bluuebunny/crossref_metadata_2025 huggingface dataset:
Efficacy of Yukmijihwang-tang on symptoms of Alzheimer disease
Authors: Lee Seunghee , Kwon Do Hyung , Kim Ju Yeon , Kim Yunna , Cho Seung-Hun , Jung In Chul
Published: June 2021

Background:

Alzheimer disease (AD) is the most common cause of dementia, which may lead to severe memory loss and other cognitive disorders. Yukmijihwang-tang (YMJ), a type of Korean traditional herbal medicine, has been shown to be effective against neurodegenerative diseases. Although a meta-analysis on the efficacy of YMJ on AD exists, the study had some limitations, and there have been several newly published studies assessing the effect of YMJ. Therefore, the purpose of this study is to evaluate the efficacy and safety of YMJ as a treatment for AD through a meta-analysis.

Methods:

A systematic search of the following electronic databases will be conducted to identify eligible studies: MEDLINE (PubMed), Elsevier (EMBASE), The Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Korean Medical Database (KMBASE), Oriental Medicine Advanced Searching Integrated System (OASIS), Korean Traditional Knowledge Portal, Citation Information by NII (CiNii), China National Knowledge Infrastructure (CNKI). All randomized controlled trials assessing the efficacy and safety of YMJ on the symptoms of AD will be included. Two independent reviewers will perform article retrieval, deduplication, data screening, data extraction, quality evaluation, and data analyses using RevMan version 5.4. The Cochrane risk of bias tool will be used to assess the quality of the trials.

Results:

This study will provide synthesis of the cognitive function measured with neuropsychological tests, behavioral and psychological symptoms of dementia (BPSD), and activities of daily living (ADL) measured using validated scales. The clinical effective rate and adverse events will also be analyzed to assess the efficacy and safety of YMJ for treating AD.

Conclusion:

This systematic review will provide evidence for the efficacy and safety of YMJ in AD.

Ethics and dissemination:

Ethical approval is not required because individual patient data will not be included in this study. The study findings will be disseminated through conference presentations.
Effectiveness and safety of Chinese herbal formula combined with western medicine for ankylosing spondylitis
Authors: Liu Miao , Deng Xiao-Lei , Yu Jing
Published: June 2021

Background:

Ankylosing spondylitis (AS) is a chronic progressive inflammatory disease of the spine, which mainly invades the sacroiliac joint, spine, and large joints near the trunk, leading to fibrous and skeletal ankylosis and deformity, and can cause damage to the eyes, lung, cardiovascular, kidney and other organs. Chinese herbal formulas (CHF) is an important interventions of Traditional Chinese Medicine (TCM), and CHFs combined with western medicine are widely used in clinical practice to treat AS.

Methods:

Eight databases will be systematically retrieved from their inceptions to March 2021. Only randomized controlled trials (RCTs) of CHFs combined with western medicine for AS treatment will meet the inclusion criteria. The primary outcomes we focus on include clinical effectiveness rate, TCM syndrome score, TCM symptom score, Bath ankylosing spondylitis disease activity index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), chest expansion, nocturnal spinal pain, adverse reactions, erythrocyte sedimentation rate (ESR), and C protein response (CRP). The research screening, data extraction, and risk of bias assessment will be performed independently by 2 researchers, and divergence will be solved by a third researcher. Revman 5.3 software will be used for meta-analysis. The confidence of evidence will be graded using grading of recommendations assessment, development, and evaluation (GRADE) algorithm and methodological quality will be assessed adopting risk of bias in systematic reviews (ROBIS).

Results:

This systematic review (SR) will provide evidence-based medical evidence for AS therapy by CHF combined with western medicine and we will submit the findings of this SR for peer-review publication.

Conclusions:

This SR will provide latest and updated summary proof for assessing the effectiveness and safety of CHF combined with western medicine for AS.

Registration number:

INPLASY 202150089.
Graves disease and metastatic hormonal-active Hürthle cell thyroid cancer
Authors: Besic Nikola , Vidergar-Kralj Barbara , Zaletel Katja , Grasic-Kuhar Cvetka
Published: June 2021

Rationale:

A hormone-active metastatic Hürthle cell thyroid carcinoma (HCTC) and Graves disease (GD) present a therapeutic challenge and is rarely reported.

Patient concerns:

We present a 64-year-old male patient, who had dyspnea and left hip pain lasting 4 months. He had clinical signs of hyperthyroidism and a tumor measuring 9 cm in diameter of the left thyroid lobe, metastatic neck lymph node and metastases in the lungs, mediastinum, and bones.

Diagnosis:

Laboratory findings confirmed hyperthyroidism and GD. Fine-needle aspiration biopsy and cytological investigation revealed metastases of HCTC in the skull and in the 8th right rib. A CT examination showed a thyroid tumor, metastatic neck lymph node, metastases in the lungs, mediastinum and in the 8th right rib measuring 20 × 5.6 × 4.5 cm, in the left acetabulum measuring 9 × 9 × 3 cm and parietooccipitally in the skull measuring 5 × 4 × 2 cm. Histology after total thyroidectomy and resection of the 8th right rib confirmed metastatic HCTC.

Interventions:

The region of the left hip had been irradiated with concomitant doxorubicin 20 mg once weekly. When hyperthyroidism was controlled with thiamazole, a total thyroidectomy was performed. Persistent T3 hyperthyroidism, most likely caused by TSH-R-stimulated T3 production in large metastasis in the 8th right rib, was eliminated by rib resection. Thereafter, the patient was treated with 3 radioactive iodine-131 (RAI) therapies (cumulative dose of 515 mCi). Unfortunately, the tumor rapidly progressed after treatment with RAI and progressed 10 months after therapy with sorafenib.

