bluuebunny/crossref_metadata_2025 huggingface dataset:
A Survey and Analysis of the American Public's Perceptions and Knowledge About Antibiotic Resistance
Authors: Carter Rebecca R. , Sun Jiayang , Jump Robin L. P.
Published: June 2016

Background.  Little is known about the American public's perceptions or knowledge about antibiotic-resistant bacteria or antibiotic misuse. We hypothesized that although many people recognize antibiotic resistance as a problem, they may not understand the relationship between antibiotic consumption and selection of resistant bacteria.

Methods.  We developed and tested a survey asking respondents about their perceptions and knowledge regarding appropriate antibiotic use. Respondents were recruited with the Amazon Mechanical Turk crowdsourcing platform. The survey, carefully designed to assess a crowd-sourced population, asked respondents to explain “antibiotic resistance” in their own words. Subsequent questions were multiple choice.

Results.  Of 215 respondents, the vast majority agreed that inappropriate antibiotic use contributes to antibiotic resistance (92%), whereas a notable proportion (70%) responded neutrally or disagreed with the statement that antibiotic resistance is a problem. Over 40% of respondents indicated that antibiotics were the best choice to treat a fever or a runny nose and sore throat. Major themes from the free-text responses included that antibiotic resistance develops by bacteria, or by the infection, or the body (ie, an immune response). Minor themes included antibiotic overuse and antibiotic resistance caused by bacterial adaptation or an immune response.

Conclusions.  Our findings indicate that the public is aware that antibiotic misuse contributes to antibiotic resistance, but many do not consider it to be an important problem. The free-text responses suggest specific educational targets, including the difference between an immune response and bacterial adaptation, to increase awareness and understanding of antibiotic resistance.
Systems-Oriented Workplace Learning Experiences for Early Learners: Three Models
Authors: O’Brien Bridget C. , Bachhuber Melissa R. , Teherani Arianne , Iker Theresa M. , Batt Joanne , O’Sullivan Patricia S.
Published: June 2016

Purpose

Early workplace learning experiences may be effective for learning systems-based practice. This study explores systems-oriented workplace learning experiences (SOWLEs) for early learners to suggest a framework for their development.

Method

The authors used a two-phase qualitative case study design. In Phase 1 (spring 2014), they prepared case write-ups based on transcribed interviews from 10 SOWLE leaders at the authors’ institution and, through comparative analysis of cases, identified three SOWLE models. In Phase 2 (summer 2014), studying seven 8-week SOWLE pilots, the authors used interview and observational data collected from the seven participating medical students, two pharmacy students, and site leaders to construct case write-ups of each pilot and to verify and elaborate the models.

Results

In Model 1, students performed specific patient care activities that addressed a system gap. Some site leaders helped students connect the activities to larger systems problems and potential improvements. In Model 2, students participated in predetermined systems improvement (SI) projects, gaining experience in the improvement process. Site leaders had experience in SI and often had significant roles in the projects. In Model 3, students worked with key stakeholders to develop a project and conduct a small test of change. They experienced most elements of an improvement cycle. Site leaders often had experience with SI and knew how to guide and support students’ learning.

Conclusions

Each model could offer systems-oriented learning opportunities provided that key elements are in place including site leaders facile in SI concepts and able to guide students in SOWLE activities.
The Predictive Validity of the National Board of Osteopathic Medical Examiners’ COMLEX-USA Examinations With Regard to Outcomes on American Board of Family Medicine Examinations
Authors: O’Neill Thomas R. , Peabody Michael R. , Song Hao
Published: June 2016

Purpose

To examine the predictive validity of the National Board of Osteopathic Medical Examiners’ Comprehensive Osteopathic Medical Licensing Examination of the United States of America (COMLEX-USA) series with regard to the American Board of Family Medicine’s (ABFM’s) In-Training Examination (ITE) and Maintenance of Certification for Family Physicians (MC-FP) Examination.

Method

A repeated-measures design was employed, using test scores across seven levels of training for 1,023 DOs who took the MC-FP for the first time between April 2012 and November 2014 and for whom the ABFM had ITE scores for each of their residency years. Pearson and disattenuated correlations were calculated; Fisher r to z transformation was performed; and sensitivity, specificity, and positive and negative predictive values for the COMLEX-USA Level 2–Cognitive Evaluation (CE) with regard to the MC-FP were computed.

Results

The Pearson and disattenuated correlations ranged from 0.55 to 0.69 and from 0.61 to 0.80, respectively. For MC-FP scores, only the correlation increase from the COMLEX-USA Level 2-CE to Level 3 was statistically significant (for Pearson correlations: z = 2.41, P = .008; for disattenuated correlations: z = 3.16, P < .001). The sensitivity, specificity, and positive and negative predictive values of the COMLEX-USA Level 2-CE with the MC-FP were 0.90, 0.39, 0.96, and 0.19, respectively.

Conclusions

Evidence was found that the COMLEX-USA can assist family medicine residency program directors in predicting later resident performance on the ABFM’s ITE and MC-FP, which is becoming increasingly important as graduate medical education accreditation moves toward a single aligned model.
Epidural Against Systemic Analgesia
Authors: Roeb Mauritz M. , Wolf Alexander , Gräber Stefan S. , Meißner Winfried , Volk Thomas
Published: June 2016

Background:

The PAIN OUT registry collected data from >30,000 patients on pain on the first postoperative day in hospitals worldwide. Utilizing the database, we compared systemic and epidural analgesia (EA) on postoperative pain and related side-effects in patients after abdominal surgeries (ASs).

