bluuebunny/crossref_metadata_2025 huggingface dataset:
Breech at the Border: An Atypical Case of Invasive Haemophilus influenzae in a Patient on a Novel Immunotherapeutic
Authors: Howard-Anderson Jessica , Satola Sarah W , Collins Matthew H
Published: June 2018

Haemophilus influenzae rarely causes pyogenic infections in the female genital tract, and even less commonly does this lead to systemic infections. Novel monoclonal antibody therapies targeting interleukin-17 may impair mucosal immunity, but increased risk for H. influenzae infections has not been documented. Here, we describe a case of H. influenzae bacteremia associated with pyosalpinx and hypothesize that immunomodulatory treatment for psoriasis predisposed our patient to this infection.
Repetitive Practice With Peer Mentoring to Foster Skill Competence and Retention in Baccalaureate Nursing Students
Authors: Ross Jennifer Gunberg
Published: June 2018

A one-group, repeated-measures study explored the effect of repetitive practice with peer mentoring on skill competence and retention of vital signs and auscultation of breath and heart sounds in baccalaureate nursing students. Vital signs competence significantly increased after repetitive practice with peer mentoring. Skill competence in vital signs and auscultation of breath and heart sounds did not significantly change four months after repetitive practice with peer mentoring. This study suggests that repetitive practice with peer mentoring may show promise to enhance skill competence and retention; however, more research is needed to support these findings.
Mannitol in Critical Care and Surgery Over 50+ Years: A Systematic Review of Randomized Controlled Trials and Complications With Meta-Analysis
Authors: Zhang Weiliang , Neal Jonathan , Lin Liang , Dai Feng , Hersey Denise P. , McDonagh David L. , Su Fan , Meng Lingzhong
Published: June 2018

Objective:

Despite clinical use spanning 50+ years, questions remain concerning the optimal use of mannitol. The published reviews with meta-analysis frequently focused on mannitol’s effects on a specific physiological aspect such as intracranial pressure (ICP) in sometimes heterogeneous patient populations. A comprehensive review of mannitol’s effects, as well as side effects, is needed.

Methods:

The databases Medline (OvidSP), Embase (OvidSP), and NLM PubMed were systematically searched for randomized controlled trials (RCTs) comparing mannitol to a control therapy in either the critical care or perioperative setting. Meta-analysis was performed when feasible to examine mannitol’s effects on outcomes, including ICP, cerebral perfusion pressure, mean arterial pressure (MAP), brain relaxation, fluid intake, urine output, and serum sodium. Systematic literature search was also performed to understand mannitol-related complications.

Results:

In total 55 RCTs were identified and 7 meta-analyses were performed. In traumatic brain injury, mannitol did not lead to significantly different MAP (SMD [95% confidence interval (CI)] =−3.3 [−7.9, 1.3] mm Hg; P=0.16) but caused significantly different serum sodium concentrations (SMD [95% CI]=−8.0 [−11.0, −4.9] mmol/L; P<0.00001) compared with hypertonic saline. In elective craniotomy, mannitol was less likely to lead to satisfactory brain relaxation (RR [95% CI]=0.89 [0.81, 0.98]; P=0.02), but was associated with increased fluid intake (SMD [95% CI]=0.67 [0.21, 1.13] L; P=0.004), increased urine output (SMD [95% CI]=485 [211, 759] mL; P=0.0005), decreased serum sodium concentration (SMD [95% CI]=−6.2 [−9.6, −2.9] mmol/L; P=0.0002), and a slightly higher MAP (SMD [95% CI]=3.3 [0.08, 6.5] mm Hg; P=0.04) compared with hypertonic saline. Mannitol could lead to complications in different organ systems, most often including hyponatremia, hyperkalemia, and acute kidney injury. These complications appeared dose dependent and had no long-term consequences.

Conclusions:

Mannitol is effective in accomplishing short-term clinical goals, although hypertonic saline is associated with improved brain relaxation during craniotomy. Mannitol has a favorable safety profile although it can cause electrolyte abnormality and renal impairment. More research is needed to determine its impacts on long-term outcomes.
Scoliosis Curvature Follows Thoracic Organ Orientation
Authors: Compton Jocelyn , Voort Wyatt Vander , Weinstein Stuart
Published: June 2018

Study Design.

Retrospective cohort study, Level of Evidence III.

Objective.

To determine the relationship between internal organ orientation and adolescent idiopathic scoliosis (AIS) convexity directionality.

Summary of Background Data.

AIS affects 2% to 3% of the general population and demonstrations 80% to 99% right thoracic curve convexity. The mechanism of AIS as well as explanation for right-sided predominance is largely unknown.

Methods.

A retrospective chart review of all patients with dextrocardia from 2008 to 2018 was performed at a single institution. Upright chest x-rays and scoliosis x-rays were evaluated for scoliosis by measurement of Cobb angle. Chart review was performed to extract age, advanced imaging results, and surgical intervention.

Results.

Of 110 patients identified with dextrocardia, 19 patients exhibited radiographic features consistent with AIS (Cobb angle >10°). Fifteen (79%) of these patients demonstrated left-sided thoracic curvature. Six patients showed isolated dextrocardia with normal abdominal organ orientation; five patients (83%) showed left-sided thoracic curvature. There was not a statistical difference with regards to sex or curve severity. Magnetic resonance imaging (MRI) was performed on five patients with left-sided curvature without evidence of intra-spinal pathology.

Conclusion.

