission by EGA (rate ratio 1.57, 95% CI 0.24–8.09, P=.77). There was no difference in maternal viral load between the two groups nor was there a difference in timing of transmission among neonates born with HIV-1.

CONCLUSION:

In pregnant women with well-controlled HIV-1, the risk of mother-to-child transmission did not differ significantly by EGA at delivery, although we were not powered to demonstrate equivalence of proportions of mother-to-child transmission between EGA groups.
Using an Elastic Band Device After a Severe Obstetric Pubic Symphyseal Separation
Authors: Lasbleiz Jeremy , Sevestre François-Xavier , Moquet Pierre-Yves
Published: August 2017

BACKGROUND:

Severe separation of the pubic symphysis is a rare delivery complication. Facing this pathology, we decided to study a new elastic band device.

METHOD:

To evaluate the elastic band device, clinical (pain-rated) and imaging (magnetic resonance imaging and radiography) evaluations with and without the device were performed. The elastic band device is a European Conformity-certified medical device, which is made of neoprene straps, that reduces the mobility of the pelvis and the use of the internal rotator muscles.

EXPERIENCE:

Once the elastic band device was in place, on postpartum day 1, radiography showed a decrease of the pubic width from 41 to 12 mm. Furthermore, pain decreased from 10 of 10 to 2 of 10 in 2 days, allowing the patient to ambulate and avoid surgery. After 1 month, the pubic width (6 mm) and anatomy were recovered but minor pain was still present with hip rotatory movements. The elastic band device was worn 24 hours a day from postpartum days 1–90 and 12 hours a day from postpartum days 90 to 150; afterward, the patient returned to normal life without the elastic band device.

CONCLUSION:

Use of an elastic band device was associated with a reduction of the pubic width and pain associated after obstetric pubic symphysis separation.
Comparison of Subcuticular Suture Type for Skin Closure After Cesarean Delivery
Authors: Buresch Arin M. , Van Arsdale Anne , Ferzli Myriam , Sahasrabudhe Nicole , Sun Mengyang , Bernstein Jeffrey , Bernstein Peter S. , Ngai Ivan M. , Garry David J.
Published: August 2017

OBJECTIVE:

To compare the rate of wound complications among women who underwent cesarean delivery through a Pfannenstiel skin incision followed by subcuticular closure with either poliglecaprone 25 suture or polyglactin 910 suture.

METHODS:

Patients undergoing nonemergent cesarean delivery at or beyond 37 weeks of gestation were randomized to undergo subcuticular skin closure with either poliglecaprone 25 or polyglactin 910. The primary outcome was a wound composite outcome of one or more of the following: surgical site infection, wound separation, hematoma, or seroma within the first 30 days postpartum. To detect a reduction in the primary outcome rate from 12% to 4%, with a power of 0.90 and a two-tailed α of 0.05, 237 women per study group were required. Analysis was performed according to the intent-to-treat principle.

RESULTS:

From May 28, 2015, to August 5, 2016, 275 women were randomized to poliglecaprone 25 and 275 to polyglactin 910, of whom 520 (95%) were included in the final analysis: 263 in the poliglecaprone 25 group [of whom 231 (88%) actually underwent poliglecaprone 25 closure) and 257 in the polyglactin 910 group [of whom 209 (81%) actually underwent polyglactin 910 closure]. The groups were similar in demographic characteristics, medical comorbidities, and perioperative characteristics. Poliglecaprone 25 was associated with a significantly decreased rate of overall wound complications when compared with polyglactin 910, 8.8% compared with 14.4% (relative risk 0.61, 95% CI 0.37–0.99; P=.04).

CONCLUSION:

Closure of the skin after cesarean delivery with poliglecaprone 25 suture decreases the rate of wound complications compared with polyglactin 910 suture.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, NCT02459093.
Optimal Order of Successive Office Hysteroscopy and Endometrial Biopsy for the Evaluation of Abnormal Uterine Bleeding
Authors: Sarkar Papri , Mikhail Emad , Schickler Robyn , Plosker Shayne , Imudia Anthony N.
Published: August 2017

OBJECTIVE:

To estimate the optimal order of office hysteroscopy and endometrial biopsy when performed successively for evaluation of abnormal uterine bleeding.

METHODS:

Patients undergoing successive office hysteroscopy and endometrial biopsy were included in a single-blind, prospective, randomized trial. The primary outcome was to evaluate the effect of order of procedures on patients' pain score. Prespecified secondary outcomes include procedure duration, hysteroscopic visualization of the uterine cavity, endometrial sample adequacy, and number of attempts at biopsy. Pain scores were assessed using a visual analog scale from 0 to 10 and endometrial sample adequacy was determined from the histopathology report. Hysteroscopy images were recorded. Sample size of 34 per group (n=68) was determined to be adequate to detect a difference of 20% in visual analog scale score between hysteroscopy first (group A) and biopsy first (group B) at α of 0.05 and 80% power.

