bluuebunny/crossref_metadata_2025 huggingface dataset:
Laboratory Investigations for Diagnosis of Autoimmune and Inflammatory Periocular Disease: Part I
Authors: Srinivasan Archana , Kleinberg Teri T. , Murchison Ann P. , Bilyk Jurij R.
Published: April 2016

Purpose:

To review the important laboratory serological investigations routinely performed for the diagnosis of autoimmune and inflammatory diseases of the orbit and ocular adnexa.

Methods:

Review of the literature as well as personal clinical experience of the authors.

Results:

Periocular inflammation is a blanket term which refers to a wide variety of conditions affecting the orbit and the ocular adnexa. Although the etiology of each of these conditions is different, their similarity lies in their clinical presentation and in the fact that each of them can be vision-threatening and even life-threatening if left untreated.

Conclusions:

This review covers important laboratory serological investigations specific to entities routinely encountered by orbitologists. The technique, parameters measured, and clinical importance of each of these laboratory tests are discussed in detail. Due to the extensive nature of the topic, the review has been split into 2 parts. Part I covers thyroid eye disease, IgG4-related disease, and myasthenia gravis. In part II of the review, sarcoidosis, vasculitis, Sjögren syndrome, and giant cell arteritis will be discussed.
Thyroid-Related Orbital Decompression Surgery: A Multivariate Analysis of Risk Factors and Outcomes
Authors: Wu Chris Y. , Niziol Leslie M. , Musch David C. , Kahana Alon
Published: April 2016

Purpose:

Despite the number of publications on orbital decompression surgery for thyroid eye disease, there are few comparative studies and most studies are underpowered. The goal of the study is to use multivariable analysis to identify independent patient and disease-related predictors of response to decompression surgery and of need for secondary decompressions.

Methods:

The authors retrospectively reviewed all patients who underwent transorbital thyroid-related orbital decompression surgery at the Kellogg Eye Center of the University of Michigan between 1999 and 2014. Demographic, medical, and surgical covariates were collected. Decompression techniques included medial, lateral, and balanced decompressions, with or without orbital fat removal. Main outcomes included proptosis reduction and secondary decompressions, both analyzed at the orbital level. Univariate and multivariable analyses (with adjustment for interorbit correlation) were conducted to determine predictors of the outcomes of interest.

Results:

Mean proptosis reduction was 3.8 ± 2.4 mm (mean ± standard deviation, N = 420 orbits). The secondary decompression rate was 13.8% (82/594). On multivariable mixed linear regression, larger preoperative proptosis (p < 0.0001), balanced decompression (p = 0.0002), thyroid eye disease duration < 4 years (p = 0.0093), and history of orbital radiation (p = 0.0111) were all predictive of greater proptosis reduction. On multivariable survival modeling, factors associated with increased hazard for secondary decompression include younger age (p = 0.0434), larger preoperative proptosis (p = 0.0001), unilateral decompression (p = 0.0272), preoperative steroid treatment (p = 0.0200), and normal thyroid function (p = 0.0148). Factors associated with decreased hazard include adjunctive fat decompression (p = 0.0004), balanced decompression (vs. lateral, p = 0.0039), and African-American ethnicity (p = 0.0076).

Conclusions:

Despite a diverse study cohort, the authors have identified factors associated with clinically relevant outcomes of decompression surgery for thyroid eye disease, including proptosis reduction and incidence of secondary decompression. Randomized controlled trials of different treatment algorithms for TED are needed to devise optimized guidelines for individualizing surgical care.
Nontraumatic Clostridium septicum Myonecrosis in Adults
Authors: Forrester Joseph D. , Shkolyar Eugene , Gregg David , Spain David A. , Weiser Thomas G.
Published: April 2016

Clostridium septicum is a spore-forming anaerobic gram-positive rod capable of causing rapidly progressive nontraumatic myonecrosis. A case of nontraumatic C. septicum myonecrosis (ntCSM) is described. A systematic review of all published cases of ntCSM from 2000–2015 was performed. Twenty-three cases of ntCSM were identified. The median age was 67 years (range, 26–84 years) and 15 (68%) were men. Only 5 (21%) patients had multifocal disease. Diabetes mellitus was the most common preexisting medical condition present in 9 (39%) patients. Occult colon cancer was frequently associated with ntCSM and most commonly right-sided colon cancer (69%). Only 10 (42%) patients survived. Clostridium septicum myonecrosis is a surgical emergency associated with morbidity and mortality. Rapid and aggressive debridement remains the cornerstone of care, although mortality has changed little in the last 30 years, suggesting an opportunity for improving diagnosis, treatment, or both.
The reciprocal associations between catastrophizing and pain outcomes in patients being treated for neuropathic pain: a cross-lagged panel analysis study
Authors: Racine Mélanie , Moulin Dwight E. , Nielson Warren R. , Morley-Forster Patricia K. , Lynch Mary , Clark Alexander J. , Stitt Larry , Gordon Allan , Nathan Howard , Smyth Catherine , Ware Mark A. , Jensen Mark P.
Published: April 2016

