bluuebunny/crossref_metadata_2025 huggingface dataset:
Stable Spondylolisthesis
Authors: Chugh Arunit J.S. , Alonso Fernando , Moore Ryan , Cox Efrem , Eubanks Jason
Published: February 2019

Study Design:

This is a retrospective cohort review.

Objective:

To determine whether a correlation exists between facet cysts and lumbar instability.

Summary of Background Data:

Lumbar facet cysts are common degenerative entities observed in patients with low-grade spondylolisthesis at a rate of 10%–50%. Surgical management with partial facetectomy with or without fusion remains controversial.

Methods:

Review of 86 patients with lumbar degenerative spondylolisthesis is performed. Preoperative magnetic resonance imagings were reviewed for the presence of lumbar facet cysts and Facet Fluid Indices (FFI)—calculated as the ratio of facet fluid width to facet width. Instability was defined as a difference of >3 mm in vertebral displacement between flexion and extension radiographs. T tests and the Pearson correlation analyses were used to determine statistical significance.

Results:

In total, 26 patients had unstable and 60 had stable spondylolisthesis. Facet cysts were present at an overall prevalence of 30.1%—in 10/26 patients in the unstable group and in 18/60 patients in the stable group (P>0.05). The average FFIs for the unstable and stable groups were 0.13 and 0.09, respectively (P>0.05). FFI in patients with facet cysts was significantly higher than those without (P<0.05). In addition, the group with facet cysts had a significantly higher proportion of patients with FF effusions >3 mm.

Conclusions:

Lack of correlation with instability hints that the presence of facet cysts may not indicate instability in lumbar degenerative spondylolisthesis. Therefore, presence of facet cysts in static magnetic resonance imaging revealing spondylolisthesis should not preclude the physician from performing dynamic films to evaluate for instability. Significantly higher FFI in patients with facet cysts reaffirms the degenerative pathophysiology involved in their formation. Although this is not an outcomes study, it does spark interest into whether patients with stable spondylolisthesis and concurrent facet cysts are suitable for partial facetectomy alone with fusion.
Is Teriparatide Beneficial to Spinal Fusion Surgery in the Older Patient?
Authors: Wanderman Nathan , Alvi Mohammed , Yolcu Yagiz , Carlson Bayard , Sebastian Arjun , Bydon Mohamad , Freedman Brett
Published: February 2019

Since FDA approval in 2002, teriparatide has gained popularity as an anabolic therapy for the treatment of osteoporosis. Animal studies have suggested a role for teriparatide in spine surgery. Several recent studies have demonstrated adjunctive use of teriparatide in osteoporotic patients undergoing spine fusions improves fusion rates, decreases time to union, and decreases osteoporosis-related complications such as proximal junctional kyphosis. On the basis of the available literature, we outline an algorithm for the use of teriparatide in spine surgery.
Hemorrhage Control
Authors: Allison Herman A.
Published: February 2019

Uncontrolled blood loss is a major cause of preventable death worldwide. A severe injury can occur anywhere at any time. Controlling blood loss is an important issue for patient care in the hospital setting. Through the casualties of war, the lifesaving value of quick interventions was developed. Since 2001, new hemostatic agents have advanced the benefits of controlling blood loss. There are unforgettable lessons learned in the preventable deaths of many soldiers and should be passed on to the next generation of health care providers, to include all hospitals up to level I trauma hospitals. This article covers the current hemostatic agents that have been used for more than 17 years on the battlefield and are slowly making their way into the hospital settings. The hemostatic agents covered include QuikClot Combat Gauze, QuikClot Control+, WoundClot Hemostatic Gauze, HemCon Nasal Plug, and RevMedx's XSTAT hemostatic device. The standard of care should not be affected by the location of a patient, whether that patient is in a remote village overseas, on the battlefield, a rural farm, or at a major metropolitan hospital here in the United States.
Implementation of a Blood Conservation Initiative to Effectively Reduce Blood Transfusions in Cardiac Surgery Patients
Authors: Lythgoe Jeanne
Published: February 2019

Perioperative and postoperative blood transfusions in cardiac surgery patients are associated with as much as a 16% increased risk of mortality and a significantly increased risk in morbid outcomes. At the project site, red blood cell transfusions in cardiac surgery patients undergoing isolated coronary artery bypass graft were above national benchmarks. The aim of the project was to reduce blood transfusions in cardiac surgery patients by 10% over 8 weeks. Primary interventions included engagement for the team and use of a shared decision-making tool for patients. Use of the Any RBC Transfusion online risk calculator was implemented with initiation of anemia protocol orders, chart identification, and blood conservation coordinator referral. There was no decrease in the blood transfusion rate during project implementation. However, this project heightened blood conservation awareness among team members and clinical leaders, brought attention to the need for evidence-based practice, and stimulated conversation about change.
Neonatal Blood Loss Risks
Authors: Fikac Lisa
Published: February 2019

There are many common risks for blood loss in the newborn infant. Blood loss can occur prenatally, intrapartally, and during the neonatal period. This article looks at the most common risks to be aware of in the newborn infant. Babies are not just tiny versions of adults. They have differences in the maturity all body systems, and that includes circulating blood volume and factors that contribute to those differences. Circulating blood volume is about 80 to 100 mL/kg in the term infant and 90 to 105 mL/kg in the preterm infant. Red blood cells live for about a month and are replaced with immature red blood cells called reticulocytes that mature within 12 to 24 hours. Therefore, potential for blood loss and its impact are issues that must be part of our overall assessment of the infant's condition. Blood loss can occur during pregnancy, the intrapartal period, or the postnatal period. Let us look at the potential issues for each of these time frames.
Educating Parents About Vitamin K in the Newborn Using Knowles' Theory of Adult Learning Principles as a Framework
Authors: Twaddell Jennifer W.
Published: February 2019

