bluuebunny/crossref_metadata_2025 huggingface dataset:
Single and Repeated Use of the Emergency Department for Chlamydia and Gonorrhea Care
Authors: Bergquist Eleanor Peters , Trolard Anne , Zhao Yueming , Kuhlmann Anne Sebert , Loux Travis , Liang Stephen Y. , Stoner Bradley P. , Reno Hilary
Published: November 2019

Objective

Chlamydia and gonorrhea infection rates are rising in the United States, and the emergency department (ED) is increasingly a site where individuals seek care for these infections, sometimes more than once. This article investigates how individuals who use the ED more than once and receive chlamydia and gonorrhea care differ from individuals who are single users of the ED, as well as characteristics associated with being a repeat user of the ED.

Methods

We analyzed 46,964 visits made by individuals who attended 1 of 4 EDs from January 1, 2010, to May 31, 2016, and received a test for chlamydia and gonorrhea infection. We used negative binomial regression to test the ability of age, sex, race, infection status, and insurance status to predict number of visits.

Results

Individuals who used the ED more than once and received chlamydia and gonorrhea care were at their first visit more likely to be younger (incident rate ratio [IRR], 0.98; 95% confidence interval [CI], 0.97–0.98 per year) nonpregnant female (IRR, 1.23; 95% CI, 1.06–1.42), black (IRR, 1.27; 95% CI, 1.04–1.57), and have no or public insurance compared with single users of the ED.

Discussions

Individuals likely to make multiple visits to the ED and receive chlamydia and gonorrhea care may be identifiable on their first visit and potentially directed elsewhere during subsequent visits for more comprehensive and potentially less expensive sexually transmitted disease care.
Prevalence of Color Vision Deficiency in an Adult Population in South Korea
Authors: Kim Hyojin , Ng Jason S.
Published: November 2019

SIGNIFICANCE

Large differences in failure rates for color vision screening have been reported among different regional groups. However, color vision deficiency prevalence in Korea has only been investigated within a small area of the country.

PURPOSE

This study examines the prevalence of failing a color vision screening and its sex-related differences using a sample that is representative of the whole Korean population.

METHODS

This population-based cross-sectional study evaluated 2686 subjects (age, 19 to 49 years) who participated in the sixth Korea National Health and Nutrition Examination Survey (2013). Color vision deficiency was assessed using the Hardy-Rand-Rittler (HRR) test by an ophthalmologist. According to standard criteria for the HRR, it classified each subject as color normal, protan, deutan, tritan, or unclassified color vision loss. All participants had comprehensive medical evaluations and ocular history taken.

RESULTS

The weighted overall prevalence of color vision deficiency in the Korean population was 3.9% (95% confidence interval, 3.0 to 5.4%). The prevalence of color vision deficiency was higher in male participants (6.5%) than in female participants (1.1%). Among all participants, deutan deficiency (2.5%) had a higher prevalence than did protan deficiency (0.4%). For male participants who failed the HRR screening, deutan-type deficiency was detected most often (64.2%), whereas an unclassified color vision deficiency type was the most common (52.9%) among female participants who failed the HRR screening. As expected, male participants were more likely to fail the HRR screening compared with female participants (prevalence ratio, 6.08; 95% confidence interval, 3.61 to 10.26).

CONCLUSIONS

This large population-based study of color vision deficiency among Koreans gives the most accurate estimate of failing a color vision screening test to date and provides useful information for planning adaptive strategies.
Significance of Morphine Concentration in Bile, Liver, and Blood
Authors: Mercurio Isabella , Ceraso Gianluigi , Melai Paola , Gili Alessio , Troiano Gianmarco , Agostinelli Fausto , Lancia Massimo , Bacci Mauro
Published: November 2019

Forensic pathologists are requested to select matrices alternative to blood in cases of toxicological interest in which blood is not available for different reasons. We evaluated morphine concentrations in blood, bile, and liver samples in 52 cases of heroin overdoses, relating them to each other, to understand the information that could be derived from their analysis. Gas chromatography/mass spectrometry analysis was performed for all the samples positive on screening for opiates. Shapiro-Wilk test, nonparametric Mann-Whitney test, linear regression analysis, and Bland-Altman test were used for analysis. Linear regression demonstrated that there was not a statistically significant association in morphine concentrations between blood and bile and blood and liver. Mean liver/blood ratio was 2.76, varying from 0.131 to 13.379, and bile/blood ratio was 28.79, varying from 0.28 to 559.16. According to these results, bile analysis is a “screening test”; biliary or hepatic concentration of morphine cannot provide information on hematic concentration at the time of death, having no forensic value taken individually.
Causes of Sudden Unexpected Death in Schizophrenia Patients
Authors: Sun Daming , Li Liliang , Zhang Xiang , Blanchard Thomas G. , Fowler David R. , Li Ling
Published: November 2019

Background

Schizophrenia is a detrimental psychiatric disorder, with an increased mortality from natural and nonnatural causes.

Methods

This study was a retrospective review of autopsy cases of all the individuals with history of schizophrenia investigated by the Office of the Chief Medical Examiner, State of Maryland, for a 5-year period from 2008 to 2012.

