bluuebunny/crossref_metadata_2025 huggingface dataset:
Dual Molecular Diagnosis of Microsporidia (Encephalitozoon hellem) Keratoconjunctivitis in an Immunocompetent Adult
Authors: Ma Kevin K. , Kinde Benyam , Doan Thuy , Jacobs Deborah S. , Ong Tone Stephan
Published: August 2020

Purpose:

To report a case of microsporidia (Encephalitozoon hellem) keratoconjunctivitis acquired through avian transmission in an immunocompetent adult, diagnosed by metagenomic deep sequencing (MDS), and confirmed by polymerase chain reaction.

Methods:

A case report.

Results:

An 18-year-old woman was referred with unilateral keratoconjunctivitis unresponsive to topical and systemic therapy after exposure to birdcage debris. Slit-lamp examination of the left eye revealed a follicular papillary reaction of the palpebral conjunctiva and multiple corneal punctate epithelial opacities that stained minimally with fluorescein. In vivo confocal microscopy revealed bright double-walled structures and smaller bright round structures in the superficial epithelial debris and epithelium. Molecular diagnosis with MDS of E. hellem was confirmed by polymerase chain reaction. Clinical resolution and normalization of in vivo confocal microscopy was observed after a 6-week course of topical azithromycin. The patient elected a 3-week course of topical voriconazole 1% for definitive antimicrosporidial treatment, with no evidence of persistent infection 1 month later.

Conclusions:

Microsporidial (E. hellem) keratoconjunctivitis can occur through avian transmission in immunocompetent hosts. Topical azithromycin may be effective against this pathogen. MDS has utility in the diagnosis of atypical keratoconjunctivