bluuebunny/crossref_metadata_2025 huggingface dataset:
Optimal Dosing of Botulinum Toxin for Treatment of Chronic Anal Fissure: A Systematic Review and Meta-Analysis
Authors: Lin Jin Xin , Krishna Sanjeev , Su’a Bruce , Hill Andrew G.
Published: August 2016

BACKGROUND:

Chronic anal fissures are associated with significant morbidity and reduced quality of life. Studies have investigated the efficacy of botulinum toxin with variable results; thus, there is currently no consensus on botulinum toxin dose or injection sites.

OBJECTIVE:

This study aimed to systematically analyze trials studying the efficacy of botulinum toxin for treatment of chronic anal fissure to identify an optimum dosage and injection regimen.

DATA SOURCES:

A comprehensive review of the literature was conducted according to PRISMA guidelines. PubMed/Medline, Embase, Scopus, and the Cochrane Library were searched from inception to June 2015.

STUDY SELECTION:

All clinical trials that investigated the efficacy of botulinum toxin for chronic anal fissure were selected according to specific criteria.

INTERVENSIONS:

The interventions used were various doses of botulinum toxin.

OUTCOME MEASURES:

Clinical outcomes, dosage, and injection site data were evaluated with weighted pooled results for each dosage and 95% confidence intervals.

RESULTS:

There were 1158 patients, with 661 in botulinum toxin treatment arms, from 18 clinical trials included in this review. The outcomes of interest were 3-month healing, incontinence, and recurrence rates. Meta-regression analysis demonstrated a small decrease in healing rate (0.34%; 95% CI, 0–0.68; p = 0.048) with each increase in dosage, a small increase in incontinence rate (1.02 times; 95% CI, 1.0002–1.049; p = 0.048) with each increase in dosage and a small increase in recurrence rate (1.037 times; 95% CI, 1.018–1.057; p = 0.0002) with each increase in dosage. The optimum injection site could not be determined.

LIMITATIONS:

This study was limited by weaknesses in the underlying evidence, such as variable quality, short follow-up, and a limited range of doses represented.

CONCLUSIONS:

Fissure healing with lower doses of botulinum toxin is as effective as with high doses. Lower doses also reduce the risk of incontinence and recurrence in the long term.
Clostridium difficile Infection Is Associated With Lower Inpatient Mortality When Managed by GI Surgeons
Authors: Stokes Audrey L. , Bible Andrew , Hollenbeak Christopher S. , Stewart David B.
Published: August 2016

BACKGROUND:

Patients admitted with Clostridium difficile infection are managed in a variety of settings. If their care is inadequate, these patients can rapidly deteriorate.

OBJECTIVE:

The purpose of this study was to evaluate whether mortality for patients admitted with C difficile differed between medical and general/colorectal surgery services.

DESIGN:

This was a retrospective cohort study with multivariable logistic regression used to evaluate the effect of admitting service on in-hospital mortality rates, with propensity score matching used to validate this relationship.

SETTINGS:

The study was conducted at a single, tertiary care center.

PATIENTS:

Inpatients with a positive C difficile stool test within 24 hours of admission to medical or surgical services were identified (2005–2015) using institutional electronic data sources.

MAIN OUTCOME MEASURE:

We measured inpatient mortality rate.

RESULTS:

Of 1175 patients, 985 (83%) were admitted to medical services, whereas 190 (17%) were admitted by surgeons. Medical patients were older (63.9 vs 58.9 years; p = 0.001) and had a mean of 0.6 additional comorbidities (p < 0.001); cohorts were similar regarding vasopressors, peak white blood cell counts, and rate of intensive care unit admissions. Mortality was lower among surgery patients (2.6% vs 6.8%; p = 0.028), and logistic regression demonstrated lower odds of mortality for this group OR = 0.18 (95% CI, 0.05–0.58)). After propensity score matching for age, comorbidities, and severity of disease, this difference was confirmed (2.6% vs. 9.5%). A higher incidence of total colectomy for surgery patients (14.2% vs 0.4%) was a causal factor in their longer lengths of stay and higher total hospital costs. The time between orders for stool testing and metronidazole therapy was shorter in the surgery group (1.8 vs 3.8 hours; p = 0.002), although this trend was not observed with vancomycin therapy.

LIMITATIONS:

This was a retrospective study from a single institution, thereby limiting generalizability, with a lack of information regarding premorbid creatinine levels, ileus, or megacolon.

CONCLUSIONS:

In-hospital mortality rates for patients admitted with C difficile were lower on surgery services, perhaps in part related to higher colectomy rates.
Progression From Perianal High-Grade Anal Intraepithelial Neoplasia to Anal Cancer in HIV-Positive Men Who Have Sex With Men
Authors: Tinmouth Jill , Peeva Valentina , Amare Henok , Blitz Sandra , Raboud Janet , Sano Marie , Steele Leah , Salit Irving E.
Published: August 2016

BACKGROUND:

High-grade intraepithelial neoplasia is known to progress to invasive squamous-cell carcinoma of the anus. There are limited reports on the rate of progression from high-grade intraepithelial neoplasia to anal cancer in HIV-positive men who have sex with men.

OBJECTIVES:

The purpose of this study was to describe in HIV-positive men who have sex with men with perianal high-grade intraepithelial neoplasia the rate of progression to anal cancer and the factors associated with that progression.

DESIGN:

This was a prospective cohort study.

SETTINGS:

The study was conducted at an outpatient clinic at a tertiary care center in Toronto.