RESULTS:

Between October 2015 and January 2017, 78 women were randomized to group A (n=40) and group B (n=38). There was no difference in global pain perception [7 (0–10) vs 7 (0–10); P=.57, 95% CI 5.8–7.1]. Procedure duration [3 (1–9) vs 3 (2–10), P=.32, 95% CI 3.3–4.1] and endometrial sample adequacy (78.9% vs 75.7%, P=.74) were similar in both groups. Group A patients had better endometrial visualization (P<.001) than group B based on the hysteroscopic images: excellent (50% vs 7.9%), good (20% vs 34.2%), and fair (22.5% vs 44.7%); group B participants required fewer endometrial biopsy attempts at obtaining adequate tissue sample (two vs one; P<.001, 1.6–1.9).

CONCLUSION:

Patients having successive office hysteroscopy and endometrial biopsy for evaluation of abnormal uterine bleeding, the global pain perception, and time required are independent of the order in which procedures are performed. Performing hysteroscopy first ensures better image, whereas biopsy first yields adequate tissue sample with fewer attempts.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, NCT02472184.
Novel insights of disability assessment in adult myositis
Authors: Espinosa-Ortega Hector Fabricio , Moreno-Ramirez Mariana , Alexanderson Helene
Published: August 2017

Purpose of review

To review the novel development of standardized clinical outcome measures used in adult patients with idiopathic inflammatory myopathies (IIMs). A further aim was to determine what aspects of IIM are covered by these outcome measures according to the International Classification of Functioning, Disability and Health (ICF).

Recent findings

The sporadic inclusion body myositis functional assessment (sIFA) is the first diagnosis-specific patient-driven patient-reported outcome measure. The adult myositis assessment tool (AMAT) is a new outcome measure assessing physical performance. Also, new criteria to assess response to treatment have been presented for both adults and children with IIM. The ICF provides a standardized frame and structure to report outcome, including functional disability. Using this framework, it is evident that there is a lack of validated patient-reported outcome measures to assess disease aspects important to patient, and that no studies have evaluated life-style factors such as physical activity in these patients.

The sIFA will ensure patient-relevant patient-reported assessment of activity limitations in patients with inclusion body myositis. The AMAT is a partly validated tool that needs to be used in clinical trials for further validation. The response criteria will enhance assessment of individual response to different treatments.
Myoepithelioma of Soft Tissue With Both Squamous and Adipocytic Metaplasia
Authors: Elsensohn Ashley , Mo Joshua H. , Maly Tyler J. , Lee Patrick K. , de Feraudy Sebastien
Published: August 2017

Soft tissue, or cutaneous, myoepitheliomas are rare tumors arising solely from a myoepithelial origin. These neoplasms are typically associated with uncertain differentiation and can contain cellular morphologies that include spindle, plasmacytoid, epithelioid, or clear cell forms. Soft tissue myoepitheliomas are commonly found on the lower limbs and in the pelvic girdle but can occur throughout the body. A small minority display heterogenous differentiation, typically osseous or cartilaginous in nature. Squamous and adipocytic cell types are much rarer. We report the case of myoepithelioma of soft tissue with both squamous and adipocytic metaplasia. In the largest myoepithelioma series of 101 soft tissue myoepitheliomas, there were only 2 cases of squamous metaplasia and 1 case of adipocytic metaplasia. Our case displays the unique occurrence of 2 rare histologic findings occurring simultaneously within an already uncommon neoplasm.
Measurement Bias of Polyp Size at Colonoscopy
Authors: Sakata Shinichiro , Klein Kerenaftali , Stevenson Andrew R. L. , Hewett David G.
Published: August 2017

BACKGROUND:

The success of current and proposed strategies to reduce colorectal cancer (CRC) incidence and mortality rates are fundamentally based on measurement accuracy.

OBJECTIVE:

The aim of this study was to evaluate the densities of colorectal polyps individually measured at colonoscopy and whether measurement bias is a systemic phenomenon among colonoscopists.

DESIGN:

A population-wide, observational study.

SETTING:

All hospitals of the government-funded health system in Brisbane, Australia.

PATIENTS:

Our study investigated measurement bias at colonoscopy through systematic analysis of 8,591 individual polyp measurements recorded from 12,597 colonoscopies. All colonoscopies performed over a 12-month period between December 1, 2014, and November 30, 2015, were included.

RESULTS:

A total of 12,597 electronic colonoscopy reports were individually reviewed, hospital-by-hospital, and 8,591 individual size measurements from 18,276 detected polyps (47%) were obtained.

LIMITATIONS:

Our study is limited because the true size of unresected polyps was unknown. We chose not to compare pathologic and histologic sizes as resection specimens sent to pathologists are morphologically different and are measured differently to the pre-resection polyp images seen by endoscopists.