Outcomes:

Despite treatment, the disease rapidly progressed and patient died due to distant metastases. He survived for 28 months from diagnosis.

Lessons:

Simultaneous hormone-active HCTC and GD is extremely rare and prognosis is dismal. Concomitant external beam radiotherapy and doxorubicin chemotherapy, followed by RAI therapy, prevented the growth of a large metastasis in the left hip in our patient. However, a large metastasis in the 8th right rib presented an unresolved problem. Treatment with rib resection and RAI did not prevent tumor recurrence. External beam radiotherapy and sorafenib treatment failed to prevent tumor growth.
Recurrent neonatal sepsis and progressive white matter injury in a premature newborn culture-positive for group B Streptococcus
Authors: Moon Cheong-Jun , Kwon Tae Hee , Lee Kyung Sang , Lee Hyun-Seung
Published: June 2021

Rationale:

Group B Streptococcus (GBS) remains a principal pathogen causing neonatal sepsis and meningitis, particularly in premature infants with relatively insufficient immunity. Recurrence may occur uncommonly, largely associated with subclinical mucosal persistence or repetitive exposure to exogenous sources. White matter injury (WMI) including cystic periventricular leukomalacia (PVL) has been associated with intrauterine infection/inflammation, and neonatal infection as a more significant predictor including postnatal sepsis and recurrent infection, even without microbial neuroinvasion. Furthermore, clinical and experimental evidence of WMI by some bacteria other than GBS without central nervous system invasion has been reported. However, there is little evidence of WMI associated with neonatal GBS sepsis in the absence of meningitis in the literature.

Patient concerns:

A newborn at 30+4 weeks’ gestation with low birthweight presented with 2 episodes (with a 13-day interval with no antibiotic therapy) of neonatal sepsis culture-proven for GBS with early-onset presentation after clinical chorioamnionitis via vertical GBS transmission and the associated conditions including prematurity-related neonatal immunodeficiency and persistent mucosal GBS carriage after the first antibiotic treatment. The perinatal GBS infection was complicated by progressive WMI presenting with ventriculomegaly and cystic PVL without a definite evidence of meningitis, intraventricular hemorrhage, and documented cerebral hypoxia or hypoperfusion conditions including septic shock.

Diagnoses:

Recurrent group B streptococcal sepsis and cystic PVL with ventriculomegaly.

Interventions:

Two episodes of GBS sepsis were treated with 15-day parenteral antibiotic therapy, respectively.

Outcomes:

Resolution of the recurrent GBS sepsis without further relapses, however, complicated by WMI and subsequent about 6 months delay in motor development at 12 months’ corrected age.

Lessons:

This case suggests WMI associated with GBS bacteremia without central nervous system entry by viable GBS and also shows that in premature infants, intrauterine GBS infection with no interventions may lead to extensive and persistent GBS colonization, early-onset and recurrent GBS disease, and WMI. Postnatal as well as intrauterine infection/inflammation controls with maternal prophylaxis may be pivotal for prevention and limiting the magnitude of neurologic injury.
The impact of Covid-19 pandemic related lockdown on clubfoot practice
Authors: Özbay Hakan , Toy Serdar , Polat Oktay
Published: June 2021

We investigated whether the number of pediatric patients with congenital clubfoot treated with the Ponseti method decreased during the Covid-19 pandemic or not in a rural area. So we aimed to guide orthopedic surgeons and health infrastructure for future pandemics to be prepared in hospitals of rural areas for the treatment of children with congenital clubfoot.

One hundred and fifty-four patients with clubfoot who were admitted to our clinic were evaluated retrospectively from March 2017 to December 2020. Institutional hospital electronic database was used to detect the number of weeks between the birth and first cast performed in clinic and the number of casts been applied and unilaterality or bilaterality. Patients were divided into four groups, which included pandemic period and three previous years. Recorded data were analyzed statistically to detect if there is a difference between the numbers of the patients in pandemic period and three previous years.

The number of patients with clubfoot admitted to our hospital between March 2020 and December 2020 increased by 140% compared to previous year. There was a statistically significant difference between the average number of cast applications of Group 4 and other groups (P <.001). Achilles tenotomy was performed in 44 (61.1%) of 72 patients admitted during the pandemic period. Only 4 (13.3%) out of 30 patients admitted between March 2019 and December 2019 were performed Achilles tenotomy.

We detected an increase in the number of clubfoot cases admitted to our rural-based hospital during the Covid-19 pandemic, treated with casting or surgically. We think this is because of preventive measures during the pandemic, which caused parents could not reach urban for treatment.
The efficacy of ivabradine in the treatment of acute myocardial infarction
Authors: Zhang Yonggeng , Sun Shu , Yi Song
Published: June 2021

Background:

Cardiovascular diseases have become a prominent threat to public health and quality of life. In recent years, some studies have reported that ivabradine can improve the cardiac function and prognosis of patients with acute myocardial infarction (AMI). Therefore, we perform a protocol for systematic review and meta-analysis to evaluate the efficacy of ivabradine for treating AMI.