Methods:

ASs were identified through the ICD9-Code and subgrouped into laparoscopic surgery and open surgery. After identifying patients in this subset with and without EA, propensity-score matching was performed on the basis of demographics and comorbidities. Primary outcomes were different qualities of pain, and secondary outcomes were pain-related sensations and treatment-related side effects measured with the numeric rating scale. They were calculated as the risk ratio (RR) using the median as the divisor.

Results:

The database contained 29,108 cases, with 5365 AS, and 646 cases remained after matching. A risk analysis revealed that for the AS group, EA posed a significantly lower risk for the perception of worst pain (RR, 0.75; confidence interval [CI], 0.64-0.87), least pain (RR, 0.61; CI, 0.5-0.75), time in severe pain (RR, 0.61; CI, 0.5-0.75), in-bed activity interference of pain (RR, 0.71; CI, 0.59-0.85), pain interference with coughing (RR, 0.68; CI, 0.57-0.82) or sleeping (RR, 0.73; CI, 0.61-0.87), and a higher chance of pain relief (RR, 1.5; CI, 1.23-1.83). The risk for itchiness (RR, 2.23; CI, 1.62-3.07) appeared to be higher, as did the probability of satisfaction (RR, 1.25; CI, 1.03-1.51). The risk for feeling helpless (RR, 0.83; CI, 0.7-0.99) and drowsiness (RR, 0.74; CI, 0.63-0.88) was reduced. Both subgroups showed similar tendencies.

Discussion:

Regarding the pain intensity, satisfaction, and relatable side-effects, EA seems to be superior compared with systemic analgesia after AS.
Prospective Evaluation of Posttraumatic Stress Disorder in Injured Patients With and Without Orthopaedic Injury
Authors: Warren Ann Marie , Jones Alan L. , Bennett Monica , Solis Jaicus K. , Reynolds Megan , Rainey Evan E. , Viere Grace , Foreman Michael L.
Published: June 2016

Objectives:

The study purposes were to prospectively evaluate occurrence of posttraumatic stress (PTS) symptoms at hospital admission and 6 months later in patients with orthopaedic injury; to explore differences in PTS symptoms in those with and without orthopaedic injury; and to determine whether PTS symptoms are influenced by orthopaedic injury type.

Design:

Prospective, longitudinal observational study.

Setting:

Level 1 Trauma Center.

Patients/Participants:

Two hundred fifty-nine participants admitted for at least 24 hours.

Main Outcome Measurements:

The Primary Care Posttraumatic Stress Disorder (PTSD) Screen (PC-PTSD) measured PTSD symptoms during hospitalization. The PTSD Checklist–Civilian Version (PCL-C) measured PTS symptoms at 6 months.

Results:

In orthopaedic patients, 28% had PTS at 6 months, compared with 34% of nonorthopaedic patients. Odds ratios (ORs) were calculated to determine the influence of pain, physical and mental function, depression, and work status. At 6 months, if the pain score was 5 or higher, the odds of PTS symptoms increased to 8.38 (3.55, 19.8) (P < 0.0001). Those scoring below average in physical function were significantly more likely to have PTS symptoms [OR = 7.60 (2.99, 19.32), P < 0.0001]. The same held true for mental functioning and PTS [OR = 11.4 (4.16, 30.9), P < 0.0001]. Participants who screened positive for depression had a 38.9 (14.5, 104) greater odds (P < 0.0001). Participants who did not return to work after injury at 6 months were significantly more likely to have PTS [OR = 16.5 (1.87, 146), P = 0.012].

Conclusions:

PTSD is common in patients after injury, including those with orthopaedic trauma. At 6 months, pain of 5 or greater, poor physical and mental function, depression, and/or not returning to work seem to be predictive of PTSD. Orthopaedic surgeons should identify and refer for PTSD treatment given the high incidence postinjury.

Level of Evidence:

Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
Awareness of human papilloma virus and cervical cancer prevention among Greek female healthcare workers
Authors: Farazi Paraskevi A. , Hadji Panayiota , Roupa Zoe
Published: June 2016

The incidence rate of cervical cancer varies by geographic region, with less developed regions showing the highest rates. All risk factors for cervical cancer are actually preventable if appropriate lifestyle changes are adopted. In addition, vaccines protecting against the majority of human papilloma virus (HPV) high-risk types have been developed. Even though cervical cancer is preventable, not all women are aware of this or how it can be prevented. Thus, it is essential for every nation to assess the level of knowledge among women of cervical cancer and HPV prevention. In this work, we assessed the level of awareness and attitudes of Greek female healthcare workers on cervical cancer and HPV prevention through the delivery of a validated questionnaire between March and June 2012 in three hospitals in Greece. Our results show that there exist gaps in the knowledge of women on this topic, especially in terms of the newest information on cervical cancer prevention through HPV testing and vaccination. In fact, only 80% of surveyed women knew about the existence of HPV testing. We propose that more information needs to be transmitted to Greek women and men on HPV testing and vaccination. Even though the incidence of cervical cancer is not extremely high in Greece, this number can easily change, especially in the face of the economic crisis and the increasing rates of migration, which can result in higher rates of HPV infection in the population if no measures for HPV prevention are implemented.
Rapid remission of symptomatic brain metastases in melanoma by programmed-death-receptor-1 inhibition
Authors: Lüttmann Nadine , Grätz Victoria , Haase Ozan , Eckey Thomas , Langan Ewan A. , Zillikens Detlef , Terheyden Patrick
Published: June 2016

