bluuebunny/crossref_metadata_2025 huggingface dataset:
THE RAP STUDY, REPORT TWO
Authors: Haj Najeeb Bilal , Deak Gabor , Schmidt-Erfurth Ursula , Gerendas Bianca S.
Published: February 2020

Purpose:

To explore the regional distribution of macular neovascularization type 3 (MNV3).

Methods:

Seventy-eight eyes of 78 patients were reviewed. We defined the location of each lesion after applying a modified ETDRS grid and the incidence of simultaneous MNV1 or 2. Also, we investigated the distribution of MNV3 at the outline of the foveal avascular zone and when the diameter of foveal avascular zone was less than 325 µm.

Results:

The distribution of MNV3 was 4 lesions (5%) from the center to 500 µm, 72 (92%) from 500 µm to 1500 µm, and 2 (3%) from 1,500 µm to 3000 µm. The distribution in respect of the ETDRS fields was 7 (9%) nasal, 16 (20%) superior, 32 (40%) temporal, and 23 (31%) inferior. No additional MNV1 or 2 were found elsewhere. Most lesions tended to distribute along straight bands radiating from the perifoveal area, mainly in the temporal half (72%). None of the cases had MNV3 at the boundary of the foveal avascular zone. Only five cases had foveal avascular zone diameter of less than 325 µm, the closest lesion was 425 µm away from the center.

Conclusion:

MNV3 lesions are most likely neither symmetrical nor uniformly distributed. They have a higher affinity to distribute radially in the temporal perifoveal area.
BILATERAL PARACENTRAL ACUTE MIDDLE MACULOPATHY AFTER CARDIOPULMONARY BYPASS
Authors: Michalak Suzanne M. , Mukherjee Nisha , Gospe Sidney M.
Published: February 2020

Purpose:

To report the first two observations of bilateral paracentral acute middle maculopathy in the early postoperative period after cardiopulmonary bypass procedures.

Methods:

Comprehensive ophthalmic examinations were performed, including best-corrected visual acuity, Humphrey visual field testing, dilated fundus examination, and optical coherence tomography.

Results:

Two patients complained of unilateral vision loss after cardiac surgery involving cardiopulmonary bypass. Unilateral optic disc edema consistent with ischemic optic neuropathy was observed in the symptomatic eye of each patient, whereas scattered cotton-wool spots were identified bilaterally. In addition, optical coherence tomography imaging revealed bilateral paracentral acute middle maculopathy, correlating with visual field defects detected on automated perimetry in the asymptomatic eyes.

Conclusion:

Although symptomatic postoperative vision loss is a rare complication of cardiac surgery, intraoperative retinal microvascular nonperfusion as a consequence of extracorporeal circulation of blood may be a more common and under-recognized occurrence.
Identification of key genes and their functions in palbociclib-resistant breast carcinoma by using bioinformatics analysis
Authors: Gao Guangyu , Shi Xinya , Yao Zhen , Shen Jiaofeng , Shen Liqin
Published: February 2020

Background:

Palbociclib resistance is a significant problem in breast carcinoma, and its underlying molecular mechanisms remain poorly understood. This study aims to elucidate the molecular mechanisms of palbociclib resistance and to identify the key genes and pathways mediating progesterone resistance in breast cancer (BC).

Methods:

Gene dataset GSE117743 was downloaded from the Gene Expression Omnibus (GEO) database, which included 3 palbociclib-resistant and 3 palbociclib-sensitive BC cell lines. Then, we calculated the differentially expressed genes (DEGs) by using R software. Gene ontology and Enriched pathway analysis of genes we identified were analyzed by using the Database for Database of Annotation Visualization and Integrated Discovery (DAVID) and R software. The protein-protein interaction network was performed according to Metascape, String, and Cytoscape software.

Results:

In total, 447 DEGs were selected, which consisted of 67 upregulated and 380 downregulated genes. According to gene ontology annotation, DEGs were associated with cytoplasm, signal transduction, and protein binding. The research of the Kyoto Encyclopedia of Genes and Genomes (KEGG) demonstrated that genes enriched in certain tumor pathways, including IL-17 signaling pathways and Herpes simplex infection signaling pathways. Also, certain hub genes were highlighted after constructed and analyzed the protein-protein interaction network, including α-2A adrenergic receptor, cytochrome P450 subfamily IIR polypeptide, Cystathionine β-synthase, nucleotide-binding oligomerization domain-containing, erythropoietin-producing hepatocellular receptor A2 and adrenomedullin, which may be related with BC prognosis. A total of 4 of 6 hub genes had a significant relationship with the overall survival (P<0.05).

Conclusions:

Using microarray and bioinformatics analyses, we identified DEGs and determined a comprehensive gene network of progesterone resistance. We offered several possible mechanisms of progesterone resistance and identified therapeutic and prognostic targets of palbociclib resistance in BC.
Comparison of astigmatism correction between anterior penetrating and intrastromal arcuate incisions in eyes undergoing femtosecond laser–assisted cataract surgery
Authors: Ganesh Sri , Brar Sheetal , Reddy Arra Raghavender
Published: February 2020

Purpose:

To compare the safety, efficacy, and predictability of femtosecond laser–enabled anterior penetrating and intrastromal arcuate incisions for the correction of preoperative astigmatism at the time of cataract surgery.

Setting:

Nethradhama Super Speciality Eye Hospital, Bangalore, India.

Design:

Prospective randomized comparison study.

Methods:

This study included 50 eyes of 50 patients who had femtosecond laser–assisted cataract surgery with the CATALYS Precision System (Johnson & Johnson Vision Care, Inc.). Twenty-five eyes received anterior penetrating and 25 eyes received intrastromal arcuate incisions for the correction of corneal astigmatism in the range of 0.75 to 2.00 diopters (D). Six months postoperatively, vector analysis of astigmatism was performed using the Alpins method with the ASSORT software.

