bluuebunny/crossref_metadata_2025 huggingface dataset:
Ovarian Vein Thrombosis
Authors: Lenz Charles J. , Wysokinski Waldemar E. , Henkin Stanislav , Cohoon Kevin P. , Casanegra Ana , Simmons Benjamin S. , Saadiq Rayya A. , Daniels Paul R. , Wysokinska Ewa M. , Bjarnason Haraldur , McBane Robert D.
Published: October 2017

OBJECTIVE:

To identify the risk of venous thromboembolism recurrence, major bleeding, and mortality in patients with ovarian vein thrombosis so as to better define optimal treatment strategies.

METHODS:

Patients with ovarian vein thrombosis (1990–2015) and age- and gender-matched patients with contemporary leg deep vein thrombosis (DVT) were assessed for differences in etiology, venous thromboembolism recurrence, and survival in a case–control study.

RESULTS:

Over the timeframe of this study, only 219 ovarian vein thrombosis cases were identified compared with 13,417 leg DVTs. Median duration of follow-up was 1.23 years (interquartile range 0.25–4.14). Pulmonary embolism was identified at presentation in 6% of patients with ovarian vein thrombosis and 16% of those with DVT (P=.001). Frequent causes of ovarian vein thrombosis included cancer, hormonal stimulation, surgery, and hospitalization. Cancer was twofold more frequent in patients with ovarian vein thrombosis (44% compared with 21%; P<.01). Despite being less frequently treated with anticoagulation (ovarian vein thrombosis 54% compared with DVT 98%, P<.001), venous thromboembolism recurrence rates were similar between groups (ovarian vein thrombosis 2.3 compared with DVT 1.8 per 100 patient-years, P=.49). A personal history of venous thromboembolism and preceding surgery was found to be an independent risk factor for venous thromboembolism recurrence among those treated with anticoagulation (hazard ratio 6.7, P=.04 and hazard ratio 13.6, P=.03, respectively). There was no significant difference in overall survival.

CONCLUSION:

Ovarian vein thrombosis is a rare thrombotic condition with an incidence 60-fold lower compared with leg DVT in our institution. The striking association with cancer adversely affects overall survival rates in patients with ovarian vein thrombosis. Venous thromboembolism recurrence rates argue for anticoagulation with a direct oral anticoagulant or vitamin K antagonist, particularly in those with a history of venous thromboembolism.
Clinical Factors Associated With Presentation Change of the Second Twin After Vaginal Delivery of the First Twin
Authors: Panelli Danielle M. , Easter Sarah Rae , Bibbo Carolina , Robinson Julian N. , Carusi Daniela A.
Published: October 2017

OBJECTIVE:

To identify clinical factors associated with a change from vertex to nonvertex presentation in the second twin after vaginal birth of the first.

METHODS:

We assembled a retrospective cohort of women with viable vertex–vertex twin pregnancies who delivered the presenting twin vaginally. Women whose second twin changed from vertex to nonvertex after vaginal birth of the first were classified as experiencing an intrapartum change in presentation. Characteristics associated with intrapartum presentation change in a univariate analysis with a P value ≤.10 were then evaluated in a multivariate logistic regression model.

RESULTS:

Four-hundred fifty women met inclusion criteria, of whom 55 (12%) had intrapartum presentation change of the second twin. Women experiencing intrapartum presentation change were more likely to be multiparous (69% compared with 47%, P<.01) and to have had a change in the presentation of the second twin between the most recent antepartum ultrasonogram and the ultrasonogram done on admission to labor and delivery (11% compared with 4%, P=.04). In an adjusted analysis, multiparity and gestational age less than 34 weeks were significantly associated with presentation change (adjusted odds ratio [OR] 2.9, 95% CI 1.5–5.6 and adjusted OR 2.6, 95% CI 1.1–5.9, respectively). Women with intrapartum presentation change were more likely to undergo cesarean delivery for their second twin (44% compared with 7%, P<.01) with an adjusted OR of 10.50 (95% CI 5.20–21.20) compared with those with stable intrapartum presentation. Twenty of the 24 (83%) cesarean deliveries performed in the intrapartum presentation change group were done for issues related to malpresentation.

CONCLUSION:

Multiparity and gestational age less than 34 weeks are associated with intrapartum presentation change of the second twin.
Comparative Effectiveness of Uterine Leiomyoma Procedures Using a Large Insurance Claims Database
Authors: Borah Bijan J. , Yao Xiaoxi , Laughlin-Tommaso Shannon K. , Heien Herbert C. , Stewart Elizabeth A.
Published: October 2017

OBJECTIVE:

To compare risk of reintervention, long-term clinical outcomes, and health care utilization among women who have bulk symptoms from leiomyoma and who underwent the following procedures: hysterectomy, myomectomy, uterine artery embolization, and magnetic resonance-guided, focused ultrasound surgery.

METHODS:

This was a retrospective analysis of administrative claims from a large U.S. commercial insurance database. Women aged 18–54 years undergoing any of the previously mentioned leiomyoma procedures between 2000 and 2013 were included. We assessed the following outcome measures: risk of reintervention between uterine-sparing procedures, risk of other surgical procedures or complications of the index procedure, 5-year health care utilization, pregnancy rates, and reproductive outcomes. Propensity score matching along with Cox proportional hazard models were used to adjust for differences in baseline characteristics between study cohorts.

