bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of Sickle Cell Anemia on Inpatient Morbidity After Spinal Fusion
Authors: Lu Young , Lin Charles C. , Doermann Alex , Patel Nilay , Bhatia Nitin N. , Kiester Phillip Douglas , Rosen Charles D. , Lee Yu-Po
Published: March 2019

Study Design:

A retrospective study.

Objective:

To determine the impact of sickle cell anemia on perioperative outcomes and resource utilization in elective spinal fusion surgery.

Summary of Background Data:

Sickle cell anemia has been identified as an important surgical risk factor in otolaryngology, cardiothoracic surgery, general surgery, and total joint arthroplasty. However, the impact of sickle cell anemia on elective spine surgery is unknown.

Methods:

Hospitalizations for elective spinal fusion surgery between the years of 2001–2014 from the US National Inpatient Sample were identified using ICD-9-CM codes and patients were grouped into those with and without sickle cell anemia. The main outcome measures were in-hospital neurological, respiratory, cardiac, gastrointestinal, renal and urinary, pulmonary embolism, and wound-related complications and mortality. Length of stay and inpatient costs were also collected. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients undergoing elective spinal fusion with or without sickle cell anemia.

Results:

From a total of 4,542,719 patients undergoing elective spinal fusions from 2001 to 2014, 456 sickle cell disease patients were identified. Sickle cell anemia is a significant independent predictor for pulmonary embolism [odds ratio (OR)=7.37; confidence interval (CI), 4.27–12.71; P<0.001], respiratory complications (OR=2.36; CI, 1.63–3.42; P<0.001), wound complications (OR=3.84; CI, 2.72–5.44; P<0.001), and overall inpatient complications (OR=2.58; CI, 2.05–3.25; P<0.001). Sickle cell anemia patients also have significantly longer length of stay (7.0 vs. 3.8 d; P<0.001) and higher inpatient costs ($20,794 vs. $17,608 P<0.05).

Conclusions:

Sickle cell anemia is associated with increased risk of perioperative complications and greater health care resource utilization. Sickle cell anemia patients undergoing spinal fusion surgeries should be counseled on these increased risks. Moreover, current strategies for perioperative management of sickle cell anemia patients undergoing spinal fusion surgery need to be improved.
Patient and Family Engagement During Treatment Decisions in an ICU: A Discourse Analysis of the Electronic Health Record*
Authors: Kruser Jacqueline M. , Benjamin Brian T. , Gordon Elisa J. , Michelson Kelly N. , Wunderink Richard G. , Holl Jane L. , Schwarze Margaret L.
Published: March 2019

Objectives:

Shared decision-making is recommended for critically ill adults who face major, preference-sensitive treatment decisions. Yet, little is known about when and how patients and families are engaged in treatment decision-making over the longitudinal course of a critical illness. We sought to characterize patterns of treatment decision-making by evaluating clinician discourse in the electronic health record of critically ill adults who develop chronic critical illness or die in an ICU.

Design, Setting, and Patients:

We conducted qualitative content analysis of the electronic health record of 52 adult patients, admitted to a medical ICU in a tertiary medical center from January 1, 2016, to December 31, 2016. We included patients who met a consensus definition of chronic critical illness (26 patients) and a matched sample who died or transitioned to hospice care in the ICU before developing chronic critical illness (26 patients).

Interventions:

None.

Measurements and Main Results:

Characterization of clinician decision-making discourse documented during the course of an ICU stay. Clinician decision-making discourse in the electronic health record followed a single, consistent pattern across both groups. Initial decisions about admission to the ICU focused on specific interventions that can only be provided in an ICU environment (intervention-focused decisions). Following admission, the documented rationale for additional treatments was guided by physiologic abnormalities (physiology-centered decisions). Clinician discourse transitioned to documented engagement of patients and families in decision-making when treatments failed to achieve specified physiologic goals. The phrase “goals of care” is common in the electronic health record and is used to indicate poor prognosis, to describe conflict with families, and to provide rationale for treatment limitations.

Conclusions:

Clinician discourse in the electronic health record reveals that patient physiology strongly guides treatment decision-making throughout the longitudinal course of critical illness. Documentation of patient and family engagement in treatment decision-making is limited until available medical treatments fail to achieve physiologic goals.
In Want of Water
Authors: Diggins Kristene
Published: March 2019

An experienced nurse describes the dehydration she observed in an African community during a short-term mission experience. Oral rehydration and spiritual hydration are discussed, and oral rehydration resources are provided.
Necessity of Genetic Evaluation of Metachronous Metastases of Colorectal Cancer: Quantitative Analysis of Genetic Discordance Between Metachronous Metastases and Radically Resected Primary Colorectal Cancers Using Next-Generation Sequencing
Authors: Lee Kyung Ha , Kim Jin Soo , Kim Ji Yeon
Published: March 2019

BACKGROUND:

Mutation analyses provide the basis of selecting an appropriate target agent for the treatment of metastatic colorectal cancer. However, metachronous metastases developed after the treatment of primary tumor could create significant opportunities for different genetic profiles relative to the primary tumors.

OBJECTIVE:

The purpose of this study was to assess the necessity of genetic evaluation of metachronous metastases; we performed a quantitative analysis of genetic discordance between metachronous metastases and radically resected primary colorectal cancers using next-generation sequencing.

DESIGN:

This was a retrospective study.

SETTINGS:

Patients from a single-institution tertiary care center were studied.

PATIENTS:

We enrolled 33 patients who underwent resection of metachronous metastases between January 2014 and December 2016, ≥6 months after radical resection of primary colorectal cancer and whose tissue was available for analysis.

MAIN OUTCOME MEASURES:

Tumor samples were analyzed by next-generation sequencing. The mutant allele frequency was analyzed to evaluate the proportion of mutations in the tumor tissue.

RESULTS:

The mutant allele frequency of KRAS in metachronous metastases was higher in 6 cases (mean difference =% 25.5% (range, 9.5%–58.0%)) and lower in 3 cases (mean difference = 9.3% (range, 8.0–10.0%) compared with each of their primary tumors. In 1 case, the KRAS mutant-type (mutant allele frequency = 22.6%) metachronous metastasis had developed from the KRAS wild-type primary tumor.

LIMITATIONS:

Tumor sample may not represent perfectly the whole tumor of the patient because of heterogeneity.

CONCLUSIONS:

Genetic discordance can exist between metachronous metastases and radically resected primary colorectal cancers. For appropriate target therapy, genetic evaluation of metachronous metastases needs to be considered when possible. See Video Abstract at http://links.lww.com/DCR/A932.
A Systematic Review of Patient-Reported Outcomes for Cosmetic Indications of Botulinum Toxin Treatment
Authors: Wang Jenny , Rieder Evan A.
Published: March 2019

BACKGROUND

Botulinum toxin (BTX) injection is the most popular cosmetic procedure in the United States. Although facial rejuvenation is considered cosmetic, physical appearance has meaningful impact on quality of life (QOL), best measured by patient-reported outcomes (PROs). Patient-reported outcomes are now often required for Food and Drug Administration approval of new pharmaceuticals.

OBJECTIVE

This review summarizes the PRO instruments and outcomes in evaluating patient QOL after aesthetic BTX administration.

METHODS

PubMed, MEDLINE, Embase, Cochrane Library, CINAHL Plus, and PsycINFO databases were searched for prospective studies using PRO instruments to directly evaluate the success of cosmetic BTX intervention.

RESULTS

Five psychometrically validated, facial rhytid-specific PRO tools are currently used in clinical research. Most studies addressing PROs after cosmetic BTX treatment use 1-item Likert scales evaluating overall satisfaction. BTX treatment generally resulted in improved satisfaction and QOL metrics, such as perception of youthfulness, attractiveness, restedness, affect, mood, and self-confidence. Combination treatments, whether of multiple facial areas or with multiple treatment modalities, may improve PROs even further.

CONCLUSION

Validated, specific PRO instruments can be used to better understand patient expectations in regards to cosmetic treatment, thus helping aesthetic dermatologists maximize patient satisfaction and retention.
Ten-Year and Beyond Follow-up After Treatment With Highly Purified Liquid-Injectable Silicone for HIV-Associated Facial Lipoatrophy: A Report of 164 Patients
Authors: Jones Derek H. , Carruthers Alastair , Brody Harold J. , Black Jeanette M. , Humphrey Shannon , Carruthers Jean , Wesley Naissan O. , Minokadeh Ardalan
Published: March 2019

BACKGROUND

Highly purified liquid-injectable silicone (LIS) has been established as a permanent agent for off-label correction of HIV-associated facial lipoatrophy (HIV-FLA). However, controversy exists about long-term safety.

OBJECTIVE

To establish the safety and efficacy at 10 years or greater of LIS for HIV-FLA.

METHODS

Patients from 3 practices with 10-year or greater in-person office follow-up were analyzed to determine the number of LIS treatments and total volume required to achieve optimal correction. The nature of any treated adverse events was noted.

RESULTS

One hundred sixty-four patients had 10-year or greater in-office follow-up. All subjects maintained long-term correction with an average of 9 treatments, average of 1.56 mL per treatment, and an average total of 14.1 mL. Two patients had severe adverse events manifesting as temporary facial edema. Four patients experienced mild-to-moderate excess fibroplasia presenting as perceived overcorrection, and 6 patients had nondisfiguring subcutaneous firmness. All adverse events were successfully treatable, mostly with intralesional 5-fluorouracil and triamcinolone.

CONCLUSION

Liquid-injectable silicone is an effective long-term treatment option for HIV-FLA. When injected in small quantities with the microdroplet serial puncture technique at monthly or greater intervals, optimal correction appears durable for more than 10 years. Adverse events consisted mostly of excess fibroplasia and were treatable.
Efficacy and Safety of a Sublative Bipolar Fractional Radiofrequency System Combined With Topical Tretinoin in Treating Striae Gravidarum: A Randomized Pilot Study
Authors: Tian Tian , Luo Yao-Jia , Wang Hua , Chen Hong-Duo , Li Yuan-Hong
Published: March 2019

BACKGROUND

Striae gravidarum is a common skin condition resulting after pregnancy, caused by fibroblast dysfunction. Although not considered a disease, it may be considered cosmetically unpleasant to sufferers and remains as a therapeutic challenge to date.

OBJECTIVE

To evaluate the efficacy and safety of a sublative bipolar fractional radiofrequency (FRF) system, associated with 0.1% topical tretinoin, in treating striae gravidarum.

MATERIALS AND METHODS

Eighteen Chinese women with striae gravidarum on the abdomen were enrolled in the study. The target area of each patient was divided into 4 sites randomly: control, tretinoin, FRF, and tretinoin and FRF. Fractional RF was used 3 times, with 3-month intervals. Changes to striae gravidarum were evaluated through subjective scaling and objective measures, using both high-frequency ultrasound and histological study.

