bluuebunny/crossref_metadata_2025 huggingface dataset:
Engineering estimates of impurity fluxes on the ITER port plugs
Authors: Kotov Vladislav
Published: August 2016

Predictions of impurity fluxes are required for design analysis of the ITER optical diagnostics. In the present paper a simplified model is proposed for calculation of the neutral impurity fluxes on the recessed surfaces which are not in direct contact with plasma. The method is based on the Monte-Carlo simulation of the neutral particles transport in prescribed and fixed plasma background. The plasma parameters are projected from experimental observations, scalings and ITER modelling results. Blobs are approximated as stationary hot species. Results of 2D simulations with toroidally uniform wall and of the ‘2.5D model’ are presented. In this latter the 3D geometry of ports is implemented, but details of the incident ion flux distribution on the first wall panels are neglected. The calculated worst case gross deposition rate of Be in the middle of the port plug faces reaches almost 0.1 nm s−1. At the same time, the obtained Be erosion to deposition ratio at those locations is always larger than 5, indicating high probability of net erosion conditions there.
Disseminated Intravascular Coagulation in Pregnancy: Insights in Pathophysiology, Diagnosis, and Management
Authors: Erez O. , Mastrolia S.A. , Thachil J.
Published: August 2016

(Am J Obstet Gynecol. 2015;213(4):452–463)

In this review, the authors discuss the underlying processes that lead to disseminated intravascular coagulation, the importance of an early diagnosis for this condition, and the principles of treatment. Disseminated intravascular coagulation is a serious medical emergency that is the result of uncontrolled systemic activation of the hemostatic system. This process creates a widespread microvascular thrombosis that can reduce the blood supply to various organs and potentially cause organ failure and uncontrolled bleeding. It is typically characterized by diffuse bleeding from multiple organs, hemorrhagic necrosis, microthrombi in small blood vessels, and thrombi in medium and large blood vessels. The underlying mechanisms of action may be endothelial dysfunction that leads to platelet activation and trophoblast disruption that releases tissue factor into the circulatory system. Disseminated intravascular coagulation can be brought about by a number of obstetric complications, including acute peripartum hemorrhage, placental abruption, preeclampsia, elevated liver enzymes/low platelet count syndrome, retained stillbirth, septic abortion, intrauterine infection, amniotic fluid embolism, and acute fatty liver of pregnancy.
The Multidisciplinary Approach to the Care of the Obese Parturient
Authors: Ghaffari N. , Srinivas S.K. , Durnwald C.P.
Published: August 2016

(Am J Obstet Gynecol. 2015;213(3):318–325)

Maternal obesity is associated with a higher risk of many complications, including gestational hypertension, preeclampsia, gestational diabetes, cesarean delivery, miscarriage, anesthesia difficulties, failed induction of labor, postpartum hemorrhage, infectious morbidity, and venous thromboembolism. The risks for the neonates involved in these pregnancies include prematurity, stillbirth, macrosomia, and childhood obesity. As the management of obese patients throughout pregnancy is such an important issue, the authors of this clinical opinion have provided a comprehensive and multidisciplinary set of guidelines for patient management.
Epilepsy in Pregnancy and Reproductive Outcomes: A Systematic Review and Meta-Analysis
Authors: Viale Luz , Allotey John , Cheong-See Fiona , Arroyo-Manzano David , Mccorry Dougall , Bagary Manny , Mignini Luciano , Khan Khalid S. , Zamora Javier , Thangaratinam Shakila
Published: August 2016

(Lancet. 2015;386(10006):1845–1852)

Quantification of the risks associated with pregnancy in women with epilepsy, one of the most common chronic disorders affecting women of reproductive age, is important in order to provide patients with appropriate counselling and care. In this study, a systematic review and meta-analysis of the medical literature was undertaken to estimate the association between epilepsy in pregnancy, with or without exposure to antiepileptic drugs, and reproductive outcomes.
Evaluation of the Systemic Inflammatory Response Syndrome Criteria for the Diagnosis of Sepsis Due to Maternal Bacteremia
Authors: Maguire P.J. , Power K.A. , Downey A.F. , O’Higgins A.C. , Sheehan S.R. , Turner M.J.
Published: August 2016

(Int J Gynaecol Obstet. 2016;133(1):116–119)

Sepsis is defined as the systemic inflammatory response syndrome (SIRS) with an infectious etiology, including but not limited to bacteremia. Recent studies have confirmed that there is overlap between standard SIRS criteria and the normal physiology of pregnancy. In 2014, a customized obstetric sepsis screening tool was implemented for pregnant and postpartum women in Irish hospitals. These obstetric sepsis screening criteria differed from standard criteria in heart rate (≥100 beats/min, obstetric vs. >90 beats/minute, standard) and leukocyte count (<4.0 or >16.9×109/L, obstetric vs. <4.0 or >12.0×109/L, standard). The authors of the present study evaluated this customized obstetric SIRS screening tool and compared its effectiveness with that of the standard SIRS screening tool, for the diagnosis of maternal sepsis in the presence of maternal bacteremia.
Effects of Preoperative Serotonin-Receptor-Antagonist Administration in Spinal Anesthesia-induced Hypotension: A Randomized, Double-blind Comparison Study of Ramosetron and Ondansetron
Authors: Shin H.J. , Choi E.S. , Lee G.W. , Do S.H.
Published: August 2016

(Reg Anesth Pain Med. 2015;40(5):583–588)

