bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of Resistance to Asiatic Citrus Canker among Selections of Pêra Sweet Orange (Citrus sinensis)
Authors: Gonçalves-Zuliani Aline M. O. , Nanami Danielle S. Y. , Barbieri Bruna R. , Guedes Terezinha A. , Zanutto Carlos A. , Bock Clive H. , Nunes William M. C.
Published: June 2016

Asiatic citrus canker (ACC, caused by the bacterium Xanthomonas citri subsp. citri) is a destructive disease of citrus in Brazil and in several other citrus-producing countries. ACC management is problematic, and bactericides such as copper can be reasonably efficacious but do not completely control the disease. Furthermore, injury by citrus leaf miner (CLM) can exacerbate severity of ACC. Host resistance is the most desirable solution for management of ACC; however, evaluations of germplasm indicate that resistance is limited in many popular species and cultivars that are grown commercially. Limited evaluations have been made of sweet orange (Citrus sinensis) selections. We evaluated resistance of 25 Pêra sweet orange selections to X. citri subsp. citri by wound inoculation and measuring lesion diameter under greenhouse conditions (wound inoculation indicates mesophyll resistance which will be valuable in areas where CLM exists). ACC severity was assessed on the same 25 selections at three locations in the field in Brazil, relying on natural inoculum and conditions to cause disease. In the greenhouse experiments, the selections EEL, Bianchi/CC, Ipiguá, Olimpia, IAC 2000/1, and Ovale Siracusa consistently had the smallest diameter lesions, indicating greatest resistance, although differences in lesion diameter were small. Results from the field experiments were less conclusive, although EEL and Ovale Siracusa were consistently numerically least affected by ACC. These results indicate selections of sweet orange that might be preferable to consider in canker-prone areas in Brazil and elsewhere.
Characterization of Colletotrichum Species Causing Bitter Rot of Apple in Kentucky Orchards
Authors: Munir M. , Amsden B. , Dixon E. , Vaillancourt L. , Gauthier N. A. Ward
Published: June 2016

Multiple species of Colletotrichum can cause bitter rot disease of apple, but the identities and relative representation of the species causing the disease in Kentucky are unknown. In total, 475 Colletotrichum isolates were collected from diseased apple fruit in 25 counties and characterized both morphologically and by using various molecular approaches. Multigene sequence analyses revealed that sample isolates belonged to several newly erected species within the Colletotrichum acutatum and C. gloeosporioides species complexes. The isolates were identified as C. fioriniae and C. nymphaeae, which reside within the C. acutatum species complex, and C. siamense, C. theobromicola, and C. fructicola, which are placed within the C. gloeosporioides species complex. C. fioriniae was the most common species causing bitter rot in Kentucky, comprising more than 70% of the isolates. Infectivity tests on detached fruit showed that C. gloeosporioides species-complex isolates were more aggressive than isolates in the C. acutatum species complex. However, isolates within the C. acutatum species complex produced more spores on lesions compared with isolates within the C. gloeosporioides species complex. Aggressiveness varied among individual species within a species complex. C. siamense was the most aggressive species identified in this study. Within the C. acutatum species complex, C. fioriniae was more aggressive than C. nymphaeae, causing larger, deeper lesions. Apple cultivar did not have a significant effect on lesion development. However, Colletotrichum spp. produced more spores on ‘Red Stayman Winesap’ than on ‘Golden Delicious’. Fungicide sensitivity tests revealed that the C. acutatum species complex was more tolerant to thiophanate-methyl, myclobutanil, trifloxystrobin, and captan compared with the C. gloeosporioides species complex. The study also revealed that mycelial growth of C. siamense was more sensitive to tested fungicides compared with C. fructicola and C. theobromicola. These research findings emphasize the importance of accurate identification of Colletotrichum spp. within each species complex, because they exhibit differences in pathogenicity and fungicide sensitivity.
Overview of pathophysiology and treatment of human lupus nephritis
Authors: Trotter Kimberly , Clark Marcus R. , Liarski Vladimir M.
Published: June 2016

Purpose of review

Despite recent developments and treatment successes, the outcome, and prognosis of patients with lupus nephritis (LuN) have not greatly changed since the 1980s. This review covers the application of new concepts to the understanding of renal inflammation and the study of new pharmacologic agents to improve patient outcomes.

Recent findings

Studies have shown that the presence of anti-vimentin antibodies and T follicular helper cells in patient biopsies is associated with more severe interstitial inflammation, which has been tied to faster disease progression and onset of end-stage renal disease. Additionally, data regarding the role of serum IgE antidouble-stranded DNA antibodies in LuN by means of mediating IFN1 production by plasmacytoid dendritic cells are highlighted. Finally, a thorough review of completed and currently open clinical trials of therapeutic agents is provided.

Current management of LuN is guided almost exclusively by glomerular involvement. Based on the data provided in this review, we argue that renal tubulointerstitial inflammation is no less important and represents an overlooked feature in the current clinical approach to patients. Tubulointerstitial inflammation is driven by both adaptive and innate immune mechanisms that are still poorly understood. Studying these pathogenic processes promises to reveal new therapeutic opportunities for those LuN patients with the worst prognosis.