Dextrocardia shows increased incidence of AIS in both male and female patients. Left-sided thoracic curvature in cases with concurrent dextrocardia may not be associated with intra-spinal pathology as seen in the general population. These data suggest that thoracic organ orientation affects AIS convexity directionality.

Level of Evidence: 3
Factors Affecting Patient Decision-making on Surgery for Lumbar Disc Herniation
Authors: Andersen Stina Brogård , Birkelund Regner , Andersen Mikkel Ø. , Carreon Leah Y. , Coulter Angela , Steffensen Karina Dahl
Published: June 2018

Study Design.

Qualitative research using semistructured interviews.

Objective.

To explore, from a patient perspective, factors influencing a patient's decision-making process and the decision to have surgery for lumbar disc herniation.

Summary of Background Data.

Since strong evidence favoring surgical over nonsurgical treatment is lacking and firm guidelines regarding the optimal timing of surgery are not available, it is essential to involve patients in the decision-making process. Thus the elements that might affect the decision-making process and the decision to have surgery must be identified.

Methods.

Using a hermeneutic-phenomenological approach, 14 patients who were referred for primary surgery for lumbar disc herniation were interviewed. Interviews were transcribed and analyzed using a meaning-condensation method to identify themes influencing a patient's decision-making process and the decision to have surgery for lumbar disc herniation.

Results.

Four main themes that could directly or indirectly influence the patients’ decision-making process were identified: A) Patient information: patients’ conceptions about treatment were not always based on sufficient information; B) Accelerated workflows: some patients needed time to process the information given, which may be limited due to accelerated workflows; C) Power imbalance: patients can be reluctant to challenge the system, as they do not want to offend, which can be seen as a power imbalance between clinicians and patients; and D) Personal past experience: experience, about treatment options from, i.e., close relatives, can impact patients thoughts about possible treatments.

Conclusion.

Several factors can influence patients’ decision-making process and the decision itself: the amount and quality of information received as compared with their preconceived notions, the amount of time given to consider their decision, reluctance to challenge the system and offend the healthcare provider, and past personal experience. Understanding these complex factors will help clinicians to better support patients choosing between surgical and nonsurgical treatment for lumbar herniated disc.

Level of Evidence: 5
Validation of the Fusion Risk Score for Thoracic and Lumbar Spine Fusion Procedures
Authors: Deogaonkar Kedar , Mehbod Amir A. , Dawson John M. , Transfeldt Ensor E.
Published: June 2018

Study Design:

This is a retrospective cohort study.

Objective:

This study aimed to determine whether the Fusion Risk Score (FRS) is valid for perioperative complications.

Summary of Background Data:

The FRS was previously formulated from a retrospective review of 364 fusion surgeries in patients over age 65. Patient demographics, comorbidities, surgical approach, levels, and osteotomies are incorporated in a weighted manner. This score correlated well with the risk of perioperative complications, operative time, estimated blood loss during surgery, and length of hospital stay.

Materials and Methods:

A new cohort of patients was studied. Subjects were 65 years old or older and had undergone routine elective thoracic or lumbar fusion surgery. The FRS was calculated for each subject to estimate risk (low, medium, or high) for perioperative complications. Actual incidences of major complications in the first 90 days after the surgery were noted and statistically compared with the predicted risk. The FRS was compared with intensive care unit admittance, estimated blood loss, operative time, and hospital length of stay to determine whether the score was predictive.

Results:

In total, 51% of our patients were at low risk (FRS, 1–3) for perioperative complications; 43% were at medium risk (FRS, 4–9); and 7% were at high risk (FRS, over 9). A total of 8% in the low-risk group, 23% in the medium-risk group, and 67% in the high-risk group actually developed significant perioperative complications. Medium-risk and high-risk patients experienced proportionally more perioperative complications than did low-risk patients; the difference was highly statistically significant.

Conclusions:

This study validated the association between the FRS and complications in the first 90 days after thoracolumbar spinal fusion surgery on the basis of patient and surgery characteristics. It also predicts the risk of intensive care unit admission, operative time, blood loss, and hospital length of stay.
Cutaneous Metastasis of Choriocarcinoma in 2 Male Patients: A Rare Presentation of an Aggressive Malignancy That Dermatopathologists Must Recognize
Authors: Marka Arthur , Hoyt Brian S. , LeBlanc Robert E.
Published: June 2018

Testicular choriocarcinoma needs to be considered in the differential diagnosis of cutaneous metastases in young adult men because of its propensity for early hematogenous dissemination. Furthermore, the diagnosis may not be suspected in many cases in which there is clinically no testicular enlargement. This highly aggressive germ cell tumor typically metastasizes to the liver, lungs, and brain. Skin metastasis is exceedingly rare with only 22 cases previously reported in the world literature. We herein report 2 additional cases: a 25-year-old man and a 32-year-old man, both of whom were treated for mixed germ cell tumors and developed multiple cutaneous metastases to the head.
Patient Perceptions and Quality of Life After Colon and Rectal Surgery: What Do Patients Really Want?
Authors: Wrenn Sean M. , Cepeda-Benito Antonio , Ramos-Valadez Diego I. , Cataldo Peter A.
Published: June 2018

BACKGROUND:

Colorectal surgery outcomes must be accurately assessed and aligned with patient priorities. No study to date has investigated the patient’s subjective assessment of outcomes most important to them during and following their surgical recovery. Although surgeons greatly value the benefits of laparoscopy, patient priorities remain understudied.

OBJECTIVE:

This study aimed to assess what aspects of patients’ perioperative care and recovery they value most when queried in the postoperative period.