Spinal anesthesia is associated with adverse effects such as arterial hypotension and bradycardia. The goal of this study was to evaluate the efficacy of 2 serotonin receptor antagonists in preventing these effects. Ramosetron is a receptor antagonist that is stronger and longer-lasting than others of its kind and has been observed to decrease hypotension resulting from spinal anesthesia. Ondansetron is another receptor antagonist that has been reported to diminish spinal-anesthesia–related hypotension in both obstetric and nonobstetric patients.
Shared Genetic Predisposition in Peripartum and Dilated Cardiomyopathies
Authors: Ware J.S. , Li J. , Mazaika E. , Yasso C.M. , DeSouza T. , Cappola T.P. , Tsai E.J. , Hilfiker-Kleiner D. , Kamiya C.A. , Mazzarotto F. , Cook S.A. , Halder I. , Prasad S.K. , Pisarcik J. , Hanley-Yanez K. , Alharethi R. , Damp J. , Hsich E. , Elkayam U. , Sheppard R. , Kealey A. , Alexis J. , Ramani G. , Safirstein J. , Boehmer J. , Pauly D.F. , Wittstein I.S. , Thohan V. , Zucker M.J. , Liu P. , Gorcsan J. , McNamara D.M. , Seidman C.E. , Seidman J.G. , Arany Z.
Published: August 2016

(N Engl J Med. 2016;374:233–241)

It is possible that peripartum cardiomyopathy is influenced by genetic factors, though this remains unclear. Similar to idiopathic dilated cardiomyopathy, this disease is associated with decreased systolic function, enlarged cardiac dimensions, and nonspecific histologic findings. These similarities are significant in that idiopathic dilated cardiomyopathy has been shown to be caused by a number of gene mutations. The authors of this study sequenced the DNA of 172 women suffering from peripartum cardiomyopathy to investigate whether there was a contribution from variants in the 43 genes known to be associated with dilated cardiomyopathy.
Maternal Cardiac Evaluation During Uncomplicated Twin Pregnancy With Emphasis on the Diastolic Function
Authors: Ghi T. , Degli Esposti D. , Montaguti E. , Rosticci M. , Tancredi S. , Youssef A. , Di Giovanni M.V. , Pilu G. , Borghi C. , Rizzo N.
Published: August 2016

(Am J Obstet Gynecol. 2015;213(3):376.e1–e8)

Evaluating the cardiac function of pregnant women has shown that when echocardiograms reveal abnormalities there is a heightened risk of obstetric complications such as hypertensive disorders and placental insufficiency. However, most of the studies investigating this association have only focused on singleton gestations and there is a scarcity of literature on how maternal hemodynamics might affect twins. The authors of this paper attempted to address this lack of data by comparing outcomes for twin gestations with the findings of echocardiograms that were used to evaluate maternal cardiac function after the first trimester.
Accuracy of Conventional Digital Palpation and Ultrasound of the Cricothyroid Membrane in Obese Women in Labour
Authors: You-Ten K.E. , Desai D. , Postonogova T. , Siddiqui N.
Published: August 2016

(Anaesthesia.2015;70(11):1230–1234)

The primary aim of this study was to determine the accuracy of identifying the cricothyroid membrane in women in labor using conventional digital palpation and ultrasonography. The study was undertaken at a teaching hospital in Canada and included “patient” and “participant” groups. The patient group included women between 37 and 40 weeks’ gestation who were in labor. Twenty-eight obese (body mass index >30 kg/m2) and 28 nonobese women were enrolled in the study. Demographic data including age, weight, and height along with morphometric measurements (neck circumference, thyromental distance and sternomental distance) were obtained. The participant group (n=10) included anesthesia staff, fellows, and residents working in the labor and delivery unit of the hospital. They were randomized to palpate the cricothyroid membrane of an obese or nonobese parturient. The study design allowed a participant to participate more than once. These participants were randomized each time they participated. Among these ten, three participants palpated the cricothyroid membrane of nonobese patients only and 7 palpated the cricothyroid membrane of both obese and nonobese patients. Years of training and experience in performing cricothyroidotomy were recorded for each participant. No one had performed a cricothyroidotomy within the previous 12 months before the study.
Higher Risk of Homicide Among Pregnant and Postpartum Females Aged 10–29 Years in Illinois, 2002–2011
Authors: Koch Abigail R. , Rosenberg Deborah , Geller Stacie E. ,   for the Illinois Department of Public Health Maternal Mortality Review Committee Working Group
Published: August 2016

OBJECTIVE:

To examine whether being pregnant or postpartum was associated with excess risk for homicide among females in Illinois and to describe the association between pregnancy status and homicide by race, ethnicity, and age group.

METHODS:

This is a retrospective, multicohort, ecologic study of females of reproductive age in Illinois between 2002 and 2011 using Illinois Department of Public Health maternal mortality data and vital records data. We compared pregnancy-associated homicides with live births using χ2 tests. Among maternal deaths in the state, we calculated mortality rates per 100,000 live births for homicide and other violent causes and the leading direct obstetric causes. We calculated aggregate, pregnancy-associated, and nonpregnancy associated homicide rates stratified by race or ethnicity and age group.

RESULTS:

There were 636 pregnancy-associated deaths in Illinois from 2002 to 2011. Of these, 82 (13%) were the result of homicide (5.0 [95% confidence interval (CI) 4.0–6.2]/100,000 live births). There were 931 homicides among females of reproductive age not associated with pregnancy (2.88 [95% CI 2.70–3.07]/100,000 population). More than half of the homicides were women aged 20–29 years (n=53 [64.6%]), non-Hispanic black women (n=43 [52.4%]), women residing in Cook County (n=47 [57.3%]), and unmarried women (n=57 [69.5%]). Pregnant and postpartum females aged 10–29 years were at twice the risk of homicide compared with their nonpregnant or postpartum counterparts (relative risk 2.20 [95% CI 1.70–2.85]). Non-Hispanic black and Hispanic females experienced higher rates of homicide than non-Hispanic white females irrespective of pregnancy or age.