Result

A total of 391 schizophrenia patients were autopsied at the Office of the Chief Medical Examiner because they died suddenly and unexpectedly. Their age ranged from 15 to 100 years with the mean age of 49.5 years. Of the 391 deaths, 191 (48.8%) were white, 185 (47.3%) were African American, and 15 (3.9%) were either Hispanic or Asian. The male and female ratio was 1.5:1. The majority of deaths (64.2%) were caused by natural diseases, 12.0% deaths were accidents, 11.5% deaths were suicides, and 9.7% deaths were homicides. The manner of death remained undetermined in 38 cases (9.7%). Of the 251 natural deaths, 198 cases (78.9%) were owing to cardiovascular diseases. Cause of death was listed as cardiac arrhythmia in 11 cases. This diagnosis of cardiac arrhythmia was made by exclusion based on death scene investigation, review of medical history, complete autopsy, and toxicological tests. Drug intoxication was the second most common cause of death.

Conclusions

The study shows high fatality caused by cardiovascular diseases and drug intoxication among schizophrenia patients, which calls attention of the medical community to closely monitor the high risk factors of sudden death among schizophrenia patients.
Forensic Spermatozoa Detection
Authors: Suttipasit Papanu
Published: November 2019

Semen is crucial evidence for some sex crimes, with its sole confirmation being sperm detection. The success of sperm detection is dependent on all levels of preanalytic and analytic procedures. Specimen collection must be performed by well-trained and competent forensic physicians as well as forensic nurses, with preservation done properly before laboratory transfer. Laboratory procedures should consider archival sperm identification, by visualization, with adequate amounts separated from other cells to obtain male DNA profiles. Differential extraction is robust and accepted as the forensic standard but is time consuming and may result in male DNA loss. Thus, alternative methods and microdevices have been developed. Challenges in sperm isolation from vaginal or buccal epithelium mixes and discrimination in multiperpetrator cases have been overcome by single-cell profiling; however, problems inherent in identical twin discrimination and azoospermia have yet to be solved. Epigenetics and future molecular biomarkers may hold the key; therefore, all laboratory processes must consider DNA and RNA protection. Long-term specimen preservation should be done when possible in light of future confirmatory tests.
Unusual Variants of Follicular Lymphoma
Authors: Chapman Jennifer R. , Alvarez Jessica P. , White Kyle , Sanchez Sandra , Khanlari Mahsa , Algashaamy Khaled , Cassidy Daniel , Peng Jing-Hong , Fan Yao Shan , Alencar Alvaro , Alderuccio Juan P. , Lossos Izidore S. , Vega Francisco
Published: November 2019

Follicular lymphoma (FL) is one of the most frequently diagnosed lymphomas in the United States and Europe. The definition of and basic approach to diagnosis and grading of FL is essentially unchanged in the recently updated revision of the World Health Organization (WHO) classification. FL is a biologically and histopathologically heterogeneous disease. Although there is an improved understanding of some FL variants and specific subtypes, there are cases whose recognition is particularly challenging, either because they have unusual features or represent examples of new or rare variants. Herein, we share a series of unusual and difficult to recognize FLs with the goal of increasing awareness of the expanding histopathologic variability in FL. Unusual FL discussed here include: FL with Castleman-like changes, FL with plasmacytic differentiation, and immunoglobulin G4-positive plasma cells in the setting of immunoglobulin G4-related disease, FL with marginal zone differentiation and involving mucosa-associated lymphoid tissue sites, diffuse FL variant expressing CD23 with STAT6 mutation, large B-cell lymphoma with IRF4 rearrangement, CD10-negative and MUM1-positive aggressive FL, and Epstein-Barr virus–positive FL.
Ovarian Intermediate Trophoblastic Tumors
Authors: Xing Deyin , Zhong Minghao , Ye Fei , O’Malley Michael T. , Li Shaotiao , Vang Russell , Ronnett Brigitte M.
Published: November 2019

Trophoblastic neoplasms involving the ovary are uncommon and include gestational tumors, which are either metastatic from the uterus or ectopic and nongestational tumors, which include those of germ cell type/origin and somatic tumors with trophoblastic differentiation; in all these types, most are pure choriocarcinoma. Intermediate trophoblastic tumors, which include placental site trophoblastic tumor (PSTT) and epithelioid trophoblastic tumor (ETT), are rare in the ovary, with most assumed to be gestational; this is the only category formally recognized in 2014 World Health Organization (WHO) classification, likely due to few well-documented nongestational examples. We report the clinicopathologic features of 6 ovarian intermediate trophoblastic tumors, including 3 PSTTs, 2 ETTs, and 1 ETT with choriocarcinomatous differentiation. DNA-based short tandem repeat genotyping identified 4 of these as nongestational (3 PSTTs and 1 ETT), as evidenced by sharing of alleles between tumor and normal tissue at all informative loci. Interestingly, all 3 of the nongestational PSTTs coexisted with mature cystic teratoma. The remaining 2 tumors (1 ETT and 1 ETT with some choriocarcinomatous differentiation) were gestational (likely ectopic due to lack of evidence of a uterine tumor), as evidenced by the presence of both maternal and novel/nonmaternal alleles at informative loci in tumor compared with normal tissue. It is important to recognize a distinct category of primary ovarian nongestational intermediate trophoblastic tumors of germ cell type/origin, including PSTT and ETT, in classification systems to guide clinical management, as gestational and nongestational tumors have different genetic origins and may require different therapy. Genotyping is useful for classification as nongestational versus gestational, particularly as traditional clinicopathologic findings cannot always predict the nature of a trophoblastic tumor.
Compound Clear Cell Sarcoma of the Skin—A Potential Diagnostic Pitfall
Authors: Luzar Boštjan , Billings Steven D. , de la Fouchardiere Arnaud , Pissaloux Daniel , Alberti Laurent , Calonje Eduardo
Published: November 2019