Although ∼40% of patients with metastatic melanoma develop brain metastases, the presence of brain metastases often precludes enrolment in clinical trials for advanced melanoma. However, the development of symptomatic brain metastases markedly increases mortality. The antiprogrammed-death-receptor-1 antibody pembrolizumab achieves extracranial metastases disease response rates of up to 50%. Here, we report the rapid and sustained response of symptomatic multifocal brain metastases in a melanoma ipilimumab-pretreated patient under pembrolizumab, combined with high-dose dexamethasone therapy during the induction phase of therapy. Complete remission has been maintained for over 1 year of follow-up and has correlated with the response rate observed in the extracranial metastases. Radiological disease response was identified during the first follow-up visit in the absence of adjuvant radiotherapy. This report highlights the need for further clinical studies to specifically address the therapeutic potential of antiprogrammed-death-receptor-1 monotherapy in the management of untreated brain metastases in melanoma.
The Path From Heart Failure to Cardiac Transplant
Authors: Freeman Regi , Koerner Erika , Clark Courtney , Halabicky Kathy
Published: June 2016

Heart failure is a progressive and fatal disease impacting millions of American each year. Divided into stages, heart failure presents with progressive symptoms requiring a wide range of medical treatments. Treatments include diet and lifestyle changes, medications, electrical therapies (defibrillator and/or cardiac resynchronization therapy), as well as mechanical circulatory support. Cardiac transplant is the gold standard treatment of heart failure, although the availability of donors limits the utility of a cardiac transplant. This article outlines heart failure treatments and the indications, contraindications, and pretransplant evaluation for a cardiac transplant. Information on the allocation of donor hearts and donor characteristics is also included for the reader.
Postoperative Care of a Liver Transplant Recipient Using a Classification System
Authors: Coscia Cari , Saxton Ernest , Dickinson Sharon
Published: June 2016

Liver transplantation has become an effective and valuable option for patients with end-stage liver disease and hepatocellular carcinoma. Liver failure, an acute or chronic condition, results in impaired bile production and excretion, clotting factor production, protein synthesis, and regulation of metabolism and glucose. Some acute conditions of liver disease have the potential to recover if the liver heals on its own. However, chronic conditions, such as cirrhosis, often lead to irreversible disease and require liver transplantation. In this publication, we review the pathophysiology of liver failure, examine common conditions that ultimately lead to liver transplantation, and discuss the postoperative management of patients who are either hemodynamically stable (type A) or unstable (type B).
Therapeutic Drug Monitoring, Electronic Health Records, and Pharmacokinetic Modeling to Evaluate Sirolimus Drug Exposure–Response Relationships in Renal Transplant Patients
Authors: Zimmerman Kanecia O. , Wu Huali , Greenberg Rachel , Guptill Jeffrey T. , Hill Kevin , Patel Uptal D. , Ku Lawrence , Gonzalez Daniel , Hornik Christoph , Jiang Wenlei , Zheng Nan , Melloni Chiara , Cohen-Wolkowiez Michael
Published: June 2016

Background:

Sirolimus, an immunosuppressive agent used in renal transplantation, can prevent allograft rejection. Identification of the therapeutic index (the ratio of minimum toxic concentration to minimum therapeutic concentration) for immunosuppresants is necessary to optimize the care of patients and set standards for bioequivalence evaluation of sirolimus products. However, the therapeutic index for sirolimus has been inconsistently defined, potentially because of inconsistencies in sirolimus exposure–response relationships.

Methods:

The authors used retrospective therapeutic drug monitoring data from the electronic health records of patients treated in a tertiary health care system from 2008 to 2014 to (1) develop a population pharmacokinetic (PK) model, (2) use the model to simulate sirolimus concentrations, and (3) characterize the exposure–response relationship. Using Wilcoxon rank-sum and Fisher exact tests, the authors determined relationships between sirolimus exposure and adverse events (AEs) (anemia, leukopenia, thrombocytopenia, hyperlipidemia, and decline in renal function) and the composite efficacy end point of graft loss or rejection.

Results:

The developed 2-compartment population PK model showed appropriate goodness of fit. In a late-phase (>12 months), postrenal transplant population of 27 inpatients, the authors identified statistically significant relationships between 83 simulated peak and trough sirolimus concentrations and outcomes: graft loss or rejection (P= 0.018) and decline in renal function (P= 0.006), respectively.

Conclusions:

Use of therapeutic drug monitoring results and PK modeling permitted correlation of sirolimus concentrations with graft loss or rejection and decline in renal function. However, the method was limited in its assessment of other AEs. To better evaluate sirolimus exposure–response relationships, the method should be applied to a larger sample of newly transplanted patients with a higher propensity toward AEs or efficacy failure.
Updates in uterine fibroid tissue extraction
Authors: Cohen Sarah L. , Hariton Eduardo , Afshar Yalda , Siedhoff Matthew T.
Published: June 2016

Purpose of review

Safety concerns regarding morcellation of presumed benign fibroid disease have led to an increase in recent research activity on this topic, as well as advances in surgical technique.

Recent findings

The prevalence of occult leiomyosarcoma is debated; however, estimates from a robust meta-analysis suggest it may be in the range of 1 case per 1960–8300 fibroid surgeries. Advancing age is an important clinical risk factor for occult malignancy. The impact of tumor morcellation may vary by mode of tissue removal, though tissue fragmentation is consistently associated with poorer outcomes. Decision and cost analyses continue to support laparoscopic hysterectomy as a low-morbidity and cost-effective approach. The increased scrutiny on fibroid procedures in the past few years may lead to changes in surgical approach; however, alternative tissue extraction options are evolving, including incorporation of contained morcellation.