DESIGN:

This study is an exploratory cross-sectional investigation of a defined retrospective patient population. Enrollees were stratified into subcategories and analyzed, with statistical analysis performed via χ2 test and unpaired t test.

SETTINGS:

This study was conducted at a single academic medical center in New England.

PATIENTS:

Patients who underwent a colorectal surgical resection between 2009 and 2015 were selected.

INTERVENTIONS:

Patients within a preidentified population were asked to voluntarily complete a 32-item questionnaire regarding their surgical care.

MAIN OUTCOME MEASURES:

The primary outcomes measured were patient perioperative and postoperative quality of life and satisfaction on selected areas of functioning.

RESULTS:

Of 167 queried respondents, 92.2% were satisfied with their recovery. Factors considered most important included being cured of colorectal cancer (76%), not having a permanent stoma (78%), and avoiding complications (74%). Least important included length of stay (13%), utilization of laparoscopy (14%), and incision appearance and length (2%, 4%).

LIMITATIONS:

The study had a relatively low response rate, the study is susceptible to responder’s bias, and there is temporal variability from surgery to questionnaire within the patient population.

CONCLUSIONS:

Overall, patients reported high satisfaction with their care. Most important priorities included being free of cancer, stoma, and surgical complications. In contrast, outcomes traditionally important to surgeons such as laparoscopy, incision appearance, and length of stay were deemed less important. This research helps elucidate the outcomes patients truly consider valuable, and surgeons should focus on these outcomes when making surgical decisions. See Video Abstract at http://links.lww.com/DCR/A596. See Visual Abstract at https://tinyurl.com/yb25xl66.
Histological Comparison of Cold versus Hot Snare Resections of the Colorectal Mucosa
Authors: Takayanagi Daisuke , Nemoto Daiki , Isohata Noriyuki , Endo Shungo , Aizawa Masato , Utano Kenichi , Kumamoto Kensuke , Hojo Hiroshi , Lefor Alan Kawarai , Togashi Kazutomo
Published: June 2018

BACKGROUND:

Delayed postpolypectomy bleeding occurs more frequently after hot resection than after cold resection.

OBJECTIVE:

To elucidate the underlying mechanism, we performed a histological comparison of tissue after cold and hot snare resections.

DESIGN:

This is a prospective study, registered in the University Hospital Medical Information Network (UMIN000020104).

SETTING:

This study was conducted at Aizu Medical Center, Fukushima Medical University, Japan.

PATIENTS:

Fifteen patients scheduled to undergo resection of colorectal cancer were enrolled.

INTERVENTION:

On the day before surgery, 2 mucosal resections (hot and cold) of normal mucosa were performed on each patient using the same snare without saline injection. The difference was only the application of electrocautery or not. Resection sites were placed close to the cancer to be included in the surgical specimen.

MAIN OUTCOME MEASURES:

The primary outcome measure was the depth of destruction. Secondary outcome measures included the width of destruction, depth of the remaining submucosa, and number of vessels remaining at the resection sites. The number and diameter of vessels in undamaged submucosa were also evaluated.

RESULTS:

All cold resections were limited to the shallow submucosa, whereas 60% of hot resections advanced to the deep submucosa and 20% to the muscularis propria (p < 0.001). There was no significant difference in the width of destruction. The number of remaining large vessels after hot resections trended toward fewer (p = 0.15) with a decreased depth of remaining submucosa (p = 0.007). In the deep submucosa, the vessel diameter was larger (p < 0.001) and the number of large vessels was greater (p = 0.018).

LIMITATIONS:

Histological assessment was not blinded to the 2 reviewers. Normal mucosa was used instead of adenomatous tissue.

CONCLUSIONS:

Hot resection caused damage to deeper layers involving more large vessels. This may explain the mechanism for the reduced incidence of hemorrhage after cold snare polypectomy. See Video Abstract at http://links.lww.com/DCR/A631.
Can Endorectal Ultrasound, MRI, and Mucosa Integrity Accurately Predict the Complete Response for Mid-Low Rectal Cancer After Preoperative Chemoradiation? A Prospective Observational Study from a Single Medical Center
Authors: Liu Sen , Zhong Guang-xi , Zhou Wei-xun , Xue Hua-dan , Pan Wei-dong , Xu Lai , Lu Jun-yang , Wu Bin , Lin Guo-le , Qiu Hui-zhong , Xiao Yi
Published: June 2018

BACKGROUND:

Patients with locally advanced rectal cancer could be managed by a watch-and-wait approach if they achieve clinical complete response after preoperative chemoradiotherapy. Mucosal integrity, endorectal ultrasound, and rectal MRI are used to evaluate clinical complete response; however, the accuracy remains questionable. Clinical practice based on those assessment methods needs more data and discussion.

OBJECTIVE:

The aim of this prospective study was to evaluate the accuracy of mucosal integrity, endorectal ultrasound, and rectal MRI to predict clinical complete response after chemoradiotherapy.

DESIGN:

Endorectal ultrasound and rectal MRI were undertaken 6 to 7 weeks after preoperative chemoradiation therapy. Patients then received radical surgery based on the principles of total mesorectal excision. Preoperative tumor staging achieved by endorectal ultrasound and rectal MRI was compared with postoperative staging by pathologic examination. Sensitivity, specificity, and accuracy of each evaluation method were calculated.

SETTINGS:

The study was conducted at a single tertiary care center.