CONCLUSION:

Although all violence against women must be addressed, we recommend that state maternal mortality review committees, in addition to reviewing deaths resulting from obstetric and clinical causes, should conduct in-depth reviews of pregnancy-associated homicides and other violent deaths.
Association of Early Amniotomy After Foley Balloon Catheter Ripening and Duration of Nulliparous Labor Induction
Authors: Battarbee Ashley N. , Palatnik Anna , Peress Danielle A. , Grobman William A.
Published: August 2016

OBJECTIVE:

To evaluate the association between early amniotomy after ripening with a Foley balloon catheter and duration of labor induction.

METHODS:

In this retrospective matched cohort study, 546 nulliparous women with a singleton viable gestation undergoing cervical ripening with a Foley balloon catheter were compared based on timing of amniotomy after catheter removal: early (defined as artificial rupture of membranes less than 1 hour after Foley removal) compared with no artificial rupture of membranes in the first hour. Women in the early amniotomy group were matched to women in the control group according to health care provider type, cervical examination after Foley removal, and indication for induction in a one-to-one ratio. Bivariable and multivariable analyses were performed to determine whether early amniotomy was associated with vaginal delivery within 24 hours and other adverse maternal and neonatal outcomes. Cox proportional hazard regression was used to compare time intervals from catheter removal to complete dilation and from catheter removal to delivery.

RESULTS:

In univariable analysis, the frequency of vaginal delivery within 24 hours of Foley placement was higher in women with early amniotomy (42.9% compared with 33.0%, P=.02). The median time intervals from Foley catheter removal to complete dilation (9.0 hours compared with 12.1 hours) and to delivery (10.6 hours compared with 13.8 hours) were also significantly shorter for women who underwent early amniotomy (P<.001 for both). There were no significant differences in any other adverse maternal or neonatal outcomes. In multivariable analysis, early amniotomy remained associated with higher odds of vaginal delivery within 24 hours and shorter times from catheter removal to complete dilation and to delivery.

CONCLUSION:

Early amniotomy after Foley balloon catheter removal is associated with shorter duration of labor induction among nulliparous women.
Polyethylene Glycol 3350 and Docusate Sodium Compared With Docusate Sodium Alone After Urogynecologic Surgery
Authors: Edenfield Autumn L. , Siddiqui Nazema Y. , Wu Jennifer M. , Dieter Alexis A. , Garrett Melissa A. , Visco Anthony G.
Published: August 2016

OBJECTIVE:

To compare time to first bowel movement and additional gastrointestinal outcomes between women receiving polyethylene glycol 3350 (PEG3350) and docusate sodium and docusate sodium alone after urogynecologic surgery.

METHODS:

Participants received twice-daily 100 mg docusate sodium and were randomized to daily 1) PEG3350 or 2) inert placebo for 5 days after urogynecologic surgery. They completed bowel diaries, Bristol stool scale, validated Patient Assessment of Constipation Symptom Questionnaire, and Patient Assessment of Constipation Quality-of-Life Questionnaire preoperatively and 1 week after surgery. Our primary outcome was time to first bowel movement after surgery. To detect a 1-day difference in time to first bowel movement (4 compared with 3 days), 63 participants were needed in each group.

RESULTS:

From September 2012 through March 2015, 145 women were randomized and 131 (90%) analyzed: 66 received PEG3350, and 65 received placebo. Polyethylene glycol 3350 did not significantly reduce time to first bowel movement after surgery compared with placebo (2.77 days [interquartile range 1.86–3.40] compared with 2.92 days [interquartile range 1.85–4.02] P=.25). Women in the PEG3350 group were less likely to take additional laxatives postoperatively, and the PEG3350 group was more adherent to the study drug regimen. Questionnaire scores, fecal incontinence, and urgency were similar between groups.

CONCLUSION:

In women taking routine docusate sodium after urogynecologic surgery, adding PEG3350 postoperatively did not reduce time to first bowel movement.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, https://clinicaltrials.gov, NCT01691742.
Disparities in Surgical Care Among Women With Endometrial Cancer
Authors: Mannschreck Diana , Matsuno Rayna K. , Moriarty James P. , Borah Bijan J. , Dowdy Sean C. , Tanner Edward J. , Makary Martin A. , Stone Rebecca L. , Levinson Kimberly L. , Temkin Sarah M. , Fader Amanda N.
Published: August 2016

OBJECTIVE:

To analyze contemporary U.S. use of minimally invasive surgery for the treatment of endometrial cancer and associated inpatient complications and costs.

METHODS:

In this retrospective cohort study, the National Inpatient Sample database was analyzed in patients with nonmetastatic endometrial cancer who underwent hysterectomy during 2012–2013. Hierarchical multiple logistic regression and propensity score matching were used to compare complications among patients treated with open compared with minimally invasive hysterectomy surgery. Cost of care was also compared using generalized linear modeling.