RESULTS:

Among the 135,522 study-eligible women with mean follow-up of 3.4 years, hysterectomy was the most common first-line procedural therapy (111,324 [82.2%]) followed by myomectomy (19,965 [14.7%]), uterine artery embolization (4,186 [3.1%]) and magnetic resonance-guided focused ultrasound surgery (47 [0.0003%]). Small but statistically significant differences were noted for uterine artery embolization and myomectomy in reintervention rate (17.1% compared with 15.0%, P=.02), subsequent hysterectomy rates (13.2% compared with 11.1%, P<.01) and subsequent complications from index procedures (18.1% compared with 24.6%, P<.001). During follow-up, women undergoing myomectomy had lower leiomyoma-related health care utilization, but had higher all-cause outpatient services. Pregnancy rates were 7.5% and 2.2% among myomectomy and uterine artery embolization cohorts, respectively (P<.001) with both cohorts having similar rates of adverse reproductive outcome (69.4%).

CONCLUSIONS:

Although the overwhelming majority of women having leiomyoma with bulk symptoms underwent hysterectomy as their first treatment procedure, among those undergoing uterine-sparing index procedures, approximately one seventh had a reintervention, and one tenth ended up undergoing hysterectomy during follow-up. Compared with women undergoing myomectomy, women undergoing uterine artery embolization had a higher risk of reintervention, lower risk of subsequent complications, but similar rate of adverse reproductive outcomes.
Functional Outcomes Following Operative Treatment of Tibial Tubercle Fractures
Authors: Riccio Anthony I. , Tulchin-Francis Kirsten , Hogue Grant D. , Wimberly Robert L. , Gill Corey S. , Collins DeRaan , Karol Lori A.
Published: October 2017

Background:

Quantitative evaluation of the functional results of surgically managed tibial tubercle fractures in adolescents is unreported in the orthopaedic literature.

Methods:

All patients treated surgically for unilateral tibial tubercle fractures at a single institution from 2007 to 2011 were invited to return for functional evaluation. Fractures were classified using the Ogden classification system. Clinical examination at follow-up included passive knee range of motion and thigh circumference. Side-to-side knee extension strength deficits were evaluated using a Biodex dynamometer. Patient-reported outcomes were assessed using the Pediatric-International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC), Tegner-Lysholm Knee Scoring Scale, and Visual Analog Pain Scale. Chart review was performed to determine postoperative protocols including the use of physical therapy and protected weight bearing. Functional parameters were compared between the involved and uninvolved extremities using the Wilcoxon Signed Ranks Test and the Spearman correlations were performed to identify any relationships between perioperative factors, functional parameters, and subjective outcomes.

Results:

In total, 19 of 42 patients completed clinical and functional testing and 18 of 19 completed all outcome surveys. Average age at injury was 13.9 years and average follow-up was 3.0 years. There was no statistical difference in knee range of motion between sides, however, thigh circumference was slightly smaller in the injured extremity (median difference, 1.7 cm at 15 cm above the patella and 4.0 cm at 50% of the length of the thigh). In total 5/19 subjects (26%) had a significant quadriceps extension strength deficit on the involved leg compared with the contralateral side. The median Visual Analog Pain Scale for affected limbs was 8/100 and for unaffected limbs was 6/100 (P=0.017). The Tegner-Lysholm Scale revealed 9 excellent results, 5 good, 4 fair, and 1 poor (median, 90/100). Results of the Pedi-IKDC were 11 excellent, 3 good, 2 fair, and 3 poor results (median, 91/100). Outcome scores did not correlate to diminished strength or thigh circumference. No difference in outcome based upon body mass index, postoperative weight-bearing status, Ogden classification, or postoperative physical therapy was noted using regression analysis.

Conclusions:

Despite promising objective results, clinical outcomes measured by subjective validated surveys are not all excellent.

Level of Evidence:

Level III.
Recommencement of Denosumab for Unresectable Giant Cell Tumor of the Cervical Spine
Authors: Law Gin Way , Yeo Nicholas Eng Meng , Howe Tet Sen , Tan Yuan Zi , Tan Seang Beng , Siddiqui Mohammad Mashfiqul Arafin
Published: October 2017

Study Design.

A case report.

Objective.

The aim of this study was to highlight that rapid progression or recurrence of giant cell tumor of the bone (GCTB) can still occur with cessation of Denosumab in the management of unresectable GCTB even in cases with prior demonstration of excellent response to treatment and stable disease over a protracted length of surveillance despite dose reduction. The close proximity of unresectable GCTB to vital structures makes it prudent that we monitor these patients closely given its locally aggressive nature.

Summary of Background Data.

Cervical spine GCTB is extremely rare. Unresectable GCTB has historically been a challenge to treat due to the lack of prospective, randomized clinical trials to guide treatment. Radiotherapy has fallen out of favor due to the risk of malignant transformation, especially as most GCTB patients are young.

In recent years, improved understanding of the receptor activator of nuclear factor-κB ligand (RANKL) in the pathophysiology of GCTB has led to the use of Denosumab in patients with recurrent/unresectable/metastatic GCTB and in patients whom surgical resection carries a high morbidity. To date, the optimal dosage and duration of therapy in the treatment of GCTB is unknown.

Methods.

We report a case of cervical spine GCTB in a 53-year-old male with positive surgical margins managed with Denosumab.

Results.

This is the first reported case of a cervical spine GCTB managed with Denosumab showing excellent response to treatment, recurrence of disease post cessation of Denosumab despite earlier satisfactory disease control and stabilization achieved even with dose reduction, and again an excellent response with recommencement of the drug.

Conclusion.