PATIENTS:

Patients diagnosed with mid-low rectal cancer by biopsy between May 2014 and December 2016 were enrolled in this study.

RESULTS:

A total of 124 patients were enrolled in this study, and postoperative pathology revealed that 20 patients (16.13%) achieved complete response (ypT0N0). The sensitivity of mucosal integrity, endorectal ultrasound, and MRI to predict clinical complete response was 25%. The specificity of mucosal integrity, endorectal ultrasound, and MRI was 94.23%, 93.90%, and 93.27%. The combination of each 2 or all 3 methods did not improve accuracy. Regression analysis showed that none of these methods could predict postoperative ypT0.

LIMITATIONS:

The sample size is small, and we did not focus on the follow-up data and cannot compare prognosis data with previous research studies.

CONCLUSIONS:

Both single-method and combined mucosal integrity, endorectal ultrasound, and rectal MRI have poor correlation with postoperative pathologic examination. A watch-and-wait approach based on these methods might not be a proper strategy compared with radical surgery after neoadjuvant therapy. See Video Abstract at http://links.lww.com/DCR/A693.
Safe and Effective Endoscopic Resection of Massive Colorectal Adenomas ≥8 cm in a Tertiary Referral Center
Authors: Emmanuel Andrew , Gulati Shraddha , Burt Margaret , Hayee Bu’Hussain , Haji Amyn
Published: June 2018

BACKGROUND:

Endoscopic resection of large colorectal lesions is well reported and is the first line of treatment for all noninvasive colorectal neoplasms in many centers, but little is known about the outcomes of endoscopic resection of truly massive colorectal lesions ≥8 cm.

OBJECTIVE:

We report on the outcomes of endoscopic resection for massive (≥8 cm) colorectal adenomas and compare the outcomes with resection of large (2.0–7.9 cm) lesions.

DESIGN:

This was a retrospective study.

SETTINGS:

The study was conducted in a tertiary referral unit for interventional endoscopy.

PATIENTS:

A total of 435 endoscopic resections of large colorectal polyps (≥2 cm) were included, of which 96 were ≥8 cm.

MAIN OUTCOME MEASURES:

Outcomes included initial successful resection, complications, recurrence, surgery, and hospital admission.

RESULTS:

Endoscopic resection was successful for 91 of 96 massive lesions (≥8 cm). Mean size was 10.1 cm (range, 8–16 cm). A total of 75% had previous attempts at resection or heavy manipulation before referral. Thirty two were resected using endoscopic submucosal dissection or hybrid endoscopic submucosal dissection and the rest using piecemeal endoscopic mucosal resection. No patients required surgery for a perforation. Five patients had postprocedural bleeding. There were 25 recurrences: 2 were treated with transanal endoscopic microsurgery, 2 with right hemicolectomy, and the rest with endoscopic resection. Compared with patients with large lesions, more patients with massive adenomas had complications (19.8% versus 3.3%), required admission (39.6% versus 11.0%), developed recurrence (30.8% versus 9.9%), or required surgery for recurrence (5.0% versus 0.8%).

LIMITATIONS:

This was a retrospective study.

CONCLUSIONS:

Endoscopic resection of massive colorectal adenomas ≥8 cm is achievable with few significant complications, and the majority of patients avoid surgery. Systematic assessment is required to appropriately select patients for endoscopic resection, which should be performed in specialist units. See Video Abstract at http://links.lww.com/DCR/A653.
The naturally derived small compound Osthole inhibits osteoclastogenesis to prevent ovariectomy-induced bone loss in mice
Authors: Zhao Dongfeng , Wang Qiang , Zhao Yongjian , Zhang Hao , Sha Nannan , Tang Dezhi , Liu Shufen , Lu Sheng , Shi Qi , Zhang Yan , Dong Yufeng , Wang Yongjun , Shu Bing
Published: June 2018

Objective:

This study was to determine the bone protective effects and underlying mechanisms of Osthole (OT) in ovariectomized (OVX) mice. We found that the inhibitory effects of OT on receptor activator of nuclear factor kappa-B ligand (RANKL)-activated osteoclastogenesis are responsible for its bone protective effects in OVX mice.

Methods:

Eight-week-old mice were ovariectomized and OT (10 mg/kg/d) was intraperitoneally administrated to OVX mice 7 days after the surgery and were sacrificed at the end of the 3 months. Osteoclasts were generated from primary bone marrow macrophages (BMMs) to investigate the inhibitory effects of OT. The activity of RANKL-activated signaling was simultaneously analyzed in vitro and in vivo using immunohistochemistry, Western blot, and PCR assays.

Results:

OT dose dependently inhibited RANKL-mediated osteoclastogenesis in BMM cultures. OT administration attenuated bone loss (mg Ha/cm: 894.68 ± 33.56 vs 748.08 ± 19.51, P 
< 0.05) in OVX mice. OT inhibits osteoclastogenesis (Oc.N/per view area: 72 ± 4.3 vs 0.8 ± 0.4, P 
< 0.05) and bone resorption activity (bone resorbed percentages %, 48.56 ± 7.25 vs 3.25 ± 1.37, P 
< 0.05) from BMMs. Mechanistically, OT inhibited the expressions of nuclear factor of activated T-cells c1 (NFATc1) and c-Fos. Moreover, OT suppressed the expression of RANKL-induced osteoclast marker genes, including matrix metalloproteinase 9 (MMP9), Cathepsin K (Ctsk), tartrate-resistant acid phosphatase (TRAP), and carbonic anhydrase II (Car2).