Video abstract

Alternate video abstract introduction (see Video, Supplemental Digital Content 1, with introduction by two of the authors – VL and KT). Abstract Video: http://links.lww.com/COR/A35
Oblique Terminal Screw Placement: Does It Improve Fixation in Plate Osteosynthesis?
Authors: Waldrop Robert , Wood William , Cunningham Brian P. , McLemore Ryan , McLaren Alex
Published: June 2016

The technique of placing an oblique screw in the terminal hole of a plate to increase screw pullout strength is widely taught in the operating room. The origin of this technique is unclear; however, it may have been used simply as a means to identify radiographs and misinterpreted to have some biomechanical benefit. The objective of this study was to measure the structural effect of oblique terminal screw placement (OTSP) during plate osteosynthesis. Foam blocks and limited contact dynamic compression plates and screws were used along with a custom fixture device. The terminal screw was placed in either an oblique (30-degree angle outward) or perpendicular fashion. A load was applied perpendicular to the plate in cantilever bending until failure. The oblique screw construct was significantly weaker than the perpendicular screw construct (399N vs. 465N, P < 0.001), independent of the block of material used. Post hoc analysis showed that the screw angle (P < 0.001) was a significant determinant of the load required to cause screw pullout. OTSP led to a decrease in pullout strength compared with a perpendicular screw in a deformable foam medium similar in density to osteoporotic bone. In patients with poor bone quality, OTSP may create a suboptimal fracture fixation construct.
Does adolescent obesity affect surgical presentation and radiographic outcome for patients with adolescent idiopathic scoliosis?
Authors: Bjerke Benjamin T. , Saiyed Rehan , Cheung Zoe B. , Uppstrom Tyler J. , Shifflett Grant D. , Cunningham Matthew E.
Published: June 2016

The purpose of this study was to test a hypothesis that overweight patients with adolescent idiopathic scoliosis present with larger curves and achieve less surgical correction than do healthy weight counterparts. A total of 251 individuals were grouped by BMI into overweight (BMI% ≥85) and healthy weight (BMI% <85) groups. Overweight patients demonstrated significantly larger intraoperative blood loss (P=0.041), although there was no significant difference in the number of intraoperative transfusions. Major curves and surgical correction were similar between the two groups. A greater postoperative thoracic kyphosis at latest follow-up may suggest a worsening sagittal profile in these individuals postoperatively.
Integrating an Academic Electronic Health Record:
Authors: Herbert Valerie M. , Connors Helen
Published: June 2016

Technology is increasing the complexity in the role of today’s nurse. Healthcare organizations are integrating more health information technologies and relying on the electronic health record for data collection, communication, and decision making. Nursing faculty need to prepare graduates for this environment and incorporate an academic electronic health record into a nursing curriculum to meet student-program outcomes. Although the need exists for student preparation, some nursing programs are struggling with implementation, whereas others have been successful. To better understand these complexities, this project was intended to identify current challenges and success strategies of effective academic electronic health record integration into nursing curricula. Using Rogers’ 1962 Diffusion of Innovation theory as a framework for technology adoption, a descriptive survey design was used to gain insights from deans and program directors of nursing schools involved with the national Health Informatics & Technology Scholars faculty development program or Cerner’s Academic Education Solution Consortium, working to integrate an academic electronic health record in their respective nursing schools. The participants’ experiences highlighted approaches used by these schools to integrate these technologies. Data from this project provide nursing education with effective strategies and potential challenges that should be addressed for successful academic electronic health record integration.
Individualized predictions of time to menopause using multiple measurements of antimüllerian hormone
Authors: Gohari Mahmood Reza , Ramezani Tehrani Fahime , Chenouri Shojaeddin , Solaymani-Dodaran Masoud , Azizi Fereidoun
Published: June 2016

Objective:

The ability of antimüllerian hormone (AMH) to predict age at menopause has been reported in several studies, and a decrease in AMH level has been found to increase the probability of menopause. The rate of decline varies among women, and there is also a variability of decline between women's cycles. As a result, individualized evaluation is required to accurately predict time of menopause. To this end, we have used the AMH trajectories of individual women to predict each one's age at menopause.

Methods:

From a cohort study, 266 women (ages 20-50 y) who had regular and predictable menstrual cycles at the initiation of the study were randomly selected from among 1,265 women for multiple AMH measurements. Participants were visited at approximately 3-year intervals and followed for an average of 6.5 years. Individual likelihood of menopause was predicted by fitting the shared random-effects joint model to the baseline covariates and the specific AMH trajectory of each woman.

Results:

In total, 23.7% of the women reached menopause during the follow-up period. The estimated mean (SD) AMH concentration at the time of menopause was 0.05 ng/mL (0.06 ng/mL), compared with 1.36 ng/mL (1.85 ng/mL) for those with a regular menstrual cycle at their last assessment. The decline rate in the AMH level varied among age groups, and age was a significant prognostic factor for AMH level (P < 0.001). Adjusting for age and body mass index, each woman had her own specific AMH trajectory. Lower AMH and older age had significant effects on the onset of menopause. Individualized prediction of time to menopause was obtained from the fitted model.

Conclusions:

Longitudinal measurements of AMH will enable physicians to individualize the prediction of menopause, thereby facilitating counseling on the timing of childbearing or medical management of health issues associated with menopause.
BIMANUAL PARS PLANA VITRECTOMY FOR REMOVAL OF A DISLOCATED DESCEMET-STRIPPING AUTOMATED ENDOTHELIAL KERATOPLASTY GRAFT FROM THE VITREOUS CAVITY
Authors: Xu Kunyong , Chin Eric K. , Carpel Emmett F. , Almeida David R. P.
Published: June 2016

Purpose:

To describe a bimanual vitrectomy technique for the removal of a descemet-stripping automated endothelial keratoplasty donor graft dislocated into the vitreous cavity.

Methods:

The surgical technique requires the use of a temporary keratoprosthesis and external chandelier illumination to overcome corneal edema and visualization of the dislocated donor graft, respectively. A bimanual pars plana vitrectomy approach is then performed with intraocular forceps and the vitrectomy handpiece for segmentation and removal of the dislocated graft. Penetrating keratoplasty is then performed to restore corneal clarity.