Denosumab is an excellent option in patients with unresectable GCTB or when surgery will result in excessive morbidity. However, further studies are required to determine optimal dosing, treatment duration, side effect profile, and whether Denosumab is truly able to achieve partial or complete disease remission in the long run.

Level of Evidence: 4
Epidemiology and Outcomes of Infectious Spondylodiscitis in Hemodialysis Patients
Authors: Lu Yueh-An , Sun Wei-Chiao , Kuo George , Chen Chao-Yu , Kao Huang-Kai , Lin YuJr , Lee Chia-Hui , Hung Cheng-Chieh , Tian Ya-Chung , Ko Yu-Shien , Hsu Hsiang-Hao
Published: October 2017

Study Design.

A retrospective study of patients who were hospitalized for infectious spondylodiscitis over a 13-year period.

Objective.

To elucidate the epidemiology and prognostic factors of infectious spondylodiscitis in hemodialysis (HD) patients and to identify the impact of HD on infectious spondylodiscitis.

Summary of Background Data.

Only a few case studies of infectious spondylodiscitis in HD patients can be found in the literature. Reports of prognostic factors are limited and patients’ outcomes have not been well described.

Methods.

The cases of 1402 patients who were hospitalized for infectious spondylodiscitis over a 13-year period were retrospectively reviewed. Of these, 102 patients on maintenance HD were enrolled in this study. Cox proportional hazard model was used to evaluate the risk factors of mortality and recurrence.

Results.

The 102 enrolled patients had an average age 63.3 ± 11.2 years old and male-to-female ratio of 1:1.04. Back pain was present in 75.5% of patients and the most commonly infected site was the lumbosacral spine. Infection associated with vascular access was identified in 31.4% of patients. The prevalence of dialysis via central venous catheters was higher than prevalent HD patients. Methicillin-resistant Staphylococcus aureus was the most common pathogen, followed coagulase-negative staphylococci. The patients’ in-hospital survival rate was 82.4%; their vascular access survival rate was 75.5%; their 1-year survival rate was 78.4%, and their 1-year recurrence rate was 20.2%. Congestive heart failure was associated with an increased 1-year mortality. Other variables exhibited no significant relationship with patients’ in-hospital mortality, 1-year mortality or recurrence.

Conclusion.

The characteristics and outcomes of infectious spondylodiscitis in HD patients were elucidated. Most of the demographic and clinical variables, evaluated upon admission, did not predict mortality or recurrence.

Level of Evidence: 3
Use of CT Scan-derived Patient-specific Instrumentation in Total Ankle Arthroplasty
Authors: Saito Guilherme H. , Sanders Austin E. , Sturnick Daniel R. , Demetracopoulos Constantine A.
Published: October 2017

Total ankle arthroplasty has evolved significantly in the last 2 decades. Improvements in surgical technique and instrumentation, as well as advances in implant design, have contributed significantly to the increased adoption of ankle replacement for the treatment of ankle arthritis. Achieving proper alignment and correct positioning of the components is critical for the function and survivorship of the prosthesis. Patient-specific instrumentation generated by preoperative computed tomography is a tool which may allow for more reliable and reproducible component positioning. This article will provide a brief review of the technique and our early results of utilizing patient-specific instrumentation in total ankle arthroplasty.

Level of Evidence:

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Botulinum Toxin in Aesthetic Medicine: Myths and Realities
Authors: Dover Jeffrey S. , Monheit Gary , Greener Mark , Pickett Andy
Published: October 2017

BACKGROUND

Several formulations of Botulinum toxin serotype A (BoNT-A) for aesthetic indications are available, with numbers likely to increase. Preparations are not interchangeable, based on dose unit comparisons.

OBJECTIVE

Numerous myths and misconceptions regarding the use of BoNT-A for aesthetic indications have arisen, which this review aims to lay to rest.

MATERIALS AND METHODS

This review assesses evidence for and against each of the most common myths regarding BoNT use in aesthetics.

RESULTS

BoNT-A neurotoxin/protein complexes are irrelevant to the toxin's therapeutic/aesthetic indications. BoNT-A neurotoxin/protein complexes do not influence movement from injection site or immunogenicity. Any relationship between neutralizing antibody formation and clinical response is complex and clinicians should consider other factors that may induce an apparent loss of clinical response. Diffusion appears predominately, perhaps exclusively, dose dependent. Careful placement and correct dosing optimizes likelihood of good outcomes. Manufacturers recommend reconstitution of products with sterile nonpreserved saline. However, compelling evidence suggests that reconstitution using preserved saline dramatically improves patient comfort without compromising efficacy. Several post-treatment instructions/restrictions are widely used despite the lack of evidence, but muscle activity after injection may be beneficial. Cooling the treatment area might hinder BoNT-A translocation and should probably be abandoned.

CONCLUSION

The existing evidence suggests that experienced users should achieve equivalent results regardless of BoNT-A formulation, but additional, well-designed, adequately powered, controlled randomized studies should be performed.
Histologic Accuracy of Mohs Micrographic Surgery
Authors: Highsmith James T. , Highsmith M. Jason , Monheit Gary D.
Published: October 2017

BACKGROUND

Mohs micrographic surgery enables the surgeon to maximize tumor removal while minimizing the amount of tissue being removed using advanced mapping techniques combined with microscopy. Interpretation of frozen section slides is vital to the success of Mohs micrographic surgery.

OBJECTIVE

Evaluate and confirm the congruence of frozen section slide interpretation between fellowship-trained Mohs surgeons and dermatopathologists.

METHODS

Retrospective cohort concordance study spanning 10 years (n = 1,720 cases).