Although the incidence of occult leiomyosarcoma is low, outcomes are poor and may be worsened by morcellation. By addressing risk factors for malignancy and incorporating evolving surgical techniques into practice, gynecologists can continue to offer patients a minimally invasive approach for fibroid management.
MESECTODERMAL LEIOMYOMA OF THE CILIARY BODY PRESENTING AS ANTERIOR STAPHYOMA
Authors: Lavric Alenka , Tsimpida Maria , Hungerford John L. , M. L. Cohen Victoria
Published: June 2016

Purpose:

To report two cases of mesectodermal leiomyoma of the ciliary body presenting as anterior staphyloma.

Methods:

Two case reports with cytopathologic correlation.

Results:

First patient (15-year-old boy) presented with a nodular lesion in the sclera. Second patient (31-year-old woman) was found to have a brown ciliary body mass. Growth of the lesion and extrascleral extension was noticed after several years of follow-up. Ultrasonography, light microscopy, and immunohistochemistry of both cases are described confirming mesectodermal leiomyoma of the ciliary body.

Conclusion:

Mesectodermal leiomyoma, despite its rarity, should be considered in the differential diagnosis of uveal tract tumors. Clinically, the diagnosis is difficult and histopathological and immunohistochemical assesment is necessary to avoid inappropriate diagnosis and erroneous treatment.
BARTONELLA QUINTANA–ASSOCIATED NEURORETINITIS: LONGITUDINAL SPECTRAL-DOMAIN OPTICAL COHERENCE TOMOGRAPHIC FINDINGS
Authors: Mello Luiz Guilherme M. , Lima Luiz H. , Cabral Thiago , Rodrigues Mariana Z. , Peçanha Paulo M. , Belfort Rubens
Published: June 2016

Purpose:

To report an unusual case of neuroretinitis caused by Bartonella quintana and its spectral-domain optical coherence tomographic (SD-OCT) features.

Methods:

A 12-year-old girl presented with unilateral neuroretinitis with stellate maculopathy. Bartonellosis was confirmed after serologic testing for antibodies to B. quintana.

Results:

Color photograph of the right eye revealed papillitis and stellate macular exudation. spectral-domain optical coherence tomography of the right eye revealed hyperreflective dots in the outer nuclear and outer plexiform layers, as well as disruption and loss of the external limiting membrane, ellipsoid zone, and interdigitation zone in the foveal area.

Conclusion:

The authors report an unusual case of neuroretinitis by B. quintana and its spectral-domain optical coherence tomographic findings.
Glaucoma Mini-Shunt Implantation After Keratoplasty
Authors: Ledesma-Gil Jasbeth , García-Rodríguez María de los Ángeles , Gurria Lulu U. , Graue-Hernández Enrique O. , Navas Alejandro
Published: June 2016

Purpose:

To report the outcomes of patients who underwent miniature glaucoma shunt implantation after secondary glaucoma due to keratoplasty.

Materials and Methods:

Prospective study of consecutive clinical cases who underwent mini-glaucoma shunt implantation following keratoplasty. In brief, a fornix-based conjunctival flap was performed, approximately 50% thickness scleral flap. Mitomycin C 0.025% placed under Tenon’s capsule. A 25-G needle created entry for mini-shunt. Ex-PRESS model P-50 was inserted. Scleral flap and conjunctiva were closed with 10-0 Nylon. STATA 8.0 and SPSS software were used for statistical analysis.

Results:

Seventeen eyes of 17 patients with a mean age of 39.70 years (SD=18.33, range: 18 to 76). A total of 64.70% were male and 35.30% female. Eleven cases after penetrating keratoplasty, 3 cases after triple procedure, 2 after deep anterior lamellar keratoplasty, and 1 following endothelial keratoplasty. Most of the indications for keratoplasty were keratoconus in 9 cases (52.94%), 4 due to endothelial failure (23.52%), 3 cases of herpetic keratitis (17.64%), and 1 case of post-LASIK ectasia (5.88%). Mean preoperative intraocular pressure was 35.94 mm Hg with maximal medical therapy (SD=9.65, range: 18 to 55). Decreasing intraocular pressure to 12.76 mm Hg postoperatively (SD=2.51, range 10 to 18) (P=0.001). Mean follow-up after mini-glaucoma shunt implantation was 23.76 months (SD=8.73, range: 10 to 35 mo). Preoperative mean uncorrected distance visual acuity (UDVA) was 1.31±0.63 (20/408 Snellen) and postoperative mean UDVA was 0.85±0.40 (20/141 Snellen) (P=0.001). Preoperative mean corrected distance visual acuity (CDVA) was 0.83±0.76 (20/135 Snellen) and postoperative mean CDVA was 0.56±0.44 (20/72 Snellen) (P=0.032).

Conclusions:

Ex-PRESS miniature glaucoma shunt could be an alternative treatment in postkeratoplasty glaucoma resistant to medical treatment. This technique may be helpful, in trying to avoid corneal damage produced by conventional glaucoma procedures.
New Ultrasound Biomicroscopy Iris Findings in Juvenile Xanthogranuloma
Authors: Syed Zeba A. , Chen Teresa C.
Published: June 2016

We report a case of juvenile xanthogranuloma in a 12-month-old girl presenting with heterochromia, hyphema, and elevated intraocular pressure. This case demonstrates new ultrasound biomicroscopy iris findings of a generalized bumpy iris contour, suggesting diffuse heterogeneous involvement. This imaging finding has not been previously described. Untreated, iris juvenile xanthogranuloma may lead to corneal blood staining, glaucoma, and amblyopia. An understanding of the full range of ultrasound features of juvenile xanthogranuloma expands our appreciation for the clinical findings in this condition.
Effect of CYP2C9 and VKORC1 Gene Variants on Warfarin Response in Patients with Continuous-Flow Left Ventricular Assist Devices
Authors: Topkara Veli K. , Knotts Robert J. , Jennings Douglas L. , Garan A. Reshad , Levin Allison P. , Breskin Alexander , Castagna Francesco , Cagliostro Barbara , Yuzefpolskaya Melana , Takeda Koji , Takayama Hiroo , Uriel Nir , Mancini Donna M. , Eisenberger Andrew , Naka Yoshifumi , Colombo Paolo C. , Jorde Ulrich P.
Published: June 2016