RESULTS

Both subjective assessment and skin thickness differences demonstrated significant improvement in the combination site (p < .001). Average optical density and density percentage of neocollagen and elastic fibers were also markedly increased in the combination site (p < .05). The adverse effects of FRF were limited to mild pain and transient erythema, edema, and microcrusts.

CONCLUSION

The combined therapy of FRF and topical tretinoin may be a potential method in treating striae gravidarum, with satisfactory efficacy and limited side effects.
How does stress, depression and anxiety affect patients undergoing treatment?
Authors: Boivin Jacky
Published: March 2019

Purpose of review

To review latest findings about the impact of fertility care on emotional distress and effect of distress on treatment outcome.

Recent findings

Treatment failure and long agonist protocols are associated with increased emotional distress during treatment. Screening tools can be used to identify men and women at risk of emotional maladjustment at the start of fertility treatment and people unlikely to need emotional support during or after treatment. There are inconclusive results about the association between emotional distress and outcome of fertility treatment. Systematic review of studies evaluating the effect of psychological and educational interventions on anxiety, depression and live birth (or ongoing pregnancy) are uninformative because of clinical heterogeneity and risk of bias.

ART is emotionally demanding, patients that adapt more poorly can be identified in advance. Fertility staff should follow good practice guidelines to provide patients with support during treatment.
Enhancement of Viable Adipose-Derived Stem Cells in Lipoaspirate by Buffering Tumescent with Sodium Bicarbonate
Authors: Francis Ashish , Wang Wei Z. , Goldman Joshua J. , Fang Xin-Hua , Williams Shelley J. , Baynosa Richard C.
Published: March 2019

Background:

Fat grafting is a growing field within plastic surgery. Adipose-derived stem cells (ASCs) and stromal vascular fracture (SVF) may have a role in fat graft survival. Our group previously demonstrated a detrimental effect on ASC survival by the lidocaine used in tumescent solution. Sodium bicarbonate (SB) buffers the acidity of lidocaine. The purpose of this study was to determine whether SB buffering is a practical method to reduce ASC and SVF apoptosis and necrosis seen with common lidocaine-containing tumescent solution.

Methods:

Human patients undergoing bilateral liposuction for any indication were included in this study. An internally controlled, split-body design was utilized. Tumescent liposuction on one side of the body was conducted with tumescent containing lidocaine. On the opposite side, liposuction was conducted by adding SB to the tumescent. Tumescent solution and lipoaspirate pH were measured. Lipoaspirate from each side was processed for SVF isolation and ASC culture. The number of viable ASCs was counted and SVF apoptosis/necrosis was examined.

Results:

The pH of the SB-buffered tumescent was significantly higher than that of the standard tumescent, an effect also seen in the lipoaspirate. Adipose-derived stem cell survival in the SB-buffered lipoaspirate was approximately 53% higher. However, there was no significant difference in SVF apoptosis and necrosis between the groups.

Conclusions:

The acidic standard tumescent solution commonly used in liposuction diminishes ASC viability from lipoaspirates. Sodium bicarbonate buffering tumescent solution can enhance ASC viability, but does not affect SVF apoptosis and necrosis. We recommend buffering tumescent with SB to potentially improve fat graft take. Our findings advocate for further research investigating mechanisms and optimal harvest techniques that maximize SVF/ASC survival and the clinical effect on overall fat graft viability.
Classification of Subtypes of Apert Syndrome, Based on the Type of Vault Suture Synostosis
Authors: Lu Xiaona , Sawh-Martinez Rajendra , Jorge Forte Antonio , Wu Robin , Cabrejo Raysa , Wilson Alexander , Steinbacher Derek M. , Alperovich Michael , Alonso Nivaldo , Persing John A.
Published: March 2019

Background:

Apert syndrome patients are different in clinical pathology, including obstructive sleep apnea, cleft palate, and mental deficiency. These functional deficiencies may be due to anatomic deformities, which may be caused by different forms of associated suture fusion. Therefore, a classification system of Apert syndrome based on the type of craniosynostosis pattern might be helpful in determining treatment choices.

Methods:

CT scans of 31 unoperated Apert syndrome and 51 controls were included and subgrouped as: class I. Bilateral coronal synostosis; class II. Pansynostosis; and class III. Perpendicular combination synostosis: a. unilateral coronal and metopic synostosis; b. sagittal with bilateral/unilateral lambdoid synostosis; and c. others.

Results:

Class I is the most common (55%) subtype. The cranial base angulation of class I was normal; however, the cranial base angulation on the cranium side of the skull in class II increased 12.16 degrees (P = 0.006), whereas the facial side cranial base angle of class IIIa decreased 4.31 degrees (P = 0.035) over time. The external cranial base linear measurements of class I showed more evident reduction in anterior craniofacial structures than posterior, whereas other subtypes developed more severe shortening in the posterior aspects.