RESULTS

The concordance rate for frozen slide interpretation between fellowship-trained Mohs surgeons and dermatopathologists in this study was 99.5%.

CONCLUSION

This study demonstrates agreement between the interpretation of histologic frozen section slides when evaluated by fellowship-trained Mohs surgeons and dermatopathologists.
CONCURRENT IDIOPATHIC MACULAR TELANGIECTASIA TYPE 2 AND CENTRAL SEROUS CHORIORETINOPATHY
Authors: Matet Alexandre , Yzer Suzanne , Chew Emily Y. , Daruich Alejandra , Behar-Cohen Francine , Spaide Richard F.
Published: October 2017

Purpose:

To describe cases presenting with features of idiopathic macular telangiectasia (MacTel) Type 2 and central serous chorioretinopathy (CSC).

Methods:

Databases from four tertiary retina centers were searched for cases copresenting CSC and MacTel Type 2.

Results:

Five cases were identified (4 men, 1 woman; mean age: 67.2 years). Four patients were referred for chronic or nonresolving CSC, and the diagnosis of MacTel Type 2 was made based on multimodal imaging findings. One patient had advanced MacTel Type 2, and developed acute CSC. Regarding the MacTel Type 2 findings, all subjects presented perifoveal telangiectasia on fluorescein angiography, and four subjects showed intraretinal cavitations typical of MacTel Type 2 on optical coherence tomography, in one or both eyes. Regarding the CSC findings, fluorescein angiography identified focal or extended retinal pigment epithelium alteration in all eyes, and an active leakage in two eyes. Indocyanine green angiography showed choroidal vascular hyperpermeability in four subjects. On optical coherence tomography, pigment epithelial detachments were detected in five eyes (four subjects), and foveal detachments were present in five eyes (three subjects), which spontaneously resolved (two eyes), responded to photodynamic therapy (two eyes), or persisted (one eye). Mean choroidal thickness was 402 ± 99 μm.

Conclusion:

The codiagnosis of CSC and MacTel Type 2 should be considered in atypical presentations associating features from both disorders.
QUANTITATIVE ANALYSIS OF HYPERAUTOFLUORESCENT RINGS TO CHARACTERIZE THE NATURAL HISTORY AND PROGRESSION IN RPGR-ASSOCIATED RETINOPATHY
Authors: Tee James J. L. , Kalitzeos Angelos , Webster Andrew R. , Peto Tunde , Michaelides Michel
Published: October 2017

Purpose:

Quantitative analysis of hyperautofluorescent rings and progression in subjects with retinitis pigmentosa associated with retinitis pigmentosa GTPase regulator (RPGR) gene mutations.

Methods:

Prospective observational study of 46 subjects. Ring area, horizontal and vertical diameter measurements taken from outer and inner ring borders. Intraobserver repeatability, baseline measurements, progression rates, interocular symmetry, and association with age and genotype were investigated.

Results:

Baseline ring area was 11.8 ± 13.4 mm2 and 11.4 ± 13.2 mm2 for right and left eyes, respectively, with very strong interocular correlation (r = 0.9398; P < 0.0001). Ring area constriction was 1.5 ± 2.0 mm2/year and 1.3 ± 1.9 mm2/year for right and left eyes, respectively, with very strong interocular correlation (r = 0.878, P < 0.0001). Baseline ring area and constriction rate correlated negatively with age (r = −0.767; P < 0.0001 and r = −0.644, P < 0.0001, respectively). Constriction rate correlated strongly with baseline area (r = 0.850, P < 0.0001). Age, but not genotype, exerted a significant effect on constriction rates (P < 0.0001), with greatest rates of progression seen in younger subjects. An exponential decline overall was found.

Conclusion:

This study provides disease-specific baseline values and progression rates together with a repeatability assessment of fundus autofluorescence metrics. Our findings can guide future treatment trials and contribute to the clinical care of patients with RPGR-associated retinitis pigmentosa.
OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN GEOGRAPHIC ATROPHY
Authors: Sacconi Riccardo , Corbelli Eleonora , Carnevali Adriano , Querques Lea , Bandello Francesco , Querques Giuseppe
Published: October 2017

Purpose:

To analyze choriocapillaris (CC) vessel density (VD) around geographic atrophy (GA) secondary to non-neovascular dry age-related macular degeneration using optical coherence tomography angiography.

Methods:

We compared CC VD surrounding GA margin (500 μm radius) with control CC (outside GA margin) in a consecutive series of GA patients presenting between August 2016 and February 2017 at the Medical Retina and Imaging Unit of University Vita-Salute, IRCCS Ospedale San Raffaele in Milan. Images were obtained through thresholding and binarization. We also compared the CC VD in a sample area of 500 μm × 500 μm surrounding GA margin rated as hyperautofluorescent on fundus autofluorescence to a similar area rated as isoautofluorescent.

Results:

Fifty eyes of 29 patients (19 women and 10 men; mean age 77 ± 6 years) with mean GA area of 9.43 ± 5.08 mm2 and mean subfoveal choroidal thickness of 164 ± 73 μm were included. Choriocapillaris VD surrounding GA margin as detected by optical coherence tomography angiography revealed a significant impairment compared with control CC outside GA margin (0.317 ± 0.083 vs. 0.461 ± 0.054, P < 0.001), which was even greater in patients with foveal involvement (P = 0.013). Furthermore, mean VD in hyperautofluorescent areas was significantly lower compared with isoautofluorescent areas (0.242 ± 0.112 vs. 0.327 ± 0.130, P = 0.001). A positive correlation was disclosed between VD surrounding GA margin and subfoveal choroidal thickness (r = 0.332, P = 0.019).