PATIENTS:

Thirty-eight patients with perianal high-grade anal intraepithelial neoplasia were identified among 550 HIV-positive men who have sex with men.

INTERVENTION:

All of the patients had high-resolution anoscopy for symptoms, screening, or surveillance with follow-up monitoring/treatment.

MAIN OUTCOME MEASURES:

We measured the incidence of anal cancer per 100 person-years of follow-up.

RESULTS:

Seven (of 38) patients (18.4%) with perianal high-grade intraepithelial neoplasia developed anal cancer. The rate of progression was 6.9 (95% CI, 2.8–14.2) cases of anal cancer per 100 person-years of follow-up. A diagnosis of AIDS, previously treated anal cancer, and loss of integrity of the lesion were associated with progression. Anal bleeding was more than twice as common in patients who progressed to anal cancer.

LIMITATIONS:

There was the potential for selection bias and patients were offered treatment, which may have affected incidence estimates.

CONCLUSIONS:

HIV-positive men who have sex with men should be monitored for perianal high-grade intraepithelial neoplasia. Those with high-risk features for the development of anal cancer may need more aggressive therapy.
Sacral Nerve Stimulation Fails to Offer Long-term Benefit in Patients With Slow-Transit Constipation
Authors: Patton Vicki , Stewart Peter , Lubowski David Z. , Cook Ian J. , Dinning Phil G.
Published: August 2016

BACKGROUND:

Sacral nerve stimulation is proposed as a treatment for slow-transit constipation. However, in our randomized controlled trial we found no therapeutic benefit over sham stimulation. These patients have now been followed-up over a long-term period.

OBJECTIVE:

The purpose of this study was to assess the long-term efficacy of sacral nerve stimulation in patients with scintigraphically confirmed slow-transit constipation.

DESIGN:

This study was designed for long-term follow-up of patients after completion of a randomized controlled trial.

SETTINGS:

It was conducted at an academic tertiary public hospital in Sydney.

PATIENTS:

Adults with slow-transit constipation were included.

MAIN OUTCOME MEASURES:

At the 1- and 2-year postrandomized controlled trial, the primary treatment outcome measure was the proportion of patients who reported a feeling of complete evacuation on >2 days per week for ≥2 of 3 weeks during stool diary assessment. Secondary outcome was demonstration of improved colonic transit at 1 year.

RESULTS:

Fifty-three patients entered long-term follow-up, and 1 patient died. Patient dissatisfaction or serious adverse events resulted in 44 patients withdrawing from the study because of treatment failure by the end of the second year. At 1 and 2 years, 10 (OR = 18.8% (95% CI, 8.3% to 29.3%)) and 3 patients (OR = 5.7% (95% CI, –0.5% to 11.9%)) met the primary outcome measure. Colonic isotope retention at 72 hours did not differ between baseline (OR = 75.6% (95% CI, 65.7%–85.6%)) and 1-year follow-up (OR = 61.7% (95% CI, 47.8%–75.6%)).

LIMITATIONS:

This study only assessed patients with slow-transit constipation.

CONCLUSIONS:

In these patients with slow-transit constipation, sacral nerve stimulation was not an effective treatment.
Direct Hospital Cost of Outcome Pathways in Implant-Based Reconstruction with Acellular Dermal Matrices
Authors: Qureshi Ali A. , Broderick Kristen , Funk Susan , Reaven Nancy , Tenenbaum Marissa M. , Myckatyn Terence M.
Published: August 2016

Background:

Current cost data on tissue expansion followed by exchange for permanent implant (TE/I) reconstruction lack a necessary assessment of the experience of a heterogenous breast cancer patient population and their multiple outcome pathways. We extend our previous analysis to that of direct hospital cost as bundling of payments is likely to follow the changing centralization of cancer care at the hospital level.

Methods:

We performed a retrospective analysis (2003–2009) of TE/I reconstructions with or without an acellular dermal matrix (ADM), namely Alloderm RTM. Postreconstructive events were analyzed and organized into outcome pathways as previously described. Aggregated and normalized inpatient and outpatient hospital direct costs and physician reimbursement were generated for each outcome pathway with or without ADM.

Results:

Three hundred sixty-seven patients were analyzed. The average 2-year hospital direct cost per TE/I breast reconstruction patient was $11,862 in the +ADM and $12,319 in the −ADM groups (P > 0.05). Initial reconstructions were costlier in the +ADM ($6,868) than in the −ADM ($5,615) group, but the average cost of subsequent postreconstructive events within 2 years was significantly lower in +ADM ($5,176) than −ADM ($6,704) patients (P < 0.05). When a complication occurred, but reconstruction was still completed within 2 years, greater costs were incurred in the −ADM than in the +ADM group for most scenarios, leading to a net equalization of cost between study groups.

Conclusion:

Although direct hospital cost is an important factor for resource and fund allocation, it should not remain the sole factor when deciding to use ADM in TE/I reconstruction.
Biopsychosocial-Spiritual Factors Impacting Referral to and Participation in Cardiac Rehabilitation for African American Patients
Authors: Koehler Hildebrandt Aubry N. , Hodgson Jennifer L. , Dodor Bernice A. , Knight Sharon M. , Rappleyea Damon L.
Published: August 2016

PURPOSE:

The purposes of this systematic review were to (1) review the literature related to the demographic and biopsychosocial-spiritual factors impacting cardiac rehabilitation (CR) referral and participation of African American patients with cardiovascular disease (CVD); (2) identify barriers and facilitators to CR referral and participation for this population; (3) identify gaps in the literature; and (4) make recommendations for future research studies and interventions.