The proliferation of cells with melanocytic lineage and a nested pattern has traditionally been regarded as a characteristic feature of a wide range of benign and malignant melanocytic proliferations. Herein, we report a series of 4 clear cell sarcomas, including 3 primary cutaneous and 1 metastatic to the skin, associated with a clear-cut intraepidermal proliferation of tumor cells representing a serious potential diagnostic pitfall. All patients were male individuals, aged from 17 to 71 years (mean: 42 y). The size of the tumors ranged from 8 to 55 mm (mean: 22.2 mm, median: 13 mm). Two tumors arose on a lower extremity and 1 each on the scalp and chest. Cutaneous metastasis developed on the limb proximal to the amputation site. Histologically, all tumors were variably circumscribed nodular or multinodular proliferations within the dermis, focally extending into the subcutis. They were composed of nests and fascicles of pale spindled and epithelioid cells with finely granular or pale cytoplasm, elongated nuclei with a single prominent nucleolus, featuring mild nuclear pleomorphism, and surrounded by delicate fibrous septa. Scattered wreath-like giant cells were present in all cases. Mitotic activity was low (mean and median: 3.5 mitoses/mm2). The intraepidermal component consisted in all 4 cases of nests of tumor cells localized at the dermal-epidermal junction. Nests were well-defined and composed of spindled or epithelioid cells with irregular hyperchromatic nuclei, prominent nucleoli, and scant to moderately abundant eosinophilic to pale cytoplasm. Lentiginous proliferation of epithelioid tumor cells was coupled with focal upward migration of isolated tumor cells in a single case. By immunohistochemistry, all tumors were S100 protein, melan A, and HMB45 positive. By fluorescence in situ hybridization analysis, 3 tumors displayed rearrangements in the EWSR1 gene, whereas reverse transcriptase polymerase chain reaction confirmed EWSR1(e8)/ATF1(e4) translocation in the remaining case. In conclusion, an epidermal component in primary cutaneous clear cell sarcomas, or cutaneous metastasis of the tumor, is exceptional and represents a potential diagnostic pitfall. Careful attention to the salient morphologic features in the dermal component of the tumor, as well as confirmation of EWSR1 gene rearrangement by fluorescence in situ hybridization or reverse transcriptase polymerase chain reaction, is necessary for correct recognition of the tumor and to avoid erroneous diagnosis of a benign or malignant melanocytic proliferation.
Prescribing Patterns of Oral Opioid Analgesic for Acute Pain at a Tertiary Care Children's Hospital Emergency Departments and Urgent Cares
Authors: Wang George Sam , Reese Jennifer , Bakel Leigh Anne , Leonard Jan , Bielsky Alan , Reid Ashley , Bos Tod , Nickels Sarah , Bajaj Lalit
Published: November 2019

Objectives

Despite Centers for Disease Control and Prevention guidelines on adult opioid prescribing, there is a paucity of evidence and no guidelines to inform opioid prescribing in pediatrics. To develop guidelines on pediatric prescribing, it is imperative to evaluate current practice on opioid use. The objectives were to describe prescribing patterns of opioids for acute pain at a children's hospital and to compare clinical characteristics of patients who received less or greater than 3 days.

Methods

A retrospective review of oral opioid analgesics prescribed for acute pain at a tertiary care children's hospital emergency department and urgent care from January 1, 2017, to December 31, 2017. Patients younger than 22 years who received an opioid prescription upon discharge were included. Patients with hematology/oncology or chronic pain diagnosis were excluded.

Results

Opioids were prescribed for a median of 2.2 days (interquartile range, 1.4–3.0 days). Most opioids were prescribed for ≤3 days (1326; 79.3%), and there were 44 (2.6%) prescriptions for >7 days. Twenty-two opioid formulations were prescribed. Single-ingredient oxycodone was the most commonly prescribed (877; 52.5%); there were 724 (43.3%) acetaminophen combination products. Common diagnoses were orthopedic (973; 58.2%), surgery/burn/trauma (195; 11.7%), and ear/nose/throat (143; 8.6%). Patients who received >3 days of opioids were younger (P < 0.001), and there was no differences in sex, ethnicity, insurance, or provider qualifications.

Conclusions

Overall, prescribing patterns for the duration of opioid analgesics were ≤3 days, with a median of 2 days. There was a large range of days prescribed, with variations in prescribing characteristics among patients and providers.
Attitudes Toward Electronic Sexual Health Assessments Among Adolescents in the Emergency Department
Authors: Langerman Steven D. , Badolato Gia M. , Goyal Monika K.
Published: November 2019

Objectives

Adolescents account for nearly half of all newly diagnosed sexually transmitted infection (STI) cases in the United States and frequently access health care via emergency departments (EDs). However, there are many barriers to ED-based STI screening. Electronic sexual health assessments may overcome some of these ED-specific barriers. Thus, the objective of this study was to assess adolescent attitudes toward electronic sexual health assessments to guide STI screening in the ED.

Methods

This was a secondary analysis of data from 2 cross-sectional studies evaluating acceptability of electronic sexual health assessments in the pediatric ED. Study participants completed an electronic questionnaire that elicited sexual behavior information and attitudes toward electronic sexual health assessments. We interrogated the electronic health record to determine if sexual histories were documented, and if so, we assessed patient preference for mode of assessment. We performed multivariable logistic regression to identify demographic factors associated with acceptance of electronic sexual health assessments.