Conclusion:

Optical coherence tomography angiography discloses CC impairment surrounding GA margin. Such CC impairment at GA margin seems to precede retinal pigment epithelium alterations at fundus autofluorescence. Optical coherence tomography angiography could be a new valuable tool for detecting CC alterations and to evaluate potential therapeutic responses in clinical studies.
ENLARGEMENT OF SCLEROCHOROIDAL CALCIFICATIONS: MULTIMODAL IMAGING UPDATE
Authors: Slean Geraldine R. , Kalevar Ananda , Chen Judy , Johnson Robert
Published: October 2017

Purpose:

To report the multimodal imaging and enlargement of sclerochoroidal calcifications over a 10-year period.

Methods:

Case report of a 74-year-old white man who presented for routine follow-up and was found to have yellow chorioretinal lesions in the right eye.

Results:

Multimodal imaging was performed and confirmed sclerochoroidal calcifications. Comparison of fundus photography over a 10-year period demonstrated growth of preexisting lesions and the development of new lesions in the right eye.

Conclusion:

Over time, this patient developed new sclerochoroidal calcifications and enlargement of preexisting calcifications. We, therefore, recommend regular follow-up with periodic multimodal imaging for these patients.
Metastatic melanoma patients’ sensitivity to ipilimumab cannot be predicted by tumor characteristics
Authors: Rossfeld Kara , Hade Erinn M. , Gangi Alexandra , Perez Matthew , Kinsey Emily N. , Grabska Joanna , Ederle Ashley , Zager Jonathan , Salama April K. , Olencki Thomas E , Beasley Georgia M
Published: October 2017

Background:

Immune checkpoint inhibitors have dramatically changed the prognosis for patients with metastatic melanoma. However, not all patients respond to therapy and toxicities can be severe leaving need for reliable clinical predictive markers.

Methods:

We examined primary tumor characteristics including ulceration, BRAF mutation status, and Breslow depth in patients who subsequently developed stage IV disease and were treated with ipilimumab at 3 institutions. Patients in this study were not treated on clinical trials. To investigate the relationship between patient characteristics at the time of diagnosis and survival following melanoma diagnosis we utilized Cox proportional hazards models, accounting for delayed entry into the study cohort. Cox models estimate the age and institution adjusted hazard ratios for risk of death.

Results:

Of patients (n=385) treated with ipilimumab for stage IV melanoma, 302 met inclusion criteria. The complete response to ipilimumab was 5%, partial response was 13%, 18% had stable disease, 62% had progressive disease, and 5 unknown. The median overall survival rate was 2.03 years [95% confidence interval (CI): 0.13, 3.05]. Primary tumor Breslow depth, lymphovascular invasion, BRAF status, and ulceration did not predict sensitivity to ipilimumab. In this study patient cohort, BRAF mutation (adjusted hazard ratio: 1.43, 95% CI: 0.98, 2.07) and presence of ulceration (adjusted hazard ratio: 1.47, 95% CI: 0.95, 2.26) contributed to an increased risk of death.

Conclusions:

The presence of ulceration did not correlate with sensitivity to ipilimumab. Ulceration of the primary tumor and a BRAF mutation were moderately associated with worse survival in patients with metastatic melanoma treated with ipilimumab.
Actinomyces turicensis Bacteremia Secondary to a Decubitus Ulcer
Authors: Snead Jessica A. , Ruggiero Nicole , Sangha Ruby , Joseph Leian , Mukherji Rajat
Published: October 2017

We present a rare case of Actinomyces turicensis bacteremia secondary to a polymicrobial sacral decubitus ulcer infection in an elderly male patient. A PubMed search revealed only 9 previously reported cases of bacteremia due to A. turicensis, mostly in female patients. Because Actinomyces species are commensal organisms of the gastrointestinal tract, sacral decubitus ulcers may have an increased propensity of becoming infected and consequently cause a bacteremia. Our patient was successfully treated with debridement and intravenous antibiotic therapy; however, the optimal antibiotic treatment and length of therapy remain unclear because only a few case reports exist in the literature.
Social learning pathways in the relation between parental chronic pain and daily pain severity and functional impairment in adolescents with functional abdominal pain
Authors: Stone Amanda L. , Bruehl Stephen , Smith Craig A. , Garber Judy , Walker Lynn S.
Published: October 2017

Having a parent with chronic pain (CP) may confer greater risk of persistence of CP from childhood into young adulthood. Social learning, such as parental modeling and reinforcement, represents one plausible mechanism for the transmission of risk of CP from parents to offspring. Based on a 7-day pain diary in 154 pediatric patients with functional abdominal CP, we tested a model in which parental CP predicted adolescents' daily average CP severity and functional impairment (distal outcomes) via parental modeling of pain behaviors and parental reinforcement of adolescent's pain behaviors (mediators) and adolescents' cognitive appraisals of pain threat (proximal outcome representing adolescents' encoding of parents' behaviors). Results indicated significant indirect pathways from parental CP status to adolescent average daily pain severity (b = 0.18, SE = 0.08, 95% confidence interval: 0.04-0.31, P = 0.03) and functional impairment (b = 0.08, SE = 0.04, 95% confidence interval: 0.02-0.15, P = 0.03) over the 7-day diary period via adolescents' observations of parent pain behaviors and adolescent pain threat appraisal. The indirect pathway through parental reinforcing responses to adolescents' pain did not reach significance for either adolescent pain severity or functional impairment. Identifying mechanisms of increased risk of pain and functional impairment in children of parents with CP ultimately could lead to targeted interventions aimed at improving functioning and quality of life in families with CP. Parental modeling of pain behaviors represents a potentially promising target for family-based interventions to ameliorate pediatric CP.
Family-Initiated Pediatric Rapid Response: Characteristics, Impetus, and Outcomes
Authors: Bavare Aarti C. , Thomas Jenilea K. , Elliott Elizabeth P. , Morgan Angela C. , Graf Jeanine M.
Published: October 2017