Catastrophizing is recognized as a key psychosocial factor associated with pain-related negative outcomes in individuals with chronic pain. Longitudinal studies are needed to better understand the temporal relationship between these constructs. The aim of this study was to determine if changes in catastrophizing early in treatment predicted subsequent changes in pain intensity and interference later in treatment, or alternately, if early changes in pain intensity and interference predicted subsequent changes in catastrophizing. A total of 538 patients with neuropathic pain were recruited from 6 multidisciplinary pain clinics across Canada. Study participants were asked to complete measures of catastrophizing, pain intensity, and interference when first seen in the clinic and then again at 3- and 6-month follow-ups. Cross-lagged panel analyses were used to determine the temporal associations among the study variables. The results showed that decreases in catastrophizing early in treatment prospectively predicted improvement in both pain intensity and interference later in treatment. Converse temporal relationships were also found, where a reduction in pain intensity and interference early in treatment predicted a subsequent diminishing of catastrophizing. All 4 unique cross-lagged correlations significantly accounted for an additional 4% to 7% of the total variance. The findings are consistent with theoretical models hypothesizing a causal impact of catastrophizing on pain, suggesting a mutual causation between these factors. The results support that treatments targeting catastrophizing may influence other pain-related outcomes, and conversely that treatments aiming to reduce pain could potentially influence catastrophizing. There may therefore be multiple paths to positive outcomes.
Short-Term Intensive Rehabilitation Induces Recovery of Physical Function After 7 Days of Bed Rest in Older Adults
Authors: Ellison Jennifer Barbee , Drummond Micah , Dickinson Jared M. , McGaugh Janna Michelle , Paddon-Jones Doug , Volpi Elena
Published: April 2016

Purpose:

Hospitalization can result in functional loss, especially in older adults. The purpose of the study was to determine the effect of intensive rehabilitation on changes in physical function in healthy older subjects after 1 week of bed rest and 3 days of rehabilitation.

Methods:

Six healthy subjects older than 60 years completed 7 days of bed rest followed by 3 days of rehabilitation including stretching, strengthening, balance, gait, and stair climbing.

Results:

Bed rest reduced the distance walked over 6 minutes, slowed gait speeds, and increased sit-to-stand times. Muscle flexibility and isokinetic quadriceps strength varied after bed rest. Three days of rehabilitation restored outcomes measures to baseline levels.

Conclusions:

A short bout of focused rehabilitation after a week of bed rest restored physical function measures to pre-bed rest levels in healthy older subjects. Similar training protocols may result in increased functional measures in older hospitalized patients.
Cardiac Rehabilitation
Authors: Astley Carolyn M. , Neubeck Lis , Gallagher Robyn , Berry Narelle , Du Huiyun , Hill Martha N. , Clark Robyn A.
Published: April 2016

Background:

Evidence-based guidelines recommend strategies for reducing risk factors for secondary prevention of acute coronary syndromes, yet referral to and completion of programs to deliver this advice are poor.

Purpose:

In this article we describe the complexity of factors that influence referral and delivery of evidence-based cardiac rehabilitation (CR) programs through an Australian context and provide direction for solutions for clinicians and policy makers to consider. The Ecological Approach is used as a framework to synthesize evidence. The approach has 5 categories, the characteristics of which may act as barriers and enablers to the promotion and adoption of health behaviors and includes (a) interpersonal factors, (b) interpersonal factors, (c) institutional factors, (d) community networks, and (e) public policy.

Conclusions:

Despite the context of strong evidence for efficacy, this review highlights systematic flaws in the implementation of CR, an important intervention that has been shown to improve patient outcomes and prevent cardiac events. Recommendations from this review include standardization of program delivery, improvement of data capture, use of technological innovations and social networks to facilitate delivery of information and support, and establishment of a cohesive, consistent message through interorganizational collaboration involved in CR.

Clinical Implications:

These avenues provide direction for potential solutions to improve the uptake of CR and secondary prevention.
Foundations of Pharmacotherapy for Heart Failure With Reduced Ejection Fraction
Authors: McIlvennan Colleen K. , Page Robert L.
Published: April 2016

Pharmacologic treatment for systolic heart failure, otherwise known as heart failure with reduced ejection fraction, has been established through clinical trials and is formulated into guidelines to standardize the diagnosis and treatment. Since the introduction of angiotensin-converting enzyme inhibitors and vasodilators in the 1980s, many guideline-recommended therapies have emerged over the past 20 years targeting specific neurohormones, aldosterone, and catecholamines to treat heart failure. Part 2 of this series will describe β-blockers, digoxin, and aldosterone antagonists in the context of the mechanism of action in heart failure, investigational trials that showed beneficial effects, and the practical applications for clinical use.
The Revised Index for Social Engagement in Long-Term Care Facilities: A Psychometric Study
Authors: Yoon Ju Young , Kim Hongsoo
Published: April 2016

Background:

Social engagement is known to be an important factor that affects the quality of life and the psychological well-being of residents in long-term care settings. Few studies have examined social engagement in long-term care facilities in non-Western countries.

Purpose:

This study aimed to evaluate the validity and reliability of the revised index for social engagement (RISE), which was derived from the Korean version of the interRAI Long Term Care Facilities instrument.

Methods:

Three hundred fourteen older adults from 10 nursing homes in Korea were included in the study. Convergent and discriminant validities were tested using correlation analysis and t tests, respectively. Factor analysis was adopted to examine the factor structure. The reliability of the RISE was tested using Cronbach’s alpha values for internal consistency, and interrater reliability was tested using item kappa values and intraclass correlation coefficients.

Results:

The RISE showed excellent convergent validity with the average time involved in activities (r = .58). The known-group comparison showed a significant difference in the means of RISE between the group with cognitive impairment and the group without cognitive impairment, indicating satisfactory discriminant validity. Factor analysis showed a good model fit for two factors in the RISE: group involvement and interaction with others. The RISE showed satisfactory internal consistency (α ≥ .70) and adequate interrater reliability (≥.40).

Conclusions/Implications for Practice:

The RISE is a valid and reliable tool for measuring the social engagement of nursing home residents in Korea. Furthermore, this tool may be a useful instrument for assessing older ethnic Korean residents who reside in nursing homes that are located outside Korea.
Bronchoscopic Removal of a Long-standing Aspirated Iron Pill
Authors: Somalaraju Sandeep R. , Patil Katherine , Campagna Anthony C.
Published: April 2016

While patients have been known to aspirate pills, they virtually never persist long enough to lead to complications. A spectrum of events, however, may arise especially from iron pill aspiration. If not identified and removed early, cytotoxic damage from local free-radical generation may result in airway damage. We report a case of an aspirated iron pill, which did not disintegrate and presented with chronic cough. Imaging revealed a foreign body in the right bronchus, and bronchoscopic removal allowed resolution of an associated pneumonia, without any further symptoms on subsequent surveillance.
Can Routine Histopathology Distinguish Between Vulvar Cutaneous Candidosis and Dermatophytosis?
Authors: Day Tania , Borbolla Foster Ailsa , Phillips Samuel , Pagano Ross , Dyall-Smith Delwyn , Scurry James , Garland Suzanne M.
Published: April 2016

Objectives

This study aimed to determine if vulvar cutaneous candidosis and dermatophytosis can be distinguished by routine histopathology.

Materials and Methods

Twenty-four cases of periodic acid-Schiff–stained vulvar biopsies with a diagnosis of cutaneous mycosis were reviewed and histopathological characteristics on both periodic acid-Schiff and hematoxylin and eosin were recorded. Data were collected on age, clinical impression, microbiological results, and treatment, and all specimens underwent multiplex polymerase chain reaction analysis.

Results

The mean age was 60 years, and all but 3 women had at least 1 risk factor for mycosis including 15 (62.5%) with lichen sclerosus and/or planus managed with topical corticosteroids. A clinical suspicion of tinea or candidosis was documented in 12 (50%) of the cases. Vulvovaginal swabs showed Candida species in 9 women; one skin scraping was positive for Trichophyton rubrum. Microbiology was not obtained in 8 patients, 5 had a negative swab, and 1 had negative skin scrapings. No histopathological or morphological features distinguished Candida species from dermatophytes. Organisms appeared as basophilic structures in the stratum corneum in 15 (62.5%) hematoxylin and eosin–stained slides. Polymerase chain reaction results were positive for Candida species in 5 (21%) and for dermatophytes in 3 (13%), negative in 13, and unassessable in 3 cases.

Conclusions

Vulvar cutaneous candidosis and dermatophytosis cannot be reliably distinguished by routine histopathology or specific polymerase chain reaction. A high index of suspicion combined with adequate microbiological testing remains the best approach to differentiating between the 2, which impacts on counseling, treatment, and prognosis.
Acute Embolic Myocardial Infarction and Heart Failure in a Fontan Patient: Recovery with Impella Device and Successful Transplantation
Authors: Deshpande Shriprasad R. , Dalal Aarti , Kim Dennis W. , Babaliaros Vasilis , Jokhadar Maan
Published: April 2016

Patients with Fontan palliation are at a higher risk of thromboembolic events, as well as sudden death. We report a case of acute thromboembolic myocardial infarction in a patient with Fontan circulation, presenting with acute heart failure. Coronary thrombolysis and reperfusion did not improve the myocardial dysfunction and warranted a unique application of mechanical support with Impella 2.5 pump as a bridge to decision. The patient was successfully transplanted. The case highlights the thromboembolic risks and provides support for the early use of mechanical support in such scenarios, even in single ventricle patients.
Single-Site Low-Flow Veno-Venous Extracorporeal Lung Support Does Not Influence Hemodynamic Monitoring by Transpulmonary Thermodilution
Authors: Redwan Bassam , Ziegeler Stephan , Freermann Stefan , Meemann Thomas , Semik Michael , Dickgerber Nicolas , Fischer Stefan
Published: April 2016

The application of extracorporeal lung support (ECLS) in patients with acute respiratory distress syndrome is a well-established concept. In patients receiving ECLS therapy, hemodynamic monitoring is often required. However, less is known about the effect of ECLS on hemodynamic measurements. In the present work, the influence of single-site low-flow veno-venous ECLS (LFVV-ECLS) on hemodynamic monitoring by transpulmonary thermodilution (TPTD) was prospectively investigated. Five consecutive patients undergoing single-site LFVV-ECLS for severe hypercapnic respiratory failure were included in this study. For single-site LFVV-ECLS, a 22 Fr twin-port double-lumen cannula was inserted percutaneously into the right jugular vein. Hemodynamic monitoring was performed using the Pulse index Continuous Cardiac Output system. Before ECLS initiation, baseline measurements of cardiac index, systemic vascular resistance, mean arterial pressure, and extravascular lung water (EVLW) were performed. During the first 3 days of ECLS therapy, repeated hemodynamic measurements at different ECLS flow rates were performed. No significant differences were seen in hemodynamic measurements. With respect to EVLW, a significant decrease over the duration of ECLS therapy was observed. This study demonstrates that LFVV-ECLS does not interfere with TPTD. It needs to be further studied if these findings also apply to other ECLS modes.
Management of portal vein thrombosis in cirrhosis: an update
Authors: Mancuso Andrea
Published: April 2016

Background

Portal vein thrombosis (PVT) is a complication of cirrhosis. However, whether PVT worsens cirrhosis outcome is a debated issue.

Aim

To report an update on the management of PVT.

Methods

A review was performed on the outcome, prevention, and treatment of PVT.

Results

Some studies suggest that PVT could worsen the rate of hepatic decompensation and survival of cirrhosis, whereas others report a non-negative impact of PVT in the outcome of cirrhosis. Therefore, the prognostic value of PVT in cirrhosis remains a gray zone. One single randomized-controlled trial reported that enoxaparin could prevent PVT, delay the occurrence of hepatic decompensation, and improve survival. However, no further study data confirmed this assumption and the issue is not actually generalizable. Numerous studies report that anticoagulation determines a relatively high rate of portal vein recanalization in cirrhotics PVT. However, further data are warranted to confirm the risk-to-benefit of anticoagulation, especially bleeding. Transjugular intrahepatic portosystemic shunt (TIPS) has been reported to be effective as a treatment of PVT in cirrhosis, with the advantage of avoiding the risk of bleeding linked to anticoagulation. However, there are no data comparing TIPS with anticoagulation as a treatment of PVT in cirrhosis. Furthermore, there is no evidence on whether both anticoagulation and TIPS improve survival.

Conclusion

It is uncertain whether PVT affects cirrhosis outcome. Further data are needed to weigh the risk/benefit ratio of enoxaparin for the prevention of PVT in cirrhosis. Anticoagulation or TIPS should probably be indicated in liver transplantation candidates, but avoided in patients not suitable for liver transplantation and with an otherwise poor prognosis. Future studies should evaluate which subgroup of cirrhotics with PVT may benefit from treatment. Management of PVT in cirrhosis should be personalized.
Noncompliance with guidelines on proton pump inhibitor prescription as gastroprotection in hospitalized surgical patients who are prescribed NSAIDs
Authors: van den Bemt Patricia M.L.A. , Chaaouit Naoual , van Lieshout Esther M.M. , Verhofstad Michael H.J.
Published: April 2016

Background and aims

As NSAIDs can cause serious upper gastrointestinal harm, guidelines have been established for the prescribing of proton pump inhibitors (PPIs) in high-risk patients using NSAIDs. Studies examining guideline compliance in surgical patients are scarce. Therefore, a retrospective cross-sectional database study was carried out aimed at determining the proportion of noncompliance with the Dutch guideline and determining the association of several factors with this noncompliance.

Materials and methods

Hospital admissions of patients on surgical wards of Erasmus University Medical Center between 1 January 2013 and 1 August 2014 were included in which an NSAID was newly prescribed. Preadmission PPI use was excluded. The main outcome was the proportion of noncompliance with the guideline. As a secondary outcome, the association of several potential risk factors with noncompliance was assessed. The proportion of guideline noncompliance was calculated as the percentage of all included surgical ward admissions. For the secondary analysis, univariate and multivariable logistic regression analyses were carried out.

Results

A total of 409 admissions were included. The proportion of admissions in which guideline noncompliance was present was 46.6%, mostly because of incorrectly added PPIs. Coxib use [adjusted odds ratio 0.22 (95% confidence interval 0.12–0.44)], polypharmacy (the use of five or more drugs) [2.18 (1.27–3.76)], and the surgical wards orthopedics [22.32 (5.38–92.55)], plastic surgery [10.82 (2.51–46.59)], trauma surgery [5.78 (1.47–22.70)], and transplant/vascular surgery [4.45 (1.10–18.00)] were statistically significantly associated with noncompliance.

Conclusion

Noncompliance with the guideline on NSAID use and gastroprotection is present in almost half of surgical hospital admissions and mainly involves overprescribing.
How do patients with chest pain access Emergency Department care?
Authors: Van Severen Evie , Willemsen Robert , Vandervoort Pieter , Sabbe Marc , Dinant Geert-Jan , Buntinx Frank
Published: April 2016

Background

It is important that patients with symptoms of acute coronary syndrome receive appropriate medical care as soon as possible. Little is known about the preadmission actions that patients with chest pain take before arrival at the Emergency Department (ED).

Objective

This study aimed to describe the actions of patients with chest pain or pressure after onset of symptoms. What is the first action following onset of symptoms? Who is the first lay or professional person to be contacted? Which steps are taken first? How is the patient transported to the hospital?

Methods

Consecutive patients, arriving at the ED of two large hospitals in Belgium, were asked additional questions during the initial assessment.

Results

Overall, 35% of 412 consecutive patients with chest pain admitted to the ED were diagnosed with acute coronary syndrome. A total of 57% contacted a GP between symptom onset and arrival at the ED. Only 32% of the patients were transported to the ED by ambulance, 16% drove themselves and 52% arrived by other means of transport (by family, neighbour, GP, public transport).