Results:

The mean preoperative keratometric astigmatism and target-induced astigmatism were 1.07 D and 1.16 D in the anterior penetrating group and 1.23 D and 1.50 D in the intrastromal group, respectively. There was no statistically significant difference between the postoperative keratometric astigmatism (anterior penetrating = 0.65, intrastromal = 0.90, P value = .13) and surgically induced astigmatism (anterior penetrating = 1.23, intrastromal = 1.08, P value = .55) at 6 months postoperatively. The correction index was 0.95 in the anterior penetrating group and 0.55 in the intrastromal group, signifying an undercorrection of 5% and 45% of eyes in the anterior penetrating and intrastromal group, respectively. Eighty percent of eyes in the anterior penetrating group and 72% of eyes in the intrastromal group were within ±0.5 D of refractive astigmatism.

Conclusions:

Both anterior penetrating and intrastromal incisions were effective in reducing preoperative astigmatism using the femtosecond laser technology. However, the anterior penetrating incisions showed comparatively better correction, whereas the intrastromal incisions resulted in significant undercorrection at 6 months.
Real-time intraoperative dynamics of white cataract—intraoperative optical coherence tomography–guided classification and management
Authors: Titiyal Jeewan S. , Kaur Manpreet , Shaikh Farin , Goel Siddhi , Bageshwar Lalit M. S.
Published: February 2020

Purpose:

To evaluate morphological characteristics and intraoperative dynamics of different types of white cataract using intraoperative optical coherence tomography (iOCT).

Setting:

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Design:

Prospective interventional study.

Methods:

Fifty eyes with white cataract undergoing phacoemulsification were evaluated. The primary outcome measure was the classification of white cataract based on morphology and intraoperative dynamics on iOCT. The secondary outcome measure was rhexis-related complications.

Results:

Four types of white cataract were identified based on iOCT—type I (9 eyes), type II (3 eyes), type III (24 eyes), and type IV (14 eyes). Type I had regularly arranged lamellar cortical fibers, type II had continuous hyperreflective bands of cortical fibers with intralenticular clefts, type III had intralenticular clefts combined with areas of homogenous ground-glass appearance, and type IV had homogenous ground-glass appearance of the anterior lens cortex. Capsulorhexis in type I cataract was uneventful. In type II cataract, cortical bulge was observed in the anterior chamber on creating the initial nick, indicating raised intralenticular pressure (ILP) with an imminent risk of rhexis extension. A bimanual irrigation/aspiration was performed until lowering of ILP was observed on iOCT. In types III and IV, fluid release was observed on initiation of rhexis leading to partial (type III) or complete (type IV) lowering of ILP, with a mild-moderate risk of capsulorhexis extension. A continuous curvilinear capsulorhexis was achieved in all cases, with no case of posterior capsular tear or vitreous loss.

Conclusions:

Intraoperative OCT helped elucidate intraoperative dynamics of the spectrum of white cataracts and facilitates completion of capsulorhexis.
Clinical outcomes of cataract surgery with implantation of a continuous transitional focus intraocular lens
Authors: Royo Mariano , Jiménez Ángel , Piñero David P.
Published: February 2020

Purpose:

To evaluate the clinical outcomes obtained after cataract or crystalline lens surgery with implantation of a new continuous transitional focus intraocular lens (IOL).

Setting:

San Rafael Hospital, Madrid, Spain.

Design:

Nonrandomized prospective case series.

Methods:

Uncomplicated phacoemulsification cataract surgery was performed with bilateral implantation of the continuous transitional focus IOL Precizon Presbyopic. Visual, refractive, and contrast sensitivity outcomes were evaluated during a 6-month follow-up. Likewise, the incidence of postoperative disturbing photic phenomena was recorded.

Results:

Sixty-two eyes of 31 patients (mean age: 61.3 years) were enrolled. Mean 6-month postoperative binocular uncorrected distance (UDVA), intermediate (UIVA), and near visual acuity (UNVA) were 0.01 ± 0.03, 0.17 ± 0.04, and 0.02 ± 0.04 logarithm of the minimum angle of resolution (logMAR), respectively. A total of 98.4% (61) and 93.5% (58) of eyes achieved 20/25 monocular UDVA and UNVA or better, respectively, whereas all eyes (100%) achieved 20/30 UIVA or better. Mean corrected visual acuity of 0.14 ± 0.05, 0.15 ± 0.06, and 0.19 ± 0.02 logMAR were obtained for the defocus levels of −1.00, −1.50, and −2.00 diopters. Mean 6-month postoperative log contrast sensitivity was 1.22 ± 0.18 and 0.75 ± 0.10 for 12 and 18 cycles per degree, respectively. A total of 9.7% (3) and 6.5% (2) of patients reported disturbing halos and glare.

Conclusions:

This presbyopia-correcting IOL provided a complete visual rehabilitation after cataract surgery, maintaining excellent levels of visual quality. Specifically, the IOL generated a continuous range of functional vision from distance to near, with minimal levels of photic phenomena associated.
Epithelial photorefractive keratectomy vs mechanical epithelial removal followed by corneal crosslinking for keratoconus: the Tel-Aviv Protocol
Authors: Rabina Gilad , Mimouni Michael , Kaiserman Igor
Published: February 2020

Purpose:

To compare the Tel-Aviv Protocol, epithelial photorefractive keratectomy (ePRK) combined with corneal crosslinking (CXL), to CXL with alcohol-assisted epithelial removal (Alc-CXL) for progressive keratoconus.

Setting:

Care-Vision Laser Centers, Tel Aviv, Israel.

Design:

Retrospective study.