Parents must make an educated decision regarding vitamin K administration for their infant prior to birth. With an abundance of information available regarding this topic, the nurse needs to guide the parents through this process. Using Knowles' Theory of Adult Learning Principles as a framework can increase the parents' knowledge and assist the nurse in providing thorough information.
Physician Engagement
Authors: McGonigal Michelle , Bauer Matthew , Post Christopher
Published: February 2019

In the 2001 Institute of Medicine report on patient outcomes in the United States, one of the key concepts was the importance of collaboration within the health care team by using quality improvement methodologies as a foundation and using data to drive change and improve patient outcomes and ultimately the health of the nation. Ensuring that all health care providers have a voice at the table on key initiatives has been a challenge to implement, especially when attempting to involve frontline staff including physicians and nurses. In regard to the particular organization to be discussed, it was important to have an understanding of what issues resonated with physicians and the health care team as a whole in order to successfully integrate their expertise into committee work and practice changes that were priorities for the organization. As a starting point, a review of physician engagement strategies was completed and priorities were matched according to physician specialty and interest. Due to the increasing external pressure to examine and improve outcomes in hospital-acquired infections and in particular, reduction of central line-associated blood stream infections, catheter-associated urinary tract infections, surgical site infections, and Clostridium difficile infections, these areas were the focus of the initial physician-led teams. The positive outcomes in both physician engagement and satisfaction as well as patient outcomes were evidence to pursue additional team approaches in complication reviews, employee injury teams, and mortality risk reduction.
Long-term Outcome of Hirschsprung Disease: Impact on Quality of Life and Social Condition at Adult Age
Authors: Drissi Farouk , Meurette Guillaume , Baayen Corine , Wyart Vincent , Cretolle Célia , Guinot Audrey , Podevin Guillaume , Lehur Paul-Antoine
Published: February 2019

BACKGROUND:

Hirschsprung disease is a rare congenital disease typically requiring surgical treatment during childhood. Quality of life and social condition at adult age can be impaired by disease-specific sequelae.

OBJECTIVE:

This study aimed to assess the quality of life and social outcome of adult patients operated on for Hirschsprung disease during childhood.

DESIGN:

Patients operated on for Hirschsprung disease during childhood were identified and specific questionnaires were sent to them.

SETTINGS:

Data from 2 referral centers were used.

PATIENTS:

Patients who completed the questionnaires regarding quality of life and social condition were included.

MAIN OUTCOME MEASURES:

The Hirschsprung’s Disease and Anorectal Malformations Quality of Life disease-specific questionnaire (8 dimensions explored; each scored from 0 to 100 maximum score) and a sociodemographic questionnaire were sent to identified patients. Sociodemographic data were compared with those of the French general population.

RESULTS:

Thirty-four patients had Hirschsprung disease (men, 76%; mean age, 32 years) were included in the study. Mean total Hirschsprung’s Disease and Anorectal Malformations Quality of Life score was 611 of 800 (maximum score 800). The 2 most impaired dimensions were “physical symptoms” and “diarrhea” (62.9/100 and 73.6/100). Fecal continence was only marginally affected (mean score, 89/100). Patients with Hirschsprung disease achieved better educational levels than the French general population. Parental and marital status did not differ between the 2 groups.

LIMITATIONS:

This study had the limitations inherent to a retrospective study.

CONCLUSION:

The quality of life of adult patients with Hirschsprung disease sequelae is marginally impaired in this study. Despite the consequences of this congenital abnormality, the condition eventually achieved can be considered as satisfactory. See Video Abstract at http://links.lww.com/DCR/A917.
Dried Blood Spot Self-Sampling by Guardians of Children With Epilepsy Is Feasible: Comparison With Plasma for Multiple Antiepileptic Drugs
Authors: Linder Camilla , Neideman Mirja , Wide Katarina , von Euler Mia , Gustafsson Lars L. , Pohanka Anton
Published: February 2019

Background:

Dried blood spot (DBS) is an attractive matrix alternative to plasma for the measurement of antiepileptic drug concentrations with the possibility of self-sampling at home. The aim of this study was to evaluate whether DBS concentrations from a children population could be used as an alternative to plasma concentrations in a clinical routine laboratory.

Methods:

Children with epilepsy using carbamazepine (CBZ), lamotrigine (LTG), levetiracetam (LEV), or valproic acid (VPA) had capillary blood collected for routine plasma analysis. DBS samples were collected by guardians or nurses, and the quality of sampling was compared between the groups. DBS samples were analyzed with liquid chromatography–tandem mass spectrometry methods and plasma samples with immunochemical methods. In the comparison between DBS and plasma concentrations, previously analyzed sample data were pooled with data in this study and resulted in 190 comparison pairs. A bioanalytical cross-validation according to European Medicines Agency was performed. Clinicians evaluated the results to understand if a DBS concentration was linked to a different clinical dose recommendation for the patient in comparison with plasma concentrations.