Methods:

This protocol of systematic review and meta-analysis has been drafted under the guidance of the preferred reporting items for systematic reviews and meta-analyses protocols. We will search PubMed, Cochrane Library, Embase, Web of Science, and Medline databases for relevant studies. In addition, we will also collect 4 databases of China: China National Knowledge Infrastructure, China Biomedical Literature Database, China Science Journal Database, and Wan-fang Database. Risk of bias will be assessed using the Cochrane Handbook risk of bias assessment tool version (V.5.1.0). We will use STATA 16.0 software (Stata Corporation, College Station, TX) to perform data analysis.

Results:

The results of this systematic review and meta-analysis will be published in a peer-reviewed journal.

Conclusion:

We hypothesized that ivabradine can reduce the resting heart rate and improve heart function in patients with AMI.
Seroprevalence of SARS-CoV-2 antibodies among 925 staff members in an urban hospital accepting COVID-19 patients in Osaka prefecture, Japan
Authors: Nishida Tsutomu , Iwahashi Hiromi , Yamauchi Kazuhiro , Kinoshita Noriko , Okauchi Yukiyoshi , Suzuki Norihiro , Inada Masami , Abe Kinya
Published: June 2021

The subclinical severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection rate in hospitals during the pandemic remains unclear. To evaluate the effectiveness of our hospital's current nosocomial infection control measures, we conducted a serological survey of anti-SARS-CoV-2 antibodies (immunoglobulin [Ig] G) among the staff of our hospital, which is treating coronavirus disease 2019 (COVID-19) patients.

The study design was cross-sectional. We measured anti-SARS-CoV-2 IgG in the participants using a laboratory-based quantitative test (Abbott immunoassay), which has a sensitivity and specificity of 100% and 99.6%, respectively. To investigate the factors associated with seropositivity, we also obtained some information from the participants with an anonymous questionnaire. We invited 1133 staff members in our hospital, and 925 (82%) participated. The mean age of the participants was 40.0 ± 11.8 years, and most were women (80.0%). According to job title, there were 149 medical doctors or dentists (16.0%), 489 nurses (52.9%), 140 medical technologists (14.2%), 49 healthcare providers (5.3%), and 98 administrative staff (10.5%). The overall prevalence of seropositivity for anti-SARS-CoV-2 IgG was 0.43% (4/925), which was similar to the control seroprevalence of 0.54% (16/2970) in the general population in Osaka during the same period according to a government survey conducted with the same assay. Seropositive rates did not significantly differ according to job title, exposure to suspected or confirmed COVID-19 patients, or any other investigated factors.

The subclinical SARS-CoV-2 infection rate in our hospital was not higher than that in the general population under our nosocomial infection control measures.
The prognostic value of inflammation markers in postoperative gliomas with or without adjuvant treatments
Authors: Luo Yuanfu , Deng Renzhi , Zhong Qiulu , Luo Danjing , Li Xiangde , Chen Xueyuan , Tao Sha , Feng Zhoubin , Jiayi Liu , Huang Yiyun , Li Jian , Liu Wenqi
Published: June 2021

Recent studies have shown that some inflammatory markers are associated with the prognosis of solid tumors. This study aims to evaluate the prognosis of glioma patients with or without adjuvant treatment using the systemic immune-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR).

All patients who were diagnosed with gliomas at the first and second affiliated hospital of Guangxi Medical University between 2011 and 2020 were included in this study. The optimal cutoff value of SII, NLR, and PLR was determined by X-tile software program. We stratified patients into several groups and evaluated the progression-free survival (PFS) and overall survival (OS) of SII, NLR, and PLR during the period of pre-surgical, con-chemoradiotherapy, and post-treatments. Multivariate Cox regression analyses were performed to detect the relationships between OS, PFS, and prognostic variables.

A total of 67 gliomas patients were enrolled in the study. The cutoff values of SII, NLR, and PLR were 781.5 × 109/L, 2.9 × 109/L, and 123.2 × 109/L, respectively. Patients who are pre-SII < 781.5 × 109/L had better PFS (P = .027), but no difference in OS. In addition, patients who had low pre-NLR (<2.9 × 109/L) meant better OS and PFS. PLR after adjuvant treatments (post-PLR) was significantly higher than pre-PLR (P = .035). Multivariate analyses revealed that pre-SII, pre-NLR were independent prognostic factors for OS (pre-SII: HR 1.002, 95% CI: 1.000–1.005, P = .030 and pre-PLR: HR 0.983, 95% CI: 0.973–0.994, P = .001), while pre-PLR was an independent factor for PFS (HR 0.989, 95% CI: 0.979–1.000, P = .041).

High pre-SII or high pre-NLR could be prognostic markers to identify glioma patients who had a poor prognosis.
Diagnostic yields and clinical features of ocular myasthenia gravis
Authors: Kim Hyuna , Oh Shin Yeop
Published: June 2021

To investigate clinical features and diagnosis process of ocular myasthenia gravis (OMG) in ophthalmology department.

A total of 36 patients with ptosis or diplopia who had follow-up for at least 3 months between March 2016 and December 2019 were included in this study. Clinical symptoms of patients and the test results were analyzed. According to the positivity of serologic test, these patients were divided into 2 groups (confirmed OMG and possible OMG with relief of symptoms after antimyasthenic treatment) for comparison.

Ptosis was present in 12 (33.33%) patients, diplopia was present in 14 (38.89%) patients, and both ptosis and diplopia were present in 10 (27.78%) patients. Acetylcholine receptor auto-antibody (AchR Ab) was positive in 14 (38.89%) of 36 patients and ice test was positive in 15 (71.43%) of 21 patients with ptosis. Unequivocal response to pyridostigmine was observed in 31 (86.11%) patients. For seropositive cases, AchR Ab titer was significantly higher in the group with 2 clinical symptoms than that in the 1 clinical symptom (P = .011).