Conclusion

In Belgium, the GP is still the first professional to be contacted for most patients. Other patients initially rely on their partner, family or friends when symptoms emerge. Too often, patients with chest pain rely on other transport to get to the ED instead of calling the Emergency Medical Services. This study included only patients who ultimately attended the ED.
Anticoagulation therapy among patients presenting to the emergency department with symptomatic atrial fibrillation – the FinFib2 study
Authors: Penttilä Tero , Mäkynen Heikki , Hartikainen Juha , Lauri Timo , Lehto Mika , Lund Juha , Mäkijärvi Markku , Raatikainen Pekka
Published: April 2016

Objectives

Atrial fibrillation (AF) causes numerous visits to emergency departments (EDs). We evaluated the thromboembolic and bleeding risk profile and use of oral anticoagulation (OAC) therapy among patients presenting with symptomatic AF to ED.

Methods

Within a 2-week period, all patients whose primary reason for the ED visit was AF were enrolled into this prospective study in 35 EDs around Finland. The risk of thromboembolic and bleeding events was assessed by the CHA2DS2VASc and the HAS-BLED score, respectively. Thereafter, we evaluated whether OAC was used according to the contemporary management guidelines.

Results

The study population included 1013 patients (mean age 70±13 years, 52.4% men) with newly or previously diagnosed symptomatic AF. The mean CHA2DS2VASc and HAS-BLED score was 3.1±2.1 and 1.9±1.2, respectively. At admission, 76.3% of the patients with previously diagnosed AF and CHA2DS2VASc score of at least 2 were using OAC (warfarin 92.3%). However, the international normalized ratio was not at the therapeutic level in 41.9% of them. At discharge, 84.1% of the high-risk patients (85.5% of previously diagnosed and 79.6% of newly diagnosed) and 57.0 and 37.0% of the moderate-risk and low-risk patients were on OAC, respectively. Of the high-risk patients, 5.4% were treated with aspirin.

Conclusion

These data showed that OAC was prescribed frequently to patients with symptomatic AF and risk factors for stroke. However, in patients using warfarin, international normalized ratio was not at the therapeutic level in a large proportion of the patients with previously diagnosed AF.
Impact of CYP2C19 Polymorphisms on Clinical Outcomes and Antiplatelet Potency of Clopidogrel in Caucasian Poststroke Survivors
Authors: Tomek Aleš , Mat'oška Václav , Frýdmanová Alena , Magerová Hana , Šrámek Martin , Paulasova-Schwabová Jaroslava , Růžičková Tereza , Janský Petr , Šarbochová Ivana , Hadačová Ivana , Kaplan Vojtěch , Lacinová Zuzana , Táborský Luděk , Serebruany Victor
Published: April 2016

Background:

Variable response after clopidogrel is well documented and may affect major adverse clinical events after stroke. Impact of CYP2C19 genetic polymorphisms is an established marker linked to variable response after clopidogrel. However, the association of certain genetic polymorphisms with prediction of major adverse clinical events following stroke still remains controversial, especially in Caucasians.

Study Question:

The primary aim was to evaluate the impact of CYP2C19 allele *2 in heterozygote form on major adverse clinical events in Caucasian poststroke survivors treated with clopidogrel. The secondary aim was to analyze the potential link between CYP2C19 genetic polymorphism and variable response after clopidogrel.

Study Design:

One hundred thirty patients of Caucasian origin following documented ischemic stroke were included. Platelet reactivity was assessed by light transmittance aggregometry (LTA) and matched with various CYP2C19 loss-of-function genetic polymorphisms and major adverse clinical events (composite of vascular deaths, stroke/transient ischemic attack, and myocardial infarction).

Results:

Over the mean follow-up of 14.9 months, 19 patients experienced major adverse clinical events. The risk of major adverse clinical events was nearly 3-fold in loss-of-function allele carriers (hazard ratio = 2.904; 95% confidence interval, 1.083–7.786; P = 0.013), whereas the risk of ischemic stroke or transient ischemic attack alone was also higher (hazard ratio = 3.170; 95% confidence interval, 1.281–7.849; P = 0.034). Platelet activity was strongly associated with allele *2 status (rs = 0.21, P = 0.016) but not with other genetic polymorphisms. Carriers of allele*2 exhibited lower platelet response to adenosine diphosphate—mean LTA (30.1% vs. 42.0%; P = 0.017). There were no significant differences in LTA results with other agonists. Strong association of increase in adenosine diphosphate–induced aggregation with diabetes mellitus (rs = 0.20, P = 0.023), increasing age (rs = 0.23, P = 0.008), and conversely diminishing over increased weight (rs = 0.23, P = 0.009) was also detected. The carriers of other gene allele variants lack uniformed impact on variable response after clopidogrel.