METHODS:

The Cooper 7-step protocol for research synthesis was followed to formulate a research question and search MEDLINE via PubMed, PsycINFO via EBSCO, and CINAHL via EBSCO. A second reviewer repeated the searches performed by the first author in the initial review.

RESULTS:

A total of 1640 articles identified using the search strategy yielded 7 articles that fit the search criteria. Most studies measured demographic or social factors. Two studies measured biological factors, 1 study measured psychological factors, and no study measured spiritual factors.

CONCLUSIONS:

According to the studies reviewed, African American patients with CVD were less likely to receive a CR referral, more likely to enroll in CR with more cardiovascular risk factors, and less likely to participate in and complete CR due to factors related to low socioeconomic status (eg, lack of insurance, work conflicts, lower level of education) than non-Hispanic white patients. Further research is needed on the interaction between demographic/biopsychosocial-spiritual factors and referral to and participation of African Americans in CR in order to ensure that interventions fit the needs of this particular population.
Prevalence of Sleep-Disordered Breathing and Patient Characteristics in a Coronary Artery Disease Cohort Undergoing Cardiovascular Rehabilitation
Authors: Fox Henrik , Purucker Hans-Christian , Holzhacker Isabelle , Tebtmann Ulrich , Bitter Thomas , Horstkotte Dieter , Graml Andrea , Woehrle Holger , Oldenburg Olaf
Published: August 2016

PURPOSE:

Coronary artery disease (CAD) is a leading cause of death and identification of risk factors for CAD is crucial. One such potential risk factor is sleep-disordered breathing (SDB). This prospective cohort study investigated the prevalence of SDB and determined risk factors for the presence of SDB in a large CAD cohort undergoing cardiac rehabilitation.

METHODS:

A total of 1425 patients with confirmed CAD starting rehabilitation were screened for SDB using cardiorespiratory polygraphy (n = 921) or polygraphy plus pulse oximetry (n = 484).

RESULTS:

A total of 1408 patients were included; 69.5% were male, 78% had acute coronary syndrome, and 22% had stable CAD. The prevalence of SDB (apnea-hypopnea index [AHI] ≥5/h) was 83%. Moderate to severe SDB (AHI ≥15/h) was present in 53%. Up to 70% of coronary artery bypass graft (CABG) recipients had an AHI ≥15/h versus 33% of those who had not undergone CABG. SDB severity did not vary significantly in patients with stable CAD or on the basis of left ventricular ejection fraction. SDB was more severe and the frequency of oxygen desaturation was higher in men than in women. Multivariate logistic regression identified age, sex, body mass index, and CABG as independent risk factors for severe SDB.

CONCLUSION:

SDB is a highly prevalent comorbidity in patients with CAD, particularly those who have undergone CABG. These results strengthen existing associations and emphasize the importance of diagnosing and monitoring SDB in patients with CAD entering a cardiac rehabilitation program. Early diagnosis and intervention has the potential to have a beneficial effect on CAD prognosis.
TARANTULA HAIR ASSOCIATED PANUVEITIS TREATED WITH SUSTAINED-RELEASE INTRAVITREAL DEXAMETHASONE IMPLANT
Authors: Morkin Melina I. , Rifkin Lana M. , Dang Sabin , Baumal Caroline R.
Published: August 2016

Purpose:

To report a case of tarantula hair–induced panuveitis treated with sustained-release intravitreal dexamethasone implant and followed by sequential spectral domain optical coherence tomography imaging.

Methods:

Findings on clinical examination, anterior segment optical coherence tomography, corneal in vivo confocal microscopy, color fundus photos, fluorescein angiography, and retinal spectral domain optical coherence tomography are presented. Sequential optical coherence tomography images demonstrated the course of the chorioretinal lesions before and after sustained-release intravitreal dexamethasone implant.

Results:

A 19-year-old female presented with localized temporal episcleritis and scleritis that incompletely resolved despite multiple courses of topical and oral corticosteroids. She subsequently developed focal vitritis and chorioretinitis, and was found to have tarantula hair–induced panuveitis. Anterior segment optical coherence tomography and in vivo confocal microscopy confirmed the presence of tarantula hairs embedded in the anterior corneal stroma. There was only transient improvement with posterior sub-Tenon's Kenalog injection. After treatment with sustained-release intravitreal dexamethasone implant, her symptoms improved and the chorioretinal lesions became inactive. Sequential spectral domain optical coherence tomography images revealed hyperreflective inner retina lesions that progressed to involve the outer retina, and then flattened to near resolution after therapy.

Conclusion:

This is the first case showing positive clinical outcomes supported by sequential retinal spectral domain optical coherence tomography using a sustained-release intravitreal dexamethasone implant to treat ophthalmia nodosa–induced by tarantula hairs.
EN FACE OPTICAL COHERENCE TOMOGRAPHY (OCT) AND OCT ANGIOGRAPHY FINDINGS IN RETINAL ASTROCYTIC HAMARTOMAS
Authors: Despréaux Raphaelle , Mrejen Sarah , Quentel Gabriel , Cohen Salomon Y.
Published: August 2016

Purpose:

To report spectral-domain optical coherence tomography, en face optical coherence tomography (OCT), and optical coherence tomography angiography findings in retinal astrocytic hamartomas.