Results:

This surgical technique allows for the dislocated descemet-stripping automated endothelial keratoplasty donor graft to be removed from the vitreous cavity safely in an efficient manner.

Conclusion:

The technique of bimanual pars plana vitrectomy with a temporary keratoprosthesis and external chandelier illumination can successfully remove a descemet-stripping automated endothelial keratoplasty donor graft dislocated into the vitreous cavity without the need for a large wound for donor graft explantation.
Computer-Assisted Transcatheter Heart Valve Implantation in Valve-in-Valve Procedures
Authors: Soulami Réda Belhaj , Verhoye Jean-Philippe , Duc Hung Nguyen , Castro Miguel , Auffret Vincent , Anselmi Amedeo , Haigron Pascal , Ruggieri Vito Giovanni
Published: June 2016

Objective

Valve-in-valve (ViV) procedures are increasingly being considered as an alternative to redo surgery for the treatment of degenerated bioprosthetic heart valves in patients with excessive reoperative risk. The objective of our study was to evaluate the feasibility of computer guidance in transcatheter heart valve (THV) implantation during ViV procedures.

Methods

Preprocedural electrocardiogram-gated computed tomography–scan images were processed using semiautomatic segmentation of the degenerated bioprosthesis’ radiopaque landmarks and of the ascending aorta. Virtual three-dimensional (3D) reconstructions were created. A virtual plane was subsequently added to the 3D reconstructions, indicating the optimal landing plane of the THV inside the tissue valve. Within a hybrid operating theater, a 3D/2D registration was used to superimpose the 3D reconstructions, while dynamic tracking was allowed to maintain the superimposition onto the fluoroscopic images. The THV was afterward implanted according to the optimal landing plane. Projection of the ascending aorta and the coronary arteries was used to assess the risk of coronary ostia obstruction.

Results

Between January 2014 and October 2014, nine patients underwent aortic ViV procedures in our institution. Among those nine patients, five procedures were retrospectively evaluated as a validation step using the proposed method. The mean (SD) superimposition error was 1.1 (0.75) mm. Subsequently, two live cases were prospectively carried out using our approach, successfully implanting the THV inside the degenerated tissue valve.

Conclusions

Our study demonstrates the feasibility of a computer-guided implantation of THV in ViV procedures. Moreover, it suggests that augmented reality may increase the reliability of THV implantation inside degenerated bioprostheses through better reproducibility.
Etiology and Management of Allergic Eyelid Dermatitis
Authors: Chisholm Smith Ann M. , Couch Steven M. , Custer Philip L.
Published: June 2016

Purpose:

Allergic dermatitis is a common but often misdiagnosed condition that can present with a variety of findings including inflammation, eyelid malposition, and tearing. This study was performed to identify likely etiologies, along with presenting findings and treatment strategies for allergic dermatitis.

Methods:

A retrospective review of clinical records was performed of patients diagnosed with allergic dermatitis in academic oculoplastics practices from 2002 to 2014. Initial consultation included review of medications and cosmeceuticals. Suspected allergens were discontinued and an ophthalmic steroid was applied. Persistent allergic dermatitis led to further medication changes or formal allergy testing in an effort to identify the causative agent.

Results:

Sixty-one patients were identified; average age was 66 years old (range: 33–94), and 45 of the patients were women (74%). Average follow up was 7 months (range: 1–60 months). Reasons for referral included epiphora (31.2%), ectropion (24.6%), blepharitis/dermatitis (18.0%), and “droopy” eyelid (14.8%). Presenting symptoms included irritation (77.1%) and tearing (50.8%). Average duration of symptoms was 16.5 months (range: 2 days–8 years). The 3 most common etiologies were eye drops (54.2%), creams/lotions (24.6%), and cosmetics (13.1%). Rubbing/manipulation was also thought to be a significant factor in 30% of the patients. Overall, the initial treatment regimen led to at least partial resolution in 88% of patients and 66% experienced complete resolution. Patients resistant to therapy were referred for patch testing. At follow up, 98% of patients had improvement in their symptoms and 90% of patients had complete resolution of their symptoms.

Conclusions:

Allergic eyelid dermatitis is commonly related to eye drops and topical cosmetics or skin care products. Identification and elimination of causative agents is the mainstay of management. Topical corticosteroids often facilitate resolution of the associated inflammation. Therapy resistant patients may benefit from formal allergy testing.
Variables Associated With Inpatient and Outpatient Resource Utilization Among Medicare Beneficiaries With Nonalcoholic Fatty Liver Disease With or Without Cirrhosis
Authors: Sayiner Mehmet , Otgonsuren Munkhzul , Cable Rebecca , Younossi Issah , Afendy Mariam , Golabi Pegah , Henry Linda , Younossi Zobair M.
Published: June 2016

Background:

Nonalcoholic fatty liver disease (NAFLD) is one of the leading causes of chronic liver disease worldwide with tremendous clinical burden. The economic burden of NAFLD is not well studied.

Goal:

To assess the economic burden of NAFLD.

Study:

Medicare beneficiaries (January 1, 2010 to December 31, 2010) with NAFLD diagnosis by International Classification of Diseases, Ninth Revision codes in the absence of other liver diseases were selected. Inpatient and outpatient resource utilization parameters were total charges and total provider payments. NAFLD patients with compensated cirrhosis (CC) were compared with decompensated cirrhosis (DC).