RESULTS:

We identified 9,799 patients; 52.4% underwent open and 47.6% minimally invasive hysterectomy. Many patients (43.4%) were treated at low-volume hospitals (less than 10 endometrial cancer cases annually). Patients were less likely to undergo open surgery in high-volume compared with low-volume hospitals (51.8% compared with 58.1%, respectively; adjusted odds ratio [OR] 0.35, 95% confidence interval [CI] 0.13–0.94) and more likely to undergo open surgery in rural compared with urban teaching hospitals (75.6% compared with 51.1%, respectively; adjusted OR 14.34, 95% CI 9.66–21.27), government compared with nonprofit hospitals (61.3% compared with 51.1%, respectively; adjusted OR 1.66, 95% CI 1.15–2.39), and in patients of black (67.9%; OR 1.46, 95% CI 1.30–1.65) and “other” race (60.5%; adjusted OR 2.39, 95% CI 1.99–2.87) compared with white race (49.2%, referent). Open surgery was associated with increased perioperative complications (adjusted OR 2.80, 95% CI 2.48–3.17) and a $1,243 increase in cost per case compared with minimally invasive approaches (P<.001). Using minimally invasive surgery for 80% of study patients may have averted 2,733 complications and saved approximately $19 million.

CONCLUSION:

Most U.S. women with endometrial cancer continue to be treated with open hysterectomy surgery despite increased complication rates and financial costs associated with this approach. A disparity in endometrial cancer surgical care exists that is affected by patient race and hospital geography and cancer volumes.
Association of a Biweekly Research Workgroup With Enhanced Resident Research Productivity
Authors: Brackmann Melissa , Reynolds R. Kevin , Uppal Shitanshu , McLean Karen
Published: August 2016

Almost all residency programs require a resident research project, yet teaching and mentoring of the required skills are often lacking. We established an every-other-week gynecologic oncology research workgroup at our institution for obstetrics and gynecology faculty, fellows, and residents with the goal of increasing resident research education, involvement, and productivity. An informal, discussion-style format was adopted as a forum for brainstorming research ideas, formulating study protocols, and collaborating on institutional review board submissions. Additional aims included editorial feedback on abstracts and manuscripts as well as oral presentation preparation. The academic productivity of trainees mentored by the gynecologic oncology division was queried for 27 months before and 27 months after workgroup initiation, specifically assessing resident involvement in institutional review board submission, abstract presentation, and manuscript preparation. Institution of our workgroup was associated with a dramatic increase in resident research output, including manuscript preparation and presentations at national meetings. We describe our experience because it may benefit other residency programs wishing to improve both resident research education and productivity.
Self-Administered Lidocaine Gel for Intrauterine Device Insertion in Nulliparous Women
Authors: Rapkin Rachel B. , Achilles Sharon L. , Schwarz E. Bimla , Meyn Leslie , Cremer Miriam , Boraas Christy M. , Chen Beatrice A.
Published: August 2016

OBJECTIVE:

To evaluate self-administration of vaginal lidocaine gel to decrease pain with intrauterine device (IUD) insertion in nulliparous women.

METHODS:

In this randomized, double-blind, placebo-controlled trial, women self-administered 2% lidocaine or placebo vaginal gel 5 minutes before IUD insertion. The primary outcome was change in pain from baseline to IUD insertion on a 100-mm visual analog scale. We also assessed pain after speculum insertion, tenaculum placement, uterine sounding, and 5 minutes after IUD insertion. Secondary outcomes included patient acceptability, ease of IUD insertion, and need for pain medication for up to 7 days.

RESULTS:

From July 2012 to May 2013, 59 women were randomized; 30 received lidocaine gel and 29 placebo. Baseline demographics, including age, race, and body mass index, were similar. There was no difference in median change in pain during IUD insertion in women receiving lidocaine (61 mm [interquartile range 53–71]) compared with placebo (69 mm [interquartile range 63–80], P=.06). Women receiving lidocaine experienced less pain with tenaculum placement (32 mm [interquartile range 18–54]) compared with placebo (56 mm [interquartile range 26–75], P=.02). Most (76%) women were satisfied with their IUD insertion experience and 86% would probably or definitely recommend an IUD to a friend. Thirty-four percent of women required pain medication for at least 3 days after IUD insertion.

CONCLUSION:

For nulliparous women, self-administered vaginal lidocaine gel does not reduce pain with IUD insertion, but does decrease pain with tenaculum placement.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, http://clinicaltrials.gov, NCT01534520.
Management of Terminal Osseous Overgrowth of the Humerus With Simple Resection and Osteocartilaginous Grafts
Authors: Fedorak Graham T. , Cuomo Anna V. , Watts Hugh G. , Scaduto Anthony A.
Published: August 2016

Background:

Osseous overgrowth is a common complication in children after humeral transcortical amputation. Capping tibial overgrowth with the proximal fibula has been shown to be the most effective treatment. However, best treatment practices are not clear for the humerus. We compared patients treated surgically for humeral osseous overgrowth with simple resection or autologous osteocartilaginous graft to determine if this treatment were as effective in the humerus as it has been in the tibia.

Methods:

A retrospective review of humeral amputees from 1987 to 2011 at a pediatric hospital was performed. Patients with 2 years follow-up who underwent surgical treatment for established humeral overgrowth were included. Patients initially managed with simple resection were compared with those managed with autologous osteocartilaginous grafts. Descriptive statistics were calculated for demographic and outcome variables. T tests and χ2 tests were used to compare differences between groups.

Results:

Eighteen humeri in 16 patients met inclusion criteria. Mean age at surgery was 8.3 (2.6 to 13.6) years and mean follow-up was 6.3 (1.5 to 10.4) years. Thirteen humeri underwent simple resection, with recurrent overgrowth in 9, and revision surgery in 8 at a mean 2.6 years. Five humeri were primarily managed with autologous osteocartilaginous grafts. Two developed non–overgrowth-related complications at 1 and 42 months. Including revision procedures after simple resection, 10 humeri were managed with autologous osteocartilaginous grafts. Thirty percent (3/10) required revision surgery; however, there were no cases of recurrent overgrowth. χ2 comparison showed lower rates of complications (P=0.004) and reoperation (P=0.012) with capping as compared with simple resection.

