bluuebunny/crossref_metadata_2025 huggingface dataset:
High Kynurenine:Tryptophan Ratio Is Associated With Liver Fibrosis in HIV-Monoinfected and HIV/Hepatitis C Virus–Coinfected Women
Authors: Kardashian Ani , Ma Yifei , Yin Michael T , Scherzer Rebecca , Nolan Olivia , Aweeka Francesca , Tien Phyllis C , Price Jennifer C
Published: June 2019

Background

Tryptophan catabolism, measured by the kynurenine:tryptophan (kyn/trp) ratio, is associated with gut microbiota alterations in people with HIV (PWH). We examined the association of the kyn/trp ratio with liver fibrosis in women with/without HIV infection.

Methods

The plasma kyn/trp ratio was measured in 137 HIV-monoinfected, HIV/hepatitis C virus (HCV)–coinfected, and uninfected women in the Women’s Interagency HIV Study. Fibrosis was estimated using FIB-4 in all participants and vibration-controlled transient elastography liver stiffness measurement (LSM) in a subset (n = 83). We used multivariable linear regression to evaluate the associations of infection status and kyn/trp ratio with relative differences in fibrosis estimates.

Results

The median kyn/trp ratio (interquartile range) was 0.056 (0.045–0.066) in HIV/HCV-coinfected, 0.038 (0.032–0.046) in HIV-monoinfected, and 0.031 (0.025–0.034) in uninfected women (P < .001). After adjustment for sociodemographic, lifestyle, and metabolic factors, HIV monoinfection and HIV/HCV coinfection were associated with 37% (95% confidence interval [CI], 9% to 73%) and 164% (95% CI, 100% to 250%) greater FIB-4, respectively. When kyn/trp ratio was included, higher kyn/trp ratio was associated with greater FIB-4 (27% per kyn/trp doubling; 95% CI, 5% to 53%), and the associations of HIV monoinfection (29% per kyn/trp doubling; 95% CI, 2% to 63%) and HIV/HCV coinfection (123% per kyn/trp doubling; 95% CI, 63% to 203%) with greater FIB-4 were attenuated. Among those with LSM, higher kyn/trp ratio was associated with greater LSM (43% per kyn/trp doubling; 95% CI, 15% to 79%) in multivariable analysis.

Conclusions

The kyn/trp ratio is elevated in PWH and is associated with greater liver fibrosis. Tryptophan catabolism may modify the relationships between HIV, HCV, and fibrosis.
The predictors of and reasons for non-adherence in an observational cohort of patients with rheumatoid arthritis commencing methotrexate
Authors: Hope Holly F , Hyrich Kimme L , Anderson James , Bluett James , Sergeant Jamie C , Barton Anne , Cordingley Lis , Verstappen Suzanne M M ,   RAMS co-investigators, Adebajo Ade , Ahmed Khalid , Al-Ansari Atheer , Amarasena Roshan , Bukhari Marwan , Callan Margaret , Chelliah Easwaradhas G , Chinoy Hector , Cooper Annie , Dasgupta Bhaskar , Davis Martin , Galloway James , Gough Andrew , Green Michael , Gullick Nicola , Hamilton Jennifer , Hassan Waji , Hider Samantha , Hyrich Kimme , Kamath Sanjeet , Knight Susan , Lane Suzanne , Lee Martin , Levy Sarah , Macphie Lizzy , Marguerie Christopher , Marshall Tarnya , Mathews Catherine , McKenna Frank , Naz Sophia , Perry Mark , Pollard Louise , Quilty Brian , Robertson Lindsay , Roy Dipak , Sanders Paul , Saravanan Vadivelu , Scott David , Smith Gillian , Smith Richard , Symmons Deborah , Teh Lee-Suan , Viner Nick
Published: June 2019

Objective

In order to develop interventions to optimize MTX use for the treatment of RA we evaluated the rate of, reasons for and predictors of MTX non-adherence during the first 6 months of therapy.

Methods

The Rheumatoid Arthritis Medication Study (RAMS) is a prospective multicentre cohort study of incident MTX users in the UK. Prior to MTX commencement demographic, clinical and psychological data were collected. A weekly patient-completed diary recorded MTX dose, possible side effects and adherence over 26 weeks. The number of non-adherent weeks was calculated. Potential baseline predictors of ever non-adherence (⩾1 week non-adherent) during the first 6 months of MTX therapy were identified using logistic regression analyses.

Results

606 patients with RA were included; 69% female, mean (s.d.) age 60 (13) years and DAS28 score 4.2 (1.2). Over the first 6 months following MTX initiation, 158 (26%) patients were ever non-adherent (71% intentional, 19% non-intentional, 10% unexplained) and mean (s.d.) number of non-adherent weeks was 2.5 (2.1). Multivariable predictors of ever non-adherence included DAS28 [odds ratios (OR) 1.1, 95% CI 1.0, 1.4], fatigue (OR 1.1, 95% CI 1.0, 1.2 per cm), ⩾2 comorbidities vs no comorbidities (OR 1.9, 95% CI 1.1, 3.5) and high medication concerns despite perceived need (OR 1.1, 95% CI 1.0, 1.1 per unit decrease in need/concern differential).

Conclusion

This is the largest study evaluating early intentional and non-intentional non-adherence to MTX, which has identified that patient beliefs and multi-morbidity strongly link with non-adherence. These findings can direct the design of and provide potential targets for interventions to improve patient adherence.
Drug provocation testing: risk stratification is key
Authors: Garvey Lene H. , Savic Louise C.
Published: June 2019

Purpose of review

This review aims to describe current best practice and recent advances in the use of risk stratification as a tool for drug provocation testing (DPT). In particular, we focus on the testing of unsubstantiated penicillin allergy labels.

Recent findings

The inherent risks of DPT are mitigated through careful selection of patients. A detailed history will elicit features of a potentially severe index reaction, as well as significant patient comorbidities which may increase the risks associated with DPT. Such patients require skin testing and/or in vitro testing prior to consideration for a DPT. However, there is increasing evidence that patients without these features may be able to proceed directly to DPT. This has been demonstrated extensively with unsubstantiated penicillin allergy labels, and a variety of risk stratification models have been employed to identify the ‘low-risk’ patient. Improved outcomes and reduced cost have been demonstrated with such models without compromising patient safety.

Risk stratification tools may enable well-tolerated and effective ‘delabelling’ of low-risk patients, with less demand on already scarce resources.
The roles of omega-3 fatty acids and resolvins in allergic conjunctivitis
Authors: Hirakata Toshiaki , Yokomizo Takehiko , Matsuda Akira
Published: June 2019

Purpose of review

Lipids are one of the most important constituents in our body. Advances of lipidomics are elucidating the new roles of various lipid molecules in allergic diseases. For example, some reports showed anti-inflammatory effects of omega-3 fatty acids (FAs), such as docosahexaenoic acid, eicosapentaenoic acid, and their metabolites, on allergic diseases. Here, we introduce the role of lipid mediators in allergic conjunctivitis mouse model.

Recent findings

Lipidomics using liquid chromatography–tandem mass spectrometry can profile numerous lipid molecules from small tissue samples such as conjunctival specimens. Lipidomics analysis showed that various inflammatory lipid mediators are produced in the conjunctival tissue of allergic conjunctivitis mouse model. Dietary omega-3 FAs reduced these inflammatory lipid mediators in the conjunctiva and alleviated allergic conjunctivitis symptoms in mouse models. In addition, the roles of specialized proresolving lipid mediators (SPMs) have been reported for allergic inflammation.

Lipid mediators have important roles for the pathophysiology of the allergic diseases including allergic conjunctivitis. Omega-3 FAs and SPMs are expected as new treatment tools for allergic conjunctivitis.
Comparing Postoperative Analgesic Effect of Dexmedetomidine or Dexamethasone Added to Lidocaine Through Infraclavicular Block in Forearm Surgery
Authors: Yaghoobi Siamak , Shahamat Hoda , Alizadeh Ali , Khezri Marzieh Beigom
Published: June 2019

Objective:

The objective of this study was to compare the analgesic efficacy of dexamethasone versus dexmedetomidine added to lidocaine using infraclavicular block in patients undergoing forearm fracture surgery.

Method:

Seventy-five patients aged 20 to 60 years were recruited for a prospective, double-blinded, randomized clinical trial. Ultrasound-guided infraclavicular brachial plexus block was performed in 3 groups by injecting 28 mL lidocaine plus 2 mL distilled water (Lido), 28 mL lidocaine plus 2 mL (8 mg) dexamethasone (Dexa), and 28 mL lidocaine plus 2 mL (1 µg/kg) dexmedetomidine (Dexm). Sensory and motor block onset time and the duration, hemodynamic variables, the time for the first analgesic request, and the total analgesic agents consumed within 6 hours after infraclavicular block were assessed.

Results:

Sensory block duration in the Dexm group was significantly greater than in the Lido (P=0.019) and Dexa (P=0.046) groups. The mean motor block duration in the Dexm group showed to be significantly longer than that in the Lido group (P=0.009). Pain intensity within 4 hours after block significantly increased in the Lido group compared with that in the Dexa and Dexm groups (P=0.001). Analgesic consumption during 6 hours after the procedure was higher in the Lido group when compared with the other 2 groups (P=0.001). The Dexm group showed the highest reduction in the mean arterial pressure (P=0.006) and heart rate (P=0.001) among the 3 groups.

Conclusions:

There was no significant difference in postoperative pain intensity between the Dexa and Dexm groups, although DEXm demonstrated a longer sensory block duration in comparison with dexamethasone as a lidocaine adjuvant in infraclavicular block.
Evaluation of Opioid Use With Split Doses of Oral Opioids in a Postcesarean Delivery Analgesia Order Set
Authors: Nanji Jalal A. , Guo Nan , Riley Edward T. , Faulkner Bethan , Do Christina , Carvalho Brendan
Published: June 2019

OBJECTIVE:

To evaluate whether an order set change that halved the initial dose of oxycodone and allowed the remainder to be given 1 hour later, if requested, was associated with reduced opioid use and side effects after cesarean delivery.

METHODS:

This retrospective, clinical practice study reviewed electronic medical records after implementation of a new order set for cesarean delivery. Oxycodone orders changed from 5 mg (for verbal pain score of 4/10 or lower) and 10 mg (for 5–10/10) to 2.5 mg (for verbal pain score 1–4/10) or 5 mg (for 5–10/10), and the patient requesting pain relief, with a nurse check within 1 hour to administer another 2.5 or 5 mg, respectively, if needed. The primary outcome was opioid use (in intravenous morphine equivalents) in the first 48 hours. Secondary outcomes included incidence and treatment of nausea or vomiting and pruritis, average and peak verbal pain scores within 48 hours, and satisfaction.