Results:

Comparison of DBS sample quality showed that 2.3% of the capillary DBS collected by guardians were rejected and 8.0% of the capillary DBS collected by nurses. For DBS, a conversion factor of 0.85 for CBZ and 1.65 for VPA was applied for the comparison with plasma. LTG and LEV results were directly comparable. In the cross-validation, 88% of CBZ, 75% of LTG, 74% of LEV, and 94% of VPA comparisons were within 20% of the difference of the mean, although LEV had a few major differences (+31% to −40%). In 4 of the 190 comparisons, the clinical evaluation indicated a risk of conflicting decisions regarding the need for dose adjustment when using DBS concentrations. However, the risk of negative patient outcomes was considered negligible.

Conclusions:

Our study demonstrates that a combination of bioanalytical cross-validation and clinical evaluation is an effective way to describe the applicability of DBS as an alternative to plasma, taking into account how therapeutic drug monitoring is used in specific patient groups. For LTG, converted CBZ and VPA, DBS is a feasible alternative for self-sampling at home. DBS for LEV can only be recommended for nonadherence queries due to the high variability of the plasma/DBS concentration ratios.
Organizational factors affecting successful physician–system integration: A qualitative study of Washington State health executives
Authors: Nguyen Ann M. , Johnson Christopher E. , Wood Suzanne J. , Dowling William L.
Published: February 2019

Background

Health care delivery is moving toward a value-based environment, which calls for increased integration between physician groups and health systems. Health executives sit at a key nexus point for determining how and when physician–system integration occurs.

Purpose

The objective of this study was to identify the organizational factors that health executives perceived to have made physician–system integration successful.

Methodology/Approach

We used a multiple-case study research design. We conducted semistructured, qualitative interviews with 25 health executives in the roles of CEO, chief medical officer, chief financial officer and physician group chief executives from eight of Washington State's largest integrated delivery systems. To guide our analysis, we employed open systems theory and Porter's Value Chain to identify physician group and hospital factors that were integral to successful integration.

Results

Using the executives' perspectives, the factors grouped into three themes: (1) organizational structure—a mix of integration contracts united by common structural characteristics between physician groups and hospitals); (2) organizational culture—alignment of leadership between physician groups and hospitals; and (3) strategic resources—designated resources to establish and support care coordination activities.

Conclusion

Our work indicates that health systems should focus on the pathway to integration success through the alignment of structure (not just the integration contract), culture, and resources and not on an end goal of the physician employment model.

Practice Implications

Health system executives are key drivers for when and how physician groups are integrated into health services organizations. This article provides executives with an evidence-based model to aid in formulating integration approaches that combine elements of organizational structure, organizational culture, and strategic resources.
Clozapine Metabolism in East Asians and Caucasians
Authors: Ruan Can-Jun , Zang Yan-Nan , Wang Chuan-Yue , Cheng Yu-Hang , Sun Chuan , Spina Edoardo , de Leon Jose
Published: February 2019

Purpose/Background

In clozapine therapeutic drug monitoring (TDM) studies, Chinese reached the same concentrations using half the dosage Caucasians use. Defining clozapine poor metabolizers (PMs) requires stratification by ethnicity, smoking, and sex.

Methods/Procedures

After sex and smoking stratification in 129 Chinese inpatients (mean, 8.8 TDM samples per patient), we explored the association between the total concentration-dose (C/D) ratio and CYP1A2 (*1C, *1F, and *7) and CYP2C19 alleles (*2 and *3). A systematic literature review identified 22 clozapine TDM prior studies (13 in Caucasians and 7 in East Asians).

Findings/Results

In our Chinese sample, the mean total clozapine C/D ratio (ng/mL per mg/d) was 1.96 for 22 male smokers, 2.07 for 5 female smokers, 2.47 for 36 male nonsmokers, and 2.95 for 66 female nonsmokers. CYP1A2 *1C had no significant effects, and CYP1A2 *1F had small effects. Five clozapine PMs (4%) needed low clozapine doses of 75 to 115 mg/d to get therapeutic concentrations. Using the same methodology in a published Italian sample, we found 5 PMs (3.3% of 152). In the systematic review, the clozapine C/D ratio (ng/mL per mg/d) was higher when comparing: (1) weighted mean values of 1.57 in 876 East Asians versus 1.07 in 1147 Caucasians and (2) ranks of 8 East Asians versus 13 Caucasian samples (P< 0.001).

Implications/Conclusions

Future TDM studies need to further explore the frequency of clozapine PMs after sex and smoking stratification in East Asian and Caucasian patients. Compared with Caucasians, East Asians appear to have a clinically relevant decrease in clozapine clearance.
The Relationship Between Work Environment Satisfaction and Retention Intention Among Nursing Administrators in Taiwan
Authors: LIN Chiou-Fen , HUANG Chung-I , YANG Che-Ming , LU Meei-Shiow
Published: February 2019

Background

Nursing administrators are essential to ensuring the quality of healthcare provided in hospitals. The nursing manpower shortage that has affected hospitals in Taiwan over the past decade has weighed particularly heavily on nursing administrators, who are expected to maintain high levels of nursing care quality in frequently understaffed healthcare settings.

Purpose

The objective of this study was to explore the relationship between work environment satisfaction and nursing administrator retention in Taiwan.