Conclusions:

OT inhibits RANKL-mediated osteoclastogenesis and prevents bone loss in OVX mice. Our findings revealed that OT is a potential new drug for treating postmenopausal osteoporosis.
Management of the Perimenopause
Authors: DELAMATER LARA , SANTORO NANETTE
Published: June 2018

Perimenopause, or the menopausal transition, represents a period of time during which newly arising symptoms can present complex management decisions for providers. Many women present to care with complaints of hot flashes, vaginal and sexual changes, altered mood and sleep, and changing bleeding patterns. The effect of these symptoms on quality of life, even before a woman enters menopause, can be significant. The appropriate evaluation and evidence-based management of women in this transition is reviewed in this article. Two case vignettes are used to highlight certain evaluation and treatment challenges.
Prognostic Value of the 6-Min Walk Test After Open-Heart Valve Surgery
Authors: Vitale Giuseppe , Sarullo Silvia , Vassallo Laura , Di Franco Antonino , Mandalà Giorgio , Marazia Stefania , Raffa Giuseppe M. , Giallauria Francesco , Sarullo Filippo M.
Published: June 2018

Purpose:

This single-center retrospective analysis aimed to evaluate the prognostic relevance of 6-min walk test (6MWT) in patients admitted to an in-hospital cardiovascular rehabilitation program after open-heart valve surgery.

Methods:

One hundred one patients able to perform a 6MWT within the first week of admission (time after surgery: 16 ± 8 d) were included (age 68 ± 11 y; 55% female; median left ventricular ejection fraction 55% [interquartile range: 50-60]; 51% after aortic valve surgery). Study endpoints were cardiovascular death and the combined outcome of cardiovascular death/cardiac hospitalization. Univariate and multivariate analyses were performed to analyze predictive value of the 6MWT.

Results:

After a median follow-up of 27 mo, cardiovascular mortality was 9.9% while combined endpoint occurrence was 33%. Patients experiencing study endpoints had lower left ventricular ejection fraction, higher N-terminal prohormone of brain natriuretic peptide serum levels, and longer in-hospital stay (all P < .05). The 6MWT distance was a significant predictor of cardiovascular death (hazard ratio [HR] = 0.89, 95% CI: 0.81-0.97, P = .007) and cardiac hospitalizations (HR = 0.95, 95% CI: 0.90-0.99, P = .02). Even after adjusting for the relevant confounding variables of cardiovascular death and cardiac hospitalization, the adjusted HR = 0.88, 95% CI: 0.75-0.98, P = .028 and adjusted HR = 0.95, 95% CI: 0.90-0.99, P = .05, respectively.

Conclusions:

In patients admitted to an in-hospital cardiovascular rehabilitation program after open-heart valve surgery, 6MWT proved to be an independent prognostic tool, potentially allowing identification of high-risk patients for whom a more intensive and tailored in-hospital cardiovascular rehabilitation program should be designed and implemented in order to avoid unfavorable cardiovascular events.
Postsurgical Cataract Prophylaxis With Intravitreal “Triamcinolone-Moxifloxacin” May Not Be Optimal For Preventing Endophthalmitis
Authors: Kowalski Regis P. , Romanowski Eric G. , Shanks Robert M. Q. , Mammen Alex , Dhaliwal Deepinder K.
Published: June 2018

Purpose:

Intravitreal injections of antibiotics and anti-inflammatories are used by some cataract surgeons for surgical prophylaxis. To support this prophylaxis, intravitreal triamcinolone–moxifloxacin (TM) and triamcinolone–moxifloxacin–vancomycin (TMV) were tested for preventing Staphylococcus aureus (SA) endophthalmitis in rabbits.

Methods:

Trademark formulations of TM (15/1 mg/mL) and TMV (15/1/10 mg/mL) were intravitreally injected into seven groups of eight rabbits each (A–G). Before intravitreal injection, the vitreous was first challenged with clinical SA endophthalmitis isolates (5,000 colony-forming unit) with varying minimum inhibitory concentrations (MICs in μg/mL) to moxifloxacin (denoted by the MIC at the end of each group listed): A) TMV-10, B) TM-10, C) Saline-10, D) TM-2, E) Saline-2, F) TM-0.032, and G) Saline-0.032. After 24 hr, the rabbit eyes were graded for clinical endophthalmitis and cultured for viable SA.

Results:

Rabbits treated with TMV and challenged by SA with a moxifloxacin MIC of 10 μg/mL did not present with endophthalmitis (0/8, no eyes with endophthalmitis). For SA with moxifloxacin MICs of 10.0 and 2.0 μg/mL, TM did not prevent endophthalmitis (16/16, 100% of eyes with endophthalmitis). For SA with a moxifloxacin MIC of 0.032 μg/mL, endophthalmitis was prevented with TM (0/8, no eyes with endophthalmitis). All saline-treated eyes developed endophthalmitis (23/23, 100% of eyes with endophthalmitis).

Conclusions:

Intravitreal monotherapy with TM did not provide consistent prevention of SA endophthalmitis, whereas intravitreal TMV successfully prevented endophthalmitis because of SA with elevated MIC values to moxifloxacin. Cataract surgeons need to be aware that vancomycin seems to be essential for intravitreal prophylaxis to cover moxifloxacin resistance.
Circular Keratotomy Combined With Wedge Resection in the Management of High Astigmatism After Penetrating Keratoplasty
Authors: Çakir Hanefi , Genç Selim , Güler Emre
Published: June 2018

Objective:

To evaluate the effectiveness of circular keratotomy combined with wedge resection for the management of high astigmatism after penetrating keratoplasty (PK).