Results

Of the 1159 adolescents surveyed, 935 (80.7%; 95% confidence interval, 78.3–82.9) found electronic assessments an acceptable method by which to provide sexual health information. The majority (n = 874 [75.4%]; 72.8–77.9) reported a preference for electronic assessments over other modes of assessment. Acceptance of electronic assessments was associated with STI-related chief complaint (adjusted odds ratio, 1.7; 1.0–2.7) and private insurance (adjusted odds ratio, 1.8; 1.2–2.7).

Conclusions

Electronic sexual health assessments are acceptable to adolescents and are an efficient alternative to face-to-face sexual health assessments. Future studies should focus on how best to integrate electronic assessments into the ED workflow.
Liaison Public Health Nurse Project: Innovative Public Health Approach to Combat Infectious Disease in Hospitals
Authors: Sakamoto Sharon , Terashita Dawn , Balter Sharon
Published: November 2019

Context:

Infectious disease threats, high incidence/prevalence of health care–associated infections, and multidrug-resistant organisms challenge hospitals to improve infection prevention/control strategies and infectious disease preparedness/response efforts.

Program:

The Los Angeles County (LAC) Department of Public Health (DPH), Hospital Outreach Unit (HOU) addressed this need with the liaison public health nurse (LPHN) project, which is designed to strengthen capacity and bridge the care continuum with hospitals to prevent/control infectious disease.

Implementation:

The project utilizes 5 LPHNs who interface with LAC hospitals to improve reporting of infectious disease/hospital outbreaks, strengthen the surveillance infrastructure, and enhance communication/collaboration. The LPHNs communicate regularly and meet one-on-one with hospital infection preventionists with focused discussion, consultation, and assessment of infectious disease, participate in joint infection control meetings/conferences/calls, outreach on joint public health projects, and educate/train hospital staff.

Evaluation:

Within the first 7 years of implementation (2003) of the unit, reporting of hospital outbreaks increased 27%; hospitals reporting infectious disease via a county reporting system increased 95% during the same period. Currently, 64% of hospitals are reporting via the electronic laboratory reporting system (automated transmission to public health of reportable laboratory findings). In addition, the number of hospital infection control committee meetings LPHNs were invited to increased 96% during the first 7 years. The LPHNs/HOU participate(d) in 9 joint infection prevention/control projects with hospitals.

Discussion:

The threat of emerging infectious disease, health care–associated infections, and multidrug-resistant organisms is an ongoing challenge. Preventing infectious disease requires innovative approaches to effect and empower hospitals to respond. The LAC DPH LPHN project has proved to be an invaluable resource and key component to enable effective communication/collaboration to improve infection prevention and control strategies/preparedness efforts and protect the public's health from infectious disease.
Factors Associated With Latent Tuberculosis Infection Treatment Failure Among Patients With Commercial Health Insurance—United States, 2005-2016
Authors: Iqbal Shareen A. , Isenhour Cheryl J. , Mazurek Gerald , Langer Adam J. , Chang Man-Huei , Truman Benedict I.
Published: November 2019

Context:

Approximately 80% of US tuberculosis (TB) cases verified during 2015-2016 were attributed to untreated latent TB infection (LTBI). Identifying factors associated with LTBI treatment failure might improve treatment effectiveness.

Objective:

To identify patients with indicators of isoniazid (INH) LTBI treatment initiation, completion, and failure.

Methods:

We searched inpatient and outpatient claims for International Classification of Diseases (Ninth and Tenth Revisions), National Drug, and Current Procedural Terminology codes. We defined treatment completion as 180 days or more of INH therapy during a 9-month period. We defined LTBI treatment failure as an active TB disease diagnosis more than 1 year after starting LTBI treatment among completers and used exact logistic regression to model possible differences between groups. Among treatment completers, we matched 1 patient who failed treatment with 2 control subjects and fit regression models with covariates documented on medical claims paid 6 months or less before INH treatment initiation.

Participants:

Commercially insured US patients in a large commercial database with insurance claims paid during 2005-2016.

Main Outcome Measures:

(1) Trends in treatment completion; (2) odds ratios (ORs) for factors associated with treatment completion and treatment failure.

Results:

Of 21 510 persons who began LTBI therapy during 2005-2016, 10 725 (49.9%) completed therapy. Treatment noncompletion is associated with those younger than 45 years, living in the Northeast or South Census regions, and women. Among persons who completed treatment, 30 (0.3%) progressed to TB disease. Diagnoses of rheumatoid arthritis during the 6 months before treatment initiation and being aged 65 years or older (reference: ages 0-24 years) were significantly associated with INH LTBI treatment failure (adjusted exact OR = 5.1; 95% CI, 1.2-28.2; and adjusted exact OR = 5.1; 95% CI, 1.2-25.3, respectively).

Conclusion:

Approximately 50% of persons completed INH LTBI therapy, and of those, treatment failure was associated with rheumatoid arthritis and persons 65 years or older among a cohort of US LTBI patients with commercial health insurance.
Factors Facilitating or Hindering Use of Evidence-Based Diabetes Interventions Among Local Health Departments
Authors: Poehler Allison R. , Parks Renee G. , Tabak Rachel G. , Baker Elizabeth A. , Brownson Ross C.
Published: November 2019

Objective:

The objective of this study was to assess facilitators, barriers, and capacities to use of evidence-based programs and policies (EBPPs) in local health departments (LHDs).