RESULTS:

The records of 1,050 women were examined (542 before and 508 after the change). Opioid use in the first 48 hours was lower after the practice change (median [interquartile range] 10.0 [1.3–25.0] mg before vs 4.4 [0–12.5] mg after; P<.001). A small increase in average verbal pain score occurred (mean [SD] 1.8 [1.0] before vs 2.0 [1.3] after; difference −0.2; 95% CI −0.3 to −0.04). Peak verbal pain score (5.9 [2.0] before vs 6.0 [2.1] after; difference −0.1; 95% CI −0.4 to 0.1) and mean (SD) satisfaction score (97.7 [7.2] before vs 97.1 [7.5] after; difference 0.6, 95% CI −0.5 to 1.6) did not change. Fewer patients reported postoperative nausea or vomiting (30.9% before vs 19.3% after; odds ratio 0.5; 95% CI 0.4 to 0.7).

CONCLUSION:

Split doses of oxycodone were associated with 56% reduction in 48 hours opioid use after cesarean delivery.
Approaches to Vaginal Bleeding and Contraceptive Counseling in Transgender and Gender Nonbinary Patients
Authors: Schwartz Amanda R. , Russell Kristen , Gray Beverly A.
Published: June 2019

The transgender community has faced a long-standing history of prejudice and discrimination that has negatively affected their health. A lack of health care provider education and comfort with transgender medicine further challenges the ability of this population to obtain competent, gender-affirming medical care. As with all patients, a thorough patient history with avoidance of assumptions of sexual orientation based on gender identity is integral to providing appropriate care for transgender individuals. Vaginal bleeding in transgender men should be evaluated in a similar manner to natal women, and with knowledge of the individual's present reproductive organs. The majority of transgender men receiving gender-affirming hormone therapy will have cessation of menses by 6 months of continuous use; thus, bleeding beyond this interval warrants measurement of hormone levels and further evaluation. Progesterone-only contraceptive methods including progesterone-only pills, medroxyprogesterone acetate, or a levonorgestrel intrauterine device can be used in transgender men and nonbinary patients with continued menses despite physiologic testosterone levels, or to act as a bridge method for menstrual cessation at the time of testosterone initiation. For bleeding refractory to progesterone methods, health care providers should discuss surgical options or the use of aromatase inhibitors with their patients. Counseling on fertility desires and family planning is integral to improving the reproductive care of transgender patients. Contraceptive counseling for transgender patients should include not only the efficacy and ease of use of available methods, but also discussion of advantages and disadvantages of contraceptive options with regard to the patient's gender identity.
Increased Rwandan Access to Obstetrician–Gynecologists Through a U.S.–Rwanda Academic Training Partnership
Authors: Small Maria , Magriples Urania , Ghebre Rahel , Bazzett-Matabele Lisa , Ntirushwa David , Kitessa Doee , Ntasumbumuyange Diomede , Lantos Paul , Ngabonziza Eugene , Hill Washington , Ruzindana Kenneth , Rukundo Jean Damascene , Moscovitz Alexandra N. , Bagambe Patrick , Brown Haywood , Rulisa Stephen
Published: June 2019

OBJECTIVE:

To evaluate the first 5 years of the Human Resources for Health Rwanda program from the program onset in the July 2012–2016 academic years, and its effects on access to care through examination of: 1) the number of trained obstetrician–gynecologists (ob-gyns) who graduated from the University of Rwanda and the University of Rwanda-Human Resources for Health program and 2) a geospatial analysis of pregnant women's access to Rwandan public hospitals with trained ob-gyns.

METHODS:

We used GPS coordinates in this cross-sectional study to identify public (government) hospitals with ob-gyns in 2011 (before initiation of the program) compared with 2016 (year 5 of the program). We compared access to care for the years 2011 and 2016 through geocoding the proportion of pregnant women within 10 and 25 km from these hospitals and compared the travel time to these hospitals in the two time periods. We used a World Pop dataset of Rwandan pregnancies from 2015, ArcGIS for spatial operations, R for statistical analysis, zonal statistics for circular distances, and friction surface for travel time analysis.

RESULTS:

The number of ob-gyns in public hospitals increased from 14 to 49 nationally. Before the program, 18 residents graduated over a 7-year period (two residents per year); 33 graduated by year 5 (six residents per year). Rwandan faculty increased by 45%. In 2011, most providers were in the capital city. Between 2011 and 2016, the proportion of pregnant women living 10 km from an ob-gyn-staffed public hospital increased from 13.0% to 31.6%; within 25 km increased from 28.4% to 82.9%. Travel time analysis from 2011 to 2016 showed 49.1% of Rwandan women within 1 hour of a hospital and 85.6% within 2 hours. In 2016, this coverage increased to 87.5% and 98.3%, respectively.