Bleeding and thrombotic complications continue to plague continuous-flow left ventricular assist device (CF-LVAD) therapy in patients with end-stage heart failure. Warfarin genotyping information can be incorporated into decision making for initial dosing as recommended by the Food and Drug Administration; however, clinical utility of this data in the CF-LVAD population has not been well studied. Genotypes testing for CYP2C9 and VCORC1 polymorphisms were determined in 90 CF-LVAD patients. Outcomes studied were the association of CYP2C9 (*1, *2, or *3) and VKORC1 (-1639 G>A) gene variants with time-to-target international normalized ratio (INR), total warfarin dose, maintenance warfarin dose. Continuous-flow left ventricular assist device patients carrying a rare variant in the VKORC1 gene had a significantly lower cumulative warfarin dose until target INR achieved (18.9 vs. 35.0 mg, p = 0.002), days spent until INR target achieved (4.9 vs. 7.0 days, p = 0.021), and discharge warfarin dose (3.2 vs. 5.6 mg, p = 0.001) compared with patients with wild-type genotype. Genotype-guided warfarin dosing may lead to safer anticoagulation and potentially improve outcomes in CF-LVAD patients.
Costs and Outcomes in the Care of Bi-ventricular Support as a Bridge to Cardiac Transplant
Authors: Swartz Michael F. , Angona Ron , Smith Karen , Kraenzlin Franca , Stypula Christine M. , Joshi Devang , Tchantchaleishvili Vakhtang , Hicks George L. , Massey H. Todd
Published: June 2016

Bi-ventricular (Bi-V) mechanical circulatory support is commonly used as a bridge to cardiac transplant. However, the optimal strategy is unknown. We examined the outcomes, as well as the costs in the use of Bi-V support as a bridge to cardiac transplant. From 2001 to 2014, three different Bi-V support strategies were utilized: 1) Para-corporeal ventricular assist device (PVAD-2001–2006), 2) Heartmate II left ventricular assist device in conjunction with a temporary CentriMag right ventricular assist device (HMII + CMAG-2006–2012), and the total artificial heart (TAH-2012–2014). Total costs were derived from the hospitalization at implant, and postimplant costs defined as equipment and re-hospitalizations before transplantation. Sixty-five (34 PVADs, 20 HMII + CMAG, and 11 TAHs) devices were used as a bridge for transplant. There were no differences in implant variables including age, INTERMACS score, or implant length of stay. Although the wait list mortality was not different between groups (PVAD-32%, HMII + CMAG-45%, TAH-54%; p = 0.3), the percentage of patients transplanted were highest in the PVAD group: (PVAD-55.8%, HMII + CMAG-30.0%, TAH-18.2%; p = 0.01). Total costs were not significantly different between groups (PVAD-$306,166 ± 247,839, HMII + CMAG-$278,958 ± 135,324, TAH-$321,387 ± 21,2477; p = 0.5). Despite variations in therapy, outcomes and costs for patients requiring Bi-V support as a bridge to cardiac transplant have remained constant.
Permanent Continuous Flow Left Ventricular Assist Devices Use After Acute Stabilization for Cardiogenic Shock in Acute Myocardial Infarction
Authors: Chou Josephine , Bermudez Christian , Kormos Robert , Teuteberg Jeffrey
Published: June 2016

Cardiogenic shock complicating acute myocardial infarctions (CS-AMIs) carries high mortality rates. Early use of durable continuous flow left ventricular assist devices (CF-LVAD) in these patients has traditionally been discouraged. Therefore we sought to assess the efficacy and complications of CF-LVAD use in CS-AMI after stabilization with temporary mechanical support. From January 2006 to November 2014, nine patients underwent CF-LVAD implant after CS-AMI (Heartmate II, six; HVAD, three). All patients required temporary mechanical circulatory support (MCS) before CF-LVAD implant and were interagency registry for mechanically assisted circulatory support profile 1; average time from MI to CF-LVAD implant was 20 days. Overall seven of nine patients (78%) survived to discharge. Survival at 1, 3, 12, and 48 months was 100%, 89%, 67%, and 67%, respectively. Two patients were successfully bridged to transplant and four patients remain alive on device support. The most common post-LVAD complication was stroke, occurring in 55% of patients. Embolic strokes were mild in severity and all patients survived with only mild deficits; hemorrhagic strokes conferred the highest mortality. This study suggests CF-LVADs are potential but high-risk treatment options for CS-AMI patients who stabilize with temporary support. Further studies will help more clearly delineate the benefits and risks of CF-LVAD implant in this population.
Immunomodulatory Device Promotes a Shift of Circulating Monocytes to a Less Inflammatory Phenotype in Chronic Hemodialysis Patients
Authors: Szamosfalvi Balazs , Westover Angela , Buffington Deborah , Yevzlin Alexander , Humes H. David
Published: June 2016