Methods:

All patients underwent Alc-CXL or ePRK, a 50 μm laser ablation of the epithelium with a myopic spherical component and an astigmatic component, followed by CXL. All patients completed at least 1 year of follow-up.

Results:

A total of 131 eyes of 131 patients were included in the study. Fifty patients (38%) were included in the Tel-Aviv Protocol group, and 81 patients (62%) were included in the Alc-CXL group. There was a significant improvement in uncorrected distance visual acuity (UDVA) (from 1.22 ± 0.75 logarithm of the minimum angle of resolution [logMAR] to 0.49 ± 0.44 logMAR, P < .001), corrected distance visual acuity (CDVA) (from 0.29 ± 0.17 logMAR to 0.16 ± 0.12 logMAR, P < .001), Kmax (from 48.50 ± 3.00 diopters [D] to 46.50 ± 3.00 D, P < .001), and cylinder (from −3.31 ± 1.70 D to −2.32 ± 1.66 D, P < .001) in the Tel-Aviv Protocol group in comparison with nonsignificant changes in the Alc-CXL group in UDVA (from 0.89 ± 0.62 logMAR to 0.81 ± 0.65 logMAR, P = .23), CDVA (from 0.25 ± 0.21 logMAR to 0.21 ± 0.17 logMAR, P = .10), Kmax (from 46.50 ± 4.50 D to 46.00 ± 4.40 D, P = .08), and cylinder (from −2.99 ± 2.05 D to −2.80 ± 1.75 D, P = .39) at the end of the follow-up period.

Conclusions:

The Tel-Aviv Protocol for progressive keratoconus patients provided good improvement in visual acuity and astigmatism while halting the progression of keratoconus.
Low-dose interleukin-2 reverses behavioral sensitization in multiple mouse models of headache disorders
Authors: Zhang Jintao , Czerpaniak Katherine , Huang Liang , Liu Xuemei , Cloud Megan E. , Unsinger Jacqueline , Hotchkiss Richard S. , Li Daizong , Cao Yu-Qing
Published: February 2020

Headache disorders are highly prevalent and debilitating, with limited treatment options. Previous studies indicate that many proinflammatory immune cells contribute to headache pathophysiology. Given the well-recognized role of regulatory T (Treg) cells in maintaining immune homeostasis, we hypothesized that enhancing Treg function may be effective to treat multiple headache disorders. In a mouse model of chronic migraine, we observed that repeated nitroglycerin (NTG, a reliable trigger of migraine in patients) administration doubled the number of CD3+T cells in the trigeminal ganglia without altering the number of Treg cells, suggesting a deficiency in Treg-mediated immune homeostasis. We treated mice with low-dose interleukin-2 (ld-IL2) to preferentially expand and activate endogenous Treg cells. This not only prevented the development of NTG-induced persistent sensitization but also completely reversed the established facial skin hypersensitivity resulting from repeated NTG administration. The effect of ld-IL2 was independent of mouse sex and/or strain. Importantly, ld-IL2 treatment did not alter basal nociceptive responses, and repeated usage did not induce tolerance. The therapeutic effect of ld-IL2 was abolished by Treg depletion and was recapitulated by Treg adoptive transfer. Furthermore, treating mice with ld-IL2 1 to 7 days after mild traumatic brain injury effectively prevented as well as reversed the development of behaviors related to acute and chronic post-traumatic headache. In a model of medication overuse headache, Ld-IL2 completely reversed the cutaneous hypersensitivity induced by repeated administration of sumatriptan. Collectively, this study identifies ld-IL2 as a promising prophylactic for multiple headache disorders with a mechanism distinct from the existing treatment options.
Effects of Exercise Intervention on Adults With Both Hypertension and Type 2 Diabetes Mellitus
Authors: Park Seojin , Kim Jinhee , Lee Jina
Published: February 2020

Background

The positive effect of exercise on blood pressure has been reported in studies that investigated mostly patients with hypertension but without diabetes mellitus. However, the effect of exercise in adults with both hypertension and type 2 diabetes mellitus (T2DM) is unclear, and no systematic review and meta-analysis has been conducted to clarify this effect.

Objective

This study was a systematic review and meta-analysis designed to investigate the effects of exercise on adults with both hypertension and T2DM.

Methods

Studies were selected using electronic databases. Data were extracted using a standardized protocol. The risk of bias was assessed using Cochrane Collaboration's tool. To estimate the effect size, a meta-analysis of the studies was conducted.

Results

Of 3207 publications identified, 8 trials were used to estimate the effect size of exercise. Effect sizes (weighted mean difference [WMD]) were heterogeneous, and random-effects models were used. Exercise was effective for systolic blood pressure (WMD, −5.25 mm Hg; 95% confidence interval [CI], −8.39 to −2.12), diastolic blood pressure (WMD, −3.16 mm Hg; 95% CI, −4.91 to −1.40), body mass index (WMD, −1.47 kg/m2; 95% CI, −2.39 to −0.55), and waist circumference (WMD, −2.91 cm; 95% CI, −5.68 to −0.15). In subgroup analyses, aerobic exercise seemed to be the most effective intervention for lowering systolic (WMD, −9.43 mm Hg; 95% CI, −13.63 to −5.23) and diastolic (WMD, −5.90 mm Hg; 95% CI, −7.69 to −4.11) blood pressure.

Conclusions

Exercise seemed effective in reducing systolic and diastolic blood pressure, with subgroup analyses indicating that this effect was most profound with aerobic exercise.
Molecular biomarkers in the neurological ICU: is there a role?
Authors: Diaz-Arrastia Ramon , Shahim Pashtun , Sandsmark Danielle K.
Published: February 2020

Purpose of review

The aim of the article is to summarize recent advances in the field of molecular biomarkers in neurocritical care.