CONCLUSIONS:

Colonoscopists may be inaccurate in the measurement of polyp size and appear biased towards and against certain size measurements. These findings cast doubt over the validity of international post-polypectomy surveillance guidelines and the safety of optical diagnosis as a potential management paradigm for diminutive colorectal polyps. They also question the historical accuracy of polyp size data and risk estimates upon which these strategies were based.
Analysis of Wait Times and Impact of Real-Time Surveys on Patient Satisfaction
Authors: Pena Sandra M. , Lawrence Naomi
Published: August 2017

BACKGROUND

Increasing emphasis is being placed on patient satisfaction, which is linked to reimbursement rates. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a national, standardized survey used to assess patient satisfaction. Its limitations include the length of the survey, delay in administration, and generalization to all specialties. Ideal patient satisfaction surveys should collect information in a way that allows for corrective action in a timely manner.

OBJECTIVE

To evaluate patient dissatisfaction with wait time using a short, in-office, real-time survey.

METHODS

A cross-sectional study in which patients from one provider's office completed a real-time survey. These results were compared with the CAHPS survey data of the same time period.

RESULTS

Seven hundred fifty-six patients were seen and 251 surveys were collected. The real-time survey response rate was 33% compared with 9% for the CAHPS survey. Overall, 95.74% of patients who completed the real-time survey were satisfied with their wait times and the duration of their visit, versus 84.2% from the CAHPS survey.

CONCLUSION

Implementation of a short in-office survey immediately after patient care can provide better feedback that can be used to ensure that improvement measures are aimed at making significant strides in improving overall health outcomes for patients.
Serum uric acid levels and hormone therapy type: a retrospective cohort study of postmenopausal women
Authors: Jung Jae H. , Song Gwan G. , Lee Young H. , Kim Jae-Hoon , Hyun Myung H. , Choi Sung J.
Published: August 2017

Objective:

Serum uric acid levels increase in postmenopausal women, but decrease when hormone therapy (HT) is administered. No study has, however, evaluated the effects of different types of HT on serum uric acid levels. We therefore examined whether estrogen therapy (ET), estrogen plus progestogen therapy (EPT), and tibolone use affected serum uric acid levels in this population.

Methods:

We performed a retrospective cohort study of postmenopausal women. From 2005 to 2015, postmenopausal women who had undergone blood uric acid-level testing at least twice were enrolled. Participants were grouped according to HT regimen: ET, EPT, or tibolone. The nonhormone therapy group did not receive HT. Differences in serum uric acid levels were examined in each group. Our analysis was adjusted to accommodate different follow-up intervals for individual participants. Multiple variables were adjusted using the Tukey-Kramer method. Age, body mass index, hypertension, diabetes mellitus, dyslipidemia, estimated glomerular filtration rate, alcohol consumption, smoking status, and comedications were also adjusted.

Results:

After adjusting for multiple variables, the serum uric acid level increased to 0.87 ± 0.27 mg/dL (least squares mean ± standard error) in the nonhormone therapy group, and serum uric levels in the EPT group were found to be significantly lower (−0.38 ± 0.29 mg/dL, P < 0.001). The serum uric acid levels in the ET and tibolone groups did not, however, differ significantly from the nonhormone therapy group level.

Conclusions:

We attribute our findings to the effects of progestogen, rather than estrogen.
PAIN AND ANTISEPSIS AFTER OCULAR ADMINISTRATION OF POVIDONE-IODINE VERSUS CHLORHEXIDINE
Authors: Oakley Carmen , Allen Penny , Hooshmand Joobin , Vote Brendan J. T.
Published: August 2017

Purpose:

To investigate ocular bacterial count before and after antisepsis with aqueous chlorhexidine (AC) or povidone-iodine (PI) and to assess discomfort with each agent.

Methods:

Bacterial swabs were taken from participants' eyes before and after antisepsis. These underwent microscopy, culture, and sensitivity testing. Aqueous chlorhexidine drops were administered to left eyes and PI to right eyes. Participants rated their pain (scale 0–10) for each eye but were blinded to the type of drop.

Results:

There were 20 participants (17 women, 3 men), and the mean age was 43 years. Pain scores were significantly higher in right (PI) than in left (AC) eyes (mean 7 vs. mean 2, P < 0.001). No abnormalities were detected on specimen microscopy and gram staining. Seven preantisepsis swabs (three left and four right) grew bacteria in culture. Two postantisepsis swabs grew bacteria in primary culture plate (1 after AC and 1 after PI). For an additional one post-PI swab, bacteria were detected in enrichment broth only.