Patients with end-stage renal disease (ESRD) on chronic hemodialysis (HD) suffer accelerated morbidity and mortality rates caused by cardiovascular disease and infections. Chronic inflammation plays a critical role in these poor outcomes. The activated monocyte (MO) has become a prime therapeutic target to modulate this inflammatory process. A selective cytopheretic device (SCD) was evaluated to assess its effects on the circulating MO pool. A pilot trial was undertaken in 15 ESRD patients on HD with C-reactive protein (CRP) levels greater than 5 mg/dl. An excellent safety profile was observed with no decline in leukocyte (LE) or platelet counts. The effect of SCD therapy on MO phenotypes in these patients was determined on peripheral blood MO utilizing flow cytometry. SCD therapy promoted a shift in MO phenotype from predominantly CD14hi expressing MO at baseline/pre-SCD therapy to CD14low expressing MO post-SCD therapy. A significant shift in MO population phenotype afforded by a single SCD therapy session was observed (p < 0.013). In a subset of patients (n = 7) presenting with type 2 diabetes mellitus (T2D), this persistent decline in MO CD14 expression was sustained as long as 2 weeks posttherapy. These results demonstrate that the SCD therapy has the potential to modulate the chronic proinflammatory state in ESRD patients.
Development of Risk Indices for Neonatal Respiratory Extracorporeal Membrane Oxygenation
Authors: Maul Timothy M. , Kuch Bradley A. , Wearden Peter D.
Published: June 2016

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has saved thousands of newborns. Population comparisons for research and quality initiatives require risk-matching, but no indices exist for this population. We sought to create a pre-ECMO risk index using the registry data from the Extracorporeal Life Support Organization. We analyzed 5,455 neonatal (<30 days old) respiratory VA-ECMO patients for the period 2000–2010. Multivariate regression examining the impact of pre-ECMO variables on survival to hospital discharge was performed to create the Pittsburgh Index for Pre-ECMO Risk (PIPER), which was ultimately was based on seven pre-ECMO variables. Each PIPER quartile demonstrated increasing mortality by 15% (R
2 = 0.98) and was associated with increased complications on ECMO. Further modeling to include on-ECMO complications (PIPER+), including complications and length of time on ECMO, increased the predictive power of the model, with 21% increases in mortality per PIPER+ quartile (R
2 = 0.97). Our developed indices provide the first steps towards risk-adjusting patients for meaningful comparisons amongst patient populations. There may be additional clinically relevant measures, both pre- and on-ECMO, which could provide better predictive capability. Future work will focus on finding these additional measures and expansion of our techniques to include other patient populations.
Features of Hepatitis in Hepatitis‐associated Aplastic Anemia
Authors: Patel Kalyani R. , Bertuch Alison , Sasa Ghadir S. , Himes Ryan W. , Wu Hao
Published: June 2016

Objectives:

Hepatitis‐associated aplastic anemia (HAA) is a rare variant of aplastic anemia in which patients present with severe pancytopenia after an episode of acute hepatitis. The marrow failure is often rapid, severe, and usually fatal if untreated. The preceding hepatitis is largely under‐studied.

Methods:

Retrospective study of the clinical and histopathologic features of hepatitis in pediatric patients who subsequently developed aplastic anemia and comparison with consecutive cases of acute liver failure and random cases of autoimmune hepatitis during the same time frame.

Results:

All 7 patients of HAA had significant elevations in aminotransferases and conjugated hyperbilirubinemia at initial presentation. Echoing liver function indices, cholestatic hepatitis with sinusoidal obstruction‐type endothelial injury was seen histomorphologically. Autoimmune hepatitis serology such as anti‐F‐actin, anti‐liver/kidney microsome, and hypergammaglobulinemia was negative in all patients. Five of 7 patients (71.4%) had, however, elevated antinuclear antibody, all with a speckled pattern. Hepatitis virus serology was negative in all patients. By immunohistochemical staining, the lobular CD8/CD4 lymphocyte ratio was markedly elevated in all of the initial samples with significant reduction in this ratio (P = 0.03) in 3 patients post treatment (ursodiol, antibiotics, and/or immunosuppressive therapy).

Conclusions:

Hepatitis preceding HAA is characterized by marked elevation of aminotransferases, conjugated hyperbilirubinemia, elevated antinuclear antibody with a speckled pattern, cholestatic hepatitis with sinusoidal obstruction morphology, and CD8+ dominant lobular infiltrates. The present study suggests HAA may result from cytotoxic T–cell‐mediated sinusoidal endothelial and hepatocytic injury.
Human Milk Oligosaccharides Influence Intestinal Epithelial Cell Maturation In Vitro
Authors: Holscher Hannah D. , Bode Lars , Tappenden Kelly A.
Published: June 2016

Objectives:

Human milk oligosaccharides (HMOs) are reported to promote epithelial cell differentiation in vitro. The aim of the present study was to assess induction of epithelial cell differentiation by individual and combined administration of 3 HMOs.

Methods:

An in vitro epithelial model of the crypt‐villus axis consisting of preconfluent HT‐29, preconfluent Caco‐2Bbe, and postconfluent Caco‐2Bbe cells was used. Cultures were randomized to 17 treatments for 72 hours of incubation: low‐ and high‐dose HMOs (3′sialyllactose [3′SL] at 0.2 and 1.0 g/L, 6′siallylactose [6′SL] at 0.4 and 1.0 g/L, and 2′fucosyllactose at 0.2 and 2.0 g/L), HMO combinations at both low and high doses, and controls (culture medium, 4 g/L pooled HMO, and lipopolysaccharide).