Conclusions:

Bicoronal synostosis is the most common subtype of Apert syndrome with the normalized cranial base angulation. Combined pansynostosis patients have flatter cranial base, whereas the combined unilateral coronal synostosis have a kyphotic cranial base. Class I has more significant nasopharyngeal airway compromise in a vertical direction, whereas classes II and III have more limited oropharyngeal space.
Neonatal Thyroid Function and Disorders
Authors: CHAPMAN ALISON K. , FARMER ZACHARY J. , MASTRANDREA LUCY D. , MATLOCK KRISTAL A.
Published: March 2019

Thyroid hormone is essential for normal fetal brain development in utero and for the first 2 years of life. The developing fetus is initially reliant upon maternal thyroid hormones that cross the placenta, until the fetal thyroid begins to supply thyroid hormone for the fetus. Maternal thyroid status affects fetal thyroid function and maternal thyroid dysfunction can have a significant impact on the fetus and neonate. There are also several neonatal factors that can influence thyroid function. Here, we describe thyroid function in the fetus and neonate and discuss the most common thyroid disorders seen in neonates.
Hyperthyroidism During Pregnancy: A Clinical Approach
Authors: CUFF RYAN D.
Published: March 2019

Hyperthyroidism is relatively uncommon during pregnancy. However, those caring for pregnant patients should be versed in the evaluation and management of hyperthyroidism, as there are potential maternal and fetal implications that are related to the disease and to treatment. The differential diagnosis of hyperthyroidism includes clinical and subclinical entities, as well as transient laboratory findings that are related to the pregnancy itself. The clinical management, including the indications for the use of thioamide or antithyroid medications, will be discussed in the context of pregnancy. Finally, considerations for the management of the postpartum and/or breastfeeding patient with hyperthyroidism will be reviewed.
Predictors of Exercise Training and Physical Activity Adherence in People Recently Hospitalized With Heart Failure
Authors: Adsett Julie A. , Morris Norman R. , Mudge Alison M.
Published: March 2019

Purpose:

For individuals with heart failure (HF), frequent attendance at exercise training programs and meeting physical activity (PA) guidelines are significantly associated with improvements in 6-min walk distance. Despite the evidence, adherence to exercise interventions remains poor. The aim of this study was to identify predictors of these 2 variables in patients recently hospitalized with HF.

Methods:

In this substudy of the Exercise Joins Education: Combined Therapy to Improve Outcomes in Newly-discharged Heart Failure (EJECTION-HF) trial, all participants were enrolled in a HF disease management program, including weekly review of a home exercise program for 12 wk. Intervention group participants additionally undertook twice weekly supervised exercise training. Primary outcomes were frequent exercise training program attendance (≥12 sessions) and attainment of PA guidelines (150 min/wk of moderate intensity exercise) at 12 wk. Participant and clinical characteristics were analyzed using a logistic regression model to identify significant predictors of each outcome.

Results:

A total of 278 participants provided PA data and 140 contributed attendance data. New diagnosis of HF was a significant predictor of frequent program attendance (OR = 2.3; 95% CI, 1.1-4.7; P = .03). Predictors of meeting PA guidelines at follow-up included new HF diagnosis (OR = 2.4; 95% CI, 1.2-4.8, P = .013), and being physically active at baseline (OR = 2.7; 95% CI, 1.3-5.6; P = .007). Gender, symptom severity, multimorbidity, and disability were not significantly associated with either outcome in multivariate analysis.

Conclusion:

To improve adherence, specific strategies may be required for patients with decompensated HF and those physically inactive at time of referral.
Thorax CT Dose Reduction Based on Patient Features: Effect of Patient Characteristics on Image Quality and Effective Dose
Authors: Koc Gizem Gul , Koc Zafer , Kaniyev Tahir , Kokangul Ali
Published: March 2019

Computed tomography (CT) radiation dose reduction is vital without compromising image quality. The aim was to determine the effects of patient characteristics on the received radiation dose and image quality in chest CT examinations and to be able to predict dose and image quality prior to scanning. Consecutive 230 patients underwent routine chest CT examinations were included. CT examination and patients input parameters were recorded for each patient. The effect of patients’ demographics/anthropometrics on received dose and image quality was investigated by linear regression analysis. All parameters were evaluated using an artificial neural network (ANN). Of all parameters, patient demographics/anthropometrics were found to be 98% effective in calculating dose reduction. Using ANN on 60 new patients was more than 90% accurate for output parameters and 91% for image quality. Patient characteristics have a significant impact on radiation dose and image quality. Dose and image quality can be determined before CT. This will allow setting the most appropriate scanning parameters before the CT scan.
The Cost and Economics of Endoscopic Cyclophotocoagulation in the United Kingdom: A Tertiary Center Experience
Authors: Ho Henrietta , Ho Jason , Rodrigues Ian , Syrimi Marina , Goyal Saurabh , Lim Kin Sheng
Published: March 2019

Precis:

As the only microinvasive glaucoma surgery (MIGS) with a reusable component, the cost per procedure of endoscopic cyclophotocoagulation (ECP) diminishes with each successive use. We present a cost comparison of ECP with other MIGS devices, based on our clinical practice.

Purpose:

ECP delivers diode laser via a reusable probe to the ciliary processes under direct visualization. The aim of our study is to evaluate the direct cost of ECP based on a retrospective review of cases and compare the cost per procedure with other MIGS devices.

Methods:

We conducted a retrospective review of ECP procedures performed at St Thomas’ Hospital over 4.5 years. The cost of the ECP endoscope and diode laser consoles, reusable probes, and maintenance contracts were obtained from the hospital procurement log. The on-site Central Sterile Services Department was contacted for probe sterilization and repackaging costs. The cost per device for ECP and commonly performed MIGS procedures were obtained from the product specialists of each company.

Results:

A total of 332 procedures were performed using 37 ECP probes during the study period. Each reusable ECP laser probe was found to give an average of 8.97 laser treatments. The cost per procedure decreased over the course of 4.5 years from £819.43 for the first 42 cases to £341.50 after 332 cases. Compared with other MIGS devices, the cost per procedure of ECP after 100 procedures is second lowest to the Kahook Dual Blade and reduces with each successive procedure performed.