Methods:

Four cases of retinal astrocytic hamartomas, with small white or yellowish typical retinal mass, were imaged with fundus photography, intravenous fluorescein angiography, fundus autofluorescence, spectral-domain OCT, en face OCT, and OCT angiography.

Results:

The tumor was solitary in all cases and involved the posterior pole. It was idiopathic in three cases and was related to tuberous sclerosis complex in one case. The OCT findings included intralesional lucencies in two cases with no exudation. The tumor was within the retinal nerve fiber layer or deeper, usually overlying the inner plexiform layer providing a protusion in the vitreous cavity. Vitreous changes were present in all cases, corresponding to thickening and adhesion of the vitreous facing the lesion (two cases), apparent interdigitation with vitreous (one case), and marked condensation of the vitreous with interdigitations (one case). En face OCT imaging at the level of the retinal pigment epithelial zone showed a hyporeflective, round, well-delineated mass. A peripheral poorly defined hyperreflectivity with a central hyporeflectivity was observed at the level of mid-retina, likely because of shadowing effect. The OCT-A reveals a dense vascular network within the tumor.

Conclusion:

Retinal astrocytic hamartomas may be well characterized by non-invasive imaging using spectral-domain OCT, en face OCT, and OCT angiography. The OCT angiography seemed to show tumor vascularity, which may represent dilated disorganized and anastomotic superficial and deep plexus capillaries. The tumor is often unique, peripapillary, small in diameter, and dome-shaped on spectral-domain OCT protruding into the vitreous cavity, responsible for vitreous changes facing the lesion.
QUIESCENT HERPES SIMPLEX KERATITIS REACTIVATION AFTER INTRAVITREAL INJECTION OF DEXAMETHASONE IMPLANT
Authors: Jusufbegovic Denis , Schaal Shlomit
Published: August 2016

Purpose:

To report reactivation of herpes simplex virus keratitis after the injection of dexamethasone implant (Ozurdex) and to raise the awareness of this potentially vision threatening side effect.

Methods:

A 90-year-old man presented with ocular pain and tearing in the left eye 3 weeks after receiving a dexamethasone implant (Ozurdex) for the treatment of macular edema associated with branch retinal vein occlusion. The patient had a history of herpes simplex virus keratitis that was quiescent for more than 30 years.

Results:

Clinical examination of the left eye showed arborizing epithelial ulcer with terminal bulbs consistent with herpes simplex virus keratitis.

Conclusion:

Quiescent herpes simplex virus keratitis can be reactivated after dexamethasone implant (Ozurdex). Prophylactic antiviral therapy might be indicated in individuals who have a high risk of recurrent herpetic disease.
Bleb Revision With Temporalis Fascia Autograft
Authors: Qu-Knafo Lise , Le Du Brivael , Boumendil Julien , Nordmann Jean-Philippe
Published: August 2016

Purpose:

We report the first description of temporalis fascia autograft to repair a late leakage bleb with scleral defect that occurred long time after trabeculectomy with mitomycin C.

Patient:

A 65-year-old woman was referred to our hospital with chronic late bleb leakage on her right eye. She had previously undergone a trabeculectomy with mitomycin C 3 years ago for a pigmentary glaucoma. Bleb leakage occurred 1½ year after the initial surgery. She underwent 2 surgical revisions consisting of a conjunctival advancement then an autologous conjunctival with partial scleral grafts without success. The initial best-corrected visual acuity of the right eye was 20/50 (Snellen scale). Slit-lamp examination revealed an avascular filtering bleb with leakage (massive positive Seidel test) and a scleral defect. The anterior chamber was deep and intraocular pressure (IOP) was 9 mm Hg.

Faced with the risk of blebitis, endophthalmitis, and with the failure of the previous surgeries announced earlier, a surgical revision with autologous superficial temporalis fascia graft was decided to repair the leaking bleb. After local anesthesia, a sample of superficial temporalis fascia was harvested. The necrotic avascular conjunctiva around the bleb was dissected to separate and excise it from the sclera. The autologous fascia graft was sutured on the scleral defect with 10-0 nylon. Subsequently healthy conjunctiva was sutured above the graft.

Results:

No bleb leakage occurred postoperatively, best-corrected visual acuity improved to 20/25, and IOP remained within normal levels 6 months after surgery without IOP-lowering medication.

Conclusions:

Superficial temporalis fascia autograft seems to be an effective, safe, and easy technique for ophthalmologists. It is a new procedure in the management of late-onset bleb leakage.
Daylight-Mediated Photodynamic Therapy for Actinic Keratosis
Authors: Spelman Lynda , Holland Teagan , Davidson Kurt
Published: August 2016

Actinic (solar) keratoses are premalignant lesions caused by prolonged exposure to ultraviolet radiation, with the potential to progress into squamous cell carcinoma. Hence, use of appropriate therapies is critical for effective treatment. Daylight-mediated photodynamic therapy with methyl aminolevulinate cream is a convenient new option for the safe and effective treatment of actinic (solar) keratosis lesions, offering similar efficacy to conventional photodynamic therapy, nearly painless treatment, and reduced in-clinic times. Use of appropriate therapies and optimization of clinical practice are critical for safe and effective treatment. Nurses play a key role in ensuring best clinical practice and effective treatment. This article explains the practicalities and principles of daylight-mediated photodynamic therapy to ensure best practice by treating nurses.
Recurrent and Persistent Urticaria: Is It Chronic Idiopathic Urticaria?
Authors: Goldstein Stanley , Weinberg Jeffrey M.
Published: August 2016

Chronic idiopathic urticaria (CIU), defined as wheals and/or angioedema lasting for ≥6 weeks without an identifiable cause, is a burdensome condition. This review provides recommendations regarding the efficient recognition and differential diagnosis of CIU from other chronic urticaria forms and discusses the importance of evaluating CIU’s impact on patients’ quality of life and assessing unmet treatment needs.