Conclusions:

Autologous osteocartilaginous capping of the humerus has a significantly lower rate of complications and reoperation compared with simple resection. However, the capping procedure has the potential for other complications related to difficulty with graft fixation. Surgeons should be aware that the outcomes are not as consistent as when the technique is applied to osseous overgrowth of the tibia and anticipate the possibilities of hardware prominence and difficulty with fixation.

Level of Evidence:

Level 3—therapeutic-retrospective comparative.
Vascular Endothelial Growth Factor Up-regulation in Human Amniotic Fluid Stem Cell Enhances Nephroprotection After Ischemia-Reperfusion Injury in the Rat
Authors: Mori da Cunha Marina Gabriela Monteiro Carvalho , Zia Silvia , Beckmann Diego Vilibaldo , Carlon Marianne Sylvia , Arcolino Fanny Oliveira , Albersen Maarten , Pippi Ney Luis , Graça Dominguita Lühers , Gysemans Conny , Carmeliet Peter , Levtchenko Elena , Deprest Jan , Toelen Jaan
Published: August 2016

Objective:

To evaluate if the up-regulation of vascular endothelial growth factor strengthens the protective effect of amniotic fluid stem cells in a renal ischemia-reperfusion injury model.

Design:

Randomized animal study.

Settings:

University research laboratory.

Subjects:

A total of 40 males 12-week-old Wistar rats were subjected to ischemia-reperfusion and assigned to four groups: amniotic fluid stem cells, vascular endothelial growth factor-amniotic fluid stem cells in two different doses, and vehicle. Ten animals were used as sham-controls.

Intervention:

Six hours after induction of renal ischemia-reperfusion injury, amniotic fluid stem cells, vascular endothelial growth factor-amniotic fluid stem cells in two different doses, or vehicle were injected intraarterially.

Measurements and Main Results:

Analyses were performed at 24 hours, 48 hours, and 2 months after treatment. Outcome measures included serum creatinine, urine microprotenuira, and immunohistomorphometric analyses. Vascular endothelial growth factor-amniotic fluid stem cells induced a significantly higher nephroprotection than amniotic fluid stem cells. This effect was mediated mainly by immunomodulation, which led to lower macrophage infiltration and higher presence of regulatory T cell after ischemia-reperfusion injury. At medium term, it inhibited the progression toward chronic kidney disease. Vascular endothelial growth factor-amniotic fluid stem cells can worsen the ischemia-reperfusion injury when delivered in a high dose.

Conclusions:

Up-regulation of vascular endothelial growth factor enhances the therapeutic effect of human amniotic fluid stem cells in rats with renal ischemia-reperfusion injury, mainly by mitogenic, angiogenic, and anti-inflammatory mechanisms.
Use of Wireless Capsule Endoscopy for the Diagnosis and Grading of Esophageal Varices in Patients With Portal Hypertension
Authors: McCarty Thomas R. , Afinogenova Yuliya , Njei Basile
Published: August 2016

Introduction:

Esophageal variceal bleeding is a severe complication of portal hypertension with significant morbidity and mortality. Although traditional screening and grading of esophageal varices has been performed by endogastroduodenoscopy (EGD), wireless video capsule endoscopy provides a minimally invasive alternative that may improve screening and surveillance compliance.

Aim of the Study:

The aim of the study was to perform a systematic review and structured meta-analysis of all eligible studies to evaluate the efficacy of wireless capsule endoscopy for screening and diagnosis of esophageal varices among patients with portal hypertension.

Methods:

Searches of PubMed, EMBASE, Web of Science, and the Cochrane Library databases were performed through December 2015. Bivariate and hierarchical models were used to compute the pooled sensitivity and specificity, and to plot the summary receiver operating characteristics curve with summary point and corresponding 95% confidence region. Bias of included studies was assessed using the quality assessment of diagnostic accuracy studies-2.

Results:

Seventeen studies from 2005 to 2015 were included in this meta-analysis (n=1328). The diagnostic accuracy of wireless capsule endoscopy in the diagnosis of esophageal varices was 90% [95% confidence interval (CI), 0.88-0.93]. The diagnostic pooled sensitivity and specificity were 83% (95% CI, 0.76-0.89) and 85% (95% CI, 0.75-0.91), respectively. The diagnostic accuracy of wireless capsule endoscopy for the grading of medium to large varices was 92% (95% CI, 0.90-0.94). The pooled sensitivity and specificity were 72% (95% CI, 0.54-0.85) and 91% (95% CI, 0.86-0.94), respectively, for the grading of medium to large varices. The use of capsule demonstrated only mild adverse events. A sensitivity analysis limited to only high quality studies revealed similar results.

Discussion:

Wireless esophageal capsule endoscopy is well tolerated and safe in patients with liver cirrhosis and suspicion of portal hypertension. The sensitivity of capsule endoscopy is not currently sufficient to replace EGD as a first exploration in these patients, but given its high accuracy, it may have a role in cases of refusal or contraindication to EGD.
Chronic Abdominal Wall Pain
Authors: Glissen Brown Jeremy R. , Bernstein Gregory R. , Friedenberg Frank K. , Ehrlich Adam C.
Published: August 2016