Methods

This study used a cross-sectional, questionnaire-based survey to collect data from a sample population of nursing administrators. A set of indicators of quality nursing work environments was developed and included in the questionnaire. A total of 1,829 questionnaires were distributed, and the effective response rate was 95.57%.

Results

The average overall rate of satisfaction with the current work environment across all domains was 3.59 (SD= 0.61). The highest level of satisfaction was found in the domain of safe practice environment (M= 3.83,SD= 0.70), and the lowest was found in the domain of informatics (M= 3.38,SD= 0.91). Length of administrative position tenure was significantly correlated with retention. Each of the eight domains significantly influenced retention. The domain of support and caring was the most significant predictor of nursing administrator retention.

Conclusions/Implications for Practice

Length of administrator position tenure was significantly correlated with nursing administrator retention. Moreover, intention to stay among junior administrators was particularly affected by the support and caring domain. Therefore, it is recommended that nursing departments develop effective strategies to assist and encourage junior administrators to strengthen their career prospects and satisfaction.
Iatrogenic Inner Ear Dehiscence After Lateral Skull Base Surgery: Therapeutic Dilemma and Treatment Options
Authors: Bartholomew Ryan A. , Poe Dennis , Dunn Ian F. , Smith Timothy R. , Corrales Carleton Eduardo
Published: February 2019

Objective:

To describe a series of patients with iatrogenic inner ear dehiscence after lateral skull base surgery and discuss treatment options.

Patients:

Three patients with history of recent lateral skull base surgery, symptoms consistent with inner ear dehiscence, and radiographically proven bony dehiscence on postoperative imaging.

Interventions:

All patients were initially managed conservatively with serial outpatient visits. Two patients with large cochlear and vestibular dehiscences had round window reinforcement procedures. One patient had transmastoid resurfacing for repair of an iatrogenic posterior semicircular canal dehiscence.

Main Outcome Measures:

Anatomical location of dehiscences; treatment options; subjective auditory and vestibular symptoms pre-dehiscence, post-dehiscence and after dehiscence repair; pre- and post-audiogram when available.

Results:

Patient ages were 46, 52, and 60 with two of three being women. None of the patients had subjective auditory or vestibular symptoms of inner ear dehiscence before initial skull base surgery, but they all had development of these symptoms afterwards. All patients were initially managed conservatively, but all ultimately required a surgical procedure. The two patients who elected for round window reinforcements, and the one patient who required transmastoid resurfacing, had significant improvement of symptoms.

Conclusions:

Iatrogenic inner ear dehiscence after skull base surgery is best dealt with and repaired intraoperatively. Should intraoperative repair not be possible, transcanal round window reinforcement is a minimally invasive option for medial otic capsule dehiscence, although long-term outcomes are unclear. For lateral otic capsule dehiscence, a transmastoid approach is recommended.

Level of Evidence: IV
Cochlear Implantation in Patients With Neurofibromatosis Type 2
Authors: Tolisano Anthony M. , Baumgart Bethany , Whitson Johanna , Kutz Joe Walter
Published: February 2019

Objective:

To describe cochlear implantation (CI) outcomes in patients with neurofibromatosis type 2 (NF2).

Study Design:

Retrospective case series.

Setting:

A multidisciplinary NF2 clinic at a university hospital.

Patients/Interventions:

Patients with NF2 who underwent CI.

Main Outcome Measures:

Pre- and postimplantation audiometric data, including pure-tone average (PTA) and AzBio Sentence scores.

Results:

Eight patients with NF2 underwent CI. The mean age at implantation was 28.6 years (range: 17–63 yr) and six were female. The average length of deafness before CI was 3.5 years (range: 0.3–10 yr). Two patients underwent previous microsurgical resection via middle fossa craniotomy and one patient was treated with stereotactic radiotherapy before CI. Two tumors were growing at the time of CI, five tumors were not growing for an average period of 3.8 years (range: 1–6 yr), and one tumor had undergone previous gross total resection. Mean preoperative unaided PTA was 103.1 dB (range: 81.3–115 dB) and all preoperative AzBio scores were 0% in the ear to be implanted. These improved to a mean postoperative PTA of 30.9 dB (range: 12.5–43.8 dB) and mean postoperative AzBio score of 20% (range: 0–82%) with an average follow-up length of 16.6 months (range: 1.4–27.6 mo). Data logging demonstrated that six patients were daily CI users and two were nonusers, one of whom had normal hearing in the contralateral ear.

Conclusions:

CI is an effective option for rehabilitating hearing loss in patients with NF2; however, patients with normal contralateral hearing or poor follow-up do not perform as well.
Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio as Prognostic Hematologic Markers of Bell's Palsy: A Meta-analysis
Authors: Oya Ryohei , Takenaka Yukinori , Imai Takao , Sato Takashi , Oshima Kazuo , Ohta Yumi , Inohara Hidenori
Published: February 2019

Objective:

Bell's palsy (BP) is the most common cause of unilateral peripheral facial paralysis, and inflammation has been proposed as the main pathological cause. The study aim was to investigate the relationship between hematologic inflammatory markers, including the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), and BP.

Data Sources:

The following key words were used to search PubMed and Scopus for English language articles: Bell's palsy, facial palsy, facial paresis or facial paralysis, neutrophil, lymphocyte, and platelet.

Study Selection:

Articles related to BP with NLR or PLR data.

Data Extraction:

The data included patient profiles, House–Brackmann score, treatment modality, NLR, and PLR.