The goal of treatment is achieving complete resolution of symptoms through a systematic approach and close patient cooperation, thereby improving quality of life. The U.S. Practice Parameter describes a step-care approach to CIU management, with second-generation H1-antihistamines at approved doses as the first-line treatment. For patients with inadequately controlled symptoms, dose advancement or add-on therapies, followed by use of potent antihistamines, may be considered. Of the alternative agents available for the treatment of patients with refractory CIU, omalizumab, an anti-immunoglobulin E monoclonal antibody, is the only treatment approved by the Food and Drug Administration for use in adults and adolescents (≥12 years old) with CIU who remain symptomatic despite H1-antihistamine therapy. Ultimately, treatment decisions should weigh the potential clinical benefit versus harm for each agent and consider the patient’s preference. By discussing available treatment options and providing evidence-based recommendations, this review aims to support aspects of decision making when managing this complex condition.
Illustrations of Unexpected Infant Sleep Deaths
Authors: Cullen Deborah , Oberle Morgan , Elomba Charles D. , Stiffler Deborah , Luna Gaye
Published: August 2016

Case illustrations from central Indiana provide the narrative for infant suffocations because of unsafe sleep environments. Accidental strangulation or suffocation in bed is caused by co-bedding, blankets and pillows in cribs, or wedging and entrapment. Knowledge of the evidence-based risks associated with case data may assist further in the prevention of unexpected infant sleep deaths and may better inform best practice for death scene investigation including forensic nurses.
The Intranodal Presence of Coexisting Granulomatous Inflammation and Carcinoma During Transbronchial Needle Aspiration of Intrathoracic Lymphadenopathy
Authors: Gilbert Christopher R. , Abendroth Catherine , Yarmus Lonny B.
Published: August 2016

The presence of intrathoracic lymphadenopathy in patients with suspected malignancy remains concerning, often prompting further evaluation with tissue sampling. The presence of nodal granulomatous inflammation in patients with underlying malignancy is well reported. However, review of 3 recent large trials of endobronchial ultrasound-guided transbronchial needle aspiration in patients with granulomatous inflammation and malignancy did not identify the presence of coexisting, intranodal malignancy, and granulomatous inflammation, rather these diagnoses remained nodally exclusive. We present a case of coexisting granulomatous inflammation and metastatic carcinoma within the same lymph node aspirates, reviewing the potential diagnostic pitfalls and implications of this rare occurrence.
EBUS-TBNA and EUS-FNA
Authors: Meena Nikhil , Abouzgheib Wissam , Patolia Setu , Rosenheck Justin , Boujaoude Ziad , Bartter Thaddeus
Published: August 2016

Background:

Clopidogrel is widely used for the prevention of thrombotic vascular complications. Its primary potential toxicity is bleeding. Management of clopidogrel therapy for patients undergoing invasive procedures is an area of ongoing study. We sought to evaluate the bleeding risk for patients undergoing needle aspiration biopsy by endobronchial ultrasound (EBUS) or esophageal ultrasound (EUS) while taking clopidogrel.

Methods:

Retrospective review of sequential cases of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and esophageal ultrasound fine needle aspiration (EUS-FNA).

Results:

Three hundred ninety-five consecutive procedures were reviewed. Thirty-seven patients were taking clopidogrel at time of biopsy. The patients taking clopidogrel were significantly older than those in the control group. Two patients (1%) in the control group were admitted for observation, but neither was found to have a significant bleed. There were no clinically significant bleeding complications in either of the study groups.

Conclusions:

It is reasonable to proceed with EBUS-TBNA or EUS-FNA when both, (1) clopidogrel cannot be stopped and, (2) an important diagnostic question is at stake.
Analysis of Human Papillomavirus Infection in 16,320 Patients From a Gynecology Clinic in Central South China
Authors: Xiao Song S. , Fan Jie L. , He Si L. , Li Yue R. , Wang Lu Y. , Yu Ke N. , Deng Xin L. , Xue Min
Published: August 2016

Objective

This study aimed to investigate the relationship between persistent human papillomavirus (HPV) infection and cervical lesion.

Methods

Clinical data of 16,320 patients who visited our clinic between January 2009 and December 2013 were collected. Retrospective analysis was performed to analyze the overall HPV infection and compare the infection rates of different subtypes among different age groups, to reveal the relationship between persistent HPV infection and cervical cytology.

Results

The overall prevalence of HPV was 26.54%. The most common genotypes were HPV 52, HPV 16, HPV 58, CP8304, and HPV 53. The highest overall high-risk HPV prevalence was found in women older than 60 years, and the lowest prevalence was found in women between the ages of 30 and 39 years. There was no significant difference in low-risk HPV prevalence among different age groups (p = .693). The HPV clearance rate after 1 year among those with initial positive test was 87.65%. The constituent ratios of high- or low-risk HPV subtypes were not significantly different (p = .545) between nonpersistent-positive and persistent-positive (PP) groups. Conversely, the constituent ratios of singe- or multi-type HPV infection were significantly different (p < .05) between these 2 groups. The most common subtypes in PP group were HPV 16, 52, 58, CP8304, and 33. The occurrence rates of atypical squamous cells of undetermined significance, high-grade squamous intraepithelial lesion, and squamous cell carcinoma in the PP group significantly increased (p < .05).