Methods:

The study included seven eyes of seven patients with previous PK who underwent circular keratotomy combined with wedge resection. The uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA), spherical equivalent (SE) refraction, and keratometric powers obtained by corneal topography were evaluated. The power vector method was used to analyze the astigmatic change postoperatively.

Results:

The mean follow-up period was 18.42±8.56 months (range 12–33 months). Uncorrected visual acuity, BCVA, and SE were improved in all eyes postoperatively. The mean preoperative astigmatism reduced from 15.11±5.48 D (range, 10.0–24.4 D) to 4.98±3.01 D (range, 2.2–9.6 D), postoperatively. According to the vector analysis, the overall mean surgically induced astigmatism at last visit was 12.87±6.20 D. The most common complication was the loosening of sutures occurred in five eyes within 2 months.

Conclusions:

Circular keratotomy combined with corneal wedge resection is a favorable option for the management of high astigmatism after PK.
Comparison of Different Corneal Power Readings From Pentacam in Post-laser In Situ Keratomileusis Eyes
Authors: Ng Alex L. K. , Chan Tommy C. Y. , Cheng Arthur C. K.
Published: June 2018

Objectives:

To compare the various Pentacam-measured K-readings with the clinical history method (CHM) in eyes that have undergone myopic laser in situ keratomileusis (LASIK).

Methods:

In this prospective study, Pentacam examination was performed in 71 eyes 1 month after myopic LASIK. The true net power (TNP) 4 mm, total corneal refractive power (TCRP) 4 mm, equivalent K-reading (EKR) 4.0 mm, and EKR 4.5 mm obtained from the same scan were compared with the K derived from CHM.

Results:

The average baseline spherical equivalence was −5.44±2.38 D. After LASIK, the mean KCHM was 37.67±2.13 D, TCRP4mm was 37.14±1.79 D, TNP4mm was 36.88±1.76 D, EKR4.0mm was 37.58±1.94 D, and EKR4.5mm was 37.51±1.94 D. TCRP4mm, TNP4mm, and EKR4.5mm showed a statistically significant deviation from the KCHM, with the mean error being 0.53 D, 0.79 D, and 0.16 D, respectively (P<0.05). Only the EKR4.0mm showed no statistically significant difference from the KCHM (mean error 0.09 D, P=0.23). The EKR4.0mm also had the narrowest 95% limits of agreement (LoA) (−1.10 to +1.28 D), whereas both TCRP4mm and TNP4mm had a wider LoA (−0.88 to +1.95 D and −0.62 to +2.20 D, respectively). All four Pentacam K-readings had a strong and statistically significant correlation with the KCHM.

Conclusions:

Using the CHM as reference, the EKR4.0mm demonstrated the closest agreement when compared with the EKR4.5mm, TNP4mm, and TCRP4mm obtained from the same scan.
Predictability of the Achieved Lenticule Thickness in Small Incision Lenticule Extraction for Myopia Correction
Authors: Zhou Jiaqi , Zhang Yan , Li Meiyan , Sun Ling , Zhou Xingtao
Published: June 2018

Purpose:

To investigate the predictability of the achieved lenticule thickness in small incision lenticule extraction (SMILE) for the correction of myopia.

Methods:

In this prospective study, a total of 80 eyes of 45 patients who underwent the SMILE procedure were included. A Scheimpflug camera was used to measure the preoperative and postoperative corneal topography. Achieved lenticule thicknesses at the pupil center and corneal vertex were calculated by subtracting the postoperative corneal thickness at the pupil center and corneal vertex from preoperative corresponding values. Predictability between the achieved and VisuMax readout at different locations (the pupil center and corneal vertex) and postoperative visits (postoperative day 1 and 6 months) were evaluated using a general linear model.

Results:

Achieved lenticule thickness at the pupil center and corneal vertex showed good correlation at both postoperative day 1 (pupil center: r=0.914, corneal vertex: r=0.903) and 6 months (pupil center: r=0.886, corneal vertex: r=0.866). The achieved lenticule thickness at postoperative day 1 was 8.5-μm thinner at the pupil center and 9.6-μm thinner at the corneal vertex than the VisuMax readout.

Conclusions:

This study suggests that the predictability between the achieved and VisuMax readout is favorable. The lenticule thickness at the pupil center is closer to the VisuMax readout than corneal vertex.
Office-Based Diagnosis of Demodex Using Smartphone
Authors: Kaya Abdullah , Gürdal Canan
Published: June 2018

Demodex is an important pathogen in ophthalmology. It is believed to cause a variety of eyelid and eyelash diseases. Currently, light microscopes are being used for imaging demodex. However, microscopes are not available everywhere. Also, it is not cost-effective to perform light microscopy in every case. In this case, we demonstrate a new method: imaging demodex using cell phone. A 90-diopter noncontact double aspheric lens was attached to the posterior camera of the smartphone with clear tape. An eyelash of a patient with blepharitis was removed. A video was taken using smartphone. There was a moving demodex parasite in the root of the eyelash. A clear video image could be taken using the smartphone. A smartphone and a 90-diopter lens are adequate for the imaging and diagnosis of demodex.
Comparison Between Diclofenac and Ketorolac Ophthalmic Drops for Pain Management After Photorefractive Keratectomy: A Randomized Clinical Study
Authors: Mohammadpour Mehrdad , Heidari Zahra , Molani Ratishta
Published: June 2018

Objectives:

To assess and compare the efficacy of two nonsteroidal anti-inflammatory drugs (NSAIDs), namely diclofenac and ketorolac, for pain control after photorefractive keratectomy (PRK).