This study presents the usefulness and diagnostic validity of antimyasthenic treatment for OMG, especially seronegative OMG, with detailed symptom analysis.
Assessing dental students’ professional satisfaction with operative dentistry teaching and curriculum
Authors: Alqarni Mohammed A.
Published: June 2021

Evaluating students’ professional training satisfaction with operative dentistry teaching and curriculum can help identify their educational needs and improve the quality of the education imparted. This study aimed to assess the professional training satisfaction of senior undergraduate dental students in Saudi Arabia from the operative dentistry course teaching and its curriculum at different levels and among genders.

A total of 193 (109 male, 56.48%; and 84 female, 43.52%) students participated in the survey. The respondents were at the 10th, 11th, and 12th levels of the Operative Dentistry course in a ratio of 34.2%, 32.1%, and 33.7%, respectively. Data were collected from survey items (18 questions) covering 6 areas: learning objectives, course materials, content relevance, instructor knowledge, instructor delivery and style, and facility and environment. Descriptive and analytical tests were performed using SPSS Software 19, with the significance level set at 0.05.

A high level of satisfaction was seen among level 10 (68.18%), 11 (79.03%), and 12 (86.15%) students. A significant statistical difference was observed among level 10 students with a low level of satisfaction and a high level of satisfaction (P = .045). The percentage of satisfaction increased with the level. A high level of satisfaction was seen among male (78.90%) and female (76.19%) students, with a total satisfaction level of 77.72%.

Continuous evaluation and assessment of teaching and curriculum can be a tool to improve the quality of education imparted, especially in clinical courses such as operative dentistry. This helps to prepare students for their professional life as healthcare providers. The role of teaching skills related to amalgam must be re-evaluated. It is recommended to include student representation and participation in course development committees, as they are the final recipients of the educational process.
Acute hemorrhagic necrotizing enterocolitis caused by non-O1/non-O139 Vibrio cholerae infection
Authors: Wu Mingjie , Zhou Liangjing , Cao Liping
Published: June 2021

Rationale:

Acute hemorrhagic necrotizing enterocolitis (AHNE) is a rapidly progressive and extremely dangerous disease. Here we report a rare case caused by Vibrio cholerae (V cholerae).

Patient concerns:

A 70-year-old man was admitted to our emergency department because of a sudden loss of consciousness.

Diagnoses:

On admission with severe toxic shock, the patient presented with elevated body temperature, decreased blood pressure, abdominal tenderness and rebound pain, predominantly on the right side. Computed tomography showed swelling and thickening of the right colon and peritoneal effusion. Necrosis was found in the hepatic flexure of the colon. On the basis of these results, the patient was diagnosed with AHNE.

Interventions and outcomes:

After fluid resuscitation, an exploratory laparotomy was performed immediately. The procedure was successful. Despite antibiotic therapy, the patient's clinical condition progressively deteriorated and he died of multi-organ failure on day 3 after admission.

Lessons:

AHNE is a rapidly progressive and extremely dangerous disease. Here we report a case of AHNE caused by non-O1/non-O139 V cholerae infection. The clinical features, phenotypic analyses and the presence of a panel of known virulence genes in the isolated strain are described. To the best of our knowledge, this is the first report of V cholerae causing severe AHNE, which is of profound pedagogical significance.
Primary malignant melanoma of the esophagogastric junction
Authors: Chu Yu-Ming , Hung Chih-Sheng , Huang Ching-Shui
Published: June 2021

Rationale:

Most gastrointestinal melanomas are metastatic from an oculocutaneous primary lesion; however, primary gastrointestinal melanomas have been found in all levels of the gastrointestinal tract. We present the case of Primary malignant melanoma of the esophagus and discuss the diagnostic methods, differentiation from metastatic lesions and treatment options.

Patient concerns:

A 78-year-old male patient presented with fresh blood vomiting and tarry stools for 1 day.

Diagnoses:

Esophagogastroduodenoscopy of this patient revealed a tumor ∼4 cm in size at the cardia side of the esophagogastric junction with dark-red and gray pigmentation. Immunohistochemical stains of the biopsy specimens were positive for S-100 and HMB-45, which are specific markers of melanoma.

Interventions:

Laparotomy with proximal gastrectomy was performed by the surgeon. Histological examination of the surgical specimen revealed the tumor arose from the distal esophagus with invasion of the proximal stomach. Primary malignant melanoma of the esophagus was diagnosed after a full skin and ophthalmic examination and positron emission tomography, which revealed no lesions elsewhere in the body.

Outcomes:

No tumor recurrence was noted at the 1-year follow-up.

Lessons:

Primary malignant melanoma of the esophagus is an extremely rare but highly aggressive tumor. The special pattern of pigmentation should be recognized while performing endoscopy. Early detection and radical resection of the tumor are critical to ensure favorable outcomes.
Bilateral breast myxedema caused by Graves’ disease and responsive to multipoint subcutaneous injection of long-acting glucocorticoid
Authors: Du Tingting , Jiang Wangyan , Luo Hongchang , Chen Fuqiong , Yuan Gang , Zhang Muxun , Liu Zhelong
Published: June 2021

Rationale:

With the absence of ophthalmopathy, thyroid dermopathy especially lesions at atypical locations is a very rare presentation. We herein report an original case of bilateral breast myxedema caused by Grave's disease.