Results:

A total of 976 inpatients and 4742 outpatients with NAFLD were included—87% were white, 36% male, 30% had cardiovascular disease (CVD) or metabolic syndrome conditions, and 12% had cirrhosis. For inpatients, median total hospital charge was $36,289. NAFLD patients with cirrhosis had higher charges and payments than noncirrhotic NAFLD patients ($61,151 vs. $33,863 and $18,804 vs. $10,146, P<0.001). Compared with CC, NAFLD patients with DC had higher charges and payments (P<0.02). For outpatients, median total charge was $9,011. NAFLD patients with cirrhosis had higher charges and payments than noncirrhotic NAFLD patients ($12,049 vs. $8,830 and $2,586 vs. $1,734, P<0.001). Compared with CC, DC patients had higher total charges ($15,187 vs. $10,379, P=0.04). In multivariate analysis, variables associated with increased inpatient resource utilization were inpatient mortality, DC, and CVD; for outpatients, having CVD, obesity, and hypertension (all P<0.001).

Conclusions:

NAFLD is associated with significant economic burden to Medicare. Presence of cirrhosis and CVD are associated with increased resource utilization.
Altered Underlying Renal Tubular Function in Patients With Chronic Hepatitis B Receiving Nucleos(t)ide Analogs in a Real-World Setting
Authors: Rodríguez-Nóvoa Sonia , García-Samaniego Javier , Prieto Martín , Calleja José L. , Pascasio Juan M. , Delgado Blanco Manuel , Crespo Javier , Buti María , Bonet Vidal Maria L. , Arenas Ruiz Tapiador Juan , Fernández-Rodríguez Conrado , Solá Ricard , Fraga Enrique , González Diéguez Luisa , Núñez Oscar , Praga Manuel , del Pino-Montes Javier , Romero-Gómez Manuel , Morillas Rosa , Diago Moisés , Castro Ángeles
Published: June 2016

Background:

Cases of renal tubular dysfunction have been reported in patients with hepatitis B and in patients with human immunodeficiency virus who are undergoing tenofovir treatment. However, little is known about the impact on tubular function in patients with chronic hepatitis B (CHB) under long-term use of entecavir (ETV) and tenofovir disoproxil fumarate (TDF). We evaluated markers of renal tubular function and bone turnover in patients with CHB treated with ETV or TDF.

Patients and Methods:

A multicenter, cross-sectional study was performed on markers of renal tubular function and bone turnover in hepatitis B virus–monoinfected patients on long-term treatment with Entecavir or Tenofovir (the MENTE study). The analyzed parameters were: retinol-binding protein/creatinine, neutrophil gelatinase-associated lipocalin/creatinine, excretion of phosphates, uric acid excretion, glomerular filtrate, protein/creatinine, albumin/creatinine, serum creatinine, phosphate, CTX, P1NP, vitamin D, and parathormone.

Results:

A total of 280 patients (ETV: 89, TDF: 69, control: 122) were included in this study. The TDF group was associated with altered levels of retinol-binding protein (RBP)/creatinine (TDF 25% vs. 7% ETV and control; P<0.001). Protein/creatinine, uric acid excretion, P1NP1, and parathormone were higher in the TDF group. The proportion of patients with serum phosphate <2.5 mg/dL was higher in both the ETV and the TDF groups compared with the control. The multivariate analysis showed that the use of TDF was independently associated with a higher risk of altered excretion of RBP/creatinine (4.4; interquartile range: 1.4 to 14; P=0.013).

Conclusions:

We found an independent association between TDF use and altered RBP excretion. This finding indicates subclinical tubular damage. Because tubular dysfunction can precede the decline of renal function, close monitoring of RBP levels in patients with CHB on nucleos(t)ide analog treatment must be performed for early detection of TDF-related renal toxicity. In this study, these differences in tubular function were not associated with concomitant changes in markers of bone turnover.
Management of Patients With Pancreatic Cysts
Authors: Kowalski Thomas , Siddiqui Ali , Loren David , Mertz Howard R. , Mallat Damien , Haddad Nadim , Malhotra Nidhi , Sadowski Brett , Lybik Mark J. , Patel Sandeep N. , Okoh Emuejevoke , Rosenkranz Laura , Karasik Michael , Golioto Michael , Linder Jeffrey , Catalano Marc F. , Al-Haddad Mohammad A.
Published: June 2016

Goals:

To examine the utility of integrated molecular pathology (IMP) in managing surveillance of pancreatic cysts based on outcomes and analysis of false negatives (FNs) from a previously published cohort (n=492).

Background:

In endoscopic ultrasound with fine-needle aspiration (EUS-FNA) of cyst fluid lacking malignant cytology, IMP demonstrated better risk stratification for malignancy at approximately 3 years’ follow-up than International Consensus Guideline (Fukuoka) 2012 management recommendations in such cases.

Study:

Patient outcomes and clinical features of Fukuoka and IMP FN cases were reviewed. Practical guidance for appropriate surveillance intervals and surgery decisions using IMP were derived from follow-up data, considering EUS-FNA sampling limitations and high-risk clinical circumstances observed. Surveillance intervals for patients based on IMP predictive value were compared with those of Fukuoka.

Results:

Outcomes at follow-up for IMP low-risk diagnoses supported surveillance every 2 to 3 years, independent of cyst size, when EUS-FNA sampling limitations or high-risk clinical circumstances were absent. In 10 of 11 patients with FN IMP diagnoses (2% of cohort), EUS-FNA sampling limitations existed; Fukuoka identified high risk in 9 of 11 cases. In 4 of 6 FN cases by Fukuoka (1% of cohort), IMP identified high risk. Overall, 55% of cases had possible sampling limitations and 37% had high-risk clinical circumstances. Outcomes support more cautious management in such cases when using IMP.