CONCLUSION:

In 5 years, the Human Resources for Health Rwanda program improved the number of residency graduates in obstetrics and gynecology and nationwide access to these providers. The program reduced rural–urban disparities in access to ob-gyns.
Menstrual Suppression for Military Women
Authors: Eagan Sheena M.
Published: June 2019

Since 2000 there has been a 17% increase in the number of women serving in the U.S. military. As women enter the services in more significant numbers and are increasingly deployed to combat operations, the military must adopt policies and practices that accommodate the health care needs of female warriors. According to the American College of Obstetricians and Gynecologists, it is essential that obstetrician–gynecologists are knowledgeable and prepared to address the unique risks to women's reproductive health that are associated with military service. This article responds to this call by focusing on issues related to menstrual regulation or suppression in the female active-duty population. Analysis shows that although servicewomen have consistently reported a desire to suppress or regulate menstruation, rates of this practice remain low. Potential reasons for this include barriers to care and issues related to health literacy within the military population of patients and health care providers. This article provides an overview of the growing body of survey and interview data focusing on military women's health to show that there are gaps in knowledge and significant barriers to care that must be addressed. Ultimately, this work argues that medical care and counseling should be more responsive to the needs of female service members. Educating female service members on the option of menstrual suppression should be made a standard part of routine well-woman care and predeployment physicals, thereby removing sex-specific barriers and enabling more women to take on forward combat roles.
Genetically Modified Babies and a First Application of Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR-Cas9)
Authors: Rose Bruce I. , Brown Samuel
Published: June 2019

The world's first babies with CRISPR-Cas9 (Clustered Regularly Interspaced Short Palindromic Repeats)–edited genes were born on November 25, 2018. Dr. Jiankui He of Southern University of Science and Technology in Shenzhen performed this gene editing. Dr. He's objectives and an assessment of how well they were achieved are discussed in the context of existing research in this area.
Implementation of the Safe Reduction of Primary Cesarean Births Safety Bundle During the First Year of a Statewide Collaborative in Maryland
Authors: Callaghan-Koru Jennifer A. , Creanga Andreea A. , DiPietro Bonnie , Mark Katrina , Sowe Ardy , Aboumatar Nour , Burke Ann B. , Curran Geoffrey
Published: June 2019

OBJECTIVE:

To describe the status of implementation of the Alliance for Innovation in Maternal Health's primary cesarean birth patient safety bundle in Maryland after 1 year (2016–2017), and assess whether hospital characteristics and implementation strategies employed are associated with bundle implementation.

METHODS:

The Alliance for Innovation in Maternal Health's bundle to decrease primary cesarean births includes 26 evidence-based practices that hospitals can adopt based on specific needs. One year after the start of a statewide implementation collaborative at 31 of 32 birthing hospitals in Maryland, we sent a computer-based survey to hospital collaborative leaders to assess progress. Respondents reported on hospital characteristics, adoption of bundle practices, and use of 15 selected implementation strategies. We conducted descriptive and bivariate analyses of their responses.

RESULTS:

Among 26 hospitals with complete reporting, 23 fully implemented at least one bundle practice (range 1–7) during the collaborative's first year. Of 26 bundle practices, on average, hospitals had fully implemented a third (mean 8.6; SD 5.5; range 0–17) before the collaborative, and 3 new practices (SD 2.4; range 0–8) during the collaborative. Hospitals' use of six implementation strategies, all highly dependent on strong clinician involvement, was significantly associated with their fully implementing more practices during the collaborative's first year.

CONCLUSION:

Our assessment has promising results, with a majority of hospitals having implemented new cesarean birth bundle practices during the collaborative's first year. However, there are lessons from the wide variability in the number and type of practices adopted. Clinicians should be aware of this variability and become more involved in the implementation of cesarean birth bundle practices. We identified six strategies associated with full implementation of more bundle practices for which clinicians' support and commitment to practice changes are critical. Clinicians' understanding of available and effective implementation strategies can better assist with the implementation of this and other Alliance for Innovation in Maternal Health patient safety bundles.
What Is New in Recurrent Pregnancy Loss?
Authors: Ros Stephanie T.
Published: June 2019

This month we focus on current research in recurrent pregnancy loss. Dr. Ros discusses four recent publications, which are concluded with a “bottom-line” that is the take-home message. A complete reference for each can be found on Box 1 on this page along with direct links to abstracts.
A Predictive Score for Determining Risk of Surgical Site Infection After Orthopaedic Trauma Surgery
Authors: Wise Brent T. , Connelly Daniel , Rocca Michael , Mascarenhas Daniel , Huang Yanjie , Maceroli Michael A. , Gage Mark J. , Joshi Manjari , Castillo Renan C. , O'Toole Robert V.
Published: June 2019

Objectives:

To determine factors predictive of postoperative surgical site infection (SSI) after fracture fixation and create a prediction score for risk of infection at time of initial treatment.

Design:

Retrospective cohort study.

Setting:

Level I trauma center.

Patients/Participants:

Study group, 311 patients with deep SSI; control group, 608 patients.

Intervention:

We evaluated 27 factors theorized to be associated with postoperative infection. Bivariate and multiple logistic regression analyses were used to build a prediction model. A composite score reflecting risk of SSI was then created.

Main Outcome Measures:

Risk of postoperative infection.

Results:

The final model consisted of 8 independent predictors: (1) male sex, (2) obesity (body mass index ≥ 30) (3) diabetes, (4) alcohol abuse, (5) fracture region, (6) Gustilo–Anderson type III open fracture, (7) methicillin-resistant Staphylococcus aureus nasal swab testing (not tested or positive result), and (8) American Society of Anesthesiologists classification. Risk strata were well correlated with observed proportion of SSI and resulted in a percent risk of infection of 1% for ≤3 points, 6% for 4–5 points, 11% for 6 to 8–9 points, and 41% for ≥10 points.