Patient concerns:

A 21-year-old unmarried woman presented with a 4-month history of Grave's disease and a 1-month history of progressive bilateral breast enlargement. She had symmetrical bilateral breast enlargement with redness and nonpitting thickening of the skin, diffusely enlarged thyroid glands, and no exophthalmos.

Diagnosis:

Ultrasonography, magnetic resonance imaging scan, and skin biopsy confirmed the diagnosis of bilateral breast myxedema.

Interventions:

The patient was treated with multipoint subcutaneous injections of triamcinolone acetonide in each breast every month.

Outcomes:

The bilateral breast returned approximately to its normal size after therapy for 6 months.

Conclusions:

Our case illustrates that multipoint subcutaneous injection of glucocorticoids is beneficial for bilateral breast myxedema.
Favorable response to second-line atezolizumab and bevacizumab following progression on nivolumab in advanced hepatocellular carcinoma
Authors: Swed Brandon , Ryan Kara , Gandarilla Omar , Shah Manish A. , Brar Gagandeep
Published: June 2021

Rationale:

Advanced hepatocellular carcinoma (HCC) remains a deadly disease in part due to decades of limited therapeutic options. With recent advances in our understanding of the tumor biology, several promising treatment strategies involving targeted and immunotherapies have emerged. However, enhancing their modest efficacy in HCC and other gastrointestinal malignancies is essential to improving survival.

Patient concerns:

A man in his late 50s with a history of type 2 diabetes mellitus and morbid obesity initially presented with progressive abdominal pain and anorexia prompting an abdominal computed tomography scan that revealed a large solitary liver mass with extensive local involvement.

Diagnoses:

Although there were features consistent with a primary gastric tumor on subsequent endoscopic evaluation leading to early diagnostic uncertainty, his clinical picture, including a dominant liver mass, immunohistochemical staining profile, and significantly elevated alpha fetoprotein ultimately favored HCC.

Interventions:

The patient received palliative systemic therapy with infusional fluorouracil for a presumed gastric primary, however restaging scans after 3 cycles demonstrated disease progression. The consensus from a multidisciplinary discussion was that his pathology was more consistent with primary HCC. He was subsequently started on nivolumab with a partial response, although after 5 months, he progressed prompting initiation of second-line atezolizumab and bevacizumab with a favorable response.

Outcomes:

The addition of atezolizumab and bevacizumab led to a sustained biochemical and radiographic response that appeared to overcome the resistance to nivolumab monotherapy. Aside from several mild immune-related adverse effects, his quality of life has greatly improved and he has tolerated treatment well to date.

Lessons:

Our findings suggest that vascular endothelial growth factor inhibition can overcome resistance to checkpoint inhibition in advanced HCC by resulting in a unique synergy that has never before been described in patients. The biological rationale for this response is likely attributable to the immunomodulatory effects of antiangiogenic agents, promoting an immunostimulatory microenvironment that can be exploited by immune checkpoint inhibitors for more effective antitumor activity. Given the considerable benefit patients may derive following progression on first-line treatment, it is important to consider this strategic combination of therapies which can ultimately lead to improved patient outcomes.
Meta-analysis of patent foramen ovale closure versus medical therapy for prevention of recurrent ischemic neurological events
Authors: Pan Xuemei , Xu Liang , Zhou Chang , Zhang Zhi , Sun Heng
Published: June 2021

Background

The optimal treatment strategy for patent foramen ovale (PFO) patients with cryptic stroke remains controversial. We performed this meta-analysis to evaluate the effect of PFO closure versus different types of medical therapy.

Methods

We searched PubMed, Embase, and Cochrane databases. The primary efficacy endpoints were the composite outcome of recurrent stroke and/or transient ischemic attack (TIA). Secondary efficacy endpoints included separate stroke and TIA. Safety endpoints included new-onset atrial fibrillation (AF)/atrial flutter and bleeding.

Results

Compared with antiplatelet therapy, PFO closure significantly reduced the risk of composite outcome (odds ratio [OR] 0.37, 95% confidence interval [CI] 0.27–0.51), stroke (OR 0.22, 95% CI 0.13–0.36], and TIA (OR 0.57, 95% CI 0.34–0.98); Compared with the mixed medical therapy group (consist of antiplatelet therapy, anticoagulant therapy, or both), PFO closure still showed some benefits, but the effect was not as significant as that of antiplatelet therapy (composite outcome: OR 0.53, 95% CI 0.41–0.69; stroke: OR 0.48, 95% CI 0.34–0.68; TIA: OR 0.69, 95% CI 0.50–0.96); Compared with anticoagulant therapy, PFO closure showed no benefit (composite outcome: OR 0.77, 95% CI 0.46–1.28; stroke: OR 0.59, 95% CI 0.28–1.25; TIA: OR 1.01, 95% CI 0.50–2.04). In terms of safe endpoints, compared with antiplatelet therapy and anticoagulant therapy, PFO closure increased the risk of AF/atrial flutter (OR 9.56, 95% CI 2.85–32.06; OR 18.96, 95% CI 1.11–323.8, respectively) and reduced the risk of bleeding (OR 0.50, 95% CI 0.24–1.05; OR 0.13, 95% CI 0.04–0.46, respectively); compared with mixed medical therapy, PFO closure increased the risk of AF/atrial flutter (OR 4.40,95% CI 2.24–8.67), but there was no difference in bleeding (OR 0.97, 95% CI 0.56–1.68).