Conclusion:

The efficacy of AC and PI are similar, and patient discomfort is lower with AC. Aqueous chlorhexidine is a good alternative to PI for antisepsis before intravitreal injection.
Psychotropics, Environmental Temperature, and Hospital Outcomes in Older Medical Patients
Authors: Mangoni Arduino A. , Kholmurodova Feruza , Mayner Lidia , Hakendorf Paul , Woodman Richard J.
Published: August 2017

Purpose

The authors investigated whether the use of psychotropics and environmental temperature on admission influence hospital length of stay (LOS) and mortality in older medical patients.

Methods

Clinical and demographic characteristics, Charlson Comorbidity Index, use of psychotropic and nonpsychotropic drugs, hospital LOS, and mortality were retrospectively collected in medical patients 65 years and older (n = 382) admitted to a metropolitan teaching hospital during 5 consecutive heat waves (HWs) between 2007 and 2009. Patients admitted either before or after each HW, matched for HW period, age, and admission day of the week, served as controls (non-HW, n = 1339).

Results

Total number of psychotropic and nonpsychotropic drugs, Charlson Comorbidity Index, comorbidities, number of daily admissions, LOS, and mortality were similar in the HW and non-HW groups. After adjusting for clinical and demographic confounders, competing risks regression showed that psychotropic use, particularly antipsychotics, predicted increased LOS during non-HW (subdistribution hazard ratio: 95% CI, 0.82, 0.72–0.94; P = 0.003) but not HW (subdistribution hazard ratio: 95% CI, 0.89, 0.69–1.14; P = 0.36) periods. The effect of psychotropics on LOS during normal weather conditions was particularly evident in the old-old subgroup (difference [SE] in coefficients between non-HW and HW periods: −0.52 [0.25], P = 0.036 in patients >80 years; 0.11 [0.19], P = 0.54, in patients 65–80 years). By contrast, psychotropics did not predict hospital mortality during non-HW or HW periods.

Conclusions

Psychotropic use on admission, particularly antipsychotics, predicted hospital LOS, but not mortality, in older medical patients, particularly those older than 80 years, during normal environmental temperature. However, there was no effect of psychotropics on LOS during extreme heat.
A Pilot Study of the Usefulness of a Single Olanzapine Plasma Concentration as an Indicator of Early Drug Effect in a Small Sample of First-Episode Psychosis Patients
Authors: Zabala Arantzazu , Bustillo Mariana , Querejeta Imanol , Alonso Marta , Mentxaka Oiane , González-Pinto Ana , Ugarte Amaia , Meana J. Javier , Gutiérrez Miguel , Segarra Rafael
Published: August 2017

Purpose/Background

Studies analyzing concentration-effect relationships in second-generation antipsychotics have reported contradictory results in chronic schizophrenia. No data are available for the early stages of the disease. The present study aims to evaluate the association between a single olanzapine plasma concentration, clinical response, and severity of adverse effects in first-episode psychosis (FEP); to test the utility of various plasma breakpoints as markers of early response to treatment; and to identify variables affecting olanzapine concentrations.

Methods

Data from 23 compliant FEP patients receiving olanzapine monotherapy (5–30 mg/d) were evaluated 2 months after beginning treatment. Clinical symptoms were assessed using the Positive and Negative Syndrome Scale and the Montgomery-Åsberg Depression Rating Scale. Adverse effects were rated using the Udvalg for Kliniske Undersøgelser scale. Plasma samples were drawn at 11 (SD, 1) hours after dosing and analyzed with high-performance liquid chromatography/tandem mass spectrometry.

Findings

Consistent with findings on chronic disease, dose, age, sex, weight, and cigarettes/day accounted for some of the variability in olanzapine concentrations. While no relationship was found between olanzapine concentrations and adverse effects or improvement of depressive symptoms, response of psychotic symptoms was associated with concentrations between 22.56 and 77.92 ng/mL. Plasma breakpoints did not show sufficiently high specificity, resulting in a large number of false-positive results.

Implications

Although olanzapine concentrations do not seem to be reliable indicators of early drug effect in FEP, they may still prove useful for detecting noncompliance, as well as pharmacokinetically relevant comorbidities or genetic particularities in drug metabolism.
Hearing Preservation During Cochlear Implantation and Electroacoustic Stimulation in Patients With SLC26A4 Mutations
Authors: Roh Kyung Jin , Park Sera , Jung Jin Se , Moon In Seok , Kim Sung Huhn , Bang Mi Young , Choi Jae Young
Published: August 2017

Background and Objectives:

Patients with SCL26A4 mutations presenting with Mondini deformity and enlarged vestibular aqueduct (EVA) tend to have comparable residual hearing. Although cochlear implantation (CI) produces good results in this group, deterioration of residual hearing can be an adverse event after surgery due to accompanying cochlear malformation and perilymph leakage during cochleostomy. The purpose of this study was to investigate if CI in patients with SCL26A4 mutations via the round window (RW) approach could achieve preservation of residual hearing, and to evaluate their speech reception with electroacoustic stimulation (EAS).