Brief Description:

Family-initiated rapid response (FIRR) empowers families to express concern and seek care from specialized response teams. We studied FIRRs that occurred in a pediatric tertiary hospital over a 3-year period. The main aims were to describe the characteristics and outcomes of FIRRs and compare them with clinician-activated RRs (C-RRs). Of the 1,906 RRs events reviewed, 49 (2.6%) were FIRRs. All FIRRs had appropriate clinical triggers with the most common being uncontrolled pain. Chronic conditions and previous admissions were present in 61%. More than half of FIRRs had a vital sign change that should have qualified C-RR activation. Seventy-six percent FIRRs needed at least one or more interventions. Twenty-seven percent of FIRRs needed transfer to intensive care unit compared with 60% transfer rate for C-RRs.

Purpose of Submission/Relevance to Healthcare Quality:

Family-initiated rapid response events were activated for legitimate concerns and frequently needed clinical interventions. Enhanced information and awareness of FIRR can improve utilization of the system and enhance family satisfaction, patient safety, and outcomes. Disseminating the information on FIRR and the importance of family involvement will improve the care of children and empower family members.
Comparing the Effects of Simulation-Based and Traditional Teaching Methods on the Critical Thinking Abilities and Self-Confidence of Nursing Students
Authors: ALAMRANI Mashael Hasan , ALAMMAR Kamila Ahmad , ALQAHTANI Sarah Saad , SALEM Olfat A.
Published: October 2017

Background:

Critical thinking and self-confidence are imperative to success in clinical practice. Educators should use teaching strategies that will help students enhance their critical thinking and self-confidence in complex content such as electrocardiogram interpretation. Therefore, teaching electrocardiogram interpretation to students is important for nurse educators.

Purpose:

This study compares the effect of simulation-based and traditional teaching methods on the critical thinking and self-confidence of students during electrocardiogram interpretation sessions.

Methods:

Thirty undergraduate nursing students volunteered to participate in this study. The participants were divided into intervention and control groups, which were taught respectively using the simulation-based and traditional teaching programs. All of the participants were asked to complete the study instrumentpretest and posttest to measure their critical thinking and self-confidence.

Results:

Improvement was observed in the control and experimental groups with respect to critical thinking and self-confidence, as evidenced by the results of the paired samples t test and the Wilcoxon signed-rank test (p < .05). However, the independent t test and Mann–Whitney U test indicate that the difference between the two groups was not significant (p > .05).

Conclusions/Implications for Practice:

This study evaluated an innovative simulation-based teaching method for nurses. No significant differences in outcomes were identified between the simulator-based and traditional teaching methods, indicating that well-implemented educational programs that use either teaching method effectively promote critical thinking and self-confidence in nursing students. Nurse educators are encouraged to design educational plans with clear objectives to improve the critical thinking and self-confidence of their students. Future research should compare the effects of several teaching sessions using each method in a larger sample.
Efficacy of branched-chain amino acid supplementation and walking exercise for preventing sarcopenia in patients with liver cirrhosis
Authors: Hiraoka Atsushi , Michitaka Kojiro , Kiguchi Daisuke , Izumoto Hirofumi , Ueki Hidetaro , Kaneto Miho , Kitahata Shogo , Aibiki Toshihiko , Okudaira Tomonari , Tomida Hideomi , Miyamoto Yuji , Yamago Hiroka , Suga Yoshifumi , Iwasaki Ryuichiro , Mori Kenichiro , Miyata Hideki , Tsubouchi Eiji , Kishida Masato , Ninomiya Tomoyuki , Kohgami Shigeru , Hirooka Masashi , Tokumoto Yoshio , Abe Masanori , Matsuura Bunzo , Hiasa Yoichi
Published: October 2017

Background/aim

Sarcopenia is recognized as a condition related to quality of life and prognosis in patients with chronic liver disease, although no useful strategy for improving muscle volume and strength has been established. Here, we evaluated the efficacy of supplementation with branched-chain amino acid (BCAA) administration and walking exercise.

Patients and methods

From December 2015 to July 2016, 33 Japanese outpatients with liver cirrhosis were enrolled (median: 67 years, HCV : HBV : alcohol : others=26 : 2 : 2 : 3, male : female=13 : 20, Child-Pugh A : B=30 : 3). None had a history of BCAA supplementation. After calculating the average number of daily steps using a pedometer for a 2–3-week period, BCAA supplementation (protein 13.5 g, 210 kcal/day) as a late evening snack and walking exercise (additional 2000 steps/day prescribed) were started. Body composition including muscle volume was analyzed using a bioelectrical impedance analysis method, and serological data and muscle strength (leg, handgrip) were evaluated at enrollment, and then 1, 2, and 3 months after starting the protocol.

Results

The median average number of daily steps was 3791 (interquartile range: 2238–5484). The average period of BCAA supplementation was 2.7±0.7 months. During the period from enrollment to 3 months after starting the protocol, HbA1c and NH3 were not significantly changed, whereas the BCAA/tyrosine ratio improved (4.3±1.35 to 5.24±2.04, P=0.001). In addition, the ratios for average daily steps (1.595, P=0.02) as well as muscle volume, leg strength, and handgrip strength (1.013, 1.110, and 1.056, respectively; all P<0.01) were increased at 3 months.