Design:

A qualitative study design was used to elicit a contextual understanding of factors. One-hour interviews were conducted among directors and diabetes/chronic disease practitioners from LHDs. A consensus coding approach was used to identify themes.

Setting and Participants:

Twenty-four participants from 14 Missouri LHDs completed interviews.

Results:

Themes were identified as facilitators, barriers, or capacities that enhance EBPP use. Facilitators included awareness of EBPPs, leadership and supervisor support of EBPP use, and facilitators to increase capacity to implement EBPPs. Skills development, targeted messaging, and understanding of evidence-based decision-making (EBDM) terminology were needed. Barriers to EBPPs use were described at the individual, organizational, and interorganizational levels and included community buy-in, limited resources, relevance to partners, and time scarcity. Capacities included the ways LHDs learn about EBPPs, methods that influence the use of EBPPs, and resources needed to sustain EBPPs. Top ways to learn about EBPPs were in-person interactions. Staff meetings, meetings with decision makers, and relevant evidence influenced decision making. Resources needed were funding, organizational capacity, and partnerships. Directors' and practitioners' views differed on type of agency culture that promoted EBPP use, preferences for learning about EBPPs, ways to influence decisions, needs, and barriers to EBPPs.

Conclusions:

These findings can inform future strategies to support uptake of EBPPs in diabetes and chronic disease control in LHDs. LHDs have a good understanding of EBPPs, but subtle differences in perception of EBPPs and needs exist between directors and practitioners. Investment in capacity building and fostering an organizational culture supportive of EBDM were key implications for practice. By investing in employee skill development, LHDs may increase agency capacity. Researchers should use preferred channels and targeted messaging to disseminate findings.
Changes in Muscle Activation and Ground Reaction Force of the Lower Limbs According to Foot Placement During Sit-to-Stand Training in Stroke Patients
Authors: Noh Hyeon-Je , Kim Chang-Yong , Kim Hyeong-Dong , Kim Suhng-Wook
Published: November 2019

Objective

The aims of the study were to investigate the kinetic effects of sit-to-stand training in various foot positions on the coronal plane in patients with strokes and to suggest appropriate exercises.

Design

Thirty-six poststroke subjects participated in this study. The subjects performed three sit-to-stand trials in the following foot positions: (a) symmetric foot positioning (symmetric), (b) affected foot placed to the side (asymmetric 1), and (c) and less affected foot placed to the side (asymmetric 2). They were asked to perform sit-to-stand training at a spontaneous velocity and remain standing for 5 secs, whereas the vertical ground reaction force was measured using force platforms. The activation of lower limb muscles was evaluated using surface electromyography, and the peak and mean vertical ground reaction force and weight-bearing symmetry ratio were evaluated using force platforms.

Results

Our results showed significant increases in the muscle activation, peak and mean vertical ground reaction force, and weight-bearing symmetry ratio of the lower limbs using the asymmetric 2 strategy (P < 0.05).

Conclusions

Our results suggest that sit-to-stand training with the less affected foot placed to the side by the width of the subject’s foot may be the most beneficial in the rehabilitation of patients with hemiparetic stroke.
The Role of Subsymptom Threshold Aerobic Exercise for Persistent Concussion Symptoms in Patients With Postconcussion Syndrome
Authors: McIntyre McKyla , Kempenaar Ainsley , Amiri Mohammadreza , Alavinia Seyed Mohammad , Kumbhare Dinesh
Published: November 2019

In recent years, there has been a shift away from rest until total symptom resolution after concussion, due to the potential adverse consequences of inactivity. Aerobic exercise has been increasingly investigated for the treatment of postconcussion syndrome, whereby symptoms persist beyond 4 wks. The aim of this review was to systematically review the literature on subsymptom threshold aerobic exercise as a treatment for postconcussion syndrome. We conducted systematic literature searches in databases: MEDLINE (Ovid), CINAHL, PubMed, and Embase. After thorough review, 12 articles met the eligibility criteria and were included in the systematic review. The quality of selected studies was low to moderate. Subsymptom threshold aerobic exercise was associated with improvement in symptoms in patients with postconcussion syndrome for all included studies. The most commonly used protocols incorporated 20 mins of exercise at 80% of the heart rate that provoked symptoms, 5–6 days per week, with no adverse events documented. However, there was considerable variation in exercise protocols, and many studies incorporated subsymptom threshold aerobic exercise as part of a broader rehabilitation plan. Evidence supports subsymptom threshold aerobic exercise as a promising treatment for postconcussion syndrome. Further studies are required to delineate the optimal intensity, duration, and frequency of exercise for postconcussion syndrome in a variety of populations.
Effects of Elastic Resistance Exercise After Total Knee Replacement on Muscle Mass and Physical Function in Elderly Women With Osteoarthritis
Authors: Liao Chun-De , Tsauo Jau-Yih , Chiu Yen-Shuo , Ku Jan-Wen , Huang Shih-Wei , Liou Tsan-Hon
Published: November 2019

Objective

Knee osteoarthritis and age are associated with high sarcopenia risk, especially in patients who have received total knee replacement. The aim of this study was to identify the effects of elastic resistance exercise training after total knee replacement on muscle mass and physical outcomes in older women with knee osteoarthritis.