Recent findings

Advances in ultrasensitive immunoassay technology have made it possible to measure brain-derived proteins that are present at subfemtomolar concentrations in blood. These assays have made it possible to measure neurofilament light chain (NfL) in serum or plasma, and early studies indicate that NfL is a promising prognostic and pharmacodynamic biomarker across a broad range of neurologic disorders, including cardiac arrest and traumatic brain injury. However, as acquired brain injury is a complex and heterogeneous disorder, it is likely that assays of panels of biomarkers will ultimately be needed to maximally impact practice. Micro-RNAs are a novel but exciting class of molecules that also show potential to provide clinically actionable information.

Although not yet ready for adoption into routine clinical practice, several molecular biomarkers are on the cusp of clinical validation. The availability of such tests likely will revolutionize the practice of neurocritical care.
Comparative Analysis of 3-Year Persistence With Vedolizumab Compared With Antibodies Against Tumor Necrosis Factor-Alpha in Patients With Inflammatory Bowel Disease in Germany
Authors: Helwig Ulf , Kostev Karel , Schmidt Carsten
Published: February 2020

Aims:

The goal of the study was to compare persistence with vedolizumab versus adalimumab, golimumab, and infliximab in biologics-naïve patients with inflammatory bowel disease treated in gastroenterological practices and outpatient clinics in Germany.

Methods:

Patients aged 18 or older who had initiated a biological therapy (vedolizumab, infliximab, adalimumab, or golimumab) were included in the present study. Prescriptions between July 2014 and March 2017 of the respective biological drug emerging from gastroenterological practices or outpatient clinics in Germany were retrieved from the longitudinal prescription (LRx) database. Patients treated with vedolizumab were matched with patients treated with infliximab, adalimumab, or golimumab on the basis of age, gender, medication before biologic therapy, and index year. The primary outcome variable of the study was the rate of persistence with vedolizumab compared with antitumor necrosis factor biologics (infliximab, adalimumab, and golimumab) within 3 years of the first prescription in outpatient settings.

Results:

Kaplan-Meier analysis was performed in 15,984 patients naïve to biologics revealing the statistically lower risk of discontinuation for vedolizumab compared with adalimumab, golimumab, or infliximab. In matched-pairs analyses, within 3 years after the first prescription, 39.5% of 2076 patients were persistent to vedolizumab compared with 33.5% of matched patients persistent to adalimumab (P<0.001). 37.6% of 716 patients were persistent to vedolizumab compared with 24.7% of matched patients persistent to golimumab (P<0.001). 35.7% of 2055 patients were persistent to vedolizumab compared with 30.2% of matched patients persistent to infliximab (P=0.119). Vedolizumab was associated with a significantly lower risk of therapy discontinuation compared with adalimumab [hazard ratio (HR)=0.86; 95% confidence interval (CI), 0.81-0.93] and golimumab (HR=0.60; 95% CI, 0.54-0.67), respectively; the vedolizumab risk of therapy discontinuation was numerically lower than infliximab but statistical significance was not achieved (HR=0.93; 95% CI, 0.85-1.02).

Conclusion:

In biologics-naïve IBD patients treated in outpatient settings in Germany, matched-pair analyses showed that vedolizumab was associated with significantly improved drug persistence compared with adalimumab or golimumab, whereas numerical improvement was shown in comparison with infliximab.
10-Day Versus 14-Day Quadruple Concomitant Nonbismuth Therapy for the Treatment of Helicobacter pylori Infection
Authors: Apostolopoulos Periklis , Ekmektzoglou Konstantinos , Georgopoulos Sotirios , Chounta Eleni , Theofanopoulou Antonia , Kalantzis Chrisostomos , Vlachou Erasmia , Tsibouris Panagiotis , Alexandrakis Georgios
Published: February 2020

Goals:

The aim of this study was to investigate the implementation of a 14-day quadruple nonbismuth concomitant regimen, as proposed by recent Guidelines and Consensus Statements.

Background:

In Greece, a region with >20% clarithromycin resistance where bismuth is unavailable, the 10-day quadruple concomitant scheme has already been adopted as the accepted first-line Helicobacter pylori eradication treatment.

Study:

Our prospective randomized study included 364 patients with newly diagnosed H. pylori infection, randomized to receive a 10-day or a 14-day nonbismuth quadruple concomitant scheme. Treatment outcome was assessed by C13-urea breath test and/or histology at least 4 weeks after therapy. Intention to treat and per protocol analyses of the eradication rates were performed. Secondary endpoints included patient adherence, safety, and the impact of prior antibiotic exposure in treatment efficacy.

Results:

The overall eradication rates of the 2 treatments were 87.9% versus 87.4% in the intention to treat analysis, P=1.000, and 93% versus 94.1%, P=0.859, in the per protocol analysis for the 10-day and the 14-day treatment group, respectively. Both groups displayed excellent compliance rates (99.5% for the 10-day vs. 96.2% for the 14-day treatment duration, P=0.067). As regards treatment safety, serious adverse events that led to the discontinuation of both regimens were few, with no statistical difference between the 2 groups (0.5% in the 10-day group and 2.2% in the 14-day group, P>0.05). Previous antibiotic exposure was not significant with regard to treatment efficacy.

Conclusion:

In Greece, the 10-day concomitant nonbismuth quadruple regimen for first-line treatment remains the most efficient strategy for H. pylori eradication.
Evaluating the TARGET and EAT-ICU trials: how important are accurate caloric goals? Point-counterpoint: the pro position
Authors: Singer Pierre , Pichard Claude , Rattanachaiwong Sornwichate
Published: February 2020

Purpose of review

Controversies about the adequate amount of energy to deliver to critically ill patients are still going on, trying to find if hypocaloric or normocaloric regimen is beneficial in this population. Our purpose is to review recent publications using or not indirect calorimetry.