Data Synthesis:

Seven articles were selected. A random effect model was used to analyze the aggregated data. Six of these articles that included the NLR and two that included the PLR of BP and control patients were analyzed for the difference between BP and control patients. Three articles that included the NLR of the recovery and nonrecovery groups were analyzed for the relationship between NLR and recovery.

Conclusions:

The NLR was significantly higher for the BP patients than for the controls. Furthermore, the NLR was significantly lower for the recovery group than for the nonrecovery group. A high NLR was associated with poor prognosis and related to the severity of facial nerve inflammation. There was no significant difference between the PLRs of the BP patients and controls. The NLR, but not the PLR, was found to be a useful prognostic indicator of BP.
Role of Interventional Radiology in Complications of Portal Hypertension
Authors: Shreve Lauren , Lee Edward Wolfgang
Published: February 2019

Portal hypertension, a consequence of end-stage liver disease and liver cirrhosis can lead to significant morbidity and mortality for patients through abnormal fluid accumulation as well as the formation of portosystemic shunts and varices. Treatment of the sequelae of portal hypertension can be achieved through endovascular management by referral to an interventional radiologist on an outpatient or emergent basis as required. Current techniques include the placement of peritoneovenous shunts and tunneled peritoneal drains, the creation of transjugular intrahepatic portosystemic shunts, or the obliteration of shunts via balloon-occluded retrograde transvenous obliteration (BRTO). In addition, newer procedural techniques utilizing vascular plugs and coils have reduced risks of the traditional BRTO procedure. Modified-BRTO procedures, known as plug-assisted and coil-assisted retrograde transvenous obliteration (PARTO and CARTO, respectively) have become the standard of care at many institutions for the treatment of gastric varices and portosystemic shunt-induced hepatic encephalopathy. This review examines the most recent literature of the management of portal hypertension by interventional radiologists, evaluating treatment options as well as the clinical and technical outcomes of TIPS, peritoneovenous shunts, tunneled peritoneal drains, BRTOs, and modified-BRTOs as well as future directions in the development of procedural techniques.
Efficacy of Different Endoscopic Stents in the Management of Postoperative Biliary Strictures
Authors: Yang Qin , Liu Jiaye , Ma Wenjie , Wang Junke , Li Fuyu , Bramer Wichor M. , Peppelenbosch Maikel P. , Pan Qiuwei
Published: February 2019

Background:

Endoscopic stents are the first-line treatment in the management of benign biliary stricture (BBS) which include multiple plastic stents (MPSs), fully covered self-expandable metal stents (FCSEMS) including the conventional and modified ones (FCSEMS-C and FCSEMS-M) and biodegradable stents. However, different stents have their distinct advantages and disadvantages. We aim to conduct this systematic review to compare the efficacy of different stents in the management of BBS.

Methods:

Several databases were searched from inception through March 2018. Studies including >10 patients with postoperative stricture treated with endoscopic stents were enrolled. Pooled odds ratio of outcomes were calculated to compare MPS with FCSEMS. Weighted pooled rates were calculated to show the efficacy of FCSEMS-M, FCSEMS-C, and MPS.

Results:

Twenty-two articles were reviewed including 4 randomized controlled studies, 4 cohort studies, and 14 case series studies. Comparing FCSEMS with MPS, the pooled odds ratio was 0.48 [95% confidence interval (CI): 0.22-1.05] (P=0.07) for stricture resolution, 0.3 (95% CI: 0.1-0.92) (P=0.03) for adverse event, 1.9 (95% CI: 0.3-12) (P=0.49) for stent migration, and 1.38 (95% CI: 0.36-5.3) (P=0.34) for stricture recurrence. The pooled rates for stricture recurrence of MPS, FCSEMS-C, and FCSEMS-M were 19%, 19%, and 7%, respectively. The pooled rates for stent migration were 4% of MPS, 25% of FCSEMS-C, and 3% of FCSEMS-M.

Conclusions:

FCSEMS-M is more favorable in the management of BBS comparing with MPS or FCSEMS-C. The biodegradable stent may be a promising option but currently available data is insufficient to draw a firm conclusion.
The clinical usefulness of elastography in the evaluation of nonalcoholic fatty liver disease patients: A biopsy-controlled study
Authors: Darweesh Samar K. , Omar Heba , Medhat Eman , Abd-Al Aziz Rasha A. , Ayman Hedy , Saad Yasmin , Yosry Ayman
Published: February 2019

Background

We aimed at determination of the usefulness of elastography [acoustic radiation force impulse (ARFI) and FibroScan] for evaluation of nonalcoholic fatty liver disease (NAFLD) patients.

Patients and methods

A prospective cross-sectional study included 60 biopsy-proven NAFLD patients (mean age: 45 years) was carried out. All patients were subjected to lab works, liver biopsy, and measurement of liver stiffness by ARFI and FibroScan and steatosis by controlled attenuation parameter (CAP). CAP measurements were adjusted for the presence of NAFLD and presence or absence of diabetes and according to BMI.

Results

Linear regression analysis showed that CAP is an independent predictor for significant hepatic steatosis (P<0.001). No significant difference was found in diagnostic accuracy between adjusted and nonadjusted CAP values for diagnosis of mild (>S1) or significant (>S2) hepatic steatosis (P=0.17 and 0.29 respectively). The median ARFI velocities for F1, F2, F3, and F4 were 0.92, 1.08, 1.07, and 2.58 m/s, respectively. Although there was an overall significant increase in ARFI values across the fibrosis grades (P<0.04), the difference in ARFI values was only significant between fibrosis grades F1 and F4 (P=0.02).