Conclusion

BCAA supplementation and walking exercise were found to be effective and easily implemented for improving muscle volume and strength in liver cirrhosis patients.
Prevention Strategies in Post-TBI Depression in Older Adults
Authors: Bay Esther , Garbinski Anne Marie , Maycock Susan E.
Published: October 2017

Purpose:

The purpose of this study was to describe a theoretically focused intervention aimed toward chronic stress and depressive symptom management that is coordinated by a case manager and delivered within a home environment by the caregiver.

Primary Practice Setting:

Home care, community setting.

Methods:

A case study of an older adult with traumatic brain injury (TBI) secondary to a fall who had significant allostatic load at the time of his injury. “Allostatic load” is a theoretical construct that suggests the brain is experiencing chronic strain on its systems that flexibly respond to stressors. Sustained allostatic load can contribute to chronic conditions and poor outcomes.

Findings:

Through actions with the family as caregivers, the case manager was able to coordinate a structured home setting and gradual resumption of social activities for this older adult. Focus was on establishing structure, meaningful social interactions, and positive home experiences that maximized the older adult's interests and capacity and mitigated chronic stress. Gradually, the older adult returned to his preinjury capacity and lives independently within the family home.

Implications for Case Management Practice:

The case management process has the potential to mitigate stressors and improve depression management through family-focused care. Although there is limited guidance on prevention of depression, this approach resulted in attainment of safe home care, no hospital readmissions, and return to previous lifestyle for the older adult. This could be useful in the prevention of post-TBI depression.
Improving Posthospital Discharge Telephone Reach Rates Through Prehospital Discharge Face-to-Face Meetings
Authors: Vergara Franz H. , Sheridan Daniel J. , Sullivan Nancy J. , Budhathoki Chakra
Published: October 2017

Purpose of the Study:

The purpose of this study was to determine whether a face-to-face meeting with patients by a telephonic case manager prehospital discharge would result in increased telephone follow-up (TFU) reach rates posthospital discharge.

Primary Practice Setting:

Acute care adult medicine inpatient units.

Methodology and Sample:

A quasiexperimental design was utilized. Two adult inpatient medicine units were selected as the intervention and comparison groups. The framework of the study is the transitions theory. A convenience sampling technique was used, whereby 88 eligible patients on the intervention unit received face-to-face meetings prehospital discharge whereas 123 patients on the comparison unit received standard care (no face-to-face meetings). Cross-tabulation and chi-square tests were employed to examine the association of face-to-face meeting intervention and TFU reach rates.

Results:

Implementing brief (<10 min) face-to-face meetings by a telephonic case manager prehospital discharge resulted in a TFU reach rate of 87% on the intervention unit, whereas the comparison unit only had a 58% TFU reach rate (p < .001).

Implications for Case Management Practice:

Increasing reach rates by a telephonic case manager facilitates communication with more patients posthospital discharge. A brief prehospital discharge face-to-face meeting with patients assisted them to understand the reasons for a posthospital discharge telephone call, identified the best times to call using accurate telephone numbers, and taught patients how best to prepare for the call. In addition, by meeting patients face-to-face, the telephonic case manager was no longer an unknown person on the telephone asking them questions about their medical condition. These factors combined may have significantly helped to increase TFU reach rates.
Enhanced Molecular Typing of Treponema pallidum subspecies pallidum Strains From 4 Italian Hospitals Shows Geographical Differences in Strain Type Heterogeneity, Widespread Resistance to Macrolides, and Lack of Mutations Associated With Doxycycline Resistance
Authors: Giacani Lorenzo , Ciccarese Giulia , Puga-Salazar Christian , Dal Conte Ivano , Colli Laura , Cusini Marco , Ramoni Stefano , Delmonte Sergio , D'Antuono Antonietta , Gaspari Valeria , Drago Francesco
Published: October 2017

Background

Although syphilis rates have been relatively high in Italy for more than 15 years, no data on the molecular types of Treponema pallidum subspecies pallidum circulating in this country are yet available. Likewise, no data on how widespread is resistance to macrolide or tetracycline antibiotics in these strains exist. Such data would, however, promote comprehensive studies on the molecular epidemiology of syphilis infections in Italy and inform future interventions aiming at syphilis control in this and other European countries.

Goals and Study Design

Swabs from oral, genital, cutaneous, or anal lesions were obtained from 60 syphilis patients attending dermatology clinics in Milan, Turin, Genoa, and Bologna. Molecular typing of T. pallidum DNA was performed to provide a snapshot of the genetic diversity of strains circulating in Northern Italy. Samples were also screened for mutations conferring resistance to macrolides and tetracyclines.

Results

T. pallidum DNA was detected in 88.3% (53/60) of the specimens analyzed. Complete and partial T. pallidum typing data were obtained for 77.3% (41/53) and 15.0% (8/53) of samples, respectively, whereas 4 samples could not be typed despite T. pallidum DNA being detected. The highest strain type heterogeneity was seen in samples from Bologna and Milan, followed by Genoa. Minimal diversity was detected in samples from Turin, despite the highest number of typeable samples collected there. Resistance to macrolides was detected in 94.3% (50/53) of the strains, but no known mutations associated with tetracycline resistance were found.