Recent findings

Numerous studies have compared hypocaloric to normocaloric regimen using predictive equations. However, these equations have been demonstrated to be inaccurate in most of the cases. Some recent PRCT using indirect calorimetry are finding some advantages to isocalorie regimens, but others not. Timing of the nutrition respecting or not the early substrate endogenous production, use of an adequate amount of protein, respect of the daily variability of needs may explain the divergent results observed.

Indirect calorimetry should be used to define the energy expenditure of the patient and to determine its requirements. More studies comparing isocalorie to hypocalorie regimens with fixed protein intake are necessary to confirm the observational and some of the PRCT-positive studies.
Fatal fulminant hemolysis-associated pulmonary embolism in mixed-type autoimmune hemolytic anemia
Authors: Imataki Osamu , Iseki Kikuo , Uchida Shumpei , Uemura Makiko , Kadowaki Norimitsu
Published: February 2020

Rationale:

Autoimmune hemolytic AQ5 anemia (AIHA) is an immune disorder caused by antibodies directed against unmodified autologous red blood cells. In rare cases, AIHA is comorbid with other immunological disorders; for instance, when AIHA is complicated with immunologic thrombocytopenic purpura (ITP) it is called Evans Syndrome (ES). These multiple autoimmune mechanisms are referred to as “immunological tolerance loss,” which is known as a characteristic autoimmunity specific for AIHA. And there are no estimation of the risk for thromboembolism in the “immunological tolerance loss” case.

Patient concerns:

A 66-year-old man was diagnosed with ES after autologous stem cell transplantation for malignant lymphoma. His background immunological status was complicated because AIHA was mixed-type (warm and cold antibody type). The direct/indirect Coombs tests were positive. The anticomplement antibody was positive and his cold hemagglutinin level had increased. Anticardiolipin antibodies were negative: anticardiolipin β2GPI antibody ≤1.2 U/mL (<3.5), anticardiolipin immunoglobulin G antibody ≤8 U/mL (<10), and anticardiolipin immunoglobulin M antibody ≤5 U/mL (<8).

Diagnoses:

ITP and mixed-type AIHA.

Interventions:

The patient achieved complete response by initial prednisolone therapy; however, he did not respond to corticosteroid therapy after AIHA recurrence. He required the red blood cell transfusion due to the progression of hemolytic anemia.

Outcomes:

On the fourth day of refractory treatment following AIHA recurrence, the patient had acute respiratory failure with severe hypoxia and died. The cause of death was identified as pulmonary embolism (PE) based on the laboratory data and echocardiography findings, and a literature search suggested rapidly progressive hemolysis-induced PE.

Lessons:

Although infrequent, comorbid thromboembolism to AIHA is well documented; however, a mixed-type AIHA case complicated with thromboembolism has not been previously reported. The combined pathophysiology of AIHA and thromboembolism should be considered in the clinical course of hemolysis. Our case suggested multiple immunological background, ITP, and mixed type AIHA, could be associated to a risk for thromboembolism (TE).
Does the Encounter Type Matter When Defining Diabetes Complications in Electronic Health Records?
Authors: Hong Dongzhe , Shen Yun , Monnette Alisha , Liu Shuqian , Shao Hui , Nauman Elizabeth , Price-Haywood Eboni , Hu Gang , Shi Lizheng
Published: February 2020

Background:

Electronic health records (EHRs) and claims records are widely used in defining type 2 diabetes mellitus (T2DM) complications across different types of health care encounters.

Objective:

This study investigates whether using different EHR encounter types to define diabetes complications may lead to different results when examining associations between diabetes complications and their risk factors in patients with T2DM.

Research Design:

The study cohort of 64,855 adult patients with T2DM was created from EHR data from the Research Action for Health Network (REACHnet), using the Surveillance Prevention, and Management of Diabetes Mellitus (SUPREME-DM) definitions. Incidence of coronary heart disease (CHD) and stroke events were identified using International Classification of Diseases (ICD)-9/10 codes and grouped by encounter types: (1) inpatient (IP) or emergency department (ED) type, or (2) any health care encounter type. Cox proportional hazards regression was used to estimate associations between diabetes complications (ie, CHD and stroke) and risk factors (ie, low-density lipoprotein cholesterol and hemoglobin A1c).

Results:

The incidence rates of CHD and stroke in all health care settings were more than twice the incidence rates of CHD and stroke in IP/ED settings. The age-adjusted and multivariable-adjusted hazard ratios for incident CHD and stroke across different levels of low-density lipoprotein cholesterol and hemoglobin A1c were similar between IP/ED and all settings.

Conclusion:

While there are large variations in incidence rates of CHD and stroke as absolute risks, the associations between both CHD and stroke and their respective risk factors measured by hazard ratios as relative risks are similar, regardless of alternative definitions.
A Multicenter Retrospective Study of Gemcitabine Plus Nab-Paclitaxel for Elderly Patients With Advanced Pancreatic Cancer
Authors: Kobayashi Satoshi , Ueno Makoto , Ikeda Masafumi , Ozaka Masato , Sano Yusuke , Hirotani Akane , Tozuka Yuichiro , Fukushima Taito , Tezuka Shun , Moriya Satoshi , Umemoto Kumiko , Watanabe Kazuo , Sasaki Mitsuhito , Hashimoto Yusuke , Imaoka Hiroshi , Ohno Izumi , Mitsunaga Shuichi , Yamada Ikuhiro , Sasaki Takashi , Sasahira Naoki , Morimoto Manabu
Published: February 2020

Objectives

This study aimed to assess the lesser known therapeutic benefit, particularly safety and effectiveness of gemcitabine plus nab-paclitaxel (GnP) treatment in elderly patients with advanced pancreatic cancer.

Methods

We retrospectively enrolled advanced pancreatic cancer patients aged ≥75 years who received GnP as first-line treatment between December 2014 and December 2016. We assessed survival, adverse events, and early treatment discontinuation.