Conclusion

Elastography is a promising noninvasive tool for diagnosis and grading of hepatic steatosis and fibrosis in patients with NAFLD/nonalcoholic steatohepatitis with good sensitivity and specificity, especially in moderate to marked grades.
Treatment strategies for patients with decompensated liver cirrhosis due to hepatitis C virus infection eligible for liver transplantation: real-life data from five German transplant centers
Authors: Sandmann Lisa , Dörge Petra , Wranke Anika , Vermehren Johannes , Welzel Tania M. , Berg Christoph P. , Grottenthaler Julia M. , Weiss Karl-Heinz , Langel Jessica , Sterneck Martina , von Wulffen Moritz , Manns Michael P. , Wedemeyer Heiner , Hardtke Svenja , von Hahn Thomas
Published: February 2019

Background

Even with highly effective direct-acting antivirals (DAAs) treatment of patients with decompensated hepatitis C (HCV) cirrhosis remains challenging. Clinical deterioration and the need for liver transplantation (LT) may arise despite previous antiviral treatment. It is unclear whether in patients with high Model for End-Stage Liver Disease (MELD) antiviral treatment is too risky and should thus be deferred until after LT. Treatment choices that are currently made in the real-world setting are unclear.

Methods

We performed a retrospective multicenter data analysis of patients with decompensated HCV cirrhosis (MELD ≥15) that presented to liver transplant centers that are part of the German Center for Infection Research when highly active DAA therapy was available. Choice of treatment strategy (DAA first vs. transplantation first) was analyzed and correlated with baseline and outcome parameters.

Results

Thirty-five patients fulfilled the inclusion criteria and their mean MELD score was 18.5±3.78 (median: 17, interquartile range=16–19). In the majority of patients (85.7%) DAA therapy was initiated before LT; survival rates and change in MELD were numerically better in this group compared with those where DAA therapy was withheld (82.1 vs. 40%, P=0.078; ΔMELD: −2.68±6.2 vs. 5.8±14.4, P=0.157). However, DAA treatment was more often initiated in patients with better liver function (MELD: 18±3.54 vs. 21.8±3.9, P=0.008). Three patients discontinued DAA treatment because of clinical deterioration; these patients all had a MELD score above 20 at the start of therapy.

Conclusion

At liver transplant centers in Germany DAA before LT is attempted in the majority of cases. It appears to be associated with an improved outcome and seems safe at least in individuals with MELD below or equal to 20.
Regional and Rural-Urban Differences in the Use of Direct-acting Antiviral Agents for Hepatitis C Virus
Authors: Njei Basile , Esserman Denise , Krishnan Supriya , Ohl Michael , Tate Janet P. , Hauser Ronald G. , Taddei Tamar , Lim Joseph , Justice Amy C.
Published: February 2019

Background:

Veterans with hepatitis C virus (HCV) infection may face geographic obstacles to obtaining treatment.

Objective:

We studied the influence of region and rural versus urban residence on receipt of direct-acting antiretroviral (DAA) medications for HCV.

Subjects:

Veterans receiving care within Veterans Affairs Healthcare System born between 1945 and 1965.

Research Design:

This is a observational study using national electronic health record data.

Measures:

Receipt of DAAs was defined as ≥1 filled prescription from January 1, 2014 to December 31, 2016. Region (South, Northeast, Midwest, and West) and residence (urban, rural-micropolitan, small rural towns, and isolated rural towns) variables were created using residential zone improvement plan codes and rural-urban commuting area (RUCA) codes. Multivariable models were adjusted for age, race, sex, severity of liver disease, comorbidities, and prior treatment experience.

Results:

Among 166,353 eligible patients 64,854 received, DAAs. Variation by rural-urban residence depended on region. In unadjusted analyses, receipt varied by rural-urban designations within Midwest, and West regions (P<0.05) but did not vary within the South (P=0.12). Southern rural small town had the lowest incidence of DAA receipt (40.1%), whereas the incidence was 52.9% in Midwestern isolated rural towns. In adjusted logistic analyses, compared with southern urban residents (the largest single group), southern rural small town residents had the lowest odds ratio, 0.85 (95% confidence interval, 0.75–0.93), and Midwestern residents from isolated and small rural towns had the highest odds (odds ratio, both 1.27) to receive treatment.

Conclusions:

Substantial geographic variation exists in receipt of curative HCV treatment. Efforts are needed to provide more equitable access to DAAs.
Association of Federal Mental Health Parity Legislation With Health Care Use and Spending Among High Utilizers of Services
Authors: Haffajee Rebecca L. , Mello Michelle M. , Zhang Fang , Busch Alisa B. , Zaslavsky Alan M. , Wharam J. Frank
Published: February 2019

Background:

Decades-long efforts to require parity between behavioral and physical health insurance coverage culminated in the comprehensive federal Mental Health Parity and Addiction Equity Act.

Objectives:

To determine the association between federal parity and changes in mental health care utilization and spending, particularly among high utilizers.

Research Design:

Difference-in-differences analyses compared changes before and after exposure to federal parity versus a comparison group.

