bluuebunny/crossref_metadata_2025 huggingface dataset:
Adapting a Low-threshold Buprenorphine Program for Vulnerable Populations During the COVID-19 Pandemic
Authors: Nordeck Courtney D. , Buresh Megan , Krawczyk Noa , Fingerhood Michael , Agus Deborah
Published: November 2020

Objectives:

To examine patient characteristics and outcomes among opioid use disorder patients enrolled in low-threshold buprenorphine treatment during the COVID-19 pandemic.

Methods:

This paper describes the adaptation of the Project Connections (PC) program, a low-threshold buprenorphine program in Baltimore, in response to the COVID-19 pandemic. This paper examines patient characteristics and initial outcomes of patients served during a rapid protocol shift to telehealth that allowed buprenorphine initiation without an in-person encounter following a state-mandated stay-at-home order. Patient characteristics were compared to a subsample of patients enrolled in the program before the COVID-19 pandemic.

Results:

In March 2020, there was a sharp increase in new enrollments to the PC program. A total of 143 patients completed an intake assessment between March and May 2020 and 140 began treatment with buprenorphine/naloxone. Those who completed an intake assessment were primarily male (68.5%), Black (83.2%), had a mean age of 43.2 years (SD = 11.7), and reported a mean of 17.0 years of opioid use (SD = 12.9). The majority of patients were unemployed (72.7%) and reported previous criminal justice involvement (69.2%). Of those who completed an intake assessment, 96.5% returned for a second visit. Among those for whom 30-day retention data was available (n = 113), 63.7% were engaged for 30 days or longer.

Conclusions:

The PC program illustrates that offering on-demand, flexible treatment is an opportunity to increase opioid use disorder treatment access, even during a public health emergency that disrupted access to services. Relaxation of buprenorphine telehealth regulations allowed for flexibility in treatment and benefits vulnerable populations.
Virtual Reality to Reduce Procedural Pain During IV Insertion in the Pediatric Emergency Department
Authors: Litwin Sasha P. , Nguyen Cynthia , Hundert Amos , Stuart Samantha , Liu Derek , Maguire Bryan , Matava Clyde , Stinson Jennifer
Published: November 2020

Objective:

The objective of this study was to evaluate the feasibility of using virtual reality (VR) for distraction during intravenous (IV) insertion in the pediatric emergency department (ED) and of conducting a full-scale randomized controlled trial.

Materials and Methods:

Children aged 8 to 17 years old attending a tertiary care pediatric ED were randomized to interactive VR or an attention control (video on a tablet) for distraction during their IV insertion. Feasibility was determined by recruitment rates, acceptability of the intervention, response rates to outcome measures, and safety or technical problems. Satisfaction questionnaires and pain, fear, and distress scores were completed by the child, caregiver, nurse, and research assistant. Immersion in the intervention was rated by the child. Heart rate was measured.

Results:

Children were recruited between February 2018 and May 2019. A total of 116 children were screened and 72.3% of eligible children were enrolled. Overall, 60 children were randomized to either VR (n=32) or attention control (n=28). Children, caregivers, and nurses were highly satisfied with both distraction methods. There were no significant safety, technical, or equipment issues. There was minimal disruption to clinical workflow in both groups due to study protocols. There was a clinically significant reduction in pain in the VR group. There was no significant difference in fear or distress. Children reported higher immersion in the VR environment. Heart rate increase from baseline was higher in the VR group.

Discussion:

Our data support the feasibility of using VR for distraction during IV insertion and of conducting a full-scale randomized controlled trial. Identifying eligible patients and minimizing the number of outcome measures will be important considerations for future research.
Family-based Interventions Benefit Individuals With Musculoskeletal Pain in the Short-term but not in the Long-Term
Authors: Fritsch Carolina G. , Ferreira Manuela L. , da Silva Anne K.F. , Simic Milena , Dunn Kate M. , Campbell Paul , Foster Nadine E. , Ferreira Paulo H.
Published: November 2020

Introduction:

The benefits of family-based interventions for patients with musculoskeletal pain have been previously shown in individual randomized controlled trials (RCTs), but no systematic review has summarized their effects.

Materials and Methods:

A systematic review was conducted to assess the effectiveness of family-based interventions on clinical and biopsychosocial outcomes in people with musculoskeletal pain (PROSPERO CRD42018118442). Meta-analyses were performed for the outcomes of pain intensity, disability, mood, self-efficacy, and marital adjustment.

Results:

Of 1223 records identified, 18 reports representing 15 RCTs were included in the qualitative review and 10 in the meta-analyses. Family-based interventions were more effective to reduce pain (mean difference [MD], −3.55/100; 95% confidence intreval [CI], −4.03 to −3.06) and disability (MD, −1.51/100; 95% CI, −1.98 to −1.05) than individual-focused interventions at short-term, but not at mid term or long term. There were no effects on other outcomes. Family-based interventions were more effective to reduce pain (MD, −6.05/100; 95% CI, −6.78 to −5.33) compared with usual care only at short-term. No effects were found on disability and other outcomes.

Discussion:

There is moderate-quality evidence that family-based interventions result in small, significantly better pain and disability outcomes in the short-term compared with individual-focused interventions in patients with musculoskeletal pain. Based on low-quality evidence, family-based interventions result in small improvements on pain in the short-term compared with usual care. Future studies should review the content and optimize the mechanisms underpinning family-based interventions in musculoskeletal pain so that the approach could be further tested in adequately powered RCTs.
Utility and Predictive Value of CHIIDA Score in Pediatric Traumatic Brain Injury: A Prospective Observational Study
Authors: Jain Ruchi A. , Karnik Hemangi S. , Kotwani Deepti M.
Published: November 2020

Background:

The Children’s Intracranial Injury Decision Aid (CHIIDA) is a tool designed to stratify children with mild traumatic brain injury (mTBI). The aim of this study was to assess the utility and predictive value of CHIIDA in the assessment of the need for intensive care unit (ICU) admission in pediatric patients with mTBI.