Design

Sixty older women who received unilateral primary total knee replacement surgery were randomized to an experimental group, which received 12 wks of postoperative elastic resistance exercise training, or a control group, which received standard care. The outcome measures included physical function performance (ie, Timed Up & Go, gait speed, forward reach, single-leg stance, timed chair rise), appendicular lean mass, and the Western Ontario and McMaster Universities Osteoarthritis Index. The assessment time points were 2 wks before surgery (T0), 1 mo after surgery (T1, before resistance exercise training), and 4 mos after surgery (T2, upon completion of resistance exercise training).

Results

After 12 wks of postoperative elastic resistance exercise training, the experimental group exhibited a significantly greater change in appendicular lean mass (mean difference = 0.81 kg, P = 0.004) than the control group. Elastic resistance exercise training also exerted significant effects on Timed Up & Go and gait speed with mean differences of 0.28 m/sec (P < 0.001) and −2.66 secs (P < 0.001), respectively.

Conclusions

A 12-wk elastic resistance exercise training program after total knee replacement exerted benefits on muscle mass, mobility, and Western Ontario and McMaster Universities Osteoarthritis Index functional outcomes in older women with knee osteoarthritis.
Outcomes in Patients Receiving Neoadjuvant Chemotherapy Undergoing Immediate Breast Reconstruction: Effect of Timing, Postoperative Complications, and Delay to Radiation Therapy
Authors: Teotia Sumeet S. , Venutolo Christopher , Haddock Nicholas T.
Published: November 2019

Background:

Neoadjuvant chemotherapy is offered to many patients with breast cancer. In patients undergoing mastectomy and immediate breast reconstruction, there is concern that this treatment could increase postoperative complications. The authors characterize which patients are at a higher risk of experiencing a postoperative complication, and assess the impact of postoperative complications on timing of radiation treatment.

Methods:

A retrospective review was performed on patients who underwent neoadjuvant chemotherapy with mastectomy and immediate breast reconstruction using tissue expanders. Multivariable binomial logistic regression analysis was used to identify risk factors for experiencing a postoperative complication. Independent samples t tests were used to compare means for neoadjuvant chemotherapy timing and time to commencement of radiation therapy between patients with and without complications.

Results:

A total of 128 patients were identified. Patients that experienced a complication had a statistically significant difference in time to commencement of radiation therapy (p = 0.021) and an elevated body mass index (p = 0.018) compared with patients who experienced no complication; there was no difference in timing interval of neoadjuvant chemotherapy (p = 0.692). Logistic regression showed an associate between body mass index and postoperative complication (OR, 1.09; 95 percent CI, 1.018 to 1.167; p = 0.013).

Conclusions:

Postoperative complications delay the commencement of radiation therapy in patients who received neoadjuvant chemotherapy and undergo mastectomy with immediate breast reconstruction. The period from the last dose of neoadjuvant chemotherapy was equivalent between those that experienced postoperative complications and those that did not. Patients with a higher body mass index are more likely to experience postoperative complications, and this should be considered when offering tissue expanders to obese patients who have received neoadjuvant chemotherapy and require adjuvant radiation treatment.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, III.
Practical Tips to Improve Efficiency and Success in Upper Limb Replantation
Authors: Woo Sang Hyun
Published: November 2019

Learning Objectives:

After reading this article, participant should be able to: 1. Describe the technique of replantation for very distal amputation of the digit and salvage procedures for venous drainage. 2. Perform single-digit replantation after viewing the videos. 3. Recognize appropriate cases for joint salvage techniques in periarticular amputation at each joint of the digit and wrist. 4. Outline the methods of flexor and extensor tendon reconstruction in an avulsed amputation of the digit or thumb. 5. Understand the order of digital replantation and transpositional replantation for a restoration of pinch or grip in multiple-digit amputation.

This article provides practical tips and caveats for the latest replantation surgical techniques for digit, hand, and upper extremity amputation. Four videos, clinical photographs, and drawings highlight important points of operative technique and outcomes of replantation.
Supermicrosurgical Lymphaticovenous Anastomosis as an Alternative Treatment Option for Patients with Lymphorrhea
Authors: Yang Johnson Chia-Shen , Yen Yuan-Hao , Wu Shao-Chun , Lin Wei-Che , Chiang Min-Hsien , Hsieh Ching-Hua
Published: November 2019

Background:

Lymphorrhea is probably the most appalling form of lymphedema and is difficult to treat. Intractable lymphorrhea is prone to infection because of skin breakdown. It is believed that supermicrosurgical lymphaticovenous anastomosis is unsuitable for treating such severe disease. Only a few lymphorrhea patients treated with lymphaticovenous anastomosis have been reported. Whether it can be used to treat lymphorrhea has remained inconclusive.

Methods:

From September of 2015 to June of 2018, 105 patients underwent supermicrosurgical lymphaticovenous anastomosis (n = 746) in the authors’ hospital. These patients are divided into the nonlymphorrhea group (three male and seven female patients) and the nonlymphedema group (lymphedema patients without lymphorrhea) (11 male and 84 female patients). Retrospective chart review with demographic data and intraoperative findings were recorded and analyzed. Post–lymphaticovenous anastomosis outcomes for lymphorrhea patients were also recorded.