Conclusions

With the addition of anticoagulants, the benefit of PFO closure decreased gradually. Patient groups that adopt individualized medical therapy strategies may benefit more.
Effects of a food preparation program on dietary well-being for stroke patients with dysphagia
Authors: Lin Shu-Chi , Lin Kuan-Hung , Tsai Yi-Chi , Chiu En-Chi
Published: June 2021

Background:

Dysphagia is one of the common issues observed in patients with stroke. Stroke patients with dysphagia have to eat blended food or similar types of food for each meal, resulting in dietary dissatisfaction. The purpose of this study was to investigate the effects of a food preparation program on dietary well-being for stroke patients with dysphagia.

Methods:

This study was a pilot randomized clinical trial. Twenty-two patients were assigned randomly into the food preparation group (n = 11) and control group (n = 11). The food preparation group received oral motor exercises, recognition of food texture and thickener, and hands-on food preparation for 6 weeks. Outcome measures included the Dietary Well-Being Scale, brief version of the World Health Organization Quality of life, Swallowing Quality of Life Questionnaire, and Mini Nutritional Assessment.

Results:

Patients in the food preparation group showed significant improvements in the Dietary Well-Being Scale, psychological and environmental domains of the brief version of the World Health Organization Quality of life (P = .001–.024) with small to large effect sizes (success rate difference = 0.23–0.46). The Swallowing Quality of Life Questionnaire and Mini Nutritional Assessment displayed non-significant differences (P = .053–.092) and revealed small to moderate effect sizes (success rate difference = 0.23–0.32).

Conclusions:

The food preparation program showed a positive impact on dietary well-being and a potential improvement in the health-related quality of life, quality of life related to the process of swallowing, and nutritional status for stroke patients with dysphagia. We recommend that stroke patients with dysphagia receive adequate knowledge and hands-on food preparation training to increase their dietary intake and well-being.
Association between pulmonary artery to aorta diameter ratio with pulmonary hypertension and outcomes in diffuse cystic lung diseases
Authors: Baldi Bruno Guedes , Fernandes Caio Júlio César dos Santos , Heiden Gláucia Itamaro , Freitas Carolina Salim Gonçalves , Sobral Juliana Barbosa , Kairalla Ronaldo Adib , Carvalho Carlos Roberto Ribeiro , Souza Rogério
Published: June 2021

To investigate the importance of pulmonary vascular measurements on computed tomography (CT) in predicting pulmonary hypertension (PH) and worse outcomes in diffuse cystic lung diseases (DCLDs).

We conducted a cross-sectional study of patients with DCLDs. Patients underwent pulmonary function tests, a six-minute walk test (6MWT), chest CT, transthoracic echocardiography, and right heart catheterization. Pulmonary artery (PA) diameter and PA-ascending aorta ratio (PA-Ao ratio) were obtained from CT. Mean pulmonary artery pressure (mPAP) from right heart catheterization was correlated with tomographic, functional, and echocardiographic variables. The association between the PA-Ao ratio with outcomes was determined by Kaplan–Meier curves.

Thirty-four patients were included (18 with pulmonary Langerhans cell histiocytosis and 16 with lymphangioleiomyomatosis, mean age 46 ± 9 years). Forced expiratory volume in the first second and lung diffusing capacity for carbon monoxide were 47 ± 20% and 38 ± 21% predicted, respectively. PA diameter and PA-Ao ratio were 29 ± 6 mm and 0.95 ± 0.24, respectively. PA-Ao ratio > 1 occurred in 38.2% of patients. PA-Ao ratio was a good predictor of PH. mPAP correlated best with PA-Ao ratio, PA diameter, oxygen desaturation during six-minute walk test, and echocardiographic variables. Patients with PA-Ao ratio > 1 had greater mPAP, and a higher risk of death or lung transplantation (log-rank, P < .001) than those with PA-Ao ratio ≤ 1.

The PA-Ao ratio measured on CT scan has a potential role as a non-invasive tool to predict the presence of PH and as a prognostic parameter in patients with DCLDs.
Reflux esophagitis is associated with higher risks of acute stroke and transient ischemic attacks in patients hospitalized with atrial fibrillation
Authors: Jiang Yi , Damiris Konstantinos , Suero-Abreu Giselle , Xu Binghong , Ahlawat Sushil
Published: June 2021

Reflux esophagitis (RE) is a subset of gastroesophageal reflux disease (GERD) with endoscopic evidence of esophageal inflammation, which has been linked to an increased incidence of atrial fibrillation (AF). However, data on the effect of RE on patient outcomes is limited. We sought to examine the potential association of RE with outcomes of patients with AF in a nationwide study.

The National Inpatient Sample (NIS) database was queried to identify hospitalized adult patients with AF and RE between 2010 and 2014. Primary outcomes included inpatient mortality, length of stay (LOS), and total hospital charges. AF related complications such as acute stroke, transient ischemic attack (TIA) and acute heart failure were assessed as secondary outcomes. Propensity score matching and multivariate regression analysis were used.

Six lakh sixty seven thousands five hundred twenty patients were admitted for primary diagnosis of AF out of which 5396 had a secondary diagnosis of RE. In the AF with RE cohort, the average age was 73.6 years, 41.5% were male, and 79.9% were Caucasian. There was a greater prevalence of concomitant dyslipidemia, chronic liver disease and chronic pulmonary disease (P < .01) when compared to the AF without RE cohort. Patients with AF and RE also had higher incidence of acute strokes and TIAs (P < .05), longer LOS (P < .001), and higher hospital charges (P < .05) with no difference in acute heart failure (P = .08), hospital mortality (P = .12), or CHA2DS2-VASc score (P = .67).