Conclusion:

The proposed postoperative infection prediction model might be able to determine which patients have fractures at higher risk of infection and provides an estimate of the percent risk of infection before fixation.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Two-Stage Combined Ortho-Plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated With Outcomes?
Authors: Al-Hourani Khalid , Fowler Tim , Whitehouse Michael R. , Khan Umraz , Kelly Michael
Published: June 2019

Objective:

To delineate whether timing to initial debridement and definitive treatment had an effect on patient outcomes in those undergoing 2-stage ortho-plastic management of Gustilo–Anderson type IIIB open tibial diaphyseal fractures.

Design:

Retrospective comparative cohort study over a 2-year period.

Setting:

Level 1 trauma center.

Patients/Participants:

A total of 148 patients were identified. After exclusion of ankle fractures, nondiaphyseal fractures and those who did not undergo 2-stage ortho-plastic management, 45 patients were eligible for final analysis.

Intervention:

Time to initial debridement and definitive management.

Main Outcome Measurement:

Deep infection. Secondary outcomes being nonunion and flap failure. Multiple linear regression was used for outcomes. We assumed a priori that P values of less than 0.05 were significant.

Results:

Mean age was 54 years (SD 23.0), with 28 men and 17 women. Over a mean 2-year follow-up, there were 4 (4/45) deep infections, 2 infection-associated flap failures, and 1 vascular flap failure. All patients progressed to union. The mean time to initial debridement for the whole cohort was 19 hours (SD 12.3), and the mean time to definitive reconstruction was 65 hours (SD 51.7). Longer time to both initial debridement and definitive reconstruction was not found to be significantly associated with deep infection, infected flap failure, or nonunion.

Conclusions:

Using a 2-stage ortho-plastic operative algorithm, timing to initial debridement and definitive fixation with soft-tissue coverage was not associated with negative outcomes.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Steindler Flexorplasty: A Description of Current Technique and Case Series
Authors: Marinello Patrick G. , Gaston R. Glenn , Loeffler Bryan J. , Lewis Daniel R.
Published: June 2019

This year marks the 100th anniversary of Dr Steindler’s original report of a proximal transfer of the flexor pronator mass to restore elbow flexion. The authors present their updated surgical technique to perform the Steindler flexorplasty. In this procedure, the flexor-pronator mass origin on the medial epicondyle is transferred proximally to the anterior humerus to restore elbow flexion. They also report a retrospective case series of patients from 2007 to 2017 who underwent a Steindler flexorplasty at their institution to restore elbow flexion. In the series, 8 of 9 patients achieved at least 90 degrees of active antigravity (M3) or greater elbow flexion. Outcomes following the Steindler flexorplasty have been reported in the literature over the course of the past 100 years. Although alternative techniques to improve elbow flexion have been developed and performed over the last century, this time tested procedure remains a powerful reconstructive option.
Pretibial Pruritic Papular Dermatitis: A Comprehensive Clinical and Pathologic Review of Cases at a Single Institution
Authors: Flores Shadai , Wada David A. , Florell Scott R. , Bowen Anneli R.
Published: June 2019

Background:

Studies characterizing clinical and pathologic details of pretibial pruritic papular dermatitis (PPPD) are scarce. Several cases of PPPD at our institution have displayed lymphocyte atypia and CD30 positivity, resembling lymphomatoid papulosis (LyP). We explore the clinical and histological spectrum of PPPD, with emphasis on lymphocyte atypia.

Methods:

Retrospective observational study of 40 archived pathological specimens (hematoxylin/eosin, CD3, CD20, and CD30 immunohistochemistry) from 38 PPPD patients in an academic center. Clinical photographs were available in 22 cases.

Results:

Microscopic epidermal changes were focal, but common (spongiosis 75%, parakeratosis 90%, interface changes 43%, Langerhans cell microgranulomas 25%, multinucleated keratinocytes 55%, Civatte bodies 55%, erosion 20%, and more than focal irregular psoriasiform hyperplasia 37%) and certain dermal changes were universal (papillary dermal fibrosis 100%, stellate fibroblasts 100%, and multinucleated fibroblasts 93%). At least focal lymphocyte atypia was present in all cases. Lymphocytes were almost exclusively CD3+ T cells with rare CD20+ B cells. Up to 30% of lymphocytes exhibited weak CD30 staining. Clinically, all cases exhibited discrete papules, but plaques and erosions were not uncommon.

Limitations:

As a retrospective series, clinical images were not available for all cases.

Conclusion:

This study suggests a broader histological and clinical spectrum of PPPD than previously described. Epidermal changes are common in PPPD, as are atypical lymphocytes and focal CD30 positivity. Although the papular clinical appearance, lymphocyte atypia, and focal CD30 positivity may resemble LyP, the relatively low number of atypical lymphocytes, low intensity of CD30 staining, and absence of spontaneous resolution help to distinguish PPPD from LyP.
Surgical Volume of Dermatologists Who Do Not Perform Mohs Micrographic Dermatologic Surgery: A Cross-Sectional Individual-Level Analysis Using Medicare Data
Authors: Kantor Jonathan
Published: June 2019

BACKGROUND

Dermatologists overall perform a large number of procedures billed to Medicare, though the proportion of surgical procedures attributable to general dermatologists who do not perform Mohs micrographic dermatologic surgery (MDS) is unknown.

OBJECTIVE

To determine the surgical volume of dermatologists who do not perform MDS and compare it to the surgical volume of MDS-performing dermatologists and all non-dermatologists.

METHODS

A cross-sectional analytical study was performed using the Medicare public use file for 2014. Data were divided by physician specialty (dermatologists vs all non-dermatologists), and dermatologists were then dichotomized by MDS performance.

RESULTS

Non-MDS dermatologists performed 42.19% of the benign excisions, 57.18% of the malignant excisions, and 46.00% of the intermediate repairs billed to Medicare in 2014. Micrographic dermatologic surgery–performing dermatologists were responsible for most of the complex repairs (67.56%), flaps (52.85%), and grafts (59.65%) billed to Medicare.

CONCLUSION

Dermatologists who do not perform MDS represent the single largest group billing Medicare for benign excisions, malignant excisions, and intermediate repairs. They also bill for more complex repairs than all non-dermatologists combined. Micrographic dermatologic surgery–performing dermatologists performed most of the complex repairs, flaps, and grafts billed to Medicare.
Poly-l-Lactic Acid for Minimally Invasive Gluteal Augmentation
Authors: Lin Matthew J. , Dubin Danielle P. , Khorasani Hooman
Published: June 2019

BACKGROUND

There is increased emphasis on the importance of the gluteal region in the perception of beauty. Biodegradable fillers provide a nonsurgical method of augmenting and rejuvenating this area.

OBJECTIVE

To review pertinent aspects of anatomy, patient evaluation, injection technique, and complications for gluteal augmentation using injectable biodegradable fillers.

METHODS

The authors review the literature for poly-l-lactic acid–based gluteal augmentation.

RESULTS

Like many aesthetic procedures, there is a paucity of literature on this emerging treatment modality (Level 4, Centre for Evidence-Based Medicine, Oxford). However, the collective clinical experience is that poly-l-lactic acid fillers are an effective treatment for patients seeking noninvasive gluteal enhancement with minimal downtime. Physicians must understand gluteal anatomy and avoid injecting deeply in the danger triangle to prevent intravascular injection into the gluteal vessels or injury to the sciatic nerve. Other safety elements include the use of blunt cannulas, reduced pressures, smaller volumes, and retrograde delivery.

CONCLUSION

Gluteal augmentation with fillers can safely and effectively improve gluteal firmness, shape, proportion, and projection. Practitioners injecting fillers in the gluteal region must be aware of appropriate patient selection, regional anatomy, and safe injection techniques. Given the increasing demand for this procedure, further high-quality studies are needed.
Is core temperature the trigger of a menopausal hot flush?
Authors: Jones Helen , Bailey Tom G. , Barr David A. , France Madeleine , Lucas Rebekah A.I. , Crandall Craig G. , Low David A.
Published: June 2019

Objective:

Menopausal hot flushes negatively impact quality of life and may be a biomarker of cardiovascular and metabolic disease risk; therefore understanding the physiology of hot flushes is important. Current thinking is that a small elevation (∼0.03-0.05oC) in core temperature surpasses a sweating threshold (that is reduced in the menopause), sweating is activated, and a hot flush ensues. Nevertheless, more recent studies examining thermoregulatory control question whether core temperature per se can explain the trigger for a hot flush. The primary aim of this study was to assess the contribution of increases in core temperature on the occurrence of menopausal hot flushes.

Methods:

For this purpose, 108 hot flushes were objectively assessed in a laboratory setting in 72 symptomatic postmenopausal women (aged 45.8 ± 5.1 years; body mass index 25.9 ± 4.5 kg/m2) from five previously reported studies. Women rested, wearing a tube-lined suit (or trousers), which was perfused with 34oC water. A subset then underwent mild heat stress (48°C water). Sweat rate, skin blood flow, blood pressure, heart rate, skin, and core temperature were measured continuously throughout. A hot flush was objectively identified during rest (spontaneous hot flush) or mild heating as an abrupt increase in sternal sweat rate. Further, a subset of symptomatic postmenopausal women (n = 22) underwent whole-body passive heating for 60 minutes to identify core temperature thresholds and sensitivities for sweat rate and cutaneous vasodilation, which were compared to a subset of premenopausal women (n = 18). Data were analyzed using t tests and/or general linear modeling, and are presented as mean (95% confidence interval).

Results:

In the 20 minutes before a spontaneous hot flush, core temperature increased by 0.03 ± 0.12oC (P < 0.05), but only 51% of hot flushes were preceded by an increase in core temperature. During mild heating, 76% of hot flushes were preceded by an increase in core temperature. The temperature thresholds for sweating were similar, but the vasodilatory threshold was higher in postmenopausal compared with premenopausal women (37.1 ± 0.2 vs 36.8 ± 0.3°C; P = 0.06).