Subjects:

Commercially insured enrollees aged 18–64 with a mental health disorder drawn from 24 states where self-insured employers were newly subject to federal parity in 2010 (exposure group), but small employers were exempt before-and-after parity (comparison group). A total of 11,226 exposure group members were propensity score matched (1:1) to comparison group members, all of whom were continuously enrolled from 1 year prepolicy to 1–2 years postpolicy.

Measures:

Mental health outpatient visits, out-of-pocket spending for these visits, emergency department visits, and hospitalizations.

Results:

Relative to comparison group members, mean out-of-pocket spending per outpatient mental health visit declined among exposure enrollees by $0.74 (1.40, 0.07) and $2.03 (3.17, 0.89) in years 1 and 2 after the policy, respectively. Corresponding annual mental health visits increased by 0.31 (0.12, 0.51) and 0.59 (0.37, 0.81) per enrollee. Difference-in-difference changes were larger for the highest baseline quartile mental health care utilizers [year 2: 0.76 visits per enrollee (0.14, 1.38); relative increase 10.07%] and spenders [year 2: $−2.28 (−3.76, −0.79); relative reduction 5.91%]. There were no significant difference-in-differences changes in emergency department visits or hospitalizations.

Conclusions:

In 24 states, commercially insured high utilizers of mental health services experienced modest increases in outpatient mental health visits 2 years postparity.
Contribution of HCAHPS Specific Care Experiences to Global Ratings Varies Across 7 Countries
Authors: Orindi Benedict O. , Lesaffre Emmanuel , Quintero Adrian , Sermeus Walter , Bruyneel Luk
Published: February 2019

Background:

Given the increased international interest in improvement strategies for patient experiences with care, it is important to understand whether the same specific care experiences affect global ratings across countries. Moreover, reporting of these global ratings currently substantially varies in both research and public reporting.

Objectives:

The objectives of this study were to examine the differential magnitude of associations between Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) specific care experiences and global ratings, and to explore implications for reporting these global ratings.

Methods:

HCAHPS data were collected from 11,289 patients across 7 European countries. We studied the association between 11 experience items and 2 global ratings (0–10 hospital rating, hospital recommendation) using multilevel ordered logistic regression analysis. Using interaction terms, we examined consistency of these associations across countries. Assuming homogeneous use and interpretations of response categories of these specific experiences across patients within and between countries, we investigated what the associations between specific experiences and global ratings imply for reporting global ratings across countries.

Results:

All specific experiences were associated with both global ratings. “Being talked to about care after leaving the hospital” showed the strongest association. There were relatively little differential effects across countries. A reporting strategy with different cutpoints across countries might provide a more equitable comparison of global ratings.

Conclusions:

Our findings highlight a differential contribution of HCAHPS specific experiences to overall ratings across countries. Research and public reporting may consider examining in more detail within and across populations global rating cutpoints that represent the same true level of positive patient experiences.
Treatment of Recurrent Refractory Pediatric Pre-B Acute Lymphoblastic Leukemia Using Inotuzumab Ozogamicin Monotherapy Resulting in CD22 Antigen Expression Loss as a Mechanism of Therapy Resistance
Authors: Paul Megan R. , Wong Victor , Aristizabal Paula , Kuo Dennis J.
Published: February 2019

Background:

Inotuzumab ozogamicin is a novel antibody-drug conjugate that targets CD22, a common antigen on pre-B acute lymphoblastic leukemia cells.

Observations:

A 7-year-old boy with pre-B acute lymphoblastic leukemia in his second relapse was given 2 cycles of inotuzumab ozogamicin. He responded morphologically with a negative bone marrow evaluation. However, he relapsed in cycle 3 of therapy with a loss of CD22 expression on his lymphoblast population.

Conclusion:

To our knowledge, this is the first published case of CD22 expression loss as a mechanism of therapy resistance for inotuzumab ozogamicin.
A Case of Uveitis in a Patient With Juvenile Myelomonocytic Leukemia Successfully Treated With Adalimumab
Authors: Cortellazzo Wiel Luisa , Pastore Serena , Taddio Andrea , Tommasini Alberto
Published: February 2019

Patients with juvenile myelomonocytic leukemia due to germline CBL mutation (10% to 15%) may have a subacute course occasionally associated with autoimmune disorders, which may resemble RAS-associated autoimmune lymphoproliferative disorder. In both conditions, prognosis and standard treatment for autoimmune phenomena remain poorly understood. We report the case of a 7-year-old boy with juvenile myelomonocytic leukemia with severe steroid-dependent uveitis, who did not respond to several therapeutic attempts with immunosuppressant agents, including sirolimus, and was finally successfully treated with adalimumab. This case offers further insight into the management of autoimmune disorders in the context of predisposing genetic conditions.
Oral Sucrose Versus Breastfeeding in Managing Infants' Immunization-Related Pain
Authors: Gad Rasha F. , Dowling Donna A. , Abusaad Fawzia E. , Bassiouny Mohamed R. , Abd El Aziz Magda A.
Published: February 2019

Background:

Treating pain during immunization should be a part of pediatric primary healthcare around the world, as untreated pain in children has short- and long-term consequences. Few studies of pharmacologic and nonpharmacologic methods of pain relief during immunization have been conducted in low- and middle-income countries. Finding pain-mitigating interventions that are low-cost, effective, and feasible across all settings, including with low-resourced settings could improve primary healthcare.