Conclusion:

The ability to reuse each ECP probe significantly lowers the cost per procedure compared with other MIGS devices in the United Kingdom. The cost per procedure continues to reduce with each successive procedure.
Modification of the Neuropathic Pain Symptom Inventory for use in eye pain (NPSI-Eye)
Authors: Farhangi Monika , Feuer William , Galor Anat , Bouhassira Didier , Levitt Roy C. , Sarantopoulos Constantine D. , Felix Elizabeth R.
Published: March 2019

Chronic eye pain, which has previously been assumed to be due to ocular surface abnormalities (ie, “dry eye [DE] disease”), has recently garnered attention as a potential indicator of neuropathic ocular pain in some patients. The purpose of this study was to evaluate the psychometric properties of a modified version of the Neuropathic Pain Symptom Inventory in individuals with eye pain (NPSI-Eye). Enrolled participants (n = 397) completed the NPSI-Eye, general pain severity questionnaires, DE symptom report, and psychological health indices. Participants also underwent mechanical pain sensitivity testing of the cornea, tear film assessment, and evaluation of the efficacy of anesthetic eye drops to relieve pain. Short-term test–retest reliability of the NPSI-Eye was excellent (intraclass correlation coefficient = 0.98, P < 0.001). Correlations between the NPSI-Eye and indicators of general eye pain were ≥0.65 (P < 0.001), whereas correlations between the NPSI-Eye and DE symptom severity and psychological health indices were lower (rho = 0.56, 0.32, 0.37; all P < 0.001). Individuals who reported little or no decrease in pain after anesthetic eye drops (hypothesized to indicate eye pain with at least partial central involvement) had significantly higher NPSI-Eye scores than participants whose eye pain was completely relieved by anesthetic (P < 0.05). Overall, our results support preliminary validation of the NPSI-Eye, yielding similar metrics to those reported in Bouhassira et al.'s original NPSI publication (2004). However, additional evaluation and refinement of some questions may be desirable, including the potential elimination of items that were not highly endorsed.
Cognitive Reserve Over the Lifespan: Neurocognitive Implications for Aging With HIV
Authors: Vance David E. , Lee Loretta , Muñoz-Moreno Jose A. , Morrison Shannon , Overton Turner , Willig Amanda , Fazeli Pariya L.
Published: March 2019

Approximately 59% of adults living with HIV experience HIV-associated neurocognitive disorder, a collection of symptoms and cognitive deficits in various cognitive domains. As the HIV population ages, the prevalence and severity of such cognitive deficits are expected to grow. Understanding how these cognitive deficits manifest is important for nurses and health care providers. This article provides an overview of cognitive reserve and evidence of how it is compromised by HIV, aging, and individual characteristics. Within this context of cognitive reserve, the role of neuroinflammation, neurotoxicity, substance use, comorbidities, depression and anxiety, social isolation, and sedentary lifestyle is reviewed. From this, strategies used to address cognitive deficits are provided, including topics such as psychostimulants, cognitive training, multimodal lifestyle interventions, and compensation strategies. Scenarios of successful and unsuccessful cognitive aging are presented to provide a lifespan perspective of cognitive reserve. Implications for clinical practice and research are provided, as it relates to aging.
Rethinking the cost of care: Nurse practitioners as stewards of clinical and patient resources
Authors: Mehra Mukul
Published: March 2019

Clinicians are the building blocks of value-based care, yet the cumulative human and financial cost of daily care decisions are mostly hidden from them. As essential primary care providers, nurse practitioners play a role in driving efficiency and resourcefulness in care. The growth and expanded capabilities of the specialty give nurse practitioners a powerful voice in setting standards for clinical stewardship. Yet to be successful in this effort, nurse practitioners must have a better understanding of cost containment and cost reduction to make better decisions. This means synthesizing cost and risk data, efficacy, and patient advocacy to propagate value-based decision making and standardized quality care across our organizations. Clinicians need to understand that caring about patients means being good stewards while caring for patients.
Metastatic pheochromocytoma and paraganglioma: recent advances in prognosis and management
Authors: Hamidi Oksana
Published: March 2019

Purpose of review

Metastatic pheochromocytomas and paragangliomas (PPGL) are rare neuroendocrine tumors with variable prognosis. This review highlights recent studies on outcomes and management of patients with metastatic PPGL.

Recent findings

Latest advances were made in identifying predictors of favorable outcomes of patients with metastatic PPGL. Recent studies evaluated the efficacy of tyrosine kinase inhibitors, high-specific-activity radiopharmaceuticals, and peptide receptors radionuclide therapy in treatment of metastatic disease. Moreover, ongoing studies are assessing the effects of hypoxia-inducible factor 2αα and heat shock protein 90 inhibitors as potential therapies.

Several active studies are evaluating the efficacy of systemic chemo, immuno, radiopharmaceutical, and peptide receptor radionuclide therapies to relieve local and adrenergic symptoms and provide survival benefit for patients with symptomatic and/or progressive advanced metastatic PPGL. Owing to rarity and wide-outcome variability, multidisciplinary team effort and personalized approach are central in caring for patients with metastatic PPGL.
The role of plasma exchange in hypertriglyceridemia-induced acute pancreatitis
Authors: Biberci Keskin Elmas , Koçhan Koray , Köker İbrahim H. , Gülen Bedia , İnce Ali T. , Şentürk Hakan
Published: March 2019

Background

Hypertriglyceridemia (HTG)-induced acute pancreatitis (AP) leads to higher morbidity and mortality compared with other etiologies. The role of plasma exchange (PE) in this context is still not well established. We aimed to assess the clinical outcomes of patients with HTG-induced AP who underwent PE and compare it with those who did not.