In hospitalized patients with AF, RE was associated with a higher rate of acute stroke and TIAs, longer LOS, and greater hospital charges.
Increased hexokinase-2 as a novel biomarker for the diagnosis and correlating with disease severity in rheumatoid arthritis
Authors: Zhou Kai-Long , Zhu Zhen-Hua , Zhou Ju-Pu , Zhao Jia-Ju , Zhang Yong , Jiang Bo
Published: June 2021

Abnormal glucose metabolism brings out joint inflammation and destruction in rheumatoid arthritis (RA). The aim of this study was to evaluate the potential of circulating hexokinase-2 (HK2) in peripheral blood mononuclear cells (PBMCs) of rheumatoid arthritis (RA) patients.

PBMCs were obtained from patients with RA or osteoarthritis (OA) and healthy controls (HCs). The expression of HK2 was assessed by quantitative reverse transcription-polymerase chain reaction (qRT-PCR). The C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), Calprotectin, rheumatoid factor (RF), anti-cyclic citrullinated peptides (anti-CCP) antibody level and 28-joint Disease Activity Score (DAS28), Clinical Disease Activity Index (CDAI) and Simplified Disease Activity Index (SDAI) were measured. Spearman's analysis was performed to determine the association between the level of HK2 and clinical characteristics. A receiver operating characteristic (ROC) curve was employed to evaluate the diagnostic value of HK2 in PBMCs. Logistic regression was used to identify risk factors. Sixty-five RA patients, 35 OA patients, and 40 HCs were included in the study.

HK2 was upregulated in RA and OA patients compared with that in HCs (P < .05). The area under the ROC of HK2 for diagnosing RA and OA was 0.808 and 0.640, respectively. In addition, HK2 levels were increased in active RA compared with those in remittent RA (P = .03). Furthermore, HK2 correlated positively with the DAS28-ESR (P < .001), CDAI (P = .02) and SDAI scores (P = .02). Moreover, HK2 was independently associated with an increased risk of disease activity (DAS28-ESR>3.2, P = .02; CDAI score>10, P = .03; SDAI score>11, P = .04). Additionally, HK2 positivity was more frequently detected in patients treated with biologic disease-modifying antirheumatic drugs (bDMARDs) than in those not treated with bDMARDs.

HK2 levels in PBMCs can be considered an ideal biomarker for diagnosing RA and involved in disease activity in RA. Dysregulation of HK2 may participate in the molecular mechanism of RA and could be an attractive selective metabolic target for RA treatment.
Possible effects of agent orange and posttraumatic stress disorder on hyperglycemia in Korean veterans from the US-Vietnam war
Authors: Hong Pa , Song Yun Gyu , Paek Sungwoo
Published: June 2021

This study was conducted to examine whether Korean veterans from the US-Vietnam War who had a diagnosis of type II diabetes mellitus (T2DM) as well as past history of exposure to agent orange (AO) are vulnerable to hyperglycemia when receiving intra-articular corticosteroid injection (IACI) for pain relief.

The current study included a total of 49 patients (n = 49) who received an injection of triamcinolone 20 or 40 mg to the shoulder under sonographic guidance or did that of dexamethasone 10 mg or triamcinolone 40 mg combined with dexamethasone 20 mg to the spine under fluoroscopic guidance. Their 7-day fasting blood glucose (FBG) levels were measured and then averaged, serving as baseline levels. This is followed by measurement of FBG levels for 14 days of IACI. Respective measurements were compared with baseline levels. The patients were also evaluated for whether there are increases in FBG levels depending on insulin therapy as well as HbA1c ≥ 7% or HbA1c < 7%.

Overall, there were significant increases in FBG levels by 64.7 ± 42.5 mg/dL at 1 day of IACI from baseline (P < .05). HbA1c ≥ 7% and HbA1c < 7% showed increases in FBG levels by 106.1 ± 49.0 mg/dL and 46.5 ± 3.8 mg/dL, respectively, at 1 day of IACI from baseline (P < .05). In the presence and absence of insulin therapy, there were significant increases in them by 122.6 ± 48.7 mg/dL and 48.0 ± 20.4 mg/dL, respectively, at 1 day of IACI from baseline (P < .05). But there were decreases in them to baseline levels at 2 days of IACI.

Clinicians should consider the possibility of hyperglycemia when using corticosteroids for relief of musculoskeletal pain in Korean veterans from the US-Vietnam War who had a history of exposure to AO.
Improving Blood Pressure Accuracy in the Outpatient Adolescent Setting
Authors: Woods Jennifer L. , Jacobs Megan D. , Sheeder Jeanelle L.
Published: June 2021

Introduction:

Hypertension (HTN) is increasing in the pediatric population, and hypertensive children become hypertensive adults. Blood pressure (BP) is often overlooked due to factors including distrust in readings, lack of time in visits, and discomfort prescribing antihypertensive medications. The objective of our multistage, clinically based quality improvement project was to improve BP measurement and HTN diagnosis and intervention in adolescents.

Methods:

Study investigators performed interventions in an adolescent medicine clinic at Children’s Hospital Colorado (ages 12–24 years), which included equipment inventory, mapping clinic processes, manual/automated BP training for staff, education of faculty/staff on guidelines, and creation/implementation of updated best practice alerts (BPAs) based on age-appropriate guidelines for stage 1, 2 HTN in patients younger/older 18years.