Conclusion:

We provide new evidence that menopausal hot flushes are unlikely triggered by an increase in core temperature. These findings provide important information about the physiology of hot flushes that have implications for treatment and management options for menopausal hot flushes.
Validation of noninvasive focal depth measurements to determine epithelial thickness of the vaginal wall
Authors: Kastelein Arnoud W. , Diedrich Chantal M. , Jansen Charlotte H.J.R. , Zwolsman Sandra E. , Ince Can , Roovers Jan-Paul W.R.
Published: June 2019

Objective:

This study investigates whether noninvasive focal depth (FD) measurements correlate with vaginal wall epithelial thickness (ET). If FD accurately reflects ET of the vaginal wall, this would allow noninvasive longitudinal assessment of (newly developed) treatment modalities aiming to increase ET, without the need for invasive biopsies.

Methods:

Fourteen women, median age 62 years (inter quartile ranges: 57-65), undergoing vaginal prolapse surgery because of anterior and/or posterior compartment pelvic organ prolapse were included. We used the CytoCam, a handheld video microscope based on incident dark field imaging, and performed FD measurements of the vaginal wall before surgery. Histology was performed on tissue that was removed during the surgical procedure, and ET was measured in stained sections. We compared ET with FD interindividually, and determined the expected linear correlation and agreement between the two measurements.

Results:

Seventeen ET measurements (mean 125 μm ± 38.7, range 48-181 μm) were compared with 17 FD measurements (mean 128 μm ± 34.3, range 68-182 μm). The lineair correlation between the two measurements was strong (r 
= 0.902, P < 0.01). Bland-Altman analysis demonstrated a mean difference of 13.5 μm when comparing ET to FD.

Conclusions:

The results demonstrate good agreement between ET and FD measurements. We consider the mean difference demonstrated with Bland-Altman analysis acceptable for these measurements. This suggests that FD accurately reflects ET, which further supports the use of FD to measure ET of the vaginal wall. For a complete assessment of the vaginal wall, FD measurements are preferably combined with the assessment of vaginal angioarchitecture.
The synergistic effects of vitamin D and estradiol deficiency on metabolic syndrome in Chinese postmenopausal women
Authors: Huang Hui , Guo Jing , Chen Qingyu , Chen Xiaotong , Yang Yabo , Zhang Wangjian , Liu Yong , Chen Xiaoli , Yang Dongzi
Published: June 2019

Objective:

Recent studies show that vitamin D (VitD) deficiency is associated with metabolic syndrome (MetS). Current evidence suggests that estrogen and VitD have similar physiological functions and potentially interact with bone health. We investigated the association between estradiol (E2) and 25-hydroxyvitamin-D [25(OH)D] with MetS and its components in Chinese postmenopausal women.

Methods:

In this cross-sectional study, we examined 616 postmenopausal women (aged 49-86 y) from southern China who were not taking estrogen and VitD/calcium supplements. At the end of data collection, serum E2 and 25(OH)D were measured for each participant. MetS was defined according to the 2006 International Diabetes Federation standard.

Results:

There was a positive correlation between 25(OH)D and E2. Higher 25(OH)D was associated with a favorable lipid profile, blood pressure, and glucose level. E2 was negatively associated with cholesterol, triglycerides, and blood pressure. The odds ratio for MetS was 2.19 (95% CI, 1.19-4.01, P value for trend=0.009) for deficient compared with sufficient women after multivariable adjustment. This association remained unchanged after further adjusting for E2 levels. After stratified analysis by VitD status, low E2 increased MetS risk in women with VitD deficiency (odds ratio = 3.49, 95% CI, 1.45-8.05 for the lowest vs the highest tertile).

Conclusions:

These results suggest a synergistic role of VitD and E2 deficiency in MetS in Chinese postmenopausal women.
The MATE survey: men's perceptions and attitudes towards menopause and their role in partners’ menopausal transition
Authors: Parish Sharon J. , Faubion Stephanie S. , Weinberg Marc , Bernick Brian , Mirkin Sebastian
Published: June 2019

Objective:

The perceptions and attitudes of menopause shared by men are largely unknown. This analysis characterized men's awareness and their understanding of their partner's menopausal transition.

Methods:

A 35-question, online survey was used to assess men's perceptions and attitudes toward menopause. Men were recruited from an online research marketplace and were eligible to participate if their female partners (45-64 years old) experienced ≥1 of the following symptoms: hot flashes, night sweats, sleepless nights, difficulty sleeping, low libido, mood swings, pain during sex, or vaginal dryness. Couples either lived together full time, or, if living separately, resided together regularly two or more times a week.

Results:

Of the 1,356 surveys sent to eligible men, 450 (33%) were completed. Most men were between 50 and 69 years (80%), married and not separated (90%), and lived with their partner full time (97%). Men were aware of the symptoms regularly experienced by their partner, with difficulty sleeping (54%) and lack of energy (49%) being frequently identified; these symptoms were attributed to menopause (26%) and/or aging (22%). Of those who were affected by symptoms (63%), most men reported they negatively impacted them (77%), their partners (70%), and relationships (56%). Men engaged in discussions with their partners regarding menopausal symptoms (72%) and believed they were somewhat/very influential (75%) in their partner's decision to seek treatment or make lifestyle adjustments.

Conclusions:

Overall, men are aware of their partner's menopausal transition and may influence decisions relating to symptom management. Educational interventions would further benefit men's awareness of menopause and available treatment options.