Patients and methods

We retrospectively evaluated the data of patients who were admitted with HTG-induced AP between January 2013 and May 2018. The endpoint of the study was to assess the clinical outcomes, which included complication rates, mortality, and pancreatitis recurrence rate.

Results

Overall, 41 patients were included in the final analysis. Of these, 12 (29.2%) underwent PE. Patients undergoing PE had more severe pancreatitis on the basis of the Japanese Severity Score [10 (83.3%) vs. 14 (48.3%), P=0.03, respectively). Although mortality was higher in patients who underwent PE [three (25.0%) vs. zero, P<0.01, respectively], there was no difference in terms of complications and recurrence rates. Over a median 21 months of follow-up, 11 (26.8%) patients had recurrent AP.

Conclusion

Although PE effectively reduced plasma triglyceride levels, there was no decrease in mortality or recurrences.
Perioperative prophylaxis with single-dose cefazolin for liver transplantation: a retrospective study
Authors: Statlender Liran , Yahav Dafna , Ben-Zvi Haim , Margalit Ili , Ferder Ayelet , Goldberg Elad , Mor Eytan , Bishara Jihad , Cohen Jonathan
Published: March 2019

Background

Early infections are common during the first month after liver transplantation (LT), whereas no consensus exists on the optimal prophylactic antimicrobial therapy. We aimed to evaluate the effectiveness of cefazolin perioperative prophylaxis in LT.

Patients and methods

We documented our experience with single-dose cefazolin as prophylaxis for LT. Infections occurring within 30 days following LT during 2006–2015 were documented retrospectively. Univariate and multivariate analyses of risk factors for infection were carried out.

Results

Among 113 LT recipients receiving cefazolin as prophylaxis, infections occurred in 50 (44%) patients, including surgical site infections (n=24, 21%) and bacteremia (n=14, 12%). Bacteria resistant to cefazolin were documented in 59/72 (82%) isolates. Enterococcal infections were documented in 6% (7/113). Almost half of the infections (44%) occurred in the first week following LT and the vast majority within 2 weeks. The 30-day mortality rate (7%, 8/113) was significantly higher among infected patients (7/50, 14% vs. 1/63, 1.6%, P=0.011). Model for End-stage Liver Disease score, age, and requirement for at least 5 U of packed red cells during transplantation were predictive for postoperative infections.

Conclusion

In our center, cefazolin was insufficient as perioperative prophylaxis in LT. We suggest that all LT recipients should receive antibiotic prophylaxis targeting microorganisms on the basis of local bacterial ecology and patterns of resistance irrespective of preoperative or intraoperative risk assessment.
The ultrasound ‘twinkling artefact’ in the diagnosis of urolithiasis: hocus or valuable point-of-care-ultrasound? A systematic review and meta-analysis
Authors: Laher Abdullah E. , McDowall Jared , Gerber Louis , Aigbodion Sunday J. , Enyuma Callistus O.A. , Buchanan Sean , Adam Ahmed
Published: March 2019

Presentation to the emergency department with renal colic has been reported as between 6.7 and 27.9 per 1000 emergency department visits. Clinicians rely on various radiological investigations for the prompt and accurate diagnosis of urolithiasis. This review assesses the validity of the colour Doppler ultrasonographic twinkling artefact (TA) sign as a diagnostic tool for the presence of urolithiasis. A systematic search of the Cochrane Database of Systematic Reviews, Embase, PubMed, Scopus and Web of Science databases was performed (October 2018) using specific search terms. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analyses) guidelines and the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tool were applied to rank and evaluate selected studies. Twenty-two articles that included 4389 participants were assessed. The median sample size was 102.5 (interquartile range: 47–292.5) and the age range of participants was 4–91 years. Meta-analysis of the studies that provided sufficient data resulted in a pooled sensitivity and specificity for the ultrasonographic TA sign of 88.16 [95% confidence interval (CI): 87.07–89.19%] and 79.22% (95% CI: 73.41–84.26%) respectively, with an estimated summary effect of 3.84 (95% CI: 1.08–6.60, P 0.006) in log odds ratio terms. There was significant interstudy heterogeneity as suggested by an I
2-statistic of 94.51% (95% CI: 94.51–99.58) and an estimated τ
2 parameter of 7.21 (SE: 7.44). Despite the suboptimal pooled sensitivity and specificity of the TA sign and the large heterogeneity between published studies, the current body of evidence suggests that the colour Doppler ultrasonographic TA sign may be useful as a complementary tool in the diagnostic workup of patients with suspected urolithiasis.
Procedural Outcomes of Patients With Heart Failure Undergoing Catheter Ablation of Atrial Fibrillation
Authors: Jayanna Manju Bengaluru , Mohsen Ala , Inampudi Chakradhari , Alvarez Paulino , Giudici Michael C. , Briasoulis Alexandros
Published: March 2019

Background:

Catheter ablation is being increasingly performed for rhythm control of atrial fibrillation (AF). Heart failure (HF) frequently coexists with AF because they share common risk factors.

Study Question:

This study aims at identifying the characteristics and procedural outcomes of patients with HF undergoing catheter ablation of AF.