Conclusions

Persistent HPV infections are mainly caused by multiple types of HPV and high-risk HPV. Our region should particularly pay attention to the prevention and treatment of HPV 16, 52, and 58.
Assessment of adequacy of volume resuscitation
Authors: Boyd John H. , Sirounis Demetrios
Published: August 2016

Purpose of review

It has recently become evident that administration of intravenous fluids following initial resuscitation has a greater probability of producing tissue edema and hypoxemia than of increasing oxygen delivery. Therefore, it is essential to have a rational approach to assess the adequacy of volume resuscitation. Here we review passive leg raising (PLR) and respiratory variation in hemodynamics to assess fluid responsiveness.

Recent findings

The use of ultrasound enhances the clinician's ability to detect and predict fluid responsiveness, whereas enthusiasm for this modality must be tempered by recent evidence that it is only reliable in apneic patients.

The best predictor of fluid response for hypotensive patients not on vasopressors is a properly conducted passive leg raise maneuver. For more severely ill patients who are apneic, mechanically ventilated and on vasopressors, point of care echocardiography is the best choice. Increases in vena caval diameter induced by controlled positive pressure breaths are insensitive to arrhythmias and can be performed with relatively brief training. Most challenging are patients who are awake and on vasopressors; we suggest that the best method to discriminate fluid responders is PLR measuring changes in cardiac output.
Factors Associated With Metachronous Gastric Cancer Development After Endoscopic Submucosal Dissection for Early Gastric Cancer
Authors: Ami Reiko , Hatta Waku , Iijima Katsunori , Koike Tomoyuki , Ohkata Hideki , Kondo Yutaka , Ara Nobuyuki , Asanuma Kiyotaka , Asano Naoki , Imatani Akira , Shimosegawa Tooru
Published: August 2016

Goals:

To clarify the factors associated with metachronous gastric cancer development after endoscopic submucosal dissection (ESD) for early gastric cancer.

Background:

Patients who undergo ESD for early gastric cancer have an appreciable risk of developing metachronous gastric cancer. However, there have been few reports on the association between life style and the development of such cancer.

Study:

Patients with early gastric cancer who underwent ESD at our institution between 2003 and 2012 were enrolled. Metachronous gastric cancer was defined as secondary gastric cancer detected >1 year after initial ESD. Factors, including age, gender, body mass index, eradication of Helicobacter pylori, cigarette smoking, drinking, and continuous use of a proton pump inhibitor, associated with metachronous gastric cancer development were evaluated by Cox proportional hazard regression analysis.

Results:

A total of 539 patients with a mean 53.6-month follow-up period were analyzed. The 5-year cumulative incidence of secondary gastric cancer was 13.0%. Multivariate analysis exhibited that age of 60 years and above [hazard ratio (95% confidence interval)=4.05 (1.23-13.4)] and cigarette smoking [2.12 (1.19-3.78)] were independent risk factors for metachronous gastric cancer development. Furthermore, ≥20 pack-years of smoking [1.51 (1.03-2.24)] was a significant risk factor with a dose-response relationship (P for trend=0.042). There was no significant association between Helicobacter pylori eradication and metachronous gastric cancer development.

Conclusions:

This is the first study to demonstrate the detailed association between cigarette smoking and metachronous gastric cancer development.
Elevated Liver Enzymes and Mortality in Older Individuals
Authors: Mahady Suzanne E. , Wong Germaine , Turner Robin M. , Mitchell Paul , Macaskill Petra , Craig Jonathan C. , George Jacob
Published: August 2016

Aim of the study:

The aim of the study was to determine the excess risk of all-cause and cardiovascular mortality in older people with elevated liver enzymes [alanine transaminase (ALT) and gamma glutamyltransferase (GGT)].

Methods:

We utilized data from a large, prospective, population based study of 2061 people aged 50 to 99 years with linkage to a National Death Registry. Participants were categorized as having elevated liver enzymes using standard thresholds (for males, GGT>51 and ALT>40 IU/L, and GGT>33 and ALT>31 IU/L for females). Adjusted Cox proportional hazards models assessed the association of elevated liver enzymes and mortality with long duration follow-up.

Results:

Over a median follow-up of 10 years (20,145 person years), 701 people died, including 203 (34%) from cardiovascular disease. Cox regression models adjusted for sex, age, smoking, and alcohol intake indicated that people with elevated liver enzymes had an increased risk of all-cause mortality that was modified by age (test for interaction P=0.01). Age-stratified analyses demonstrated no increased risk at younger ages [age 59 y and below; hazard ratio (HR): 0.46; 95% confidence interval, 0.06-3.49], but increased risk with age; age 60 to 69, HR: 1.05 (0.53-2.07), age 70 to 79 years, HR: 1.54 (0.81 to 2.93), and age 80 years and above, HR: 3.53 (1.55 to 8.04). Similarly, the risk of cardiovascular mortality with elevated liver enzymes was also modified by, and increased with age (test for interaction P=0.02); age 70 to 79, HR: 3.15 (1.37 to 7.23), age 80 years and above, HR: 6.86 (2.44 to 19.30).