Results

The cohort comprised 116 patients (median age, 77 [range, 75–84] years). The overall survival and progression-free survival were 21.8 and 12.1 months in patients with locally advanced cancer and 13.3 and 5.9 months, in patients with metastasis, respectively. The response and disease control rates were 31% and 81%, respectively. Within the first 2 months of treatment, grade 4 hematological and grade 3–4 nonhematological toxicities occurred in 10 and 23 patients, respectively. Early discontinuation due to adverse events occurred in 12 patients; the associated risk factors were age ≥80 years (odds ratio, 9.43) and serum albumin level <3.5 g/dL (odds ratio, 5.12).

Conclusions

In selected patients aged ≥75 years, GnP showed acceptable toxicities and effectiveness. However, patients aged ≥80 years and those with serum albumin levels <3.5 g/dL should be carefully assessed for treatment eligibility.
The Influence of Patients' Age on the Outcome of Treatment for Pancreatic Ductal Adenocarcinoma
Authors: Malik Abdullah K. , Lamarca Angela , Siriwardena Ajith Kumar , O'Reilly Derek , Deshpande Rahul , Satyadas Thomas , Jamdar Saurabh , Sheen Aali , McNamara Mairead , Hubner Richard , Valle Juan , De Liguori Carino Nicola
Published: February 2020

Objective

The aim of the study was to determine the impact of age on curative management and outcomes of patients with pancreatic ductal adenocarcinoma.

Methods

Patients who underwent resection for pancreatic ductal adenocarcinoma at 2 units were retrospectively reviewed (between 2005 and 2017) and stratified by age (older patients ≥70 years). Regression analysis was used to explore factors impacting administration of adjuvant chemotherapy and survival. The Kaplan-Meier method was used to estimate overall survival (time from surgery to death). Statistical significance was set at P < 0.05.

Results

From 2005 to 2014, 222 patients were identified (<70 years, n = 128; ≥70 years, n = 94). Elderly patients were less likely to receive adjuvant chemotherapy compared with younger patients (odds ratio, 0.57, P = 0.041). Tumor stage, margin, and year of surgery (post-2011 vs pre-2011) were not predictors for chemotherapy receipt (P > 0.05). Frailty was the commonest reason (36.8%) to decline chemotherapy in elderly patients. In patients receiving adjuvant chemotherapy, completion rates (P = 0.32) and overall survival (24 months vs 30 months, P = 0.50) were no different.

Conclusions

Elderly patients demonstrate similar outcomes to younger yet are less likely to commence chemotherapy because of frailty. Holistic preoperative assessment may improve selection for curative treatment.
Eupatilin Ameliorates Cerulein-Induced Pancreatitis Via Inhibition of the Protein Kinase D1 Signaling Pathway In Vitro
Authors: Park Won Suk , Paik Kyuhyun , Yang Keum Jin , Kim Jong Ok
Published: February 2020

Objective

The aim of this study was to investigate the effects of eupatilin on protein kinase D1 (PKD1) and nuclear factor kappa B (NF-κB) signaling pathways in cerulein-induced in vitro pancreatitis.

Methods

We used collagenase digestion to isolate pancreatic acinar cells from male C57BL/6 mice. In vitro acute pancreatitis was induced by treatment with a supramaximal dose of cerulein. Eupatilin was pretreated before stimulation with cerulein.

Results

Eupatilin significantly reduced cerulein-induced amylase release in pancreatic acini. Eupatilin treatment downregulated cerulein-induced expression of interleukin (IL)-1β, IL-6, and CC chemokine ligands 2 and 5, but it upregulated expression of IL-4 and IL-10. We demonstrated that eupatilin pretreatment attenuated cerulein-induced necrosis in isolated pancreatic acinar cells. This effect of eupatilin was confirmed by lactic dehydrogenase assay, fluorescence-activated cell sorting analysis, and cytopathologic analysis. Eupatilin inhibited cerulein-induced activation of PKD1/NF-κB and the nuclear translocation of NF-κB.

Conclusions

Our data demonstrated that eupatilin is a potential therapeutic candidate for the treatment of pancreatitis through its ability to reduce cellular necrosis and inflammatory responses by inhibition of the PKD1/NF-κB signaling pathway.
Using Point-of-Care Ultrasound to Characterize Acute Inguinal Swelling of Young Children in the Pediatric Emergency Department
Authors: Friedman Nir , Lee Michelle S. , Mclean Lianne , Tessaro Mark O.
Published: February 2020

Acute inguinal swelling in young children is frequently assumed to be an inguinal hernia, often prompting a bedside reduction attempt. We report 3 cases of inguinal swelling where the use of point-of-care ultrasound changed the patients' management by identifying an alternate diagnosis, thus avoiding unnecessary and painful procedures as well as their associated sedation risks.
Opportunities for and Perceptions of Integrating Community Health Workers Via the Affordable Care Act: Medicaid Health Homes
Authors: Lockhart Elizabeth , Turner DeAnne , Martinez-Tyson Dinorah , Baldwin Julie A. , Marhefka Stephanie L.
Published: February 2020

Context:

The Affordable Care Act created opportunities for innovative, cost-saving measures to improve health care access. Community health workers (CHWs) are frontline public health workers who have a close understanding of the communities they serve. States that expanded Medicaid coverage could also create Medicaid Health Homes (MHHs)—virtual health care networks—to coordinate care for people with chronic conditions. New York was the second state to implement MHHs and gave the option to include CHWs as part of the health care team.

Objective:

To understand the perceptions of MHH administrators regarding CHW engagement in MHHs, as well as the facilitators and barriers to adoption in MHHs that are unknown.