Chronic abdominal wall pain (CAWP) refers to a condition wherein pain originates from the abdominal wall itself rather than the underlying viscera. According to various estimates, 10% to 30% of patients with chronic abdominal pain are eventually diagnosed with CAWP, usually after expensive testing has failed to uncover another etiology. The most common cause of CAWP is anterior cutaneous nerve entrapment syndrome. The diagnosis of CAWP is made using an oft-forgotten physical examination finding known as Carnett’s sign, where focal abdominal tenderness is either the same or worsened during contraction of the abdominal musculature. CAWP can be confirmed by response to trigger point injection of local anesthetic. Once diagnosis is made, treatment ranges from conservative management to trigger point injection and in refractory cases, even surgery. This review provides an overview of CAWP, discusses the cost and implications of a missed diagnosis, compares somatic versus visceral innervation, describes the pathophysiology of nerve entrapment, and reviews the evidence behind available treatment modalities.
Use of Sofosbuvir-Based Treatment of Chronic Hepatitis C in Liver Transplant Recipients on Hemodialysis
Authors: Saab Sammy , A. Jimenez Melissa , N. Bau Sherona , Choi Gina , Durazo Francisco A. , M. El-Kabany Mohammed , Han Steven-Huy B. , Busuttil Ronald W.
Published: August 2016

Background:

The use of direct acting agents has changed the management paradigm of hepatitis C (HCV) in liver transplant (LT) recipients. However, the appropriate antiviral regimen in LT recipients on hemodialysis (HD) remains unclear.

Methods:

We retrospectively evaluated the safety and efficacy of sofosbuvir-based LT recipients on HD followed at the University of California Los Angeles.

Results:

Twelve LT recipients on HD were treated for recurrent HCV with sofosbuvir-based therapy. Indications for antiviral therapy included fibrosing cholestatic hepatitis, symptomatic cryoglobulinemia, and recurrent HCV. The causes of renal failure included hepatorenal syndrome, acute tubular necrosis and cryoglobulinemia. Of those who were not on dialysis at the time of transplantation, the mean creatinine (±SD) was 1.7 (±0.8) mg/dL. The mean age (±SD) of the cohort was 62.2 (±6.0) years. Most recipients were male (67%) and infected with genotype 1 (83%). Baseline alanine aminotransferase, total bilirubin, hemoglobin and HCV RNA values (±SD) were 53.2 (±59.4) IU/L, 3.2 (±5.5) mg/dL, 10.5 (±1.8) g/dL, and 30,499,500 (±29,655,754) IU/mL. HCV RNA levels were undetectable in all recipients at the end of therapy. The trough mean (±SD) hemoglobin of patients on treatment and on HD was 8.4 (±2.3). The sustained viral response was 58% (7/12), and the overall patient survival was 42%. All the deaths occurred a mean (±SD) after 5.4 (±3.6) months after treatment was completed.

Conclusions:

All patients achieved viral suppression from therapy, and over half the recipients achieved a sustained virological response. A high mortality underscores the necessity of starting antiviral treatment sooner in LT recipients and the need for larger cohort studies.
Characteristics, treatment and outcomes for all emergency department patients fulfilling criteria for septic shock: a prospective observational study
Authors: Williams Julian M. , Greenslade Jaimi H. , Dymond Chelsea A. , Chu Kevin , Brown Anthony F.T. , Lipman Jeffrey
Published: August 2016

Objective

Most published data on emergency department (ED) patients with septic shock have been generated from studies examining the effect of early protocolised resuscitation in selected cohorts. Consequently, these data do not generally represent patients falling outside trial inclusion criteria or judged unsuitable for aggressive treatment. Our aim was to determine the characteristics, treatment and outcomes for all ED patients fulfilling the criteria for septic shock.

Methods

Septic shock patients were identified from a prospective database of consecutive ED patients admitted with infection. Descriptive data were compared with those from previous studies and associations between ED processes of care and mortality were determined.

Results

A total of 399 septic shock patients were identified, with a 30-day mortality of 19.5%. The median ED length of stay was 9.2 h. Rates of vasopressor use (22.6%) and ICU admission (37.3%) were low. Subgroups fulfilling the lactate criteria alone, hypotension criteria alone and both criteria represented distinct shock phenotypes with increasing severity of illness and mortality. Mortality for patients with limitations to treatment determined in the ED was 65.6% and 6.1% for those without limitations. Greater volumes of intravenous fluid and early vasopressor therapy for appropriate patients were associated with survival.

Conclusion

Median length of stay over 9 hours may have enhanced identification of patients with limitations to treatment and fluid responders, reducing invasive therapies and ICU admissions. Distinct shock phenotypes were apparent, with implications for revision of septic shock definitions and future trial design. Liberal fluids and early vasopressor use in appropriate patients were associated with survival.
Health Care Utilization Rates After Oregon’s 2008 Medicaid Expansion
Authors: O’Malley Jean P. , O’Keeffe-Rosetti Maureen , Lowe Robert A. , Angier Heather , Gold Rachel , Marino Miguel , Hatch Brigit , Hoopes Megan , Bailey Steffani R. , Heintzman John , Gallia Charles , DeVoe Jennifer E.
Published: August 2016

Background:

Although past research demonstrated that Medicaid expansions were associated with increased emergency department (ED) and primary care (PC) utilization, little is known about how long this increased utilization persists or whether postcoverage utilization is affected by prior insurance status.

Objectives:

(1) To assess changes in ED, PC, mental and behavioral health care, and specialist care visit rates among individuals gaining Medicaid over 24 months postinsurance gain; and (2) to evaluate the association of previous insurance with utilization.

Methods:

Using claims data, we conducted a retrospective cohort analysis of adults insured for 24 months following Oregon’s 2008 Medicaid expansion. Utilization rates among 1124 new and 1587 returning enrollees were compared with those among 5126 enrollees with continuous Medicaid coverage (≥1 y preexpansion). Visit rates were adjusted for propensity score classes and geographic region.