Results:

High doses of individual HMOs (P < 0.05), combined HMOs (P < 0.05), and pooled HMO decreased (P < 0.001) proliferation in preconfluent HT‐29 cultures. Pooled means of individual low and high treatments with 3′SL and 6′SL, combinations of 2 or 3 high‐dose HMOs, and total HMO significantly reduced (P < 0.05) proliferation in preconfluent Caco‐2Bbe cells. HMOs increased differentiation in preconfluent HT‐29 and Caco‐2Bbe cells. 3′SL and 6′SL increased alkaline phosphatase activity but did not affect disaccharidase activity in postconfluent Caco‐2Bbe cells. Apoptosis and necrosis were both decreased (P < 0.001) in postconfluent Caco‐2Bbe cells treated with pooled HMO.

Conclusions:

HMO treatments inhibited proliferation with some associated enhancement of epithelial differentiation. Effects of HMOs were additive but no specific combinations of HMOs were especially potent. These results suggest that commercially viable individual HMOs and specific combinations may promote intestinal epithelial cell maturation.
The Pathway to Excellence Experience
Authors: Mahoney Jane S. , Jackson Jennifer M. , Palyo Nancy
Published: June 2016

Psychiatric nurse executives and managers face an ongoing challenge to create positive professional work environments that support the recruitment and retention of the best nurses. The Pathway to Excellence program is an organizational credentialing program that designates a hospital as a workplace of choice for nursing. This article describes one psychiatric hospital's journey to become and maintain a Pathway to Excellence designation in the midst of transition. Challenges faced and novel approaches used, along the journey, are shared. The use of Appreciative Inquiry techniques has led to positive changes and heightened energy among nurses. Our experiences suggest that effective shared governance is central to a hospital's Pathway to Excellence success. We attribute the steady increase in the retention rate of nurses, in large part, to the Pathway to Excellence program.
Addressing the Elephant in the Room
Authors: Gilbert Rebecca T. , Hudson John S. , Strider David
Published: June 2016

Health care bullying is a pervasive, underestimated, and underreported problem that results in poor outcomes for staff, patients, and health care organizations. The most common form of health care bullying occurs between nurses. Nurse managers hold an important role in the prevention and elimination of frontline nurse-to-nurse bullying. An anonymous Web-based survey was conducted to uncover what behaviors nurse managers perceive as bullying and how they respond to bullying acts. Respondents who had witnessed or been victimized by bullying were more apt to identify bullying and those who had been victimized or supervised nurses for more than 20 years were more prone to act upon bullying behaviors. There was only a moderate correlation between the identification of and response to bullying behaviors. Finally, overt bullying elicited a stronger response for intervention than covert bullying. Although nurse managers are well positioned to prevent and eliminate nurse-to-nurse bullying, they may not recognize it and often lack the skills and support necessary to address it. Decreases in nurse-to-nurse bullying reduce health care costs, improve nurse and patient satisfaction, and enhance patient outcomes. Therefore, nurse managers at all levels need education and support to ensure proper identification of bullying and, furthermore, to prevent and eliminate the behaviors.
Trauma Arrest and Spinal Injury in a 3-Year-Old Girl
Authors: High Kevin , Walsh Michele , Kidd Rebecca
Published: June 2016

Management of an acutely injured pediatric patient with multiple traumas is a common challenge facing clinicians in pediatric emergency care. Blunt trauma is more common in the pediatric population with motor vehicle accidents being the most common cause of injury. Spinal injury, especially in young children, is only seen in 1% to 2% of cases and can be lethal. It is incumbent upon clinicians to be able to meet the challenges of patient management including airway management, providing hemodynamic support, and addressing potentially reversible causes of arrest while recognizing presenting symptoms of spinal injury. This case presents a child in trauma arrest after a motor vehicle crash requiring advanced interventions, diagnostics, and support. Her clinical course is described and reveals a complete distraction of the cervical and thoracic spine. This case illustrates pathology and management along with the importance of proper management and interventions by pediatric emergency clinicians to manage the patient and attempt to maximize the patient's outcome.
Mechanism of Hyponatremia in Community-Acquired Pneumonia
Authors: Hausman-Kedem Moran , Reif Shimon , Danino Dana , Limor Rona , Grinspan Zachary M. , Yerushalmi-Feler Anat , Ben-Tov Amir , Birger Amir
Published: June 2016

Objective

Hyponatremia is a well-known sequela of community-acquired pneumonia (CAP). B-type natriuretic peptide (BNP) has a natriuretic effect and was found to be elevated in patients with CAP. We investigated whether BNP has a role in the pathophysiology of hyponatremia in pediatric CAP.

Methods

Serum and urine electrolytes and osmolality, as well as NT-pro-BNP (N-BNP), were obtained in 49 hospitalized pediatric patients with CAP (29 with hyponatremia, 20 with normal sodium levels.

Results

Urine sodium levels were lower in the hyponatremic group compared with the normonatremic group (24.3 meq/L vs 66.7 meq/L,P= 0.006). No difference in N-BNP levels was found between groups (median, 103.8 vs 100.1;P= 0.06; interquartile range, 63.7–263.3 pg/mL vs 47.4–146.4 pg/mL). N-BNP was not associated with serum or urinary sodium levels.