Design, Setting, and Participants:

Semistructured qualitative interviews (n = 18) were conducted with MHH administrators throughout New York State guided by the Diffusion of Innovations (DOI) framework. Qualitative thematic analysis was used to explore the domains and themes.

Results:

Most MHH administrators believed that CHWs fit within MHHs. The DOI constructs of compatibility and complexity and the Consolidated Framework for Implementation Research construct of external policies helped explain CHW integration. CHWs were compatible with MHHs by enrolling patients, helping coordinate patient care, and providing social support. The complexities of CHW integration into MHHs included barriers to CHW integration, no direct reimbursement for their services, lack of clarity for CHW roles and responsibilities, and no explicit external policy for their use in MHHs.

Conclusions:

CHWs can, and have, been integrated into the relatively novel Health Home system. While some barriers have prevented their integration into all MHHs, lessons learned could provide guidance for CHW integration into other health care systems in the United States.
Measuring retention in HIV care: the impact of data sources and definitions using routine data
Authors: Phillips Tamsin K. , Orrell Catherine , Brittain Kirsty , Zerbe Allison , Abrams Elaine J. , Myer Landon
Published: February 2020

Objectives:

Measuring retention is critical for antiretroviral therapy (ART) management and program monitoring; however, many definitions and data sources, usually from single health facilities, are used. We used routine electronic data, linked across facilities, to examine the impact of definitions and data sources on retention estimates among women in Cape Town, South Africa.

Design:

Retrospective cohort study.

Methods:

We compiled routine electronic laboratory, pharmacy and clinic visit data for 617 women who started ART during pregnancy (2013–2014) and estimated 24-month retention using different definitions and data sources. We used logistic regression to assess consistency of associations between risk factors and retention, and receiver operating characteristics analyses to describe how different retention estimates predict viremia at 12 months on ART.

Results:

Using all available data sources, retention ranged from 41% (no gap >180 days) to 72% (100% 12-month visit constancy). Laboratory data (expected infrequently) underestimated retention compared with clinic visit data that identified more than 80% of women considered retained in all definitions. In all estimates, associations with known risk factors for nonretention remained consistent and retention declined over time: 77, 65 and 58% retained using all data sources in months 6–12, 12–18 and 18–24, respectively (P < 0.001). The 180-day gap definition was most strongly associated with viremia (odds ratio 24.3 95% confidence interval 12.0–48.9, all data sources).

Conclusion:

Researchers must carefully consider the most appropriate retention definition and data source depending on available data. Presenting more than one approach may be warranted to obtain estimates that are context-appropriate and comparable across settings.
Plasma nucleotide reverse transcriptase inhibitor concentration and their associations with liver and renal parameters in people living with HIV
Authors: Wang Xinzhu , Boffito Marta , Dickinson Laura , Bagkeris Emmanouil , Khoo Saye , Post Frank A. , Vera Jaime , Williams Ian , Ndoutoumou Amalia , Anderson Jane , Mallon Patrick , McClure Myra , Winston Alan , Sabin Caroline
Published: February 2020

Associations between markers of liver and renal dysfunction and nucleotide reverse transcriptase inhibitor plasma exposure are ill-defined. As part of a large cohort study (Pharmacokinetic and Clinical Observations in People over Fifty), we analysed associations between alanine aminotransferase and estimated glomerular filtration rate results in people living with HIV on tenofovir disoproxil fumarate, emtricitabine, abacavir and lamivudine. While we found no associations between nucleotide reverse transcriptase inhibitor concentrations and alanine aminotransferase, lower estimated glomerular filtration rate values were associated with greater tenofovir, emtricitabine and lamivudine exposure, whereas abacavir showed no associations.
Ventilator-associated pneumonia: new principles guiding empiric antibiotic therapy
Authors: Dominedò Cristina , Ceccato Adrian , Torres Antoni
Published: February 2020

Purpose of review

Ventilator-associated pneumonia (VAP) is a serious event in critically ill patients. We aim to review the most recent evidences about VAP, including its cause, the main differences between the American and European guidelines in the definition of risk factors for multidrug-resistant pathogens, the main principles guiding empirical antibiotic treatment, and the potential role of molecular diagnostic tests.

Recent findings

The 2016 ATS/IDSA and the 2017 ERS/ESICM/ESCMID/ALAT guidelines provide different approaches for the management of VAP. Both guidelines highlight the need to use local epidemiological data for antibiotic choice; however, they identify different risk factors that can assist with decision making when local data are not available. Nevertheless, validation studies of the American guidelines suggest that empiric antibiotic therapy based on risk factors may lead to an overuse of broad-spectrum antibiotics. Rapid diagnostic tests may allow a faster identification of VAP cause, resulting in more adequate antimicrobial therapy and reduced exposition to broad-spectrum antibiotics.

Clinical studies should be conducted to evaluate the benefits of implementing guidelines and new approaches such as combinations of clinical data with rapid diagnostic tests; meantime adaptations of guidelines to local settings should be carried out by a local multidisciplinary expert team.
Reducing Opioid Prescribing After Ambulatory Plastic Surgery With an Opioid-Restrictive Pain Protocol
Authors: Johnson Shepard P. , Wormer Blair A. , Silvestrini Rachel , Perdikis Galen , Drolet Brian C.
Published: February 2020

Background

Opioids are often prescribed in excess, or unnecessarily, after ambulatory surgery. Perioperative opioid stewardships should be a priority with an emphasis on multimodal pain control.

Methods

In this prospective cohort study, prescribing patterns after implementation of an opioid-restrictive pain protocol, Plastic Surgery Initiative to provide Controlled Analgesia and Safe Surgical Outcomes (PICASSO), were compared with historical controls in an academic plastic surgery department. The protocol was initiated on July 1, 2018, and applied to all adult patients undergoing outpatient plastic surgery. Plastic Surgery Initiative to provide Controlled Analgesia and Safe Surgical Outcomes provides an algorithm for analgesic prescribing based on type of surgery and patient factors. A hospital-based pharmaceutical database was used to identify prescriptions, and univariate analyses were used to compare cohorts.