Subjects and Methods:

This is a retrospective chart review of eight patients with bilateral EVA, who were bi-allelic patients with SCL26A4 mutations. CI was performed in all patients by a single surgeon using the RW approach. Audiological results were compared before and after implantation.

Results:

Additional hearing loss after CI was less than 10 dBHL in five out of eight patients. Average hearing deterioration after CI was 8.75 dB (range, 0–26). Six out of eight patients used EAS mode after CI. The acoustic stimulation frequency ranged from 271 to 438 Hz. Patients showed better speech recognition in quiet and in noise using EAS mode compared with electrical stimulation alone.

Conclusions:

Preservation of residual hearing could be achieved after CI in patients with the SLC26A4 mutation via the RW approach. For successful preservation of residual hearing, application of newly-developed soft electrode and meticulous surgical is necessary. Our study showed that patients with the SLC26A4 mutation can be good candidates for EAS surgery.
Comparing Outcomes Following Salvage Microsurgery in Vestibular Schwannoma Patients Failing Gamma-knife Radiosurgery or Microsurgery
Authors: Lee Hyun-Jin , Kim Mi Joo , Koh Seung Hyun , Chang Won Seok , Moon In Seok
Published: August 2017

Objective:

The increasing use of primary gamma-knife radiosurgery (GKS) for the treatment of vestibular schwannoma (VS) has led to a concomitant increase in the number of patients requiring salvage surgery for GKS failure. When patients underwent GKS as the primary treatment, it is known that dissecting tumor from adjacent nerves during salvage surgery is more difficult. In this report, we share our clinical experience with such patients and analyze the clinical findings of patients with tumor regrowth/recurrence.

Study Design:

Retrospective chart review.

Setting:

Tertiary center.

Patients:

Nine patients who underwent salvage surgery for VS regrowth/recurrence after GKS or microsurgery were enrolled.

Main Outcome Measures:

Symptom progression, radiological changes, intraoperative findings, and surgical outcomes were evaluated and compared.

Results:

Six patients with previous GKS and three with previous microsurgery underwent salvage microsurgery. The most obvious symptom of tumor regrowth was aggravation of hearing loss. Salvage surgery in all patients was limited to subtotal or near-total resection via a translabyrinthine/transotic approach. Severe adhesion, thickening, and fibrosis were more prominent findings in the GKS than in the previous microsurgery group. Dissection of the tumor from the facial nerve was more difficult in the GKS than in the microsurgery patients. Despite anatomical preservation of the facial nerve in all the six patients, three in the GKS group, but none in the revision microsurgery group, had worsening of facial nerve function.

Conclusion:

Salvage microsurgery of VS after failed GKS is more difficult than revision microsurgery, and the facial nerve outcomes are relatively poor. Therefore, the primary method of VS treatment should be carefully chosen. Additional imaging studies are recommended in patients with a sudden change in hearing loss who underwent GKS.
Initial Alpha-Fetoprotein Response Predicts Prognosis in Hepatitis B-related Solitary HCC Patients After Radiofrequency Ablation
Authors: Yu Su Jong , Kwon Jee Hye , Kim Won , Yoon Jung-Hwan , Lee Jeong Min , Lee Jae Young , Cho Eun Ju , Lee Jeong-Hoon , Kim Hwi Young , Jung Yong Jin , Kim Yoon Jun
Published: August 2017

Background:

Radiofrequency ablation (RFA) is effective for early-stage hepatocellular carcinoma but recurrence is problem.

Goals:

To identify prognostic factors including alpha-fetoprotein (AFP) for overall survival and intrahepatic recurrence after RFA.

Patients and Methods:

Not only naïve but also previously treated patients with solitary hepatitis B virus-related hepatocellular carcinoma <5 cm were prospectively enrolled and a ≥50% decrease from baseline to 1 month after RFA was defined as an initial AFP response. Tumor responses were assessed by the modified response evaluation criteria in solid tumors.

Results:

Among 255 patients, 156 patients (61.2%) developed intrahepatic recurrence. Radiologic progression occurred in 54.8% (86/157) in the AFP responders and 71.4% (70/98) in the AFP nonresponders. In multivariate analysis, a history of previous treatment [hazard ratio (HR), 2.037; P=0.015 for percutaneous ethanol injection vs. none; and HR, 2.642; P<0.001 for transarterial chemoembolization vs. none] and an initial AFP nonresponse (HR, 1.899; P<0.001) were independent predictors of accelerated progression after RFA. Moreover, those who had a history of previous treatment and did not achieve an initial AFP response had significantly unfavorable overall survival (HR, 3.581; P<0.001) and the increased risk of intrahepatic remote recurrence (HR, 5.385; P<0.001) compared with those with an initial AFP response and no history of previous treatment.

Conclusions:

Biological response evaluation by the measurement of serial AFP levels is a useful predictor of overall survival and intrahepatic remote recurrence after RFA. Therefore, an initial AFP response may aid in determining the need of closer follow-up as a therapeutic response indicator of RFA.
Addressing Occupational Fatigue in Nurses
Authors: Steege Linsey M. , Pinekenstein Barbara J. , Rainbow Jessica G. , Arsenault Knudsen Élise
Published: August 2017

OBJECTIVE

The aim of this study was to describe the current state of fatigue risk management systems (FRMS) to address nurse fatigue in hospitals.

BACKGROUND

Although multiple studies have examined sources and consequences of fatigue, little is known about the current state of FRMS.

METHODS

This study used a sequential exploratory mixed-method design including a survey of nurse leaders from across the United States.

FINDINGS

Although healthcare organizations have implemented strategies to address fatigue, most participants’ organizations did not have a formal FRMS in place. Monitoring individual nurses’ levels of fatigue and using tools to predict fatigue risk were rare.

CONCLUSIONS

Significant opportunities exist to implement formal FRMS in healthcare. Nursing leaders, in partnership with other organizational leaders, should develop a formal plan to monitor fatigue and implement multiple levels of interventions to prevent fatigue and mitigate its consequences.
Acyanotic Hypoxia in a Febrile Child
Authors: Murphy Fiona , Blackham Julian , Moppett John , Lyttle Mark
Published: August 2017

Glucose-6-phosphate dehydrogenase deficiency affects approximately 400 million people worldwide and is an X-linked disorder most commonly found in individuals of African, Asian, Mediterranean, and Middle Eastern descent. It can present with acute hemolysis in response to certain drugs, infections, or fava beans, and affected individuals may not be aware that they have glucose-6-phosphate dehydrogenase deficiency. This case illustrates the importance of those working in the acute and urgent care sector having an awareness of the condition and the value of a full set of vital signs in an unwell child.
Morphologic and Immunohistochemical Study of Clear Cell Carcinoma of the Uterine Endometrium and Cervix in Comparison to Ovarian Clear Cell Carcinoma
Authors: Ju Baohui , Wang Jianmei , Yang Bo , Sun Lin , Guo Yuhong , Hao Quan , Wu Jianghua
Published: August 2017

Endometrial clear cell carcinoma (ECCC) and clear cell adenocarcinoma of the cervix (CCAC) are uncommon gynecologic cancers that have morphologic and phenotypic features similar to ovarian clear cell carcinoma (OCCC), but the 3 entities may not be completely identical. This study identified the morphologic and phenotypic characteristics and the differences between ECCC and CCAC in comparison to OCCC. The morphologic features of 16 ECCCs, 7 CCACs, and 22 OCCCs are described. The immunoprofiles of hepatocyte nuclear factor (HNF) 1β, napsin A, estrogen, progesterone, p53, and Ki-67 were assessed. The results confirm that clear cell carcinomas of the gynecologic tract have a similar spectrum of histopathologic features with the exception that ECCCs have focal solid components more often than CCACs and OCCCs and ECCCs have a slightly higher average mitotic index. Similar to OCCCs, both ECCCs and CCACs were positive for HNF1β and napsin A, and rarely expressed estrogen and progesterone. HNF1β was a sensitive marker for clear cell carcinoma at all 3 sites. Napsin A was less sensitive in ECCCs than in OCCCs (56.3% vs. 90.9%, P=0.021). The average Ki-67 index was higher in ECCCs than in OCCCs (52.6% vs. 39.1%) in hotspot scoring, and more ECCC cases had a higher expression (56.3% vs. 22.7%). Diffuse p53 expression, which is associated with TP53 mutation, was observed slightly more often in ECCCs than in OCCCs (25% vs. 9.1%). Our findings revealed morphologic and immunophenotypic similarities and differences among different gynecologic clear cell carcinomas, which may help in improving diagnosis and knowledge of CCC in the female genital tract.
Gray matter alteration associated with pain catastrophizing in patients 6 months after lumbar disk surgery: a voxel-based morphometry study
Authors: Chehadi Omar , Suchan Boris , Konietzny Kerstin , Köster Odo , Schmidt-Wilcke Tobias , Hasenbring Monika I.
Published: August 2017

Introduction:

Pain catastrophizing (PC), the increased attention to harmful aspects of pain (magnification), and the belief of low controllability (helplessness) has been shown to be important in the maintenance of pain. A growing research on structural alterations in chronic pain revealed an association between PC and brain areas that are involved in affective and cognitive pain processing. However, little is known about a differential effect of the components magnification and helplessness.

Objective:

The aim of this study was to identify brain regions associated with overall PC and with the single components of magnification and helplessness.

Methods:

We investigated 29 patients 6 months after lumbar disk surgery using voxel-based morphometry. Magnification and helplessness were assessed with subscales of the Avoidance-Endurance Questionnaire (AEQ); overall PC was computed using the sum score. The structural brain imaging data were preprocessed and analyzed using SPM8 and VBM8. Multiple regression analyses were performed with PC scales as predictors and depression as covariate.

Results:

Pain catastrophizing was significantly associated with cortical gray matter in brain areas involved in processing attentional, sensory, and affective aspects of pain, including the left posterior cingulate cortex, supplementary motor area, and medial frontal gyrus. In addition, we provide preliminary evidence for brain structure association related to magnification and helplessness.

Conclusion:

This study provides evidence for PC-related structural alterations in patients with low back pain, which are consistent with findings from previous research in different chronic pain disorders. This study is the first to evaluate brain changes related to differential domains of PC.
Accuracy and Repeatability of Automated Injector Versus Manual Administration of an MRI Contrast Agent—Results of a Laboratory Study
Authors: Endrikat Jan , Barbati Ron , Scarpa Marcella , Jost Gregor , (Ned) Uber Arthur E.
Published: August 2017

Objective

The aim of this study was to compare flow rates over time and the deviations from the target flow rate of a magnetic resonance imaging contrast agent achieved by an automated injector versus manual injection.

Materials and Methods

In this laboratory study, the magnetic resonance contrast agent gadobutrol was repeatedly injected by an injector and by 10 experienced technologists. Six scenarios with 2 different target flow rates (1 and 5 mL/s), 2 different contrast volumes (10 and 20 mL), and 2 different intravenous (IV) catheters (22 gauge and 20 gauge) were tested. The flow rates over time were recorded. The target variable was the average absolute deviation and average absolute percentage deviation from the target flow rate.

Results

The flow rates over time achieved by an injector were almost identical. Slight deviations from the target flow rate occurred during ramp-up and ramp-down only. Those of manual injection showed high variability over the whole course of the injection. In the 1 mL/s scenarios, the injector deviated from the target flow rate by 0.06 mL/s or less (≤6%) and in the 5 mL/s scenarios by 1.02 mL/s or less (<20%). For the manual injections at the same flow rates, these figures were 0.35 mL/s or less (≤35%) and 3.1 mL/s or less (≤62%).

Conclusions

Injector administration of a magnetic resonance contrast agent minimally deviated from the target flow rate, whereas manual injection varied widely. Injector administration is more accurate and repeatable.
The Nature and Natural History of Posterior Cortical Atrophy Syndrome
Authors: Panegyres Peter K. , Goh Judy , McCarthy Michael , Campbell Andrew I.
Published: August 2017

A prospective longitudinal evaluation of 12 patients over a 16-year interval using clinical neurological and imaging data to determine whether posterior cortical atrophy syndrome (PCA) related to early-onset Alzheimer disease (AD) and to examine its natural history. Our 12 patients had a median age of onset of 56 years (range, 48 to 63 y) and were followed for a median of 6 years (range, 3 to 9 y). Patients either presented with complex visual phenomena or developed them with time. Six patients underwent flurodeoxyglucose and Pittsburgh investigational compound B imaging which showed a mismatch between metabolic activity and amyloid deposition with reduced metabolism in parieto-occipital regions on flurodeoxyglucose positron emission tomography and diffuse neocortical uptake of amyloid without occipital predominance. All patients progressively deteriorated using a quality of life and total functional capacity assessments and this change is similar to the natural history of other early-onset AD variants (typical amnestic presentation, logopenic, and frontal). Two patients had neuropathologic assessments and were shown to have AD using standard pathologic criteria. Of interest, 5 of our 12 patients had occupations strongly dependent on visuospatial functioning. PCA is a syndrome that is most likely a variant of early-onset AD and our correlative clinical, structural, functional, and amyloid imaging data, along with neuropathologic studies in 2 patients, support this concept. The natural history of PCA shows progression with time and this trajectory seems to reflect that of other variants of early-onset AD.
Depth perception: the need to report ocean biogeochemical rates as functions of temperature, not depth
Authors: Brewer Peter G. , Peltzer Edward T.
Published: August 2017

For over 50 years, ocean scientists have oddly represented ocean oxygen consumption rates as a function of depth but not temperature in most biogeochemical models. This unique tradition or tactic inhibits useful discussion of climate change impacts, where specific and fundamental temperature-dependent terms are required. Tracer-based determinations of oxygen consumption rates in the deep sea are nearly universally reported as a function of depth in spite of their well-known microbial basis. In recent work, we have shown that a carefully determined profile of oxygen consumption rates in the Sargasso Sea can be well represented by a classical Arrhenius function with an activation energy of 86.5 kJ mol
−1
, leading to a
Q
10
of 3.63. This indicates that for 2°C warming, we will have a 29% increase in ocean oxygen consumption rates, and for 3°C warming, a 47% increase, potentially leading to large-scale ocean hypoxia should a sufficient amount of organic matter be available to microbes. Here, we show that the same principles apply to a worldwide collation of tracer-based oxygen consumption rate data and that some 95% of ocean oxygen consumption is driven by temperature, not depth, and thus will have a strong climate dependence. The Arrhenius/Eyring equations are no simple panacea and they require a non-equilibrium steady state to exist. Where transient events are in progress, this stricture is not obeyed and we show one such possible example.