Methods:

This prospective observational study included 425 children below 18 years of age admitted to the ICU of a tertiary care hospital with mTBI (Glasgow Coma Scale 13 to 15). The primary outcome was the composite of neurosurgical intervention, intubation for more than 24 hours for TBI, or death from TBI. Sensitivity, specificity, predictive values and likelihood ratios were calculated at CHIIDA scores 0 and 2.

Results:

Among 425 children with mTBI, 210 (49%) had a CHIIDA score 0, 16 (4%) scored 2 points, and 199 (47%) scored more than 2 points. Thirty-six (8.47%) patients experienced the primary outcome, and there were 3 deaths. A cutoff CHIIDA >0 to admit to ICU had a sensitivity of 97.22% (95% confidence interval [CI], 97.05%-97.39%) and a negative predictive value of 99.54% (95% CI, 99.50%-99.56%). A cutoff of score >2 had a sensitivity of 97.22% (95% CI, 97.05%-97.39%), and negative predictive value of 99.56% (95% CI, 99.54%-99.59%). The post-test probability at cutoff score of 0 and 2 was 16.65% and 16.27%, respectively.

Conclusions:

CHIIDA score does not serve as reliable triage tool for identifying children with TBI who do not require ICU admission.
Intentional Temporary Limb Deformation for Closure of Soft-Tissue Defects in Open Tibial Fractures
Authors: Hernández-Irizarry Roberto , Quinnan Stephen M. , Reid John Spence , Toney Clarence Brian , Rozbruch S Robert , Lezak Bradley , Fragomen Austin T.
Published: November 2020

Objectives:

(1) Evaluate intentional temporary limb deformation for closure of soft-tissue defects as a reconstruction strategy in open tibia fractures and (2) analyze the deformity parameters required for such reconstruction.

Design:

Multicenter retrospective cohort.

Setting:

Level I trauma center.

Patients/Participants:

Nineteen patients 18 years of age and older at the time of initial trauma, with a Gustilo–Anderson type IIIB or IIIC open tibia fracture treated with hexapod external fixation and intentional bony deformity created to facilitate soft-tissue closure.

Intervention:

Intentional limb deformation for soft-tissue closure, followed by gradual correction with a hexapod external fixator.

Outcome Measurements:

Radiographic healing, radiographic assessment of limb alignment, and functional and bony Application of the Method of Ilizarov Group score.

Results:

The average age was 45.3 (20–70), and 79% of patients were men. The most common mechanism of injury was motor vehicle accidents. The distal 1 of 5 of the tibia was the most common fracture location, with 37% of these involving the articular surface at the plafond. After wound closure, deformity correction was initiated after 30 days on average. Varus and apex posterior were the most common initial deformity required for primary soft-tissue closure. Bony and functional Application of the Method of Ilizarov Group outcomes were good or excellent in 94% of patients.

Conclusion:

Intentional deformation followed by a gradual correction can be an effective strategy to obtain bone union and soft-tissue coverage in certain open fractures. This technique, in essence, converts these injuries from type IIIB to IIIA. This strategy obviates the need for flap coverage and results in satisfactory outcomes.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Immediate Weight-Bearing and Range of Motion After Internal Fixation of Selected Malleolar Fractures: A Retrospective Controlled Study
Authors: Fram Brianna R. , Rogero Ryan G. , Chang Gerard , Krieg James C. , Raikin Steven M.
Published: November 2020

Objectives:

We studied the safety of immediate weight-bearing as tolerated (IWBAT) and immediate range of motion (IROM) after open reduction internal fixation (ORIF) of selected malleolar ankle fractures (defined as involving bony or ligamentous disruption of 2 or more of the malleoli or syndesmosis without articular comminution) and attempted to identify risk factors for complications.

Design:

Retrospective case–control study.

Setting:

Level 1 Urban Trauma Center and multiple community hospitals, orthopedic specialty hospitals, and outpatient surgicenters within one metropolitan area.

Patients/Participants:

Of 268 patients at our level 1 trauma center who underwent primary ORIF of a selected malleolar fracture from 2013 to 2018, we identified 133 (49.6%) who were selected for IWBAT and IROM. We used propensity score matching to identify 172 controls who were non–weight-bearing (NWB) and no range of motion for 6 weeks postoperatively. The groups did not differ significantly in age, body mass index, Charleston Comorbidity Index, smoking status, diabetes status, malleoli involved, percentages undergoing medial malleolus (60.9% IWBAT vs. 51.7% NWB), posterior malleolus (24.1% IWBAT, 26.7% NWB), or syndesmosis fixation (41.4% IWBAT, 42.4% NWB, P = 0.85).

Intervention:

IWBAT and IROM after ankle ORIF versus NWB for 6 weeks.

Main Outcome Measurements:

Postoperative complications, including delayed wound healing, superficial or deep infection, and loss of reduction.

Results:

There was no significant difference in total complications (P = 0.41), nonoperative complications (P = 0.53), or operative complications, including a loss of reduction (P = 0.89). We did not identify any factors associated with an increased complication risk, including posterior malleolus or syndesmosis fixation, diabetes, age, or preinjury-assisted ambulation.

Conclusions:

We failed to demonstrate a difference in complications in general and loss of reduction in particular when allowing immediate weight-bearing/ROM in selected cases of operatively treated malleolar fractures, suggesting this may be safe. Future prospective randomized studies are necessary to determine if immediate weight-bearing/ROM is safe and whether it offers any benefits to patients with operatively treated malleolar fractures.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Evolution of blood lipids and risk factors of dyslipidemia among people living with human immunodeficiency virus who had received first-line antiretroviral regimens for 3 years in Shenzhen
Authors: Sun Li-Qin , Liu Jia-Ye , He Yun , Zhou Yang , Xu Liu-Mei , Zhang Lu-Kun , Zhao Fang , Liu Xiao-Ning , Song Ying , Cao Ting-Zhi , Tian Yi-Mei , Rao Man , Wang Hui
Published: November 2020

Background

Lipid abnormalities are prevalent among people living with human immunodeficiency virus (HIV) (PLWH) and contribute to increasing risk of cardiovascular events. This study aims to investigate the incidence of dyslipidemia and its risk factors in PLWH after receiving different first-line free antiretroviral regimens.

Methods

PLWH who sought care at the Third People's Hospital of Shenzhen from January 2014 to December 2018 were included, and the baseline characteristics and clinical data during the follow-up were collected, including total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C). The risk factors of dyslipidemia after antiretroviral therapy were analyzed with the generalized estimating equation model.

Results

Among the 7623 PLWH included, the mean levels of TC, HDL-C and LDL-C were 4.23 ± 0.85 mmol/L, 1.27 ± 0.29 mmol/L and 2.54 ± 0.65 mmol/L, respectively, and the median TG was 1.17 (IQR: 0.85−1.68) mmol/L. Compared with that in PLWH receiving tenofovir disoproxil fumarate (TDF) + lamivudine (3TC) + ritonavir-boosted lopinavir (LPV/r), zidovudine (AZT) + 3TC + efavirenz (EFV), and AZT + 3TC + LPV/r, the incidence of dyslipidemia was lower in PLWH receiving TDF + 3TC + EFV. In multivariate analysis, we found that the risks of elevations of TG, TC, and LDL-C were higher with TDF + 3TC + LPV/r (TG: odds ratio [OR] = 2.82, 95% confidence interval [CI]: 2.55−3.11, P < 0.001; TC: OR = 1.24, 95% CI: 1.14−1.35, P < 0.001; LDL: OR = 1.06, 95% CI: 1.00−1.12, P = 0.041), AZT + 3TC + EFV (TG: OR = 1.41, 95% CI: 1.28−1.55, P < 0.001; TC: OR = 1.43, 95% CI: 1.31−1.56, P < 0.001; LDL: OR = 1.18, 95% CI: 1.12−1.25, P < 0.001), and AZT + 3TC + LPV/r (TG: OR = 3.08, 95% CI: 2.65−3.59, P < 0.001; TC: OR = 2.40, 95% CI: 1.96−2.94, P < 0.001; LDL: OR = 1.52, 95% CI: 1.37−1.69, P < 0.001) than with TDF + 3TC + EFV, while treatment with TDF + 3TC + LPV/r was less likely to restore HDL-C levels compared with TDF + 3TC + EFV (OR = 0.95, 95% CI: 0.92−0.97, P < 0.001). In addition to antiretroviral regimens, antiretroviral therapy duration, older age, overweight, obesity and other traditional factors were also important risk factors for dyslipidemia.

Conclusion

The incidence of dyslipidemia varies with different antiretroviral regimens, with TDF + 3TC + EFV having lower risk for dyslipidemia than the other first-line free antiretroviral regimens in China.
Determination of Oxidative Stress Markers in the Aqueous Humor and Corneal Tissues of Patients With Congenital Hereditary Endothelial Dystrophy
Authors: Guha Sanjukta , Bhogapurapu Bharathi , Ramappa Muralidhar , Chaurasia Sunita , Roy Sanhita
Published: November 2020

Purpose:

The aim of this study is to determine the presence of oxidative stress markers in the aqueous humor (AH) and corneal tissues of patients with congenital hereditary endothelial dystrophy (CHED).

Methods:

Interventional prospective study was undertaken to quantify levels of ascorbic acid and glutathione in the AH of patients with CHED. AH was collected from patients undergoing keratoplasty and levels of ascorbic acid and glutathione were determined using biochemical assays and measured spectrophotometrically. AH collected from pediatric patients with cataract were used as control. Corneal sections of patients who underwent penetrating keratoplasty were obtained, and presence of glutathione peroxidase 1, catalase, and superoxide dismutase was determined by immunohistochemistry. Tissue sections obtained from cadaveric corneas unsuitable for clinical transplant were used as control.

Results:

Significantly increased ascorbic acid levels were determined in patients with CHED (605.6 ± 158.9 μM) compared with those in controls (190.5 ± 74.72 μM). However, a trend toward reduced level of glutathione was detected in patients with CHED compared with that in the controls. Increased glutathione peroxidase 1 staining and reduced expression of catalase was detected in corneal tissues of patients with CHED compared with those in control corneal tissues. There was no apparent changes observed in the expression of superoxide dismutase in the corneal sections obtained from patients with CHED.