Conclusions

Genetic diversity among T. pallidum strains circulating in Northern Italy varies significantly among geographical areas regardless of physical distance. Resistance to macrolides is widespread.
The Influence of Tumor Stage on the Prognostic Value of Ki-67 Index and Mitotic Count in Small Intestinal Neuroendocrine Tumors
Authors: Sun Yu , Lohse Christine , Smyrk Thomas , Hobday Timothy , Kroneman Trynda , Zhang Lizhi
Published: October 2017

Tumor cell proliferation rate determined by either Ki-67 index or mitotic count (MC) has shown to be a prognostic factor for gastrointestinal neuroendocrine tumors in general, and after its incorporation in the 2010 World Health Organization tumor grading system, it has become essentially mandatory in pathology reports for all gastrointestinal neuroendocrine tumors, regardless of tumor location. Nevertheless, clinical significance for the Ki-67 index or MC has not been well demonstrated in small intestinal neuroendocrine tumor (SINET), especially those without distant metastasis, the majority of which have very low proliferation rates. We assessed the clinical behavior of 130 SINETs in relation to stage, Ki-67 index, MC, and other pathologic features. Most SINETs (86%) were grade 1 and 14% were grade 2. There were no grade 3 tumors or poorly differentiated neuroendocrine carcinomas. On multivariate analysis, age, Ki-67 index >5%, MC >10/50 high-power field, stage IV, and liver metastases were associated with increased risk of death in all patients. When both stage and grade were considered, Ki-67 index >5% was associated with a nearly 4-fold increased risk of death in stage IV cases (n=60). In contrast, Ki-67 index did not show prognostic value for patients with stages I to III disease (n=70), although MC >1/50 high-power field was significantly associated with death on multivariable analysis. Our study confirms that liver metastasis and increased tumor cell proliferation rate are independent prognostic factors for SINETs, but shows that most SINETs have a very low proliferation rate, which limits its value for predicting tumor behavior. By combining staging and grading information, we demonstrate different roles and cutoff values of Ki-67 index and MC in SINET with different stages.
Pediatric Poisonings in a Rural Ugandan Emergency Department
Authors: Boyle Katherine L. , Periyanayagam Usha , Babu Kavita M. , Rice Brian T. , Bisanzo Mark
Published: October 2017

Objective

This study aims to describe pediatric poisonings presenting to a rural Ugandan emergency department (ED), identifying demographic factors and causative agents.

Methods

This retrospective study was conducted in the ED of a rural hospital in the Rukungiri District of Uganda. A prospectively collected quality assurance database of ED visits was queried for poisonings in patients under the age of 5 who were admitted to the hospital. Cases were included if the chief complaint or final diagnosis included anything referable to poisoning, ingestion, or intoxication, or if a toxicologic antidote was administered. The database was coded by a blinded investigator, and descriptive statistics were performed.

Results

From November 9, 2009, to July 11, 2014, 3428 patients under the age of 5 were admitted to the hospital. A total of 123 cases (3.6%) met the inclusion criteria. Seventy-two patients were male (58.5%). The average age was 2.3 (SD, 0.97) years with 45 children (36.6%) under the age of 2 years. There were 19 cases (15.4%) lost to 3-day follow-up. The top 3 documented exposures responsible for pediatric poisonings were cow tick or organophosphates (36 cases, 29.2%), general poison or drug overdose (26 cases, 21.1%), and paraffin or hydrocarbon (24 cases, 19.5%).

Of the admitted patients, 1 died in the ED and 2 died at 72-hour follow-up, for an overall 72-hour mortality of 2.4%. Patients who died were exposed to iron, cow tick, and rat poison.

Conclusions

Pediatric poisoning affects patients in rural sub-Saharan Africa. The mortality rate at one rural Ugandan hospital was greater than 2%.
Alterations in the Mechanical Response of Deep Dorsal Neck Muscles in Individuals Experiencing Whiplash-Associated Disorders Compared to Healthy Controls
Authors: Rahnama Leila , Peterson Gunnel , Kazemnejad Anoshirvan , Trygg Johan , Peolsson Anneli
Published: October 2017

Objective

The aim of this study was to investigate and compare the mechanical responses of dorsal neck muscles in individuals with whiplash-associated disorders (WAD) versus healthy individuals.

Design

This study included 36 individuals with WAD (26 women and 10 men) and 36 healthy controls (26 women and 10 men). Ultrasound imaging with speckle tracking was used to measure deformation and deformation rate in five dorsal neck muscles during a neck extension task.

Results

Compared with controls, individuals with WAD showed higher deformations of the semispinalis cervicis (P= 0.02) and multifidus (P= 0.002) muscles and higher deformation rates (P= 0.03 and 0.0001, respectively). Among individuals with WAD, multifidus deformation and deformation rate were significantly associated with pain, disability, and fatigue (r= 0.31–0.46,P= 0.0001–0.01).

Conclusions

These findings indicate that the mechanical responses of the deep dorsal neck muscles differ between individuals with WAD and healthy controls, possibly reflecting that these muscles use altered strategies while performing a neck extension task. This finding provides new insight into neck muscles pathology in patients with chronic WAD and may help improve rehabilitation programs.

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CME Objectives

Upon completion of this article, the reader should be able to: (1) Summarize the mechanical responses of dorsal neck muscles during loading of the neck muscles via an extension task in individuals with chronic whiplash associated disorders and healthy volunteers; (2) Differentiate mechanical responses between five dorsal neck muscles while loading the neck via an extension task; and (3) Describe the relationships between the mechanical responses of the dorsal neck muscles with the patients' perception of neck pain, disability, and fatigue.

Level

Advanced

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