Methods:

In this double-masked clinical study, 60 patients treated bilaterally with PRK were randomly allocated into two groups. Postoperatively, one group of patients received diclofenac 0.1% drops and the other group was prescribed ketorolac 0.5% ophthalmic drops in both eyes every 6 hr on the first day and then, no NSAID was applied until the third day. No oral analgesic drug was used after surgery. Patients completed the Visual Analog Scale questionnaire to determine the degree of pain and ocular discomfort (tearing, foreign body sensation, blurred vision, and photophobia) on the first and the third day after surgery.

Results:

Pain relief was achieved with both medications after surgery, and there was no significant intergroup difference in the level of pain reduction at 24 and 72 hr postoperatively (P>0.05). The ketorolac group experienced less tearing and photophobia only at 24 hr postoperatively (P=0.01), and by 72 hr after surgery, the results were similar in two groups (P>0.05). There was no significant intergroup difference in terms of foreign body sensation or blurred vision on the first or third postoperative days (P>0.05).

Conclusions:

Both diclofenac and ketorolac are effective in reducing pain and ocular discomfort after PRK, and ketorolac may have greater control on tearing and photophobia during the first 24 postoperative hours.
The Impact of Sleep Duration on Performance Among Competitive Athletes: A Systematic Literature Review
Authors: Kirschen Gregory W. , Jones Jason J. , Hale Lauren
Published: June 2018

The athletic advantage of sleep, although commonly touted by coaches, trainers, and sports physicians, is still unclear and likely varies by sport, athletic performance metric, and length of sufficient or insufficient sleep. Although recent literature reviews have highlighted circadian and nutritional factors that influence different aspects of athletic performance, a systematic summary of the effects of sleep duration and sleep quality on performance among competitive athletes is lacking. Here we systematically review the relationship between sleep duration and sleep quality and objective athletic performance among competitive athletes across 19 studies representing 12 sports. Taken holistically, we find that the sports requiring speed, tactical strategy, and technical skill are most sensitive to sleep duration manipulations. Furthermore, longer-term sleep manipulations are more likely than acute sleep manipulations (whether deprivation or extension) to affect athletic performance. Thus, the importance of sleep for competitive athletes to achieve high performance is dependent on the demands of the sport as well as the length of sleep interventions. In light of the limited number of studies investigating sleep quality and performance, the potential relevance of subjective sleep quality remains an interesting question for future work.
Association Between Clinical and Imaging Outcomes After Therapeutic Loading Exercise in Patients Diagnosed With Achilles or Patellar Tendinopathy at Short- and Long-Term Follow-up: A Systematic Review
Authors: Rabello Lucas M. , van den Akker-Scheek Inge , Brink Michel S. , Maas Mario , Diercks Ron L. , Zwerver Johannes
Published: June 2018

Objective:

To determine the association between clinical and imaging outcomes after therapeutic loading exercise in Achilles tendinopathy (AT) and patellar tendinopathy (PT) populations at both short- and long-term follow-up.

Data Sources:

The PUBMED and EMBASE databases were searched (up to June 2017) to identify articles that meet the inclusion criteria: (1) patients diagnosed with AT (insertional or midportion) or PT; (2) rehabilitation based on therapeutic loading exercise; and (3) assessment of clinical outcomes and tendon structure using an imaging modality.

Main Results:

Two independent reviewers screened 2894 search results, identifying 21 suitable studies. According to the studies included in this review, clinical results showed significant improvements for patients with AT and PT after eccentric exercise (ECC) and heavy slow resistance (HSR) at short- and long-term follow-up. Imaging outcomes were not consistent. Moderate-to-strong evidence for patients with AT suggested an association between clinical outcomes and imaging outcomes (tendon thickness and tendon neovascularization) after ECC at long-term follow-up. For patients with PT, there was moderate evidence supporting an association between clinical outcomes (questionnaire score and pain) and imaging (tendon thickness and tendon neovascularization) after ECC at short-term follow-up. For both the AT and PT groups, there was moderate evidence for an association between clinical outcomes and tendon thickness and neovascularization after HSR exercise. Results related to the HSR exercise should be interpreted with caution because of the small number of studies.

Conclusions:

Based on the findings of the present review, the use of imaging outcomes as a complementary examination to the clinical assessment was confirmed. Overall, an improvement in clinical outcomes seems to be associated with a reduction in tendon thickness and tendon neovascularization. Clinicians should be aware that during the interpretation of the imaging outcomes, factors such as tendinopathy location, exercise modality performed, and a follow-up period should be considered.
Nonaneurysmal Subarachnoid Hemorrhage in Sickle Cell Disease
Authors: Zuccoli Giulio , Nardone Raffaele , Rajan Deepa , Khan Abdullah S. , Cummings Dana D.
Published: June 2018