Conclusions:

To the best of our knowledge, this is the first study to determine the levels of ascorbic acid and glutathione in AH of patients with CHED. Our data suggest the presence of oxidative stress in CHED that might be responsible for the pathological changes in patients with CHED.
Outcome of Bleb Revision With Autologous Conjunctival Graft Alone or Combined With Donor Scleral Graft for Late-onset Bleb Leakage With Hypotony After Standard Trabeculectomy With Mitomycin C
Authors: Laspas Panagiotis , Wahl Jochen , Peters Henning , Prokosch-Willing Verena , Chronopoulos Panagiotis , Grehn Franz , Pfeiffer Norbert , Hoffmann Esther M.
Published: November 2020

Précis:

Treatment of leakage with ocular hypotony after trabeculectomy with mitomycin C (MMC) can be safely achieved through conjunctival patch alone or combined with donor scleral graft in cases of melted underlying sclera.

Purpose:

To report outcomes of 2 surgical approaches for treating ocular hypotony in eyes with blebs with late-onset leakage after standard trabeculectomy with MMC.

Methods:

Thirty consecutive cases with bleb leakage and hypotony underwent bleb revision surgery between 2009 and 2014 by the same surgeon (J.W.) at the Department of Ophthalmology of the Mainz University Medical Center, Germany. In 18 patients, an autologous conjunctival patch graft was applied. In 12 patients, the underlying sclera was found melted and an additional scleral donor graft was sutured in place. The authors analyzed intraocular pressure, visual acuity, and optical coherence tomography of the macula preoperatively at 1 day, 1 week, 4 weeks, and 6 months after surgery.

Results:

The mean IOP was 6.2±3.5 mm Hg preoperatively and 21.7±16.4 mm Hg at 1 day, 13.7±6.7 at 1 week, 13.1±5.1 mm Hg at 4 weeks, and 12.1±4.7 mm Hg at 6 months after surgery. Visual acuity (logMar) increased from 0.57±0.49 preoperatively to 0.49±0.40 at 6 months. Optical coherence tomography showed flattening of macular folds that were present before treatment. No serious adverse event was reported.

Conclusions:

This revision technique with conjunctival patch and/or additional donor scleral graft is an effective and safe method for treating late bleb leakage and hypotony maculopathy after trabeculectomy with MMC.
Group-based trajectory analysis of postoperative pain and outcomes after liver cancer surgery
Authors: Teng Wei-Nung , Wu Hsiang-Ling , Tai Ying-Hsuan , Lei Hao-Jan , Tsou Mei-Yung , Chang Kuang-Yi
Published: November 2020

Background:

Although previous studies have shown connections between pain and worse cancer outcomes, few clinical studies have evaluated their direct association, and the current study aimed to investigate the potential association between acute pain trajectories and postoperative outcomes after liver cancer surgery.

Methods:

This retrospective study was conducted in a single medical center and included patients who received liver cancer surgery between January 2010 and December 2016. Maximal pain intensity was recorded daily using a numerical rating scale during the first postoperative week. Group-based trajectory analysis was performed to classify the variations in pain scores over time. Cox and linear regression analyses were used to assess the effect of pain trajectories on recurrence-free survival, overall survival, and length of hospital stay (LOS) after surgery and to explore predictors of these outcomes.

Results:

A total of 804 patients with 5396 pain score observations were analyzed within the present study. Group-based trajectory analysis categorized the changes in postoperative pain into three groups: group 1 had constantly mild pain (76.6%), group 2 had moderate/severe pain dropping to mild (10.1%), and group 3 had mild pain rebounding to moderate (13.3%). Multivariable analysis demonstrated that on average, group 3 had a 7% increase in LOS compared with the group 1 (p = 0.02) and no significant difference in the LOS was noted between pain trajectory groups 2 and 1 (p = 0.93). Pain trajectories were not associated with recurrence-free survival or overall survival after liver cancer surgery.

Conclusion:

Acute pain trajectories were associated with LOS but not cancer recurrence and survival after liver cancer surgery. Group-based trajectory analysis provided a promising approach for investigating the complex relationships between variations in postoperative pain over time and clinical outcomes.
The clinical manifestations and interval changes of reverse-transcriptase quantitative polymerase chain reactions among different specimens of coronavirus disease 2019 patients
Authors: Chen Po-Liang , Hsiao Yi-Han , Chuang Chien , Feng Jia-Yih , Ho Hsiang-Ling , Lin Yi-Tsung , Chen Su-Jung , Huang Shiang-Fen , Chen Hsin-Pai , Chou Teh-Ying , Chen Yuh-Min , Wang Fu-Der
Published: November 2020

Background:

Since December 2019, a number of cases and deaths due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic have been reported worldwide. In spite of clinical manifestations similar to the SARS-CoV epidemic in 2003, affected organs and severity are yet to be defined. Moreover, viral load alterations and viral shielding among different specimens remained scarce. Therefore, clarifying clinical presentations and correlations among viral loads, disease severity, and viral shielding of SARS-CoV-2 infection is crucial in the disease prevention.

Methods:

The clinical courses of SARS-CoV-2 cases were presented through Gantt charts. Laboratory examinations and reverse-transcriptase quantitative polymerase chain reactions (RT-qPCR) among different specimens were tested periodically. Cycle thresholds (CT) were recorded and presented as viral loads.

Results:

From March 2020 to April 2020, 4 SARS-CoV-2 cases were presented, of which, cases 1 and 2 manifested the symptoms severer than cases 3 and 4, along with higher serum lactate dehydrogenase levels and graded for lymphocytopenia. Case 4 initially exhibited anosmia but recovered within a short period. Curves of the CT of all the cases, except case 2, concaved upward after prescribing hydroxychloroquine (HCQ) and azithromycin. Except for case 4, the CT in most stool specimens remained undetectable; however, none of the cases presented gastrointestinal symptoms. Surprisingly, the CT values of the saliva specimens were inconsistent with those of the nasopharyngeal swabs and sputum.

Conclusion:

SARS-CoV-2 manifests various symptoms. Sudden onset of central nervous system symptoms should be considered. The timing of HCQ and azithromycin administration might be a key factor in the viral load reduction. Positive prediction values of RT-qPCR of different specimens should be tested carefully to prevent false-negative results.
Contribution of Patient Care Technicians to the Prevention of External Ventricular Drain Infection: A Retrospective Study
Authors: Fang Wenchao , Wei Anqi , Zhu Yuanrun , You Wendong , Wang Hao , Wen Liang , Yang Xiaofeng
Published: November 2020

BACKGROUND: External ventricular drains (EVDs) are commonly used in neurosurgery. Preventing EVD-related infections is important, and nursing plays a significant role in infection control. However, because of the limited number of neurosurgical nurses and heavy workload in developing countries, well-trained patient care technicians (PCTs) might be able to assist nurses under this circumstance. METHODS: This study retrospectively screened patients who underwent EVD procedures in our medical center from January 2012 to June 2018. Clinical characteristics including EVD-related infection rates of patients with or without PCTs were compared. RESULTS: We analyzed 234 patients in total. There were 26 EVD infection cases, and the overall infection rate was 11.1%. There were 122 patients who were given additional care by PCTs. They were elder (58.1 ± 13.1 vs 49.9 ± 17.0 years old, P < .001) and had lower level preoperational Glasgow Coma Scale (7.04 ± 3.66 vs 13.5 ± 2.53, P < .001) and higher intubation rate (28.7% vs 3.6%, P < .001) than those without PCTs. They also had a longer drainage duration (10.3 ± 4.97 vs 8.01 ± 4.35, P < .001) as well as more cerebrospinal fluid sampling times (2.45 ± 2.00 vs 1.75 ± 1.83, P = .006) and were kept at artificial airway status for a longer duration (10.1 ± 18.7 vs 1.93 ± 7.86, P < .001). External ventricular drain–related infection rates were similar between 2 groups (11.5% vs 10.7%, P = .853). CONCLUSION: Patient care technicians with proper training are beneficial to the prevention of EVD-related infection as a measure of improving staffing adequacy.
The Importance of Small Business Safety and Health Climates During COVID-19
Authors: Brown Carol E. , Schwatka Natalie , Dexter Lynn , Dally Miranda , Shore Erin , Tenney Liliana , Newman Lee S.
Published: November 2020

Objective:

This study examines employee perceptions of safety and health climates for well-being during the COVID-19 pandemic in a sample of small businesses.

Methods:

We evaluated changes to employees’ work and home life resulting from COVID-19 and perceptions of safety and health climates. Cross-sectional relationships were assessed using multivariable linear regression models for a sample of 491 employees from 30 small businesses in Colorado in May 2020.

Results:

Employee perceptions of safety and health climates were significantly related to their self-reported well-being during the first wave of COVID-19, even when there were changes to childcare, the ability to work, and limited social contacts.

Conclusion:

Safety and health climates may influence employee well-being even when other disruptions occur, suggesting that during emergencies, small businesses with strong climates may be better prepared to maintain employee well-being.
Cholesteatoma Imaging Using a Digital Image Enhancement System During Endoscopic Ear Surgery
Authors: Miwa Toru , Takeda Hiroki , Minoda Ryosei
Published: November 2020

Supplemental Digital Content,
http://links.lww.com/MAO/B68.
Association of Subjective Hearing Loss and Apolipoprotein E ε4 Allele on Alzheimer's Disease Neurodegeneration
Authors: Neff Ryan M. , Jicha Gregory , Hawk Gregory S. , Bush Matthew L. , McNulty Beth
Published: November 2020

Objective:

Hearing loss (HL) and apolipoprotein E ε4 (ApoE4) allele are both dementia risk factors. No research has investigated the association of these variables regarding dementia, specifically Alzheimer's disease. Our goal was to evaluate HL and ApoE4 allele positivity toward degree of Alzheimer's neurodegeneration.

Study Design:

Retrospective.

Setting:

Academic.

Patients:

Alzheimer's neuropathology obtained from brain tissue databank. Documented demographics, subjective hearing status, cognition, and ApoE4. Subjects divided into four groups based on hearing status and ApoE4 positivity.

Main Outcome Measures:

Differences in cognition (clinical dementia rating, mini mental state examination (MMSE), geriatric depression score) and Alzheimer's neuropathology staging (Braak, CERAD) between groups.

Results:

Two-hundred and fifty-nine subjects. No significant difference between groups, with regard to hearing status or ApoE4 positivity, in premorbid cognition, including scores for clinical dementia rating and MMSE (p = 0.2332). HL subjects had less severe neuropathology, as compared with normal hearing subjects. For example, high grade Braak stage was present in 27.1 and 51.0% of HL and normal hearing subjects, respectively (p = 0.0263). This finding was in context of equivocal clinical cognition between groups. ApoE4+ individuals had more severe neurodegeneration; for example, 65.7 and 33.5% with high grade Braak stage for ApoE4+ and ApoE4– subjects, respectively (p < 0.0001).

Conclusion:

Subjective HL subjects had less severe neuropathology with no difference in cognition, suggesting an additive effect of HL to cognitive burden of Alzheimer's neuropathology. HL appeared to increase cognitive burden, but wasn’t manifested by greater neurodegeneration. This is clinically relevant in that treating HL could slow Alzheimer's disease progression.
A Protective Cap: Fundal Fluid Cap Facilitates a Reduction in Inner Ear Radiation Dose in the Radiosurgical Treatment of Vestibular Schwannoma
Authors: Bojrab Dennis I. , Fritz Christian G. , Lin Kenny F. , Schutt Christopher A. , Hong Robert S. , Babu Seilesh C. , Chen Peter Y. , Maitz Ann , Bojrab Dennis I.
Published: November 2020

Objective:

Assess inner ear radiation dose magnitude as it relates to fundal cap length and hearing outcomes in the radiosurgical treatment of vestibular schwannoma.

Study Design:

Retrospective case series.

Setting:

Tertiary neurotology referral center.

Patients:

Patients treated with Gamma Knife radiosurgery for vestibular schwannoma between March 2007 and March 2017 were considered for this study. Exclusion criteria included pretreatment pure-tone average (PTA) >90 dB, neurofibromatosis type II, history of previous surgical resection, and follow-up less than 1 year.

Main Outcome Measure:

(s): Hearing function was assessed by maintenance of class A/B hearing level and maintenance of baseline hearing (≤20 dB change in PTA following Gamma Knife radiosurgery).

Results:

Lower radiation doses delivered to the inner ear were associated with longer fundal cap lengths: mean cochlear dose (r = −0.130; p = 0.184), mean labyrinth dose (r = −0.406; p < 0.001), max cochlear dose (r = −0.326; p = 0.001), and max labyrinth dose (r = −0.360; p < 0.001). Kaplan–Meier analysis with log-rank testing revealed that patients with a mean labyrinth dose < 3 Gy achieved higher rates of preserving baseline hearing (≤20 dB change in PTA) following radiosurgery, compared to patients with a mean labyrinth dose ≥3 Gy (p < 0.001). A fundal fluid cap length of 2.5 mm was associated with the 3 Gy mean labyrinth dose threshold.

Conclusions:

We report that fundal cap presence facilitated the creation of treatment plans with a lower dose delivered to the labyrinth. By affording this dose reduction, a fundal cap may be associated with a slight improvement in hearing outcomes.
Within-Subject Comparisons of the Auditory Brainstem Response and Uncomfortable Loudness Levels in Ears With and Without Tinnitus in Unilateral Tinnitus Subjects With Normal Audiograms
Authors: Shim Hyun Joon , Cho Yong tae , Oh Hyeon Sik , An Yong-Hwi , Kim Dong Hyun , Kang Yeon Shin
Published: November 2020

Objective:

To evaluate whether cochlear synaptopathy is a common pathophysiologic cause of tinnitus in individuals with normal audiograms.

Study Design:

Prospective study.

Setting:

Tertiary referral center.

Methods:

We enrolled 27 subjects with unilateral tinnitus and normal symmetric hearing thresholds, and 27 age- and sex-matched control subjects with normal symmetric hearing thresholds. We measured 1) the amplitudes of waves I and V with 90 dB nHL click stimuli in quiet conditions; 2) the latency shift of wave V with 80 dB nHL click stimuli in background noise, varying from 40 dB HL to 70 dB HL; and 3) uncomfortable loudness levels (UCLs) at 500 Hz and 3000 Hz pure tones.

Results:

There were no significant differences in the wave V/I amplitude ratio or the latency shift in wave V with increasing noise levels among the tinnitus ears (TEs), nontinnitus ears (NTEs), and control ears. There were no significant differences in UCLs at 500 Hz or 3000 Hz between TEs and NTEs, but the UCLs were lower in TEs (mean 111.3 dB or 104.1 dB) and NTEs (mean 109.4 dB or 100.6 dB) than in control ears (mean 117.9 dB or 114.1 dB, p 
< 0.017). No subject met our criteria for cochlear synaptopathy or increased central gain in terms of all three parameters.

Conclusion:

Based on these results for UCL, increased central gain is a major mechanism of tinnitus in humans with normal audiograms. However, this compensatory mechanism for reduced auditory input may originate from other pathophysiologic factors rather than from cochlear synaptopathy.
Clinical safety and efficacy of thrombolytic therapy with low-dose prolonged infusion of tissue type plasminogen activator in patients with intermediate-high risk pulmonary embolism
Authors: Güner Ahmet , Kalçik Macit , Aykan Ahmet Ç. , Gürsoy Mustafa O. , Kalkan Ali K. , Astarcioğlu Mehmet A. , Ertürk Mehmet , Uzun Fatih , Güner Ezgi G. , Yildiz Mustafa , Özkan Mehmet
Published: November 2020

The patients with intermediate-high risk pulmonary embolism who have acute right ventricular (RV) dysfunction and myocardial injury without overt hemodynamic compromise may be candidates for thrombolytic therapy. Alternative low-dose thrombolytic therapy strategies with prolonged infusion may further decrease the complication rates as its efficacy and safety have been previously proven in the management of prosthetic valve thrombosis. In this study, we aimed to investigate the clinical outcomes of low-dose prolonged thrombolytic therapy regimen in intermediate-high risk pulmonary embolism patients. This study enrolled 16 retrospectively evaluated patients (female 9, mean age: 70.9 ± 13.5 years) with the diagnosis of acute pulmonary embolism who were treated with low-dose and slow-infusion of tissue-type plasminogen activator (t-PA). All patients underwent transthoracic echocardiography and computed tomography scan for assessment of thrombolytic therapy success. Low-dose prolonged thrombolytic therapy was successful in all patients. The mean t-PA dose used was 48.4 ± 6.3 mg. There was residual segmental thrombus in nine (56.3%) patients after thrombolytic therapy. The arterial oxygen saturation and tricuspid annular plane systolic excursion increased after thrombolytic therapy whereas heart rate, RV to left ventricular (LV) ratio, systolic pulmonary artery pressure, and the frequencies of hypotension and tachypnea significantly decreased. There was no cerebrovascular accident or major bleeding requiring transfusion. There were two minor bleedings (12.5%) including hemoptysis and epistaxis. Thrombolytic therapy in these intermediate-high risk pulmonary embolism patients was associated with excellent clinical outcomes and survival to discharge (100%) without any 60-day mortality. Prolonged thrombolytic therapy regimen with low-dose and slow-infusion of t-PA may be associated with lower complication rates without comprimising effectiveness in patients with acute intermediate-high risk pulmonary embolism.
Influence of Intraoperative Microelectrode Recording in Deep Brain Stimulation
Authors: Reddy Sujan T. , Fenoy Albert J. , Furr-Stimming Erin , Schiess Mya C. , Mehanna Raja
Published: November 2020