Conclusions:

In community-dwelling elderly persons, an elevation in both ALT and GGT are associated with an excess risk of all-cause and cardiovascular mortality which increases with age.
The Inflammatory Bowel Disease-Disability Index: validation of the Portuguese version according to the COSMIN checklist
Authors: Soares João B. , Pereira Rafaela , Costa Juliana M. , Arroja Bruno , Gonçalves Raquel
Published: August 2016

Background and aim

Recently, the Inflammatory Bowel Disease-Disability Index (IBD-DI) was developed to assess disability in inflammatory bowel disease (IBD). Our aim was to validate the Portuguese version of IBD-DI according to the COnsensus-based Standards for the selection of the health Measurement INstruments (COSMIN) recommendations.

Materials and methods

After translation into Portuguese, the IBD-DI was administered by two interviewers to IBD patients at baseline and after 4 weeks and 4 months. We evaluated reliability (internal consistency, test–retest, and inter-rater reliability and measurement error), construct validity, responsiveness, and interpretability.

Results

At baseline, 129 patients (73=Crohn’s disease; 56=ulcerative colitis) completed the IBD-DI. After 4 weeks and 4 months, 118 and 89 patients repeated the questionnaire, respectively. Factor analysis confirmed the unidimensionality of the scale and reduced the final version to 14 items. The Cronbach’s α was 0.88. The intraclass correlation coefficients were 0.87 and 0.99 for test–retest (baseline and 4 weeks) and inter-rater reliability, respectively. The smallest detectable change was 18.64 at the individual level and 1.87 at the group level. IBD-DI scores correlated negatively with the total, physical, and mental scores of Short Form-36 items. The change score of IBD-DI between baseline and 4 months correlated negatively with the clinical evolution of patients. The minimal important change was 16.96. IBD-DI scores ranged from 0 to 78.6, with a mean of 21.8±18.1. Female sex, professional inactivity, and clinical disease activity were associated with higher IBD-DI scores.

Conclusion

The Portuguese version of IBD-DI obtained is a reliable, valid, responsive, and interpretable (at the group level) tool to assess disability in Portuguese IBD patients.
Examining Measures of Income and Poverty in Medicare Administrative Data
Authors: Samson Lok Wong , Finegold Kenneth , Ahmed Azeem , Jensen Matthew , Filice Clara E. , Joynt Karen E.
Published: August 2016

Disparities by economic status are observed in the health status and health outcomes of Medicare beneficiaries. For health services and health policy researchers, one barrier to addressing these disparities is the ability to use Medicare data to ascertain information about an individual’s income level or poverty, because Medicare administrative data contains limited information about individual economic status. Information gleaned from other sources—such as the Medicaid and Supplemental Security Income programs—can be used in some cases to approximate the income of Medicare beneficiaries. However, such information is limited in its availability and applicability to all beneficiaries. Neighborhood-level measures of income can be used to infer individual-level income, but level of neighborhood aggregation impacts accuracy and usability of the data. Community-level composite measures of economic status have been shown to be associated with health and health outcomes of Medicare beneficiaries and may capture neighborhood effects that are separate from individual effects, but are not readily available in Medicare data and do not serve to replace information about individual economic status. There is no single best method of obtaining income data from Medicare files, but understanding strengths and limitations of different approaches to identifying economic status will help researchers choose the best method for their particular purpose, and help policymakers interpret studies using measures of income.
Early nutrition, epigenetics, and cardiovascular disease
Authors: Loche Elena , Ozanne Susan E.
Published: August 2016

Purpose of review

Here, we provide a summary of the current knowledge on the impact of early life nutrition on cardiovascular diseases that have emerged from studies in humans and experimental animal models. The involvement of epigenetic mechanisms in the Developmental Origins of Health and Disease will be discussed in relation to the implications for the heart and the cardiovascular system.

Recent findings

Environmental cues, such as parental diet and a suboptimal in utero environment can shape growth and development, causing long-lasting cardiometabolic perturbations. Increasing evidence suggest that these effects are mediated at the epigenomic level, and can be passed onto future generations. In the last decade, epigenetic mechanisms (DNA methylation, histone modifications) and RNA-based mechanisms (microRNAs, piRNAs, and tRNAs) have therefore emerged as potential candidates for mediating inheritance of cardiometabolic diseases.

The burden of obesity and associated cardiometabolic diseases is believed to arise through interaction between an individual's genetics and the environment. Moreover, the risk of developing poor cardiometabolic health in adulthood is defined by early life exposure to pathological cues and can be inherited by future generations, initiating a vicious cycle of transmission of disease. Elucidating the molecular triggers of such a process will help tackle and prevent the uncontrolled rise in obesity and cardiometabolic disease.
Cognitive Abilities of Children With Neurological and Liver Forms of Wilson Disease
Authors: Favre Emilie , Lion‐François Laurence , Canton Marie , Vanlemmens Claire , Bonneton Marjorie , Bouillet Lise , Brunet Anne‐Sophie , Lachaux Alain
Published: August 2016

Cognitive impairment in adult patients experiencing Wilson disease is now more clearly described, even in liver forms of the disease. Although this condition can appear during childhood, the cognitive abilities of children have not yet been reported in a substantial case series. This retrospective study included 21 children with Wilson disease who had undergone general cognitive assessment. The results argue in favor of a poor working memory capacity in the liver form of the disease, and more extensive cognitive impairments in its neurological form. Extensive neuropsychological investigations on all children experiencing Wilson disease are thus required.
Complex Relation Between Diet and Phospholipid Fatty Acids in Children With Cystic Fibrosis
Authors: Moukarzel Sara , Dyer Roger A. , Innis Sheila M.
Published: August 2016

Objectives:

Altered total plasma n‐6 and n‐3 fatty acids are common in cystic fibrosis (CF). Whether alterations extend to plasma phosphatidylcholine (PC) and phosphatidylethanolamine (PE) and are explained by diet is unclear. The present study was to describe the dietary intake of a large group of children with CF and to determine whether dietary fat composition explains differences in plasma PC and PE fatty acids between children with and without CF.