Conclusions:

Adjunct use of IMP can provide evidence for relaxed surveillance of patients with benign cysts that meet Fukuoka criteria for closer observation or surgery. Although infrequent, FN results with IMP can be associated with EUS-FNA sampling limitations or high-risk clinical circumstances.
Treatment of Pulmonary Exacerbations Improves Short But Not Long‐Term Growth Trajectory in Children With Cystic Fibrosis
Authors: Loong Christine , Breton Jessica , Yang Connie L.
Published: June 2016

Objectives:

The present study sought to determine the long‐term growth consequences after a pulmonary exacerbation in children with cystic fibrosis (CF).

Methods:

Retrospective cohort study of pediatric patients with CF with a hospital admission for a pulmonary exacerbation. Logistic regression used to determine risk factors for failure to recover baseline body mass index (BMI) percentile.

Results:

Of 72 patients, 43% failed to recover their baseline BMI percentile 12 months after discharge and these patients also had a lower forced expiratory volume in 1 second at follow‐up. A greater decrease in weight percentile from baseline to admission was the only risk factor identified (odds ratio 0.83, P = 0.0015).

Conclusions:

Greater decrease in weight percentile from baseline to admission predicts failure to recover BMI percentile 1 year after a pulmonary exacerbation. Children with CF with poor growth preceding a pulmonary exacerbation continue to be at risk for long‐term nutritional failure despite treatment for pulmonary exacerbation.
Total Pancreatectomy With Islet Autotransplantation Resolves Pain in Young Children With Severe Chronic Pancreatitis
Authors: Bellin Melena D. , Forlenza Gregory P. , Majumder Kaustav , Berger Megan , Freeman Martin L. , Beilman Gregory J. , Dunn Ty B. , Pruett Timothy L. , Murati Michael , Wilhelm Joshua J. , Cook Marie , Sutherland David E.R. , Schwarzenberg Sarah J. , Chinnakotla Srinath
Published: June 2016

Objectives:

Fear of diabetes and major surgery may prohibit referral of young children severely affected by pancreatitis for total pancreatectomy with islet autotransplant (TPIAT). We evaluated outcomes in our youngest TPIAT recipients, 3 to 8 years of age at surgery.

Methods:

Medical records were reviewed for 17 children (9 girls) ages 8 years or younger undergoing TPIAT from 2000 to 2014. Most (14/17) had genetic risk factors for pancreatitis. Since 2006, TPIAT recipients were followed prospectively with health questionnaires including assessments of pain and narcotic use, and scheduled hemoglobin A1c (HbA1c) and mixed‐meal tolerance tests (6 mL/kg Boost HP) before surgery, and at regular intervals after. Patients are 1 to 11 years post‐TPIAT (median 2.2 years). Data are reported as median (25th, 75th percentile).

Results:

All had relief of pain, with all 17 patients off narcotics at most recent follow‐up. Hospitalization rates decreased from 5.0 hospitalization episodes per person‐year of follow‐up before TPIAT, to 0.35 episodes per person‐year of follow‐up after TPIAT. Fourteen (82%) discontinued insulin, higher than the observed insulin independence rate of 41% in 399 patients older than 8 years of age undergoing TPIAT over the same interval (P = 0.004). Median post‐TPIAT HbA1c was 5.9% (5.6%, 6.3%), and within patient post‐TPIAT mean HbA1c was ⩽6.5% for all but 2 patients.

Conclusions:

Young children with severe refractory chronic pancreatitis may be good candidates for TPIAT, with high rates of pain relief and insulin independence, and excellent glycemic control in the majority.
Effective Use of Computed Tomography for Detection of Press-Through-Package Sheet Ingestion in a Pediatric Patient
Authors: Takeuchi Ichiro , Ito Tomoya , Ito Yurie , Uematsu Satoko , Misato Migita , Oono Michinobu , Tsuji Satoshi , Sakai Hirokazu
Published: June 2016

Press-through-package sheet (PTPS) ingestion can cause perforation of gastrointestinal tract. Such incidents, which require immediate medical attention, are often observed in elderly people. In this report, we describe the case of a 12-year-old patient who ingested PTPS. The patient, who has attention-deficit/hyperactivity disorder, presented with abdominal pain at our hospital. While it was not revealed by a chest x-ray, computed tomography scan showed a PTPS lodged in his lower esophagus. The ingested PTPS was removed by endoscopy without complications. Press-through-package sheets ingestion can occur in pediatric patients, and computed tomography scan is useful in the diagnosis.
Implementing Safe Practices in Administering Pro re nata Medications in a Rural Hospital
Authors: Hogan Kerry-Anne , Lapenskie Julie , Leclair Joanne , Thick Naomi , Gazarin Mohamed , Webster Penny , Devin Brian
Published: June 2016

Developing and implementing a policy for safe pro re nata medications practices became a priority when 1 nurse questioned a regularly occurring double-range narcotic order. This article describes how double-range medications can compromise patient safety and how a small rural hospital with minimal resources was able to develop an interdisciplinary practice standard to ensure safe medication practices.
Evaluating Opportunities for Achieving Cost Efficiencies Through the Introduction of PrePex Device Male Circumcision in Adult VMMC Programs in Zambia and Zimbabwe
Authors: Vandament Lyndsey , Chintu Naminga , Yano Nanako , Mugurungi Owen , Tambatamba Bushimbwa , Ncube Gertrude , Xaba Sinokuthemba , Mpasela Felton , Muguza Edward , Mangono Tichakunda , Madidi Ngonidzashe , Samona Alick , Tagar Elva , Hatzold Karin
Published: June 2016

Background:

Results from recent costing studies have put into question potential Voluntary Medical Male Circumcision (VMMC) cost savings with the introduction of the PrePex device.