Purpose:

To evaluate the effectiveness of oral sucrose versus breastfeeding as methods of pain management during immunization of infants through 6 months of age.

Methods:

A randomized controlled experimental design was used; 120 infants were randomly assigned to control, sucrose, or breastfeeding groups. Data were collected in an Egyptian primary health center. Outcome measures including pain (as per the FLACC pain scale), crying time, and heart rate were measured at three time points.

Results:

There were significant differences in pain scores and crying duration during and after immunization (p < .001) for the breastfeeding group compared with the sucrose and control groups.

Implications for Practice:

Health staff and parents need education and support in use of breastfeeding for pain management during immunization. More studies are needed to evaluate effectiveness of breastfeeding versus other pain management methods for managing infants' immunization-related pain.
Breastfeeding Guidance for Orthodox Jewish Families When Newborns Require Special Care and Continued Hospitalization
Authors: Candelaria Laura M. , Bressler Toby , Spatz Diane L.
Published: February 2019

There is a growing Orthodox Jewish population in the United States and Canada. Many Orthodox Jewish families have a large number of children and choose to breastfeed. The Orthodox Jew observes Jewish laws and customs literally as dictated by the Torah. Orthodox Jews consult a rabbi or posek before making most major life decisions, including matters related to breastfeeding to ensure adherence to religious law. Cultural practices applicable to the Orthodox Jewish family related to the provision of human milk and breastfeeding when a sick newborn may require special care and continued hospitalization after the mother has been discharged are presented. Guidelines for preconception lactation counseling for families are provided to tailor nursing care to meet the individual needs of each Orthodox Jewish infant and family. Special considerations related to pumping schedule, use of mechanisms such as timers for breast pumps, and discussions with religious leader about the saving of colostrum and/or milk when an infant is critically ill will be addressed. To provide culturally sensitive and appropriate counseling related to the provision of human milk and breastfeeding, nurses need to be culturally aware of the specific needs of the Orthodox Jewish family. Clinical implications and suggestions are provided.
How the DSM Is Used in Clinical Practice
Authors: First Michael B. , Erlich Matthew D. , Adler David A. , Leong Shirley , Dixon Lisa B. , Oslin David W. , Goldman Beth , Koh Steve , Levine Bruce , Berlant Jeffrey L. , Siris Samuel G.
Published: February 2019

Despite widespread use, how clinicians use the DSM in psychiatric practice is not well understood. Recognizing public and professional attitudes toward the DSM are integral to future DSM development, to assess a commonly held assumption such as that the DSM is used primarily for coding, and to assess its clinical utility. A convenience sample of Psychiatric Times readers was surveyed to assess the DSM's use in clinical practice. A total of 394 behavioral health care practitioners fully completed the online survey. Results suggest that the DSM, beyond administrative and billing use, is used for communication with health care providers, for teaching diagnoses to trainees, and, importantly, as an educational tool to inform patients and caregivers alike.
Extubation Failure Rates After Pediatric Cardiac Surgery Vary Across Hospitals*
Authors: Rooney Sydney R. , Donohue Janet E. , Bush Lauren B. , Zhang Wenying , Banerjee Mousumi , Pasquali Sara K. , Gaies Michael G.
Published: February 2019

Objectives:

Many hospitals aim to extubate children early after cardiac surgery, yet it remains unclear how this practice associates with extubation failure. We evaluated adjusted extubation failure rates and duration of postoperative mechanical ventilation across hospitals and assessed cardiac ICU organizational factors associated with extubation failure.

Design:

Secondary analysis of the Pediatric Cardiac Critical Care Consortium clinical registry.

Setting:

Pediatric Cardiac Critical Care Consortium cardiac ICUs.

Patients:

Patients with qualifying index surgical procedures from August 2014 to June 2017.

Interventions:

None.

Measurements and Main Results:

We modeled hospital-level adjusted extubation failure rates using multivariable logistic regression. A previously validated Pediatric Cardiac Critical Care Consortium model was used to calculate adjusted postoperative mechanical ventilation. Observed-to-expected ratios for both metrics were derived for each hospital to assess performance. Hierarchical logistic regression was used to assess the association between cardiac ICU factors and extubation failure. Overall, 16,052 surgical hospitalizations were analyzed. Predictors of extubation failure (p < 0.05 in final case-mix adjustment model) included younger age, underweight, greater surgical complexity, airway anomaly, chromosomal anomaly/syndrome, longer cardiopulmonary bypass time, and other preoperative comorbidities. Three hospitals were better-than-expected outliers for extubation failure (95% CI around observed-to-expected < 1), and three hospitals were worse-than-expected (95% CI around observed-to-expected > 1). Two hospitals were better-than-expected outliers for both extubation failure and postoperative mechanical ventilation, and three were worse-than-expected for both. No hospital was an outlier in opposite directions. Greater nursing hours per patient day and percent nursing staff with critical care certification were associated with lower odds of extubation failure. Cardiac ICU factors such as fewer inexperienced nurses, greater percent critical care trained attendings, cardiac ICU–dedicated respiratory therapists, and fewer patients per cardiac ICU attending were not associated with lower odds of extubation failure.

Conclusions:

We saw no evidence that hospitals trade higher extubation failure rates for shorter duration of postoperative mechanical ventilation after pediatric cardiac surgery. Increasing specialized cardiac ICU nursing hours per patient day may achieve better extubation outcomes and mitigate the impact of inexperienced nurses.