Conclusions:

Even heterozygous CYP2C19*2 allele carriers among Caucasian patients after ischemic stroke had a higher risk of major adverse clinical events. The LTA, however, did not predict major adverse clinical events. The exact clinical utility of these findings is still uncertain and requires large outcome-driven randomized trial in Caucasians for proof of concept.
What Works in Readmissions Reduction
Authors: Brewster Amanda L. , Cherlin Emily J. , Ndumele Chima D. , Collins Diane , Burgess James F. , Charns Martin P. , Bradley Elizabeth H. , Curry Leslie A.
Published: April 2016

Background:

Hospitals across the United States are pursuing strategies to reduce avoidable readmissions but the evidence on how best to accomplish this goal is mixed, with no specific clinical practice shown to reduce readmissions consistently. Changes to hospital organizational practices, a key component of context, also may be critical to improving performance on readmissions, but this has not been studied.

Objective:

The aim of this study was to understand how high-performing hospitals improved risk-stratified readmission rates, and whether their changes to clinical practices and organizational practices differed from low-performing hospitals.

Design:

This was a qualitative study of 10 hospitals in which readmission rates had decreased (n=7) or increased (n=3).

Participants:

A total of 82 hospital staff drawn from hospitals that had participated in the State Action on Avoidable Readmissions quality improvement initiative.

Results:

High-performing hospitals were distinguished by several organizational practices that facilitated readmissions reduction, that is, collective habits of action or interpretation shared by organization members. First, high-performing hospitals reported focused efforts to improve collaboration across hospital departments. Second, they helped postacute providers improve care by sharing the hospital’s clinical and quality improvement expertise and data. Third, high performers enthusiastically engaged in trial and error learning to reduce readmissions. Fourth, they emphasized that readmissions represented bad outcomes for patients, de-emphasizing the role of financial penalties. Both high-performing and low-performing hospitals had implemented most clinical practice changes commonly recommended to reduce readmissions.

Conclusions:

Our findings highlight several organizational practices that hospitals may be able to use to enhance the effectiveness of their readmissions reduction efforts.
The many layers of epigenetic dysfunction in B-cell lymphomas
Authors: Jiang Yanwen , Dominguez Pilar M. , Melnick Ari M.
Published: April 2016

Purpose of review

Perturbation of the epigenome is emerging as a central driving force in the pathogenesis of diffuse large B-cell lymphomas (DLBCL) and follicular lymphoma. The purpose of this review is to explain how alteration of different layers of the epigenome contributes to the biology and clinical features of these tumors.

Recent findings

Key new findings implicate DNA methylation heterogeneity as a core feature of DLBCL. Epigenetic diversity is linked to unfavorable clinical outcomes, clonal selection at relapse, and is driven at least in part because of the actions of activation-induced cytosine deaminase, which is a unique feature of B-cell lymphomas. Somatic mutations in histone modifier genes drive lymphomagenesis through the establishment of aberrant gene-specific histone modification signatures. For example, EZH2 somatic mutations drive silencing of bivalent gene promoters through histone 3 lysine 27 trimethylation, whereas KMT2D (MLL2) mutations disrupt specific sets of enhancers through depletion of histone 3 lysine 4 mono and dimethylation (H3K4me1/me2).

Appreciation of the epigenome in determining lymphoma clonal heterogeneity and in driving lymphoma phenotypes through altered promoter and enhancer histone modification profiles is leading to a paradigm shift in how we understand and design therapies for DLBCL and follicular lymphoma.
NASPGHAN Clinical Report on the Diagnosis and Treatment of Gluten‐related Disorders
Authors: Hill Ivor D. , Fasano Alessio , Guandalini Stefano , Hoffenberg Edward , Levy Joseph , Reilly Norelle , Verma Ritu
Published: April 2016

Dietary exclusion of gluten‐containing products has become increasingly popular in the general population, and currently ~30% of people in the United States are limiting gluten ingestion. Although celiac disease (CD), wheat allergy (WA), and nonceliac gluten sensitivity (NCGS) constitute a spectrum of gluten‐related disorders that require exclusion of gluten from the diet, together these account for a relatively small percentage of those following a gluten‐free diet, and the vast majority has no medical necessity for doing so. Differentiating between CD, WA, and NCGS has important prognostic and therapeutic implications. Because of the protean manifestations of gluten‐related disorders, it is not possible to differentiate between them on clinical grounds alone. This clinical report will compare and contrast the manifestations of gluten‐related disorders, emphasize the importance of differentiating between these conditions, discuss initial and subsequent tests needed to confirm the diagnosis, and provide recommendations on treatment and follow‐up for each condition.
Radiologic Predictors of Surgery in Newly Diagnosed Pediatric Crohn Disease Patients
Authors: Parker Damien , Karmazyn Boaz , Steiner Steven J.
Published: April 2016

Objectives:

The aim of the present study was to assess whether small bowel imaging conducted at the time of diagnosis could be used as a predictor of small bowel surgical intervention in a population of pediatric patients with Crohn disease (CD).

Methods:

A retrospective analysis of small bowel imaging within 30 days of diagnosis of pediatric CD was conducted. Patients were divided into 2 groups based on small bowel imaging: those with no or minor abnormalities (71%) and those with more extensive or obstructive abnormalities (29%). Medical records were reviewed for small bowel surgical intervention and clinic follow‐up visits.

Results:

A total of 232 patients were included in the study group (average age at diagnosis 11.7 years). Twenty‐seven patients (12%) underwent small bowel surgical intervention. The relative risk for small bowel surgical intervention was 2.91 in the group with more extensive imaging abnormalities. The majority of increased surgical risk occurred in the first year after diagnosis, when the normal‐minor group had a 2% surgical risk and the more abnormal group had a 17% surgical risk. Both groups had a 2% to 3% surgical risk per year after the first year.