Methods:

We evaluated the cost drivers and the overall unit cost of VMMC for a variety of service delivery models providing either surgical VMMC or both PrePex and surgery using current program data in Zimbabwe and Zambia. In Zimbabwe, 3 hypothetical PrePex only models were also included. For all models, clients aged 18 years and older were assumed to be medically eligible for PrePex and uptake was based on current program data from sites providing both methods. Direct costs included costs for consumables, including surgical VMMC kits for the forceps-guided method, device (US $12), human resources, demand creation, supply chain, waste management, training, and transport.

Results:

Results for both countries suggest limited potential for PrePex to generate cost savings when adding the device to current surgical service delivery models. However, results for the hypothetical rural Integrated PrePex model in Zimbabwe suggest the potential for material unit cost savings (US $35 per VMMC vs. US $65–69 for existing surgical models).

Conclusions:

This analysis illustrates that models designed to leverage PrePex's advantages, namely the potential for integrating services in rural clinics and less stringent infrastructure requirements, may present opportunities for improved cost efficiency and service integration. Countries seeking to scale up VMMC in rural settings might consider integrating PrePex only MC services at the primary health care level to reduce costs while also increasing VMMC access and coverage.
Safety and Efficacy of the PrePex Male Circumcision Device: Results From Pilot Implementation Studies in Mozambique, South Africa, and Zambia
Authors: Feldblum Paul , Martinson Neil , Bvulani Bruce , Taruberekera Noah , Mahomed Mehebub , Chintu Namwinga , Milovanovic Minja , Hart Catherine , Billy Scott , Necochea Edgar , Samona Alick , Mhazo Miriam , Bossemeyer Debora , Lai Jaim Jou , Lebinai Limakatso , Ashengo Tigistu A. , Macaringue Lucinda , Veena Valentine , Hatzold Karin
Published: June 2016

Background:

Fourteen countries in East and Southern Africa have engaged in national programs to accelerate the provision of voluntary medical male circumcision (VMMC) since 2007. Devices have the potential to accelerate VMMC programs by making the procedure easier, quicker, more efficient, and widely accessible.

Methods:

Pilot Implementation studies were conducted in Mozambique, South Africa, and Zambia. The primary objective of the studies was to assess the safety of PrePex device procedures when conducted by nurses and clinical officers in adults and adolescent males (13–17 years, South Africa only) with the following end points: number and grade of adverse events (AEs); pain-related AEs measured using visual analog score; device displacements/self-removals; time to complete wound healing; and procedure times for device placement and removal.

Results:

A total of 1401 participants (1318 adult and 83 adolescent males) were circumcised using the PrePex device across the 3 studies. Rates of moderate/severe AEs were low (1.0%; 2.0%; and 2.8%) in the studies in Mozambique, Zambia, and South Africa, respectively. Eight early self-removals of 1401 (0.6%) were observed, all required corrective surgery. High rates of moderate/severe pain-related AEs were recorded especially at device removal in South Africa (34.9%) and Mozambique (59.5%). Ninety percent of participants were healed at day 56 postplacement.

Discussion:

The study results from the 3 countries suggest that the implementation of the PrePex device using nonphysician health care workers is both safe and feasible, but better pain control at device removal needs to be put in place to increase the comfort of VMMC clients using the PrePex device.
Surgical Outcomes of Newly Trained ShangRing Circumcision Providers
Authors: Awori Quentin D. , Lee Richard K. , Li Philip S. , Zulu Robert , Agot Kawango , Combes Stephanie , Simba Raymond O. , Hart Catherine , Lai Jaim Jou , Zyambo Zude , Goldstein Marc , Feldblum Paul J. , Barone Mark A.
Published: June 2016

Background:

Devices can potentially accelerate scale-up of voluntary medical male circumcision in sub-Saharan Africa. Studies have demonstrated advantages of the ShangRing device over conventional circumcision. With the need to train providers rapidly for scale-up, concerns arise about the transferability of techniques and the expertise of new trainees.

Methods:

We compared outcomes of ShangRing circumcisions conducted in Kenya by experienced providers (experience with more than 100 ShangRing circumcisions) and newly trained providers (trained in Kenya by the experienced providers before the study began). During training, trainees performed at least 7 ShangRing circumcisions and 3 removals. Newly trained providers received intermittent clinical mentoring initially during the study but otherwise conducted circumcisions on their own.

Results:

Four hundred six and 115 ShangRing procedures were performed by the new trainees and the experienced providers, respectively. The mean duration of circumcisions was 6.2 minutes for both trained and experienced provider groups (P = 0.45), whereas the mean pain score (on an 11-point scale) was 2.5 and 3.2, respectively (P = 0.65). There was no difference in the proportion of participants healed by the day 42 visit (P = 0.13) nor in the incidence of moderate and severe adverse events observed (P = 0.16). Participants in both groups were equally satisfied with final wound cosmesis.

Discussion:

Results demonstrate that the ShangRing circumcision technique is easy to learn and master. Newly trained providers can safely conduct ShangRing circumcisions in routine service settings. The ShangRing can facilitate rapid rollout of voluntary medical male circumcision for HIV prevention in sub-Saharan Africa.
Acceptability and Satisfaction Associated With the Introduction of the PrePex Circumcision Device in Maputo, Mozambique
Authors: Cummings Beverley , Necochea Edgar , Ferreira Thais , Soares Benilde , Mahomed Mehebub , Muquingue Humberto , Nhambi Leonel , Bossemeyer Debora , Ashengo Tigistu A.
Published: June 2016

Background:

Adult device circumcision may potentially reach more men in Sub-Saharan Africa, with fewer human resource and capacity needs than surgical procedures. Despite these advantages, little is known about device acceptability, including pain and maintaining the device in situ.

Methods:

Healthy, HIV-negative men, between 18 and 49 years, in a Maputo clinic, were consecutively asked to participate in a circumcision device study that included assessing acceptability. Clinical forms and self-administered surveys were used to collect data at various times during the circumcision process for consenting men. Data were entered into a central database and analyzed using statistical software.

Results:

Between May and July, 2013, 504 men received device circumcision. Placement was painless for 98.2% of the male population, but the pain was more common during removal with 38.3% reporting severe or unbearable and 21.5% moderate pain. Satisfaction was high at both time points with 88.8% and 92.6% of men being very or somewhat satisfied at placement and removal, respectively. Half of the male population (50.2%) was very or somewhat comfortable with the device in situ; whereas, 36.8% were somewhat or very uncomfortable. Common device difficulties experienced were painful erections (38.5%) and difficult urination (21.8%) and hygiene (21.4%). By the final clinic visit at day 49, 90.4% of them were very or somewhat satisfied with the procedure.

Discussion:

High levels of satisfaction were reported for device circumcision, despite the pain noted during removal and some challenges with the device in situ. Given the advantages and acceptability among Mozambican men in this study, device circumcision could be offered, when clinically appropriate, as an alternative to surgery.
Participant Experiences and Views of Odor and PrePex Device Removal Pain in a VMMC Pilot Study in Botswana
Authors: Musiige Adrian M. , Ashengo Tigistu A. , Stolarsky Galina , Dialwa Rosinah T. , Manda Robert , Ntsuape Conrad O. , Mafeni Jerome , Busang Lesego , Curran Kelly , Motlhoiwa Kenanao , Mwangemi Frank J. , Lukobo-Durrell Mainza , Glenshaw Mary T.
Published: June 2016

Objective:

To assess participant experiences and perceptions of removal pain and odor associated with the PrePex device procedure.

Methods:

We analyzed data from a PrePex device pilot implementation study of 802 male participants aged 18–49 years at 2 clinics in Botswana, 2013. Study staff administered survey questions on device-related odor and assessed pain using visual analog scale scores categorized as no pain (0), mild (1–4), moderate (5–7), or severe pain (8–10).

Results:

Mean participant age was 27.7 (range = 18–48) years. Of the 802 participants, 751 (94%) reported to have noticed an unusual or unpleasant odor while wearing the device. Of these, 193 (26%) participants tried something to combat the odor. A total of 84 (10%) participants reported no pain, 655 (82%) mild pain, 48 (6%) moderate pain, and 15 (2%) severe pain at 2 minutes after device removal. Pain reports at 15 minutes after removal were 553 (69%) no pain, 247 (31%) mild pain, and 2 (0.25%) moderate pain, with no report of severe pain at this time point. Of 740 participants interviewed on day 42 after device placement, 678 (92%) were satisfied with the procedure and 681 (92%) would recommend it to another man considering circumcision, including 488 (66%) who would recommend it strongly.

Conclusions:

An unusual or unpleasant odor while wearing the PrePex device and mild self-limiting pain at device removal were common, but overall, these did neither seem to impair satisfaction nor deter participants from recommending PrePex to others, which could suggest good prospects for uptake of the device in this setting.
Randomized Controlled Trial of the ShangRing for Adult Medical Male Circumcision: Safety, Effectiveness, and Acceptability of Using 7 Versus 14 Device Sizes
Authors: Feldblum Paul J. , Zulu Robert , Linyama David , Long Sarah , Nonde Thikazi Jere , Lai Jaim Jou , Kashitala Joshua , Veena Valentine , Kasonde Prisca
Published: June 2016

Objectives:

To assess the safety, effectiveness, and acceptability of providing a reduced number of ShangRing sizes for adult voluntary medical male circumcision (VMMC) within routine service delivery in Lusaka, Zambia.

Methods:

We conducted a randomized controlled trial and enrolled 500 HIV-negative men aged 18–49 years at 3 clinics. Participants were randomized to 1 of 2 study arms (Standard Sizing arm vs Modified Sizing arm) in a 1:1 ratio. All 14 adult ShangRing sizes (40–26 mm inner diameter, each varying by 1 mm) were available in the Standard Sizing arm; the Modified Sizing arm used every other size (40, 38, 36, 34, 32, 30, 28 mm inner diameter). Each participant was scheduled for 2 follow-up visits: the removal visit (day 7 after placement) and the healing check visit (day 42 after placement), when they were evaluated for adverse events (AEs), pain, and healing.

Results:

Four hundred and ninety-six men comprised the analysis population, with 255 in the Standard Sizing arm and 241 in the Modified Sizing arm. Three men experienced a moderate or severe AEs (0.6%), including 2 in the Standard Sizing arm (0.8%) and 1 in the Modified Sizing arm (0.4%). 73.2% of participants were completely healed at the scheduled day 42 healing check visit, with similar percentages across study arms. Virtually all (99.6%) men, regardless of study arm, stated that they were very satisfied or satisfied with the appearance of their circumcised penis, and 98.6% stated that they would recommend ShangRing circumcision to family/friends.

Conclusions:

The moderate/severe AE rate was low and similar in the 2 study arms, suggesting that provision of one-half the number of adult device sizes is sufficient for safe service delivery. Effectiveness, time to healing, and acceptability were similar in the study arms. The simplicity of the ShangRing technique, and its relative speed, could facilitate VMMC program goals. In addition, sufficiency of fewer device sizes would simplify logistics and inventory.
Implementation and Operational Research: Clinical Impact of the Xpert MTB/RIF Assay in Patients With Multidrug-Resistant Tuberculosis
Authors: Padayatchi Nesri , Naidu Naressa , Yende-Zuma Nonhlanhla , O'Donnell Max Roe , Naidoo Kogieleum , Augustine Stanton , Zumla Alimuddin , Loveday Marian
Published: June 2016

Background:

The Xpert MTB/RIF assay has been widely implemented in South Africa for rapid tuberculosis (TB) screening. However, its usefulness in management and improving treatment outcomes in patients with multidrug-resistant TB (MDR-TB) remains undefined. The aim of this study was to evaluate the clinical impact of introduction of the Xpert MTB/RIF assay in patients with MDR-TB.