Results:

PC visit rates in both newly and returning insured individuals significantly exceeded those in the continuously insured in months 4 through 12, but were not significantly elevated in the second year. In contrast, ED utilization rates were significantly higher in returning insured compared with newly or continuously insured individuals and remained elevated over time. New visits to PC and specialist care were higher among those who gained Medicaid compared with the continuously insured throughout the study period.

Conclusions:

Predicting the effect of insurance expansion on health care utilization should account for the prior coverage history of new enrollees. In addition, utilization of outpatient services changes with time after insurance, so expansion evaluations should allow for rate stabilization.
Longitudinal MRI and Ferritin Monitoring of Iron Overload in Chronically Transfused and Chelated Children With Sickle Cell Anemia and Thalassemia Major
Authors: Aubart Mélodie , Ou Phalla , Elie Caroline , Canniffe Carla , Kutty Shelby , Delos Vincent , Graffigne Christine , de Montalembert Mariane , Brousse Valentine
Published: August 2016

Iron overload is an ineluctable complication in chronically transfused children warranting accurate assessment to avoid related morbidity. We investigated longitudinally the relationships between ferritin levels and hepatic and cardiac T2* magnetic resonance imaging (MRI) in a cohort of chronically transfused children receiving chelation therapy. Thirty children with sickle cell anemia (SCA) and 7 with thalassemia major (TM) chelated similarly by deferasirox were analyzed. Sex ratio, age, median duration of transfusion programs (5 y; range, 2 to 14 y), median transfusion iron intake 0.54 mg/kg/d (range, 0.27 to 0.74 mg/kg/d), and median ferritin level (1550 mg/L; range, 184 to 6204 mg/L) were comparable in TM and SCA. A significant relation was found between ferritin level and transfusion iron intake (P<0.001) despite chelation therapy. Analysis of 73 hepatic T2* MRI performed yearly demonstrated severe hepatic iron overload (≥14 mg/g) in 38.3% cases and a strong relationship between serum ferritin level and liver iron content both in SCA and TM (P<0.001). Analysis of 55 cardiac T2* MRI measurements found no cardiac overload in patients with SCA. Cardiac iron overload was moderate in 4 cases and severe in 1 case of TM. In almost half the cases, ferritin trend correctly predicted hepatic iron trend, both in patients with SCA and TM but failed to predict cardiac iron trend, notably in TM patients. Despite chelation therapy, iron burden in chronically transfused patients remains a threat. Ferritin levels are associated with liver iron overload in chelated children with SCA and TM, but iron burden should be best monitored with MRI whenever the setting allows it.
Hemophagocytic Lymphohistiocytosis in A Child With Very Severe Aplastic Anemia: Double Jeopardy Resulting in Fatality
Authors: Chandar Rumesh , Chandrasekaran Venkatesh , Jagadisan Barath , Kumar Delhi , Biswal Niranjan
Published: August 2016

A 7-year-old male child with very severe aplastic anemia developed refractory disease, which was attributed to febrile hemolytic transfusion reactions and was treated with immunosuppressants, which lead to a transient improvement. However, the child worsened subsequently and succumbed to an underlying hemophagocytic lymphohistiocytosis that was recognized late due to an overlap of clinical and biochemical parameters in both the conditions. Hemophagocytic lymphohistiocytosis should be an early suspicion in children with refractory very severe aplastic anemia and the detection of underlying gene mutations can predict disease severity.
Azithromycin Treatment Failure for Chlamydia trachomatis Among Heterosexual Men With Nongonococcal Urethritis
Authors: Kissinger Patricia J. , White Scott , Manhart Lisa E. , Schwebke Jane , Taylor Stephanie N. , Mena Leandro , Khosropour Christine M. , Wilcox Larissa , Schmidt Norine , Martin David H.
Published: August 2016

Background

Three recent prospective studies have suggested that the 1-g dose of azithromycin for Chlamydia trachomatis (Ct) was less effective than expected, reporting a wide range of treatment failure rates (5.8%–22.6%). Reasons for the disparate results could be attributed to geographic or methodological differences. The purpose of this study was to reexamine the studies and attempt to harmonize methodologies to reduce misclassification as a result of false positives from early test-of-cure (TOC) or reinfection as a result of sexual exposure rather than treatment failure.

Methods

Men who had sex with women, who received 1-g azithromycin under directly observed therapy for presumptive treatment of nongonococcal urethritis with confirmed Ct were included. Baseline screening was performed on urethral swabs or urine, and TOC screening was performed on urine using nucleic acid amplification tests. Posttreatment vaginal sexual exposure was elicited at TOC. Data from the 3 studies were obtained and reanalyzed. Rates of Ct retest positive were examined for all cases, and a sensitivity analysis was conducted to either reclassify potential false positives/reinfections as negative or remove them from the analysis.

Results

The crude treatment failure rate was 12.8% (31/242). The rate when potential false positives/reinfections were reclassified as negative was 6.2% (15/242) or when these were excluded from analysis was 10.9% (15/138).