Study Design:

In this retrospective cohort study, we analyzed 264 consecutive patients who underwent catheter ablation for AF. Seventy-three patients (28%) had a known history of stage C HF either with reduced ejection fraction or preserved ejection fraction.

Measures and Outcomes:

We compared procedural outcomes between patients who had known HF with those who did not.

Results:

Patients with HF were more likely to have higher rates of atrial fibrillation recurrence at both 3 months (odds ratio 2.9, confidence interval = 1.5–5.7, P = 0.0022) and 1 year after the procedure (odds ratio 2.3, confidence interval 1.2–4.3, P = 0.0097) and risk factors for recurrence of AF including left atrial enlargement, persistent AF, and a higher CHA2DS2-VASc score. However, on logistic regression analysis adjusting for left atrial size, atrial fibrillation type (persistent vs. paroxysmal), and CHA2DS2-VASc score as covariates, there was no significant difference in AF recurrence rates at both 3 months and 1 year. Recurrence rates did not differ significantly between patients with HF either with reduced ejection fraction or preserved ejection fraction. Among patients with paroxysmal AF, HF was predictive of AF recurrence at both 3 months and 1 year after ablation. The procedure length was longer in patients with HF, but there were no differences in periprocedural complications.

Conclusion:

Patients with HF undergoing catheter ablation of AF tend to have more risk factors for recurrence, but after adjustment for risk factors, the recurrence rates were similar at 3 months and 1 year. Among patients with paroxysmal atrial fibrillation, HF was predictive of higher recurrence rates.
Management of benign vocal fold lesions: current perspectives on the role for voice therapy
Authors: White Anna
Published: March 2019

Purpose of review

Benign vocal fold lesions (BVFLs) cause dysphonia by preventing full vocal fold closure, interrupting vibratory characteristics and increasing compensatory muscle tension. Management includes phonosurgery, voice therapy, pharmacological treatment or more commonly a combination of these interventions. This review aims to present current perspectives on the management of BVFLs, particularly exploring the role of voice therapy.

Recent findings

The review highlights variation in the management of BVFLs. There is evidence that phonosurgery is a well tolerated and effective intervention for BVFLs. Primary voice therapy can frequently prevent surgery in vocal fold nodules and some types of polyps. Used as an adjunct to phonosurgery, preoperative and postoperative voice therapy can improve patient-reported outcomes and acoustic parameters of the voice. However, heterogeneity of studies and poor descriptions of intervention components prevent a robust analysis of the impact of voice therapy.

The current evidence consists of low-level studies using mixed aetiology groups, which compromises internal and external validity. There are a few exceptions to this. Poor reporting and heterogeneous methodologies lead to difficulties determining the components of a voice therapy intervention for this population. Consequently, we are unable to evaluate, which intervention elements are beneficial to patients.
Should Proton Pump Inhibitors be Systematically Prescribed in Patients With Esophageal Atresia After Surgical Repair?
Authors: Righini Grunder Franziska , Petit Laetitia‐Marie , Ezri Jessica , Jantchou Prevost , Aspirot Ann , Laberge Sophie , Faure Christophe
Published: March 2019

Objective:

To evaluate outcomes of patients with esophageal atresia (EA) on systematic treatment with proton pump inhibitors (PPI) since the neonatal period and to determine factors associated with successful discontinuation of PPI.

Study design:

Longitudinal cohort study with prospective data collection of 73 EA patients, over 11 years systematically treated with PPI. Outcome and predictive factors for discontinuation of PPI treatment were evaluated at study end in February 2017. The incidence of anastomotic strictures was compared with a historical cohort of 134 EA patients followed in the same institution between 1990 and 2005 before the era of systematic PPI treatment.

Results:

PPI treatment was discontinued definitively in 48% of patients during follow‐up. Prematurity, longer initial hospitalization, moderate‐to‐severe tracheomalacia, anastomotic leak and anastomotic stricture had a significant negative association with PPI discontinuation on univariate analysis (P < 0.05). On adjusted multivariable Cox regression analysis, moderate‐to‐severe tracheomalacia and anastomotic leak were negatively associated with discontinuation of PPI treatment (hazard ratio 0.26 [95% CI 0.12–0.59]; P = 0.001 and hazard ratio 0.38 [95% CI 0.16–0.93]; P = 0.03, respectively). There was no significant difference in the incidence of anastomotic strictures in the present cohort compared with the historical cohort (44% vs 39%); (P > 0.05).

Conclusions:

PPI treatment does not prevent the formation of anastomotic strictures and appears to be over‐prescribed in children with airway symptoms because of tracheomalacia. This suggests that PPI treatment could be prescribed more selectively. Close monitoring and long‐term follow‐up, however, of these vulnerable patients in specialized multidisciplinary clinics is imperative.
Associations for tasks requiring single stimulus and working memory with different aspects of gait and posture: an exploratory study
Authors: Boolani Ali , Martin Rebecca , Goodwin Aurora , Avolio Abigail , Sur Shantanu , Lee Smith Matthew , Fulk George
Published: March 2019