Conclusions:

Small bowel imaging at the time of diagnosis in pediatric CD can help predict the risk of small bowel surgical intervention and should be recommended for all newly diagnosed patients. Nearly one third of our cohort underwent small bowel surgical intervention through 8 years of follow‐up. Surgical complications of CD often occur in the small bowel, and counseling families about surgical risk is an integral part of pediatric CD management.
Anemia in Pediatric Celiac Disease
Authors: Rajalahti Teemu , Repo Marleena , Kivelä Laura , Huhtala Heini , Mäki Markku , Kaukinen Katri , Lindfors Katri , Kurppa Kalle
Published: April 2016

Goals:

The aim of the present study was to compare clinical, serological, and histological manifestations between children with anemia and without anemia at celiac disease (CD) diagnosis.

Background:

Despite being a common finding, the association between the presence of anemia and clinicohistopathological presentation of CD in children remains obscure.

Study:

A total of 455 patients with CD <18 years of age were divided into those with anemia and those without anemia at diagnosis. The groups underwent comparisons of a variety of clinical, serological, and laboratory parameters and severity of small‐bowel mucosal damage. Furthermore, adherence and clinical and serological response to the gluten‐free diet (GFD) were compared.

Results:

Anemia was detected in 18.0% of the patients. Children with anemia had higher values for transglutaminase 2 antibodies (120.0 U/L vs 88.0 U/L, P < 0.001) and, by definition, lower values for hemoglobin (10.5 g/dL vs 12.8 g/dL, P < 0.001) and other iron parameters. They were also less often screen‐detected (13.4% vs 34.6%), had more severe histological damage (P = 0.048), and poorer dietary adherence (78.3% vs 87.5%, P = 0.035) than the patients without anemia. A total of 92% of the patients recovered from anemia after a median of 1 year on a GFD, but hemoglobin values remained significantly lower compared with the nonanemic group (12.5 g/dL vs 13.2 g/dL, P = 0.045). There was no difference between the groups in the clinical and serological response to the GFD (P = 0.318).

Conclusions:

Anemia at CD diagnosis is associated with more severe histological and serological presentation in children. Furthermore, low hemoglobin may not fully recover even after a median of 1 year on a strict GFD.
Assessing the Colonic Microbiota in Children
Authors: Shaw Alexander G. , Black Naomi , Rushd Azelea , Sim Kathleen , Randell Paul , Kroll J. Simon , Epstein Jenny
Published: April 2016

Objectives:

Inflammatory bowel disease states are associated with gastrointestinal dysbiosis. Mucosal biopsy sampling, retrieving the bacterial community that most directly interacts with the host, is an invasive procedure that, we hypothesis, may be sufficiently approximated by other sampling methods. We investigate the relatedness of samples obtained by different methods and the effects of bowel preparation on the gastrointestinal community in a paediatric population.

Methods:

We recruited a cohort of patients undergoing colonoscopy, collecting serial samples via differing methods (rectal swabs, biopsies, and faecal matter/luminal contents) prebowel preparation, during colonoscopy and after colonoscopy. Next‐generation sequencing was used to determine the structure of the microbial community.

Results:

The microbial community in luminal contents collected during colonoscopy was found to be more similar to that of mucosal biopsies than rectal swabs. Community traits of the mucosal biopsies could be used to segregate patients with inflammatory bowel disease from other patients, and the similarity of the communities in the luminal contents was sufficient for the segregation to be reproduced. Microbial communities sampled by rectal swabs and prebowel preparation faeces were less similar to mucosal biopsies. Bowel preparation was found to have no significant long‐term effects on the microbial community, despite the transient effects evident during colonoscopy.

Conclusions:

A clinically relevant description of the mucosal microbial community can be obtained via the noninvasive collection of luminal contents after bowel cleansing. Bowel preparation in a paediatric population results in no consistent sustained alterations to the gastrointestinal microbiota.
Postsurgical Perforation of the Esophagus Can Be Treated Using a Fully Covered Stent in Children
Authors: Chauvet Chantal , Bonnard Arnaud , Mosca Alexis , Bellaïche Marc , Philippe‐Chomette Pascale , Viala Jérôme
Published: April 2016

Objectives:

Surgery and conservative treatment of esophageal or gastric perforations are both often associated with poor results and carry a high morbidity and mortality rate. The aim of the present study was to evaluate the effectiveness and safety of using fully covered self‐expending metallic stents (SEMS) in children with upper digestive leaks.

Methods:

This retrospective study reviewed all children with esophageal or gastric perforation who were treated with placement of an SEMS from January 2011 to January 2015. Closure of the perforation was the primary outcome measured. Secondary outcomes were the duration of antibiotic therapy and parenteral nutrition, adverse events, and length of hospitalization.

Results:

A total of 19 SEMS were placed in 10 patients (median age: 5.5 years; 5 girls) treated for postanastomotic leaks of esophageal atresia (n = 3), esophagogastroplasty (n = 4), resection of esophageal duplication (n = 1) or perforation during Toupet surgical dismantling (n = 1), and gastric rupture after Nissen surgery (n = 1). The perforation closed in 9 out of 10 patients in a mean of 36 days after stenting (range: 13–158 days). All patients received antibiotic therapy for an average of 17.5 days (3–109 days) and parenteral nutrition for 49 days (17–266 days). During a median follow‐up of 8.9 months, 4 out of 9 sealed perforations developed stenosis, which was efficiently treated by endoscopic dilations in 2 patients and surgical redo in 2 patients with dilation‐resistant stenosis.