Results:

No significant differences were found in patient age, sex, or affected limbs between these two groups. As for intraoperative findings, no differences were found in the percentage of indocyanine green–enhanced lymphatic vessels (52.7 ± 41.1 percent versus 67.3 ± 36.7 percent; p = 0.227) or the pathologic changes of lymphatic vessels based on the normal, ectasis, contraction, and sclerosis type classification (2.2 ± 1.0 versus 2.1 ± 1.0; p = 0.893) between the lymphorrhea and nonlymphorrhea groups, respectively. The average follow-up period was 14.5 months (range, 3 to 31 months). Five lymphorrhea patients (50 percent) showed complete recovery without relapse; significant lymphorrhea reduction was found in three patients (30 percent), and two patients showed minimal improvements (20 percent).

Conclusion:

With comparable functional lymphatic vessels identified in lymphorrhea patients, supermicrosurgical lymphaticovenous anastomosis is a viable option for lymphorrhea treatment, with satisfactory results.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
A Novel Approach to Quantifying Lymphatic Contractility during Indocyanine Green Lymphangiography
Authors: Granoff Melisa D. , Johnson Anna Rose , Lee Bernard T. , Padera Timothy P. , Bouta Echoe M. , Singhal Dhruv
Published: November 2019

Lymphedema arises from impaired lymphatic function. Quantification of lymphatic contractility has previously been shown using a custom-built near-infrared imaging system. However, to broaden the clinical use of functional lymphatic measurements, these measurements need to be performed using a standard-of-care, clinically available camera. The authors propose an objective, algorithmic, and clinically accessible approach to quantify lymphatic contractility using a 3-minute indocyanine green lymphangiograph recorded with a commercially available near-infrared camera. A retrospective review of the authors’ indocyanine green lymphangiography video repository maintained in a Research Electronic Data Capture database was performed. All patients with a newly diagnosed unilateral breast cancer undergoing preoperative indocyanine green lymphangiography were included in the analysis. Patient medical records were then analyzed for patient demographics, and videos were analyzed for contractility. Seventeen consecutive patients with unilateral breast cancers underwent video processing to quantify lymphatic contractility of the ipsilateral extremity in contractions per minute. All patients were women, with an average age of 60.5 years (range, 38 to 84 years). The average lymphatic contractility rate was 1.13 contractions per minute (range, 0.67 to 2.5 contractions per minute). Using a clinically accessible standard-of-care device for indocyanine green lymphangiography, the authors were able to determine lymphatic contractility rates of a normal extremity. The authors’ finding falls within the range of previously published data quantifying lymphatic contractility using a research device, suggesting that the authors’ technique provides a clinically accessible, time-effective means of assessing lymphatic contractility. Potential future applications include both lymphedema surveillance and evaluation of nonsurgical and surgical interventions.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Diagnostic, IV.
Unilateral Cleft Lip Nasal Deformity: Foundation-Based Approach to Primary Rhinoplasty
Authors: Tse Raymond W. , Mercan Ezgi , Fisher David M. , Hopper Richard A. , Birgfeld Craig B. , Gruss Joseph S.
Published: November 2019

Background:

Cleft lip results in disruption of the nasal foundation and collapse of tip structures. Most approaches to primary rhinoplasty focus on correction of lower lateral cartilages; however, recurrent deformity is common, and secondary revision is frequently required. The authors describe an alternate approach that focuses on the foundation to “upright the nose,” without any nasal tip dissection. This study assessed changes with surgery and with growth. Secondary goals were to compare methods of sidewall reconstruction and septoplasty and to identify predictors of relapse.

Methods:

Consecutive patients undergoing repair (n = 102) were assessed. Images were captured preoperatively, postoperatively, and at 5 years of age (when available) using three-dimensional stereophotogrammetry. Standard anthropometric and contemporary shape-based analysis (volume ratio, dorsal deviation, and alar-cheek definition) was performed to assess longitudinal changes. Images of age-matched normal control subjects were used for comparison.

Results:

Significant changes in anthropometric and morphometric measurements occurred following surgery. Postoperative form was similar to controls immediately after surgery and at 5 years. Nasal corrections were satisfactory, and only two patients have elected to undergo revision. When subjects were grouped according to cleft type, we found the same trends. When comparing different methods of nasal sidewall reconstruction or septoplasty, we found no differences. Alveolar cleft width was a significant predictor of worse preoperative and postoperative form.

Conclusions:

Significant nasal correction can be achieved by means of reconstruction of nasal foundation, without nasal tip dissection. Preservation of tissue planes may allow for easier secondary revision, if necessary.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
The Association of Comorbid Depression and Anxiety Symptoms With Disability Onset in Older Adults
Authors: Dong Liming , Freedman Vicki A. , Mendes de Leon Carlos F.
Published: November 2019

Objective

Despite the high prevalence of late-life depression and anxiety at threshold and subthreshold levels, their joint role in the disablement process remains unclear. This study aims to examine the association of comorbid occurring depression and anxiety across the full spectrum of symptom severity with disability onset in older adults.

Methods

The study included 3663 participants from the 2011 National Health and Aging Trends Study, who reported no limitations in self-care and mobility activities at baseline. Disability onset was defined as a report of receiving help from another person in any of the activities for 3 consecutive months. Depression and anxiety symptoms were measured using the four-item Patient Health Questionnaire, grouped into low, mild, and moderate/severe symptom groups. Cox proportional hazards models were used to estimate relative risks for disability onset over a 5-year period by depression/anxiety symptom groups.