Evidence suggests that there is a significant relationship between cognition and gait. However, studies have primarily focused on overall cognition when elucidating the relationship with gait. This study aimed to delineate specific aspects of cognition that are related to gait and postural control parameters. Participants (N = 11, age = 76.55 ± 7.58 years) performed a series of cognitive tasks categorized as either lower-level (serial subtract 3 and continuous performance task) or higher-level (serial subtract 7 and rapid visual input processing task) tasks. Following the completion of the cognitive tasks, participants performed balance and gait activities. This procedure was performed on two separate days with a minimum 48-h rest period between days. A bivariate Pearson correlation analysis was utilized to identify relationships between cognitive task scores and gait speed, step length, gait imbalance as well as the visual, vestibular, and somatosensory aspect of postural control. Lower-level cognitive tasks, specifically the serial subtract 3 was significantly (P < 0.05) associated with gait speed (r = 0.457), step length (r = 0.481), and the ability to maintain postural control with occluded vision and unreliable somatosensory input (r = −0.504). In contrast, higher-level cognitive tasks, specifically serial subtract 7 were associated (P < 0.05) with gait imbalance (r = −0.540), while rapid visual input processing primary reaction time was associated with the ability to maintain postural control in the absence of visual input (r = −0.751). Our findings align with functional magnetic resonance imaging (fMRI) studies that examine gait, postural control, and cognitive task performance and provide a granular insight. These results may help us to better understand the relationship between cognitive deficits, gait, and postural control with aging.
Pharyngeal width and aspiration after stroke
Authors: Jung Il Hwan , Lee Ho Young , Cha Eunsil , Song Jimin , Baek Seungki , Jung Kwang-Ik , Yoo Woo-Kyoung , Ohn Suk Hoon
Published: March 2019

It is important to assess aspiration in stroke patients. The aim of this study was to develop a new additional tool to predict aspiration based on the pharyngeal width at rest in stroke patients with aspiration symptoms. The pharyngeal width was measured at the middle level of the second and third cervical vertebral bodies using a lateral neck roentgenogram in stroke patients and healthy controls. We named the average of the two pharyngeal widths as the JOSCYL width and calculated the ‘JOSCYL width × 100 / neck circumference’ as the JOSCYL scale. The correlation between the individual JOSCYL width, JOSCYL scale, and severity of dysphagia was analyzed in the stroke group using Spearman correlation analysis. The optimal cutoff point for predicting aspiration was determined by receiver-operating characteristic curve analysis of the JOSCYL width and JOSCYL scale. The JOSCYL width and JOSCYL scale of the stroke group were larger than those of the control group (P < 0.05). The correlation between the JOSCYL width, JOSCYL scale, and the severity of dysphagia was significant for the whole stroke group and the chronic stroke group (P < 0.05). The optimal cutoffs of the JOSCYL width and JOSCYL scale for predicting aspiration were approximately 18 mm and 50 in the stroke group. The JOSCYL width and JOSCYL scale are new indicators for predicting aspiration in stroke patients and are precise and easy to use. The accuracy of the JOSCYL width and JOSCYL scale for predicting aspiration was shown to be higher in the chronic stroke stage.
Review of Drug-induced Injury in Mucosal Biopsies From the Tubular Gastrointestinal Tract
Authors: Allard Felicia D. , Stelow Edward B.
Published: March 2019

The use of prescription and over-the-counter medications is on the rise in the US population, especially among those aged 65 and over, with over 46% of the population taking at least 1 prescription medication. Given the frequency of medication use, and that the majority of these medications are taken orally, it has become increasingly relevant for pathologist examining endoscopically obtained gastrointestinal tract mucosal biopsies to consider and recognize patterns of mucosal injury associated with various drugs. Reports on injuries associated with certain classes of drugs can be scattered among different sources, making a comprehensive view of various injury patterns and the drugs known to cause them difficult to obtain. Herein, we provide a comprehensive overview of the drugs known to cause mucosal injuries in the tubular gastrointestinal tract organized by the organ involved and the prominent pattern of injury.
Impact of Integrase Inhibition Compared With Nonnucleoside Inhibition on HIV Reservoirs in Lymphoid Tissues
Authors: Rothenberger Meghan , Nganou-Makamdop Krystelle , Kityo Cissy , Ssali Francis , Chipman Jeffrey G. , Beilman Gregory J. , Hoskuldsson Torfi , Anderson Jodi , Jasurda Jake , Schmidt Thomas E. , Calisto Samuel P. , Pearson Hope , Reimann Thomas , David Caitlin , Perkey Katherine , Southern Peter , Wietgrefe Steve , Helgeson Erika , Reilly Cavan , Haase Ashley T. , Douek Daniel C , Fletcher Courtney V. , Schacker Timothy W.
Published: March 2019

Background:

HIV is produced in lymphoid tissues (LT) and stored on the follicular dendritic cell network in LT. When antiretroviral therapy is started, plasma viremia decays in 2 phases; the first within days of starting therapy and the second over weeks. Raltegravir (RAL), an integrase inhibitor, has been associated with only a single rapid phase of decay, and we speculated this may be due to higher intracellular concentration (IC) of RAL in LT. We have previously measured suboptimal ICs of antiretroviral therapy agents in LT, which were associated with slower decay of both vRNA+ cells and the follicular dendritic cell network pool.

Setting:

Outpatient clinic at the Joint Clinical Research Center in Kampala, Uganda.

Methods:

We compared the rate of decay in LT in people starting RAL with those starting efavirenz (EFV).

Results:

There was no difference in the rate of virus decay in LT. The ratio of the ICs of RAL and EFV in lymph node to the concentration of drug that inhibits 95% of virus in blood was 1 log lower in lymph node for EFV and >3 logs lower for RAL.

Conclusion:

These data further highlight the challenges of drug delivery to LT in HIV infection and demonstrate that RAL is not superior to EFV as judged by direct measurements of the source of virus in LT.