Methods:

We enrolled 921 patients with MDR-TB, who presented to a specialist drug-resistant TB facility in KwaZulu-Natal, South Africa, pre- and post-rollout and implementation of the Xpert MTB/RIF assay. Clinical, laboratory, chest radiograph, and follow-up data from 108 patients with MDR-TB, post-introduction of the Xpert MTB/RIF assay (Xpert group) in November 2010, were analyzed and compared with data from 813 MDR-TB patients from the pre-MTB/RIF assay period (Conventional group), July 2008–2010. Primary impact measure was “treatment success” (World Health Organization definition) at 24 months. Secondary outcomes were time to treatment initiation and disease morbidity.

Results:

There were no significant differences in treatment success rates between the pre-Xpert MTB/RIF and post-Xpert MTB/RIF groups (54% versus 56.5%, P = 0.681). Median time to treatment initiation was 20 days (interquartile range, 13–31) in the Xpert group versus 92 days (interquartile range, 69–120) in the Conventional group (P < 0.001).

Conclusions:

Although use of Xpert MTB/RIF assay significantly reduces the time to initiation of MDR-TB treatment, it had no significant impact on treatment outcomes of patients with MDR-TB. Studies on the impact of the Xpert MTB/RIF assay usage on transmission of MDR-TB are required.
Brief Report: Association of Adipokines With Bone Mineral Density in HIV-Infected and HIV-Uninfected Women
Authors: Sharma Anjali , Ma Yifei , Scherzer Rebecca , Wheeler Amber L. , Cohen Mardge , Gustafson Deborah R. , Keating Sheila M. , Yin Michael T. , Tien Phyllis C.
Published: June 2016

Background:

HIV infection is associated with low bone mineral density (BMD) and alterations in adipokines, which may mediate the relationship between fat and bone.

Objective:

To evaluate the relationship of adiponectin and leptin with BMD in HIV-infected and uninfected women.

Methods:

We measured BMD over 5 years at the lumbar spine, total hip (TH), and femoral neck (FN) using dual-energy X-ray absorptiometry in 318 HIV-infected and 122 HIV-uninfected participants of the multicenter Women's Interagency HIV Study (WIHS). Total adiponectin and leptin were assayed on stored sera. Multivariable linear mixed models assessed the effects of adipokines and HIV status on BMD.

Results:

HIV-infected women had higher adiponectin (median 6.2 vs. 5.6 μg/mL,) but lower leptin (11.7 vs. 19.8 ng/mL) levels at baseline (both P < 0.05) compared with HIV-uninfected women. HIV infection was associated with lower BMD at the lumbar spine (−0.074 g/cm2), FN (−0.049 g/cm2), and TH (−0.047 g/cm2) (all P < 0.05) after adjusting for demographic, behavioral, and metabolic factors. HIV infection remained associated with lower BMD at each site, with little change in the effect sizes after additional adjustment for adiponectin or leptin. Among HIV-infected women, higher adiponectin was associated with lower TH BMD (−0.025 g/cm2 per 10-fold increase, P = 0.035), whereas higher leptin was associated with higher BMD at FN (+0.027 g/cm2 per 10-fold increase, P = 0.005) and TH (+0.019 g/cm2, P = 0.028). After multivariable adjustment, the adipokines showed little association with BMD at any site (P > 0.8 for adiponectin; P > 0.2 for leptin).

Conclusions:

Alterations in serum adiponectin and leptin do not explain low BMD in HIV-infected women.
Ultrasonographic Morphologic Changes of the Central Aponeurosis of the Rectus Femoris Muscle in Individuals With Knee Osteoarthritis
Authors: Takahashi Yusuke , Okada Kyoji , Saito Akira , Saito Isao , Kinoshita Kazuo , Wakasa Masahiko , Sato Hiromichi , Shibata Kazuyuki
Published: June 2016

The aim of this study was to clarify the morphologic characteristics of central aponeurosis (CA) of the rectus femoris (RF) muscle in individuals with medial knee osteoarthritis (OA). Forty legs in 26 individuals with medial knee OA (OA group), 41 legs in 21 elderly individuals (elderly group), and 40 legs in 20 young individuals (young group) were investigated. We measured the following 4 parameters: (1) ratio of CA length, expressed as the percentage of RF length; (2) CA morphologic type (curved, straight, S-shaped, or irregular); (3) CA direction, defined as the direction of the line from the anterior to posterior ends of the CA (lateral or medial); and (4) intercondylar distance (ICD). Ratio of CA length in the OA group was significantly smaller than that in the other 2 groups. The curved CA type was significantly more frequent in the young group than in the other 2 groups. The irregular type was observed in only 7 legs in the OA group. In the young group, CA direction was classified as medial in all cases. Laterally directed CA was observed only in the OA and elderly groups. Within the OA group, ICD in laterally directed CA was significantly larger than that in medially directed CA. Central aponeurosis observed in the RF muscle in individuals with medial knee OA is shorter and sometimes shows an irregular shape. Laterally directed CA is associated with increased ICD in knee OA. Attention should be given to the tendon-aponeurosis complex in individuals with medial knee OA.