Background:

There is considerable debate regarding the use of intraoperative microelectrode recording (MER) in deep brain stimulation (DBS).

Objective:

To determine if the use of intraoperative MER impacts the final position of the lead implant in DBS of the subthalamic nucleus (STN) and globus pallidus (GPi) and to evaluate the incidence of complications.

Methods:

The authors conducted a retrospective chart review of all patients who underwent STN and GPi DBS with MER, at the University of Texas Health Science Center in Houston from June 1, 2009 to October 1, 2013 to compare initial and final coordinates. Hemorrhagic and infectious complications were reviewed.

Results:

A total of 90 lead implants on 46 patients implanted at the center during this time period were reviewed and included in the study. A statistically significant difference between the initial and final coordinates was observed in the superior-inferior direction with a mean difference of 0.40 mm inferiorly (±0.96 mm, P<0.05) and 0.96 mm inferiorly (±1.32 mm, P<0.05) in the STN and GPi locations, respectively. A nonstatistically significant difference was also observed in the anterior-posterior direction in both locations. There were no intraparenchymal hemorrhages on postoperative computed tomography. Two patients developed postoperative seizures (7.4%). One STN electrode (1.1%) required revision because of a suboptimal response.

Conclusions:

Intraoperative MER in STN and GPi DBS implant does not seem to have a higher rate of surgical complications compared with historical series not using MER and might also be useful in determining the final lead location.
Diffusion Tensor Imaging Tractography Detecting Isolated Oculomotor Paralysis Caused by Pituitary Apoplexy
Authors: Hou Xiaolin , Li Chengxun , Yang Dongdong , Li Dingjun , Zeng Lin , Mei Yuqian
Published: November 2020

Objectives:

Pituitary apoplexy (PA)-induced oculomotor palsy, although rare, can be caused by compression on the lateral wall of the cavernous sinus. This study aimed to visualize PA-induced oculomotor nerve damage using diffusion tensor imaging (DTI) tractography.

Materials and Methods:

We enrolled 5 patients with PA-induced isolated oculomotor palsy (patient group) and 10 healthy participants (control group); all underwent DTI tractography preoperatively. Fractional anisotropy (FA) and mean diffusion (MD) values of the cisternal portion of the bilateral oculomotor nerve were measured. DTI tractography was repeated after the recovery of oculomotor palsy.

Results:

While no statistical difference was observed in FA and MD values of the bilateral oculomotor nerve in the control group (P>0.05), the oculomotor nerve on the affected side was disrupted in the patient group, with a statistical difference in FA and MD values of the bilateral oculomotor nerve (P<0.01). After the recovery of oculomotor palsy, the FA value of the oculomotor nerve on the affected side increased, whereas the MD value decreased (P<0.01). Meanwhile, no significant difference was observed in FA and MD values of the bilateral oculomotor nerve (P>0.05). DTI tractography of the oculomotor nerve on the affected side revealed restoration of integrity. Furthermore, the symptoms of oculomotor palsy improved in all patients 7 days postoperatively.

Conclusion:

DTI tractography could be a helpful adjunct to the standard clinical and paraclinical ophthalmoplegia examinations in patients with PA; thus, this study establishes the feasibility of DTI tractography in this specific clinical setting.
Real-time Assessment of Neurology Residents’ Perceptions of Inappropriate Consults
Authors: Gentile Caroline , Loebel Emma , Sanky Charles , Krieger Stephen
Published: November 2020

Background:

We sought to characterize perceptions of inappropriate neurology consults of neurology residents (NR) and requesting providers (RP) immediately following the consult interaction.

Methods:

Student investigators were embedded in the Mount Sinai neurology consult service for 4 weeks in May/June 2018. For each consecutive neurology consult the NR’s real-time attitudes toward the consult were evaluated with a survey using Likert scales. A similar survey was immediately administered to the RP who called the consult. Response scores for each attribute were dichotomized and data were analyzed descriptively in SPSS.

Results:

Data from 69 consults were collected. NRs perceived 45% of consults as inappropriate and 82% of all consults as low urgency. When NRs perceived a consult as inappropriate, they felt more resistance (r=−0.79). NRs also felt more resistant when they thought that the RP could have cared for the patient without the consult (r=0.79). NRs felt that perceived medicolegal risk highly influenced the RP’s decision to call a consult in 36% of cases. Of these “high liability” consults, NRs considered 76% inappropriate and 100% low urgency.