Descriptions of the natural history of cerebrovascular complications of sickle cell disease (SCD) characterize ischemic stroke as common during childhood and hemorrhagic stroke as more common in adulthood. Childhood ischemic stroke is attributed to vasculopathy with moyamoya syndrome. Hemorrhagic stroke is commonly attributed to aneurysms accompanying HbSS cerebral vasculopathy in SCD. However, a growing body of literature highlights multiple contributing factors to hemorrhagic stroke in children. Primary hemorrhagic stroke is one of the most devastating neurological complications of SCD. We describe the case of an 18-year-old female affected by HbSS genotype SCD presenting with reversible cerebral vasoconstriction syndrome (RCVS) as well as features of posterior reversible encephalopathy syndrome and convexity subarachnoid hemorrhage (SAH) after transfusion of red blood cells. We reviewed the existing literature dealing with SCD, blood transfusion, and hemorrhagic strokes. To our knowledge, this case presentation is unique with convexity SAH predominantly attributable to a RCVS spectrum disorder occurring in the setting of a recent blood transfusion in an adolescent female with SCD. As this case illustrates, neurological deterioration accompanied by intracranial hemorrhage in children and young adults with SCD after blood transfusion should raise suspicion for RCVS as part of a complex cerebral vasculopathy. A better understanding of the risk factors leading to hemorrhagic stroke may help prevent this severe complication in subjects with SCD. Neuroimaging including angiography in these subjects may enable prompt diagnosis and management.
Myelitis and Polyradiculoneuropathy With Severe Pain
Authors: Marques Inês B. , Marto Natália , Raimundo Anabela , Gil-Gouveia Raquel
Published: June 2018

Brucellosis, an endemic zoonosis in Portugal, is a multisystem disease, presenting with neurological manifestations in up to 25% of cases. Neurobrucellosis diagnostic criteria include evidence of central nervous system invasion, either by documenting increased blood-brain barrier permeability that normalizes after treatment or by Brucella isolation. We report 2 patients with systemic brucellosis presenting with neurological symptoms: A 28-year-old female with progressive hemiparesis associated with severe refractory thoracic and lumbar pain, whose spinal magnetic resonance imaging identified longitudinally extensive myelitis. Brucella agglutination test was positive in blood; however, cerebrospinal fluid cytochemical, serological testing, and cultures were negative. A 58-year-old male with intermittent fever in the evening, associated with severe refractory cervical and lumbar spinal and radicular pain. Blood workup identified leukocytosis, elevated inflammatory markers and positive Brucella agglutination test. Cerebrospinal fluid presented mild protein increase and negative serological testing and cultures. Electromyogram revealed demyelinating polyradiculoneuropathy. In both cases, antibiotic therapy induced symptom resolution. Despite the neurological presentation, no evidence of direct nervous system infection was found. An indirect mechanism appears to be involved, such as a parainfectious syndrome or circulating endotoxins release by the bacteria. Brucellosis should be considered in patients presenting with inflammatory neurological symptoms in endemic regions. Prompt diagnosis and treatment are important as chronic infection has significant morbidity.
A Fatal Case of Undiagnosed Candida Meningitis
Authors: Finelli Pasquale F.
Published: June 2018

Diagnostic error is an increasing health care concern. An intravenous drug abuser with chronic meningitis died after a prolonged hospitalization from fungal meningitis diagnosed at autopsy. We examine the diagnostic pitfalls and consider how a computer-assisted diagnostic system may influence the outcome of an otherwise fatal condition.
Challenges of Rapid Plasma Reagin Interpretation in Syphilis Screening in Uganda: Variability in Nontreponemal Results Between Different Laboratories
Authors: Hamill Matthew M. , Mbazira Kimeze J. , Kiragga Agnes N. , Gaydos Charlotte A. , Jett-Goheen Mary , Parkes-Ratanshi Rosalind , Manabe Yukari C. , Nakku-Joloba Edith , Rompalo Anne
Published: June 2018

Background

Syphilis is a cause of morbidity and mortality and is of particular concern in pregnancy in low-income countries because of the risks associated with maternal-fetal transmission. Ugandan national guidelines recommend a nontreponemal rapid plasma reagin (RPR) followed by treponemal testing for diagnosis of syphilis. The RPR test confirms a reactive specific treponemal test, or confirms serological “cure” with a 4-fold dilutional decrease; RPR is beset with technical and biological limitations, making accurate diagnosis and appropriate treatment problematic. The aim of this analysis was to compare performance of RPR testing in different laboratories.

Methods

Stored, freeze-thawed sera from 215 participants were additionally tested for RPR and dilutional titer in 2 different reference laboratories. Discrepant results were tested at a third reference laboratory which served as a tie-breaker. Equivalence in RPR titer was defined as within 2-fold or less. All patients with reactive rapid tests were treated as per Ugandan National Guidelines.

Results

Of 215 sera, 97 (45.1%) were RPR reactive in clinic laboratory A, 81 (37.7%) and 65 (30.2%) were RPR reactive in laboratories B and C, respectively. All reported positive in laboratory C were positive in laboratory B. Discrepant results were tested in laboratory D. χ2 Test was highly significant (P = <0.001) for difference between each dyad of laboratories (A and B, A and C, and B and C) RPR results. There were significant differences between RPR titers by paired t test and Wilcox rank test (P = <0.001); with up to a 3-fold difference between laboratories. Two one-sided test approach demonstrated nonequivalence. Agreement between laboratories B-D, and C-D: 48 (98.0%) of 49 and 34 (69.4%) of 49, respectively (P = <0.001). Laboratories B and D showed no significant difference and had equivalent RPR titers. Laboratories C and D had different titers (P = <0.001) and were not equivalent.

Conclusions

We found significant interlaboratory discrepant RPR results. A 3-fold difference in results is likely to be clinically significant and could result in undertreatment or overtreatment. These data demonstrate a key limitation of the RPR test and underline the urgent need for a more reproducible quantitative test than the current RPR for diagnosing and determining cure of syphilis.