Methods:

Dietary intake was assessed using a food frequency questionnaire. Venous blood was collected. Plasma PC and PE were separately analyzed for fatty acids.

Results:

Children with CF, n = 74, consumed more calories and fat (g/day and % energy), with significantly more saturates mainly from dairy foods and less polyunsaturates including linoleic acid (LA), arachidonic acid (ARA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA) (% fat) than reference children, n = 71. A subset of children with CF, not differing in dietary intake from the larger group, had significantly lower LA and DHA, but higher EPA in plasma PC and had higher LA and lower ARA and DHA in plasma PE, compared to a subset of reference children. In both groups, LA intake and LA in plasma PC and PE were not associated. EPA and DHA intakes were positively associated with EPA and DHA, respectively, in plasma PC, but not PE, in reference children only.

Conclusions:

The fatty acid composition of plasma PC and PE is altered in CF. Fatty acid differences between children with and without CF are inconsistent between PC and PE and are not explained by dietary fat.
Biliary Dyskinesia in Children
Authors: Santucci Neha R. , Hyman Paul E. , Harmon Carroll M. , Schiavo Julie H. , Hussain Sunny Z.
Published: August 2016

Cholecystectomy rates for biliary dyskinesia in children are rising in the United States, but not in other countries. Biliary dyskinesia is a validated functional gallbladder disorder in adults, requiring biliary colic in the diagnosis. In contrast, most studies in children require upper abdominal pain, absent gallstones on ultrasound, and an abnormal gallbladder ejection fraction (GBEF) on cholecystokinin‐stimulated cholescintigraphy for diagnosis. We aimed to systematically review existing literature in biliary dyskinesia in children, determine the validity and reliability of diagnostic criteria, GBEF, and to assess outcomes following cholecystectomy. We performed a systematic review following the PRISMA checklist and searched 7 databases including PubMed, Scopus, Embase, Ovid, MEDLINE, ProQuest, Web of Science, and the Cochrane library. Bibliographies of articles were screened for additional studies. Our search terms yielded 916 articles of which 28 were included. Three articles were manually added from searched references. We reviewed 31 peer‐reviewed publications, all retrospective chart reviews. There was heterogeneity in diagnostic criteria and GBEF values. Outcomes after laparoscopic cholecystectomy varied from 34% to 100% success, and there was no consensus concerning factors influencing outcomes. The observational, retrospective study designs that comprised our review limited interpretation of safety and efficacy of the investigations and treatment in biliary dyskinesia in children. Symptoms of biliary dyskinesia overlapped with functional dyspepsia. There is a need for consensus on symptoms defining biliary dyskinesia, validation of testing required for diagnosis of biliary dyskinesia, and randomized controlled trials comparing medical versus surgical management in children with upper abdominal pain.
Partly Fermented Infant Formulae With Specific Oligosaccharides Support Adequate Infant Growth and Are Well‐Tolerated
Authors: Huet Frédéric , Abrahamse‐Berkeveld Marieke , Tims Sebastian , Simeoni Umberto , Beley Gérard , Savagner Christoph , Vandenplas Yvan , Hourihane Jonathan O'B.
Published: August 2016

Objective:

Fermented formulae (FERM) and a specific mixture of 90% short‐chain galacto‐oligosaccharides and 10% long‐chain fructo‐oligosaccharides (scGOS/lcFOS; 9:1) have a potential beneficial effect on gastrointestinal function and microbiota development in infants. The present study assessed the safety and tolerance of the combination of partly fermented infant milk formulae and scGOS/lcFOS compared with either 1 feature, in healthy term infants.

Methods:

Four hundred thirty‐two infants were enrolled before 28 days of age and followed up to 17 weeks of age and assigned to 1 of the 4 groups: (i) formula with scGOS/lcFOS, (ii) scGOS/lcFOS + 15% FERM, (iii) scGOS/lcFOS + 50% FERM, or (iv) 50% fermented formula (50% FERM). Primary outcome was daily weight gain during intervention (equivalence criterion: difference in daily weight gain ⩽3 g/day). Infants’ anthropometrics, formula intake, number, and type of (serious) AEs were monitored monthly. Stool samples were collected at baseline and after 17 weeks for analysis of physiological and microbiological parameters.

Results:

Equivalence of weight gain per day was demonstrated in both the intention‐to‐treat and per‐protocol population, with a mean weight gain (SD) of 29.7 (6.1), 28.2 (4.8), 28.5 (5.0), and 28.7 (5.9) g/day for the groups i to iv respectively. No differences were observed in other growth parameters, formula intake, and the number or severity of AEs. In all scGOS/lcFOS‐containing formulae, a beneficial effect of scGOS/lcFOS was observed, indicated by the lower pH, lower Clostridium difficile levels, and higher secretory immunoglobulin A levels.

Conclusions:

The partly fermented infant milk formulae containing the specific mixture scGOS/lcFOS were well‐tolerated and resulted in normal growth in healthy infants.