Results

The preprotocol and postprotocol cohorts consisted of 539 and 632 patients, respectively. There was no difference in age (48.2 years vs 48.3 years) or sex (72.2% vs 67.8% female). The proportion of patients filling opioid prescriptions went down from 95% to 76% after PICASSO. The total oral morphine equivalent per opioid prescription (217.5 ± 109.5 vs 87.2 ± 43.4) was significantly less in the PICASSO cohort. Additionally, the proportion of patients receiving nonopioid prescriptions, acetaminophen (60.7% vs 86.9%), ibuprofen (8.7% vs 74.2%), and gabapentin (23.6% vs 57.9%), increased significantly. Opioid refill rates were not increased after implementation (9.1% vs 7.3%, P = 0.35).

Conclusions

The PICASSO pain protocol resulted in a 20% decrease in opioid prescriptions and a 2.5-fold decrease in the oral morphine equivalent per prescription, equivalent to eighteen 5-mg oxycodone pills. This opioid-restrictive protocol can improve the analgesic prescribing culture in a plastic surgery department.
Microsurgical Breast Reconstruction in the Obese Patient Using Abdominal Flaps
Authors: Boczar Daniel , Huayllani Maria T. , Forte Antonio J. , Rinker Brian
Published: February 2020

Background

The obesity epidemic has led to larger numbers of obese patients seeking breast reconstruction. The aim of this study was to compare complication rates and patient satisfaction between obese and nonobese women undergoing autologous breast reconstruction using abdominal free flaps.

Methods

The records of all patients who underwent microsurgical breast reconstruction by one surgeon for 15 years were reviewed. Patients were divided into obese (body mass index [BMI] ≥ 30 kg/m2) and nonobese groups. Demographic data, medical and smoking history, cancer type and treatments, surgical details, and complications were recorded. Breast-Q surveys were mailed to all patients, and satisfaction ratings were compared between obese and nonobese patients.

Results

There were 109 patients and 149 breast reconstructions, with a mean age of 49 years. Follow-up ranged from 6 to 112 months (median = 19 months). There were 59 patients in the obese group and 52 in the nonobese group. The 2 groups did not differ significantly in median age, follow-up, pathology type, presence of chemotherapy or radiation, or smoking history. Obese group had a higher incidence of mastectomy flap necrosis (19.3% vs 7.7%, P < 0.01) and a higher rate of unplanned reoperations (38.6% vs 21.1%, P < 0.01). Obesity was not associated with a higher risk of microsurgical complications or flap loss (7.0% vs 3.8%, P = 0.21). Overall wound complications did not differ between the groups, but the obese group had a higher rate of severe wound complications requiring operative intervention (15.8% vs 3.8%, P < 0.01). The obese group had a higher incidence of hernia or bulge (10.5% vs 0%, P = 0.03). Thirty-three patients returned completed surveys (response rate of 30%). There was no statistically significant difference in any Breast-Q category associated with BMI.

Conclusions

Obesity was associated with higher rates of wound complications, reoperation, and abdominal bulge after microsurgical breast reconstruction. However, patient satisfaction remained high. Patients should be counseled regarding their relative risks, but high BMI should not be considered an absolute contraindication for microsurgical breast reconstruction.
Experience With LDLT in Patients With Hepatocellular Carcinoma and Portal Vein Tumor Thrombosis Postdownstaging
Authors: Soin Arvinder S. , Bhangui Prashant , Kataria Tejinder , Baijal Sanjay S. , Piplani Tarun , Gautam Dheeraj , Choudhary Narendra S. , Thiagarajan Srinivasan , Rastogi Amit , Saraf Neeraj , Saigal Sanjiv
Published: February 2020

Background.

Median survival in patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombosis (PVTT) is 2–6 months; conventionally liver transplantation is contraindicated.

Methods.

We studied outcomes following living donor liver transplantation (LDLT) post-PVTT downstaging (DS) with stereotactic body radiotherapy (SBRT), and tumor ablation (with transarterial chemo- or radio-embolization).

Results.

Of 2348 consecutive LDLTs, 451 were for HCC, including 25 with PVTT (mainly Vp1-3) after successful DS and 20 with Vp1/2 PVTT without previous treatment. DS was attempted in 43, was successful in 27 (63%), and 25 underwent LDLT. Median alpha fetoprotein (AFP) at diagnosis and pre-LDLT were 78.1 ng/mL (3-58 200) and 55 ng/mL (2-7320), respectively. Mean DS to LDLT time was 10.2 weeks (5–16). Excluding 2 postoperative deaths, 1- and 5-year overall survival (OS) and recurrence-free survival (RFS) were 82%, 57%, and 77%, 51%, respectively, comparable to survival in 382 HCC patients without PVTT undergoing upfront LDLT (5-y OS 65%, P = 0.06; RFS 66%, P = 0.33, respectively). There was a trend toward better OS in DS+LDLT versus non-DS LDLT group (5-y OS/RFS—48%/40%). OS was significantly better than in HCC-PVTT patients receiving no intervention or palliative Sorafenib alone (1-y OS of 0%) or Sorafenib with TARE/SBRT (2-y OS of 17%) at our center during the study period. Initial AFP <400 ng/mL and AFP fall (initial minus pre-LDLT) >2000 ng/mL predicted better RFS; Grade III/IV predicted worse OS in DS patients.

Conclusions.

HCC patients with PVTT can achieve acceptable survival with LDLT after successful DS. Low initial AFP level, a significant drop in AFP with DS and low tumor grade, favorably influence survival in these patients.