Conclusions:

NRs were more likely to rate consults as inappropriate if they were also perceived as low urgency, strongly influenced by liability concerns, or unnecessary due to belief that the RP could have cared for the patient without the consult. Our findings suggest a discrepancy in how NRs and RPs perceive neurology consult appropriateness, and help to elucidate potential drivers of these perceptions that could be barriers to education and to interdisciplinary care.
Rosai-Dorfman Disease Displays a Unique Monocyte-Macrophage Phenotype Characterized by Expression of OCT2
Authors: Ravindran Aishwarya , Goyal Gaurav , Go Ronald S. , Rech Karen L.
Published: November 2020

Rosai-Dorfman disease (RDD) is a rare histiocytosis with heterogenous clinical features. In this study, we characterized the histologic and phenotypic features in 33 RDD patients to better define the pathologic diagnosis. Cases included 24 patients with extracutaneous disease (“R” group), and 9 patients with lesions limited to the skin or subcutaneous tissue (“C” group). We identified OCT2 as a novel marker for the monocyte-macrophage phenotype of RDD, expressed in 97% of RDD cases. In contrast, OCT2 expression was seen in 0% of Erdheim-Chester disease cases and 6.7% of Langerhans cell histiocytosis cases. Other markers useful in the diagnosis of RDD included S100 (100%), CD163 (88%), and cyclin D1 (97%). In a subset of cases, RDD showed moderate to strong expression of factor 13a (30%), p16 (64%), and phosphorylated extracellular signal-regulated kinase (45%); RDD was uniformly negative for ZBTB46, CD1a, and langerin. Within the “R group” of RDD, increased expression of factor 13a or phosphorylated extracellular signal-regulated kinase showed a statistically significant association with multifocal disease (P<0.05). Identification of the unique monocyte-macrophage phenotype of RDD with OCT2 expression furthers our understanding of this complex disease and allows for more uniform classification.
Late-onset Cytomegalovirus Infection Associated With Gastric Outlet Obstruction in a Preterm Twin
Authors: Dries Verena , Müller Dirk , Schnekenburger Franz G. , Berger Irina , Rottscholl Robert , Jenke Andreas C.W.
Published: November 2020

The infant was born at a gestational age of 28 + 2 weeks as second twin to a 26-year-old woman, G1/P0, due to eclampsia. The patient developed well and was on full oral feeds when he started to develop nonbilious vomiting at 5 weeks. He was diagnosed with pyloric hypertrophy and underwent pylorotomy, but the condition did not improve and the patient was referred to our hospital. Here, esophagogastroduodenoscopy showed severely inflamed esophageal and gastric mucosa which was found to be due to cytomegaly virus (CMV) infection and a nonpassable pylorus. The patient underwent pyloroplasty revealing a fibrous pyloric ring. Histology showed giant cells suggestive of CMV infection which was confirmed by polymerase chain reaction. He was started on valganciclovir and discharged 4 weeks later on full enteral feeds. To our knowledge, this is the first case of gastric outlet obstruction due to CMV infection in a premature infant.
Review of Outcomes in Prepectoral Prosthetic Breast Reconstruction with and without Surgical Mesh Assistance
Authors: DeLong Michael R. , Tandon Vickram J. , Bertrand Anthony A. , MacEachern Mark , Goldberg Mytien , Salibian Arthur , Pusic Andrea L. , Festekjian Jaco H. , Wilkins Edwin G.
Published: November 2020

Background:

In the past decade, surgeons have increasingly advocated for a return to prepectoral breast reconstruction with claims that surgical mesh (including acellular dermal matrix) can reduce complication rates. However, numerous surgical and implant advancements have occurred in the decades since the initial prepectoral studies, and it is unclear whether mesh is solely responsible for the touted benefits.

Methods:

The authors conducted a systematic review of all English language articles reporting original data for prepectoral implant-based breast reconstruction. Articles presenting duplicate data were excluded. Complications were recorded and calculated on a per-breast basis and separated as mesh-assisted, no-mesh prior to 2006, and no-mesh after 2006 (date of first silicone gel–filled breast implant approval). Capsular contracture comparisons were adjusted for duration of follow-up.

Results:

A total of 58 articles were included encompassing 3120 patients from 1966 to 2019. The majority of the included studies were retrospective case series. Reported complication outcomes were variable, with no significant difference between groups in hematoma, infection, or explantation rates. Capsular contracture rates were higher in historical no-mesh cohorts, whereas seroma rates were higher in contemporary no-mesh cohorts.

Conclusions:

Limited data exist to understand the benefits of surgical mesh devices in prepectoral breast reconstruction. Level I studies with an appropriate control group are needed to better understand the specific role of mesh for these procedures. Existing data are inconclusive but suggest that prepectoral breast reconstruction can be safely performed without surgical mesh.
Muscle Spindles in the Levator Palpebrae Superioris Muscle of Human Adults
Authors: Takahashi Yasuhiro , Ohmichi Yusuke , Lee Patricia Ann L. , Naito Munekazu , Nakano Takashi , Kakizaki Hirohiko
Published: November 2020

In this experimental anatomic study, the authors examined the number and distribution of muscle spindles in the levator palpebrae superioris (LPS) muscle of human adults. This study included 11 orbits from 11 cadavers (mean age at death, 81.9 years). The LPS muscles were harvested and equally divided into 5 sections using transverse incisions. Muscle spindles were counted in each section. Consequently, muscle spindles were identified in 4 (36.4%) of the 11 orbits studied. One to 4 muscle spindles were identified in each of these 4 orbits. All muscle spindles were found in the most proximal section (the muscle origin), and no muscle spindles were identified in the other sections. The results indicate that the LPS muscle is associated with a smaller number of muscle spindles as compared with the rest of the extraocular muscles. Since higher muscle spindle numbers are associated with finer motor movements, eyelid opening does not seem to require much precision, compared to ocular movement.