Conclusions

In these samples of men who have sex with women with Ct-related nongonococcal urethritis, azithromycin treatment failure was between 6.2% and 12.8%. This range of failure is lower than previously published but higher than the desired World Health Organization's target chlamydia treatment failure rate of < 5%.
Implementation of Oral and Rectal Gonococcal and Chlamydial Nucleic Acid Amplification-Based Testing as a Component of Local Health Department Activities
Authors: Nall Jennifer , Barr Breona , McNeil Candice J. , Bachmann Laura H.
Published: August 2016

From January 1, 2014, to May 31, 2015, 452 individuals received extragenital nucleic acid amplification-based Neisseria gonorrhoeae and Chlamydia trachomatis testing through public health venues. Seventy-four individuals (16%) tested positive for Neisseria gonorrhoeae and/or Chlamydia trachomatis at an extragenital site and 40 (54%) would not have been effectively diagnosed and treated in the absence of extragenital testing.
Prevalence of 9-Valent Human Papillomavirus Types by Race/Ethnicity in the Prevaccine Era, United States, 2003–2006
Authors: Liu Gui , Unger Elizabeth R. , Hariri Susan , Steinau Martin , Markowitz Lauri E.
Published: August 2016

Before any vaccine introduction, overall DNA prevalence of any 9-valent human papillomavirus (9vHPV) types, HPV 31/33/45/52/58, and HPV 16/18 was 16.0%, 9.5%, and 6.2%, respectively, among female participants in National Health and Nutrition Examination Survey. Non-Hispanic black females were more likely to have infection with HPV 31/33/45/52/58, but not HPV 16/18, compared to non-Hispanic white females.
Sex Work as an Emerging Risk Factor for Human Immunodeficiency Virus Seroconversion Among People who Inject Drugs in the SurvUDI Network
Authors: Blouin Karine , Leclerc Pascale , Morissette Carole , Roy Élise , Blanchette Caty , Parent Raymond , Serhir Bouchra , Alary Michel
Published: August 2016

Background

Recent analyses have shown an emerging positive association between sex work and human immunodeficiency virus (HIV) incidence among people who inject drugs (PWIDs) in the SurvUDI network.

Methods

Participants who had injected in the past 6 months were recruited across the Province of Quebec and in the city of Ottawa, mainly in harm reduction programs. They completed a questionnaire and provided gingival exudate for HIV antibody testing. The associations with HIV seroconversion were tested with a Cox proportional hazard model using time-dependent covariables including the main variable of interest, sexual activity (sex work; no sex work; sexually inactive). The final model included significant variables and confounders of the associations with sexual activity.

Results

Seventy-two HIV seroconversions were observed during 5239.2 person-years (py) of follow-up (incidence rates: total = 1.4/100 py; 95% confidence interval [CI], 1.1–1.7; sex work = 2.5/100 py; 95% CI, 1.5–3.6; no sex work = 0.8/100 py; 95% CI, 0.5–1.2; sexually inactive = 1.8/100 py; 95% CI, 1.1–2.5). In the final multivariate model, HIV incidence was significantly associated with sexual activity (sex work: adjusted hazard ratio [AHR], 2.19; 95% CI, 1.13–4.25; sexually inactive: AHR, 1.62; 95% CI, 0.92–2.88), and injection with a needle/syringe used by someone else (AHR, 2.84; 95% CI, 1.73–4.66).

Conclusions

Sex work is independently associated with HIV incidence among PWIDs. At the other end of the spectrum of sexual activity, sexually inactive PWIDs have a higher HIV incidence rate, likely due to more profound dependence leading to increased vulnerabilities, which may include mental illness, poverty, and social exclusion. Further studies are needed to understand whether the association between sex work and HIV is related to sexual transmission or other vulnerability factors.
Outcome of Benign Acute Childhood Myositis
Authors: Rosenberg Tom , Heitner Shmuel , Scolnik Dennis , Levin Ben-Adiva Einav , Rimon Ayelet , Glatstein Miguel
Published: August 2016

Objective

The aims of the study were to determine the evolution of benign acute childhood myositis in children and to assess the relationship between creatine phosphokinase (CPK) values and myoglobinuria.

Study design

A retrospective study of patients with benign acute childhood myositis seen in 2 tertiary care university-affiliated pediatric hospitals during overlapping 4-year periods.

Methods

Demographic data, historical details, clinical, and laboratory results were extracted from the charts of children younger than 16 years with a CPK greater than 3 times normal. Complications, treatments, and outcomes were recorded.

Results

Fifty-four children were included, 43 (80%) were male, and mean age was 7.3 years (median [range], 6 [3–16] years), none showed abnormal neurological findings, manifested hematuria, or developed renal failure. Mean CPK level at presentation was 1872 IU/L (range, 511–8086 IU/L). None developed renal failure, and there were no adverse outcomes on follow-up.

Conclusions

Acute childhood myositis is a predominantly benign disease. Neurological examination is usually normal and rhabdomyolysis is rare. Although severe pathological comorbid conditions must be excluded, a complete history and examination, coupled with simple blood and urine tests, can help minimize unnecessary diagnostic investigations.
Crowding-induced transcriptional bursts dictate polymerase and nucleosome density profiles along genes
Authors: Berg Aafke A van den , Depken Martin
Published: August 2016

During eukaryotic transcription, RNA polymerase (RNAP) translocates along DNA molecules covered with nucleosomes and other DNA binding proteins. Though the interactions between a single nucleosome and RNAP are by now fairly well understood, this understanding has not been synthesized into a description of transcription on crowded genes, where multiple RNAP transcribe through nucleosomes while preserving the nucleosome coverage. We here take a deductive modeling approach to establish the consequences of RNAP-nucleosome interactions for transcription in crowded environments. We show that under physiologically crowded conditions, the interactions of RNAP with nucleosomes induce a strong kinetic attraction between RNAP molecules, causing them to self-organize into stable and moving pelotons. The peloton formation quantitatively explains the observed nucleosome and RNAP depletion close to the initiation site on heavily transcribed genes. Pelotons further translate into short-timescale transcriptional bursts at termination, resulting in burst characteristics consistent with instances of bursty transcription observed in vivo. To facilitate experimental testing of our proposed mechanism, we present several analytic relations that make testable quantitative predictions.