This article is part of the themed issue ‘Ocean ventilation and deoxygenation in a warming world’.
Climate change and ocean deoxygenation within intensified surface-driven upwelling circulations
Authors: Bakun Andrew
Published: August 2017

Ocean deoxygenation often takes place in proximity to zones of intense upwelling. Associated concerns about amplified ocean deoxygenation arise from an arguable likelihood that coastal upwelling systems in the world's oceans may further intensify as anthropogenic climate change proceeds. Comparative examples discussed include the uniquely intense seasonal Somali Current upwelling, the massive upwelling that occurs quasi-continuously off Namibia and the recently appearing and now annually recurring ‘dead zone’ off the US State of Oregon. The evident ‘transience’ in causal dynamics off Oregon is somewhat mirrored in an interannual-scale intermittence in eruptions of anaerobically formed noxious gases off Namibia. A mechanistic scheme draws the three examples towards a common context in which, in addition to the obvious but politically problematic remedy of actually reducing ‘greenhouse’ gas emissions, the potentially manageable abundance of strongly swimming, finely gill raker-meshed small pelagic fish emerges as a plausible regulating factor.

This article is part of the themed issue ‘Ocean ventilation and deoxygenation in a warming world’.
Photosynthetic oxygen production in a warmer ocean: the Sargasso Sea as a case study
Authors: Richardson Katherine , Bendtsen Jørgen
Published: August 2017

Photosynthetic O
2
production can be an important source of oxygen in sub-surface ocean waters especially in permanently stratified oligotrophic regions of the ocean where O
2
produced in deep chlorophyll maxima (DCM) is not likely to be outgassed. Today, permanently stratified regions extend across approximately 40% of the global ocean and their extent is expected to increase in a warmer ocean. Thus, predicting future ocean oxygen conditions requires a better understanding of the potential response of photosynthetic oxygen production to a warmer ocean. Based on our own and published observations of water column processes in oligotrophic regions, we develop a one-dimensional water column model describing photosynthetic oxygen production in the Sargasso Sea to quantify the importance of photosynthesis for the downward flux of O
2
and examine how it may be influenced in a warmer ocean. Photosynthesis is driven in the model by vertical mixing of nutrients (including eddy-induced mixing) and diazotrophy and is found to substantially increase the downward O
2
flux relative to physical–chemical processes alone. Warming (2°C) surface waters does not significantly change oxygen production at the DCM. Nor does a 15% increase in re-mineralization rate (assuming
Q
10
 = 2; 2°C warming) have significant effect on net sub-surface oxygen accumulation. However, changes in the relative production of particulate (POM) and dissolved organic material (DOM) generate relatively large changes in net sub-surface oxygen production. As POM/DOM production is a function of plankton community composition, this implies plankton biodiversity and food web structure may be important factors influencing O
2
production in a warmer ocean.

This article is part of the themed issue ‘Ocean ventilation and deoxygenation in a warming world’.
Ocean ventilation and deoxygenation in a warming world: introduction and overview
Authors: Shepherd John G. , Brewer Peter G. , Oschlies Andreas , Watson Andrew J.
Published: August 2017

Changes of ocean ventilation rates and deoxygenation are two of the less obvious but important indirect impacts expected as a result of climate change on the oceans. They are expected to occur because of (i) the effects of increased stratification on ocean circulation and hence its ventilation, due to reduced upwelling, deep-water formation and turbulent mixing, (ii) reduced oxygenation through decreased oxygen solubility at higher surface temperature, and (iii) the effects of warming on biological production, respiration and remineralization. The potential socio-economic consequences of reduced oxygen levels on fisheries and ecosystems may be far-reaching and significant. At a Royal Society Discussion Meeting convened to discuss these matters, 12 oral presentations and 23 posters were presented, covering a wide range of the physical, chemical and biological aspects of the issue. Overall, it appears that there are still considerable discrepancies between the observations and model simulations of the relevant processes. Our current understanding of both the causes and consequences of reduced oxygen in the ocean, and our ability to represent them in models are therefore inadequate, and the reasons for this remain unclear. It is too early to say whether or not the socio-economic consequences are likely to be serious. However, the consequences are ecologically, biogeochemically and climatically potentially very significant, and further research on these indirect impacts of climate change via reduced ventilation and oxygenation of the oceans should be accorded a high priority.

This article is part of the themed issue ‘Ocean ventilation and deoxygenation in a warming world’.