Results

A total of 1047 participants developed disability (24.6%; 6.0 per 1000 person-months). At baseline, one-fifth of the sample reported symptoms that were mild (n = 579 [14.9%]; 31.6% with disability onset) or moderate/severe (n = 156 [4.2%]; 38.1% with disability onset). After adjustment for sociodemographics, there was a dose-response relationship between depression/anxiety symptom groups and disability onset (mild versus low: hazard ratio [HR] = 1.43, 95% confidence interval [CI] = 1.20–1.70; moderate/severe versus low: HR = 1.94, 95% CI = 1.45–2.59). The increased risk remained significant after adjustment for health status variables for the mild symptom group (HR = 1.26, 95% CI = 1.07–1.49), but not for the moderate/severe symptom group (HR = 1.30, 95% CI = 0.94–1.79), possibly reflecting lower statistical power.

Conclusions

Findings suggest that the full spectrum of depression and anxiety symptoms are associated with increased risk for disability in late life. Their role in the disablement process warrants further investigation.
Multiphase Iodine Contrast-Enhanced SPECT/CT Outperforms Nonenhanced SPECT/CT for Preoperative Localization of Small Parathyroid Adenomas
Authors: Sandqvist Patricia , Nilsson Inga-Lena , Grybäck Per , Sanchez-Crespo Alejandro , Sundin Anders
Published: November 2019

Purpose

The aim of this study was to assess the value of intravenously contrast-enhanced CT in conjunction with 99mTc-MIBI SPECT for preoperative localization of parathyroid adenoma.

Methods

One hundred ninety-two patients with primary hyperparathyroidism were enrolled in the study between May 2015 and May 2017. The patients underwent a preoperative “one-stop shop” examination with 99mTc-MIBI SPECT/CT by using dual time-point (10 and 90 minutes) protocol and both nonenhanced CT and contrast-enhanced CT acquisition in the arterial and venous phase, 35 and 75 seconds, respectively, after contrast medium injection start. For 149 patients, the imaging results could be correlated to those at surgery and histopathology.

Results

The median adenoma weight was 330 mg. The addition of contrast-enhanced CT increased the sensitivity from 81.1% to 89.9% (P = 0.003). The specificity of nonenhanced SPECT/CT was similar to contrast-enhanced CT (96.1% vs 97.9%; P = 0.077). For patients with uniglandular disease (n = 140, 94.0%), the sensitivity increased from 86.4% to 93.6% (P = 0.021) and the specificity from 96.2% to 97.9% (P = 0.118) by adding contrast-enhanced CT. In patients with multiglandular disease (n = 9, 6.0%), adding contrast-enhanced CT improved detection sensitivity from 42.1% to 63.2%. However, these patients were few and significance was not reached (P = 0.125).

Conclusions

In this cohort, with generally small parathyroid adenomas, the sensitivity in preoperative localization was greatly improved by adding contrast-enhanced CT to 99mTc-MIBI SPECT/CT.
18F-FDG PET Imaging Features of Patients With Autoimmune Lymphoproliferative Syndrome
Authors: Carrasquillo Jorge A. , Chen Clara C. , Price Susan , Whatley Millie , Avila Nilo A. , Pittaluga Stefania , Jaffe Elaine S. , Rao V. Koneti
Published: November 2019

Introduction

Autoimmune lymphoproliferative syndrome (ALPS) is a rare immune dysregulatory condition, usually presenting in childhood with massive lymphadenopathy, splenomegaly, and an increased incidence of lymphoma. Methods to differentiate between benign ALPS adenopathy and lymphoma are needed. To this end, we evaluated the usefulness of FDG PET.

Methods

We prospectively evaluated 76 ALPS/ALPS-like patients including FS-7–associated surface antigen (FAS) germline mutation with (n = 4) and without lymphoma (n = 50), FAS-somatic (n = 6), ALPS-unknown (n = 6), and others (n = 10) who underwent FDG PET. Uptakes in 14 nodal sites, liver, and spleen were determined.

Results

In 76 ALPS patients, FDG PET showed uptake in multiple nodal sites in all but 1 patient. The highest SUVmax values in FAS mutation without lymphoma, FAS mutation with lymphoma, FAS somatic, ALPS-unknown, and other genetic mutations were a median (range) 9.2 (4.3–25), 16.2 (10.7–37.2), 7.6 (4.6–18.1), 11.5 (4.8–17.2), and 5.5 (0–15.3), respectively. Differences between uptake in the FAS group with and without lymphoma were statistically significant, but overlapped, making discrimination between individuals with/without lymphoma impossible. The spleen:liver uptake ratio was greater than 1 in 82% of patients.

Conclusions

While statistically significant differences were observed in FAS mutation ALPS with and without lymphoma, the significant overlap in FDG uptake and visual appearance in many patients prevents discrimination between patients with and without lymphoma. Similar patterns of FDG biodistribution were noted between the various ALPS subgroups.
Granulomatous Myositis Showing Fluctuating “Leopard-Man” Sign
Authors: Koyama Masamichi , Terauchi Takashi , Koizumi Mitsuru , Sugiura Yoshiya
Published: November 2019

A 57-year-old woman with a history of uterine endometrial carcinoma underwent PET/CT examinations for initial staging and posttreatment survey. Multiple patchy accumulations were noted in the muscles, particularly in both thighs. These accumulations resolved spontaneously 6 months after the follow-up examination. However, 3.5 years after the surgery, the multiple patchy accumulations reappeared in the muscle of the upper and lower extremities showing an increase in signal intensity from previous examination. A biopsy of the right thigh revealed epithelioid cell granuloma without necrosis. We therefore consider that this case might be “idiopathic” granulomatous myositis.