Conclusions

These results indicate that BNP is unlikely to play a causative role in the mechanism of hyponatremia in CAP.
Altered Mental Status in a Child With an Unwitnessed Fall
Authors: Fleurat Michelle R. , Zaia Brita E.
Published: June 2016

We report a case of altered mental status in a 5-year-old boy who presented to the emergency department after presumed head trauma. A computed tomography head was conducted and its findings were normal, and the boy was discharged home. He returned the next day with persistent altered mental status and was found to have an abnormal MR brain suggestive of embolic strokes. An echocardiogram revealed a large atrial mass that was later confirmed by pathology to be an atrial myxoma. This is a unique and, to our knowledge, unreported presentation of a known but rare disease process in a pediatric patient.
Brief Report: European Mitochondrial Haplogroups Impact on Liver Fibrosis Progression Among HCV and HIV/HCV-Coinfected Patients From Northwest Spain
Authors: Tabernilla Andres , Rego-Pérez Ignacio , Grandal Marta , Pernas Berta , Pértega Sonia , Delgado Manuel , Mariño Ana , Álvarez Hortensia , Mena Alvaro , Rodríguez-Osorio Iria , Pedreira Jose Domingo , Blanco Francisco Javier , Poveda Eva
Published: June 2016

The impact of mitochondrial DNA haplogroups on the outcome of liver fibrosis was evaluated in 362 hepatitis C virus infection (HCV)-monoinfected and HIV/HCV-coinfected patients (147 and 215, respectively) in clinical follow-up at 2 reference hospitals in the Northwest of Spain. The mitochondrial DNA haplogroup H was the most prevalent (50.3%) in this population. The cluster Others and V were recognized as risk factors for the development of liver fibrosis while haplogroup H and HCV genotype 4 confer a lower risk. This information might be useful for prioritization of HCV treatment, especially for F0-F1 patients for whom there is no urgency for treatment.
County-Level Vulnerability Assessment for Rapid Dissemination of HIV or HCV Infections Among Persons Who Inject Drugs, United States
Authors: Van Handel Michelle M. , Rose Charles E. , Hallisey Elaine J. , Kolling Jessica L. , Zibbell Jon E. , Lewis Brian , Bohm Michele K. , Jones Christopher M. , Flanagan Barry E. , Siddiqi Azfar-E-Alam , Iqbal Kashif , Dent Andrew L. , Mermin Jonathan H. , McCray Eugene , Ward John W. , Brooks John T.
Published: June 2016

Objective:

A recent HIV outbreak in a rural network of persons who inject drugs (PWID) underscored the intersection of the expanding epidemics of opioid abuse, unsterile injection drug use (IDU), and associated increases in hepatitis C virus (HCV) infections. We sought to identify US communities potentially vulnerable to rapid spread of HIV, if introduced, and new or continuing high rates of HCV infections among PWID.

Design:

We conducted a multistep analysis to identify indicator variables highly associated with IDU. We then used these indicator values to calculate vulnerability scores for each county to identify which were most vulnerable.

Methods:

We used confirmed cases of acute HCV infection reported to the National Notifiable Disease Surveillance System, 2012–2013, as a proxy outcome for IDU, and 15 county-level indicators available nationally in Poisson regression models to identify indicators associated with higher county acute HCV infection rates. Using these indicators, we calculated composite index scores to rank each county's vulnerability.

Results:

A parsimonious set of 6 indicators were associated with acute HCV infection rates (proxy for IDU): drug-overdose deaths, prescription opioid sales, per capita income, white, non-Hispanic race/ethnicity, unemployment, and buprenorphine prescribing potential by waiver. Based on these indicators, we identified 220 counties in 26 states within the 95th percentile of most vulnerable.

Conclusions:

Our analysis highlights US counties potentially vulnerable to HIV and HCV infections among PWID in the context of the national opioid epidemic. State and local health departments will need to further explore vulnerability and target interventions to prevent transmission.
Electronic surveillance and using administrative data to identify healthcare associated infections
Authors: Gastmeier Petra , Behnke Michael
Published: June 2016

Purpose of review

Traditional surveillance of healthcare associated infections (HCAI) is time consuming and error-prone. We have analysed literature of the past year to look at new developments in this field. It is divided into three parts: new algorithms for electronic surveillance, the use of administrative data for surveillance of HCAI, and the definition of new endpoints of surveillance, in accordance with an automatic surveillance approach.

Recent findings

Most studies investigating electronic surveillance of HCAI have concentrated on bloodstream infection or surgical site infection. However, the lack of important parameters in hospital databases can lead to misleading results. The accuracy of administrative coding data was poor at identifying HCAI. New endpoints should be defined for automatic detection, with the most crucial step being to win clinicians’ acceptance.

Electronic surveillance with conventional endpoints is a successful method when hospital information systems implemented key changes and enhancements. One requirement is the access to systems for hospital administration and clinical databases.

Although the primary source of data for HCAI surveillance is not administrative coding data, these are important components of a hospital-wide programme of automated surveillance. The implementation of new endpoints for surveillance is an approach which needs to be discussed further.
Prevention of common healthcare-associated infections in humanitarian hospitals
Authors: Murphy Richard A. , Chua Arlene C.
Published: June 2016

Purpose of review

Humanitarian medical organizations focus on vulnerable patients with increased risk for healthcare-associated infections (HAIs) and are obligated to minimize them in inpatient departments (IPDs). However, in doing so humanitarian groups face considerable obstacles. This report will focus on approaches to reducing common HAIs that the authors have found to be helpful in humanitarian settings.

Recent findings

HAIs are common in humanitarian contexts but there are few interventions or guidelines adapted for use in poor and conflict-affected settings to improve prevention and guide surveillance. Based on existing recommendations and studies, it appears prudent that all humanitarian IPDs introduce a basic infection prevention infrastructure, assure high adherence to hand hygiene with wide accessibility to alcohol-based hand rub, and develop pragmatic surveillance based on clinically evident nosocomial infection. Although microbiology remains out of reach for most humanitarian hospitals, rapid tests offer the possibility of improving the diagnosis of HAIs in humanitarian hospitals in the decade ahead.

There is a dearth of new studies that can direct efforts to prevent HAIs in IPDs in poor and conflict-affected areas and there is a need for practical, field-adapted guidelines from professional societies, and international bodies to guide infection prevention efforts in humanitarian environments.