Results:

With equipment updates, medical assistant manual BP certifications, educational sessions for faculty/staff, and creation of a BPA with instruction before the go-live date, confidence in using automated and manual BP measurements increased for faculty/staff. The number of unique patient visits presenting with elevated BPs decreased significantly in the postintervention period reflecting the education/training. Staff used the new order set minimally, but there was an increase in correct diagnoses of elevated BP and laboratory workup.

Conclusions:

Having appropriate equipment while introducing BP guideline education in the ambulatory setting with electronic health record reminders and utility of BPAs can decrease erroneous BP values saving providers and staff encounter time. Real-time alerts can aid in accurate diagnosis rates and improved intervention for youth with elevated BP readings. Providers still inconsistently interact with order sets despite such parameters
Prevention of Latent Safety Threats: A Quality Improvement Project to Mobilize a Portable CT
Authors: Lawrence Julia F. , Tsang Rocky , Fedee George , Musick Matthew A. , Lichliter Royanne L. , Bastero Patricia , Pedroza McDonald Nadia , Wallin Kelly , Doughty Cara
Published: June 2021

Introduction:

Transporting critically ill patients to diagnostic imaging for needed studies can be challenging and even prohibitive. A portable computerized tomography (CT) scanner allows the patient to remain in the intensive care unit, but presents new positioning and team challenges. Before activation of a portable CT scanner in our pediatric intensive care unit and through the use of iterative simulation-based Plan-Do-Study-Act (PDSA) cycles in the clinical environment, a multidisciplinary team of bedside caregivers determined optimal patient positioning, equipment needs, and specific staffing and choreography to develop detailed portable CT guidelines.

Method:

Our team engaged stakeholders from radiology, critical care, respiratory therapy, environmental services, facilities operations, and the CT vendor to develop scenarios. Simulations included infant and pediatric patients who required critical invasive monitoring and treatment devices, such as ventilators, and high-risk intracardiac and intravascular lines. Scenario objectives centered on the safe positioning, transfer, and scanning of the patient. Trained simulation specialists from the hospital’s simulation center facilitated simulation sessions.

Results:

Simulation-based PDSA testing identified 31 latent safety threats, including the need for a custom bed adapter due to pediatric patients’ variable size. We paused portable CT activation pending the custom adapter’s availability and remediation of other latent safety threats. Additional simulation-based PDSA cycles further refined the process once the custom adapter was available.

Conclusions:

Simulation identified unanticipated latent safety threats before the implementation of a portable CT scanner.
Increasing Use of Ambulatory Video Visits for Pediatric Patients by Using Quality Improvement Methods
Authors: Rosenthal Jennifer L. , Sigal Ilana S. , Kamerman-Kretzmer Rory , Say Daphne S. , Castellanos Bianca , Nguyen Stephanie , Nakra Natasha A. , Restrepo Bibiana , Crossen Stephanie S.
Published: June 2021

Introduction:

Live video visits for ambulatory encounters offer potential benefits, including access to remote subspecialty services, care coordination between providers, and improved convenience for patients. We aimed to increase the utilization of video visits for pediatric patients at our medical center using an iterative quality improvement process.

Methods:

A multispecialty improvement team identified opportunities to increase video visit utilization and prioritized interventions using benefit-effort analyses. Interventions focused on 6 key drivers. The outcome measure was the percentage of ambulatory encounters conducted by video. The process measure was the percentage of ambulatory pediatricians conducting video visits. The balancing measure was the percentage of no-shows among scheduled video visits. All measures were analyzed using statistical process control.

Results:

Interventions were associated with increases in our outcome and process measures from 0.1% to 1.2% and 0.6% to 6.3%, respectively, during the first 8 months. Subsequently, the novel coronavirus (COVID-19) pandemic was associated with further increases in these measures to 41.8% and 73.5%, respectively, over 3 months. The balancing measure increased from 0% at baseline to 14.7% with no special cause variation during the intervention period. The most impactful interventions included clinician training outreach, providing equipment, and streamlining MyChart patient enrollment.

Conclusions:

This improvement project effectively increased pediatric ambulatory video visit utilization, although the most significant driver of utilization was the COVID-19 pandemic. Project interventions implemented before COVID-19 facilitated rapid video visit adoption during the pandemic. A similar improvement process may be beneficial for other medical centers aiming to improve video visit utilization.
Association between erythrocyte dynamics and vessel remodelling in developmental vascular networks
Authors: Zhou Qi , Perovic Tijana , Fechner Ines , Edgar Lowell T. , Hoskins Peter R. , Gerhardt Holger , Krüger Timm , Bernabeu Miguel O.
Published: June 2021

Sprouting angiogenesis is an essential vascularization mechanism consisting of sprouting and remodelling. The remodelling phase is driven by rearrangements of endothelial cells (ECs) within the post-sprouting vascular plexus. Prior work has uncovered how ECs polarize and migrate in response to flow-induced wall shear stress (WSS). However, the question of how the presence of erythrocytes (widely known as red blood cells (RBCs)) and their impact on haemodynamics affect vascular remodelling remains unanswered. Here, we devise a computational framework to model cellular blood flow in developmental mouse retina. We demonstrate a previously unreported highly heterogeneous distribution of RBCs in primitive vasculature. Furthermore, we report a strong association between vessel regression and RBC hypoperfusion, and identify plasma skimming as the driving mechanism. Live imaging in a developmental zebrafish model confirms this association. Taken together, our results indicate that RBC dynamics are fundamental to establishing the regional WSS differences driving vascular remodelling via their ability to modulate effective viscosity.