Video Summary:

http://links.lww.com/MENO/A424.
Family history of pain and risk of musculoskeletal pain in children and adolescents: a systematic review and meta-analysis
Authors: Dario Amabile B. , Kamper Steven J. , O'Keeffe Mary , Zadro Joshua , Lee Hopin , Wolfenden Luke , Williams Christopher M.
Published: June 2019

Emerging evidence suggests that musculoskeletal (MSK) pain should be viewed from a biopsychosocial perspective and consider the influence of family factors. We conducted a review with meta-analysis to provide summary estimates of effect of family history of pain on childhood MSK pain and explore whether specific family pain factors influence the strength of the association (PROSPERO CRD42018090130). Included studies reported associations between family history of pain and nonspecific MSK pain in children (age <19 years). The outcome of interest was MSK pain in children. We assessed the methodological quality using a modified version of the Quality in Prognosis Studies instrument and quality of evidence for the main analyses using the GRADE criteria. After screening of 7281 titles, 6 longitudinal and 23 cross-sectional studies were included. Moderate quality evidence from 5 longitudinal studies (n = 42,131) showed that children with a family history of MSK pain had 58% increased odds of experiencing MSK pain themselves (odds ratio [OR] 1.58, 95% confidence interval 1.20-2.09). Moderate quality evidence from 18 cross-sectional studies (n = 17,274) supported this finding (OR 2.02, 95% 1.69-2.42). Subgroup analyses showed that the relationship was robust regardless of whether a child's mother, father, or sibling experienced pain. Odds were higher when both parents reported pain compared with one ([mother OR = 1.61; father OR = 1.59]; both parents OR = 2.0). Our findings show moderate quality evidence that children with a family history of pain are at higher risk of experiencing MSK pain. Understanding the mechanism by which this occurs would inform prevention and treatment efforts.
Model-Guided Antipsychotic Dose Reduction in Schizophrenia
Authors: Ozawa Chisa , Bies Robert R. , Pillai Nikhil , Suzuki Takefumi , Mimura Masaru , Uchida Hiroyuki
Published: June 2019

Purpose/Background

Patients with schizophrenia as well as their psychiatrists are hesitant to reduce the antipsychotic dose in fear of relapse. To overcome such dilemmas, we developed models to individually calculate an oral dose that corresponds to a given target dopamine D2receptor occupancy.

Methods/Procedures

In this pilot, 52-week single-blind randomized controlled trial, 35 clinically stable patients with schizophrenia receiving either risperidone or olanzapine monotherapy were randomly assigned to dose reduction (n = 17) or dose maintenance group (n = 18). In the former group, baseline doses were reduced to the doses corresponding to 65% D2occupancy (the lower end of therapeutic window) at trough that were calculated from randomly collected plasma concentrations using our models.

Findings/Results

In the dose reduction group, doses of risperidone and olanzapine were decreased from 4.2 ± 1.9 to 1.4 ± 0.4 and 12.8 ± 3.9 to 6.7 ± 1.8 mg/d, whereas the doses in the dose maintenance group were 4.3 ± 1.9 and 15.8 ± 4.6 mg/d, respectively. Twelve subjects (70.5%) and 13 subjects (72.2%) in the dose reduction and dose maintenance groups completed the study (P= 0.604), whereas 3 subjects (18.8%) and none dropped out because of clinical worsening in the dose reduction and dose maintenance groups, respectively. There were not significant differences in score changes in Positive and Negative Syndrome Scale between the 2 groups but in Positive subscale scores in the Clinical Global Impression–Schizophrenia (0.4 ± 0.7 in the dose reduction group vs −0.1 ± 0.7 in the dose maintenance group,P= 0.029).

Implications/Conclusions

Although our model-guided dose reduction strategy was found to be comparable with no-dose change in terms of dropout rates, safety issues have to be further examined.
Prior Antidepressant Treatment Trials May Predict a Greater Risk of Depressive Relapse During Antidepressant Maintenance Therapy
Authors: Amsterdam Jay D. , Kim Thomas T.
Published: June 2019

Background

We examined the influence of prior antidepressant treatment trials on the likelihood of depressive relapse, and time to depressive relapse, during maintenance therapy of bipolar II disorder in treatment-responsive subjects who had recovered from a major depressive episode.

Methods

Data were derived from a prospective, randomized, double-blind trial of 148 adult subjects with bipolar II major depressive episode who were initially administered open-label fluoxetine monotherapy for 12 weeks. Remitters with a final Hamilton Rating Scale for Depression score of 8 or lower were then randomized to continuation therapy with either fluoxetine (n = 28), lithium (n = 26), or placebo (n = 27) for 50 additional weeks.

Results

An increase in the number of prior antidepressant treatment trials was significantly associated with a greater likelihood of depressive relapse for all treatment conditions taken together [odds ratio (OR) = 1.42, z = 2.49, P = 0.01] and for the 2 active treatment conditions together (OR = 1.51, z = 2.28, P = 0.02). An increase in the number of prior antidepressant trials was also associated with a trend-level shortening in the time to relapse for all treatment conditions taken together (hazard ratio = 1.15; confidence interval, 0.99–1.35; P = 0.07) and a significantly shorter time to relapse for subjects in the 2 active treatment conditions (hazard ratio = 1.30; confidence interval, 1.05–1.62; P = 0.02).

Conclusions

These findings support prior evidence of a negative influence of the number of prior antidepressant treatment trials on the likelihood of response and suggest that the number of prior antidepressant trials may also be associated with a greater odds of depressive relapse, and a shorter time to relapse, during antidepressant maintenance therapy in recovered depressed subjects with bipolar II disorder.