Conclusions:

Covered stents appear to be beneficial in closing esophageal perforations in children and can avoid the high morbidity of a surgical repair. Stenosis, however, occurred frequently after larger leakages.
Assessment of sit-to-stand movement in nonspecific low back pain: a comparison study for psychometric properties of field-based and laboratory-based methods
Authors: Kahraman Turhan , Ozcan Kahraman Buse , Salik Sengul Yesim , Kalemci Orhan
Published: April 2016

One of the most difficult tasks associated with the management of nonspecific low back pain (LBP) is its clinical assessment. Objective functional methods have been developed for assessment. However, few studies have used daily activities such as sit-to-stand (STS). The aim was to compare the psychometric properties of two commonly used STS assessment methods. A test–retest reliability study design was used. Participants with nonspecific LBP performed the 30-s chair stand test (30CST) and the STS test in Balance Master, which measures weight transfer, rising index and centre of gravity sway velocity. The same tests were reperformed after 48–72 h. The intraclass correlation coefficient (ICC), standard error of measurement (SEM), minimal detectable change and coefficient of variation were calculated to compare the reliability. The correlations between the tests, the Oswestry Disability Index and pain intensity were examined for validation. The 30CST had very high intrarater reliability (ICC=0.94). The variables of STS test in Balance Master had moderate intrarater reliability (ICC=0.62–0.69). There were significant correlations between the 30CST, Oswestry Disability Index and pain intensity at activity (P<0.01). The rising index was the only one variable that was significantly correlated with pain intensity at activity (P<0.05). The 30CST as the field-based method to measure STS movement was better than the laboratory-based method in terms of their psychometric properties. Moreover, the 30CST was associated with disability and pain related to LBP. The 30CST is a simple, cheap, less time consuming and psychometrically appropriate method to use in individuals with nonspecific LBP.
Differences in motor recovery between upper and lower limbs: does stroke subtype make the difference?
Authors: Paci Matteo , Nannetti Luca , Casavola Davide , Lombardi Bruna
Published: April 2016

Previous studies comparing the patterns of recovery for upper (UL) and lower limbs (LL) reported similar patterns of motor recovery of extremities. However, the influence of clinical stroke subtypes on the difference between recovery of extremities has never been investigated. The aim of this study is to compare the time course of the UL and LL in a sample of patients who have had distinct subtypes of ischemic stroke. A total of 443 consecutive patients following ischemic stroke were assessed at admission, discharge, and 1 month after discharge with the arm and leg motor parts of the Fugl-Meyer scale. Separate analyses were carried out for the entire sample and for samples of each stroke subtype classified according to the Oxfordshire Community Stroke Project. All groups showed significant improvements in motor function (P<0.001). Within the group of patients with total anterior circulation infarcts, the LL showed greater improved motor recovery than the UL (P<0.001). No significant difference was found between the time course of UL and LL motor recovery in the entire sample and in the other groups. This study confirms similar motor recovery of limbs in the entire sample, but also shows that the LL has greater recovery than the UL in patients with total anterior circulation infarcts. Functional prognosis should take into account the distinct stroke subtypes.
Coping With Prediagnosis Symptoms of Colorectal Cancer
Authors: Rogers Heather L. , Siminoff Laura A. , Longo Daniel R. , Thomson Maria D.
Published: April 2016

Background:

Colorectal cancer (CRC) symptoms are often vague and vary in severity, intensity, type, and timing. Receipt of medical care is dependent on symptom recognition and assessment, which may impede timely diagnosis.

Objective:

The aim of this study was to describe and categorize how CRC patients coped with symptoms prior to seeking medical care, examine sociodemographic differences in these coping strategies, and determine the strategies associated with time to seek medical care and overall time to diagnosis.

Methods:

Two hundred forty-four white and African American patients in Virginia and Ohio who received a diagnosis of CRC and who experienced symptoms prior to diagnosis were administered a semistructured interview and the Brief COPE questionnaire.

Results:

Eighty-three percent used more than 1 coping strategy. Common symptom-specific coping strategies were to “wait-and-see,” self-treat, and rationalize symptoms. Males were more likely to wait and see (P < .001); African Americans and Medicaid recipients were more likely to self-treat via lifestyle changes (P’s < .01). Younger individuals (<50 years old) had higher Brief COPE reframing, planning, and humor scores; those with lower education and income had higher denial scores (P’s < .01). Using more symptom-specific coping strategies and engaging in avoidance/denial were associated with longer time to seek medical care and overall time to diagnosis (P’s < .01).

Conclusions:

Individuals experiencing CRC symptoms use multiple, diverse coping strategies that are influenced by sociodemographic characteristics. Denial is particularly relevant for delay in seeking care and timely diagnosis.

Implications for Practice:

Public health campaigns could focus on secondary prevention of CRC by targeting at-risk groups such as males, African Americans, or Medicaid recipients, who choose waiting or self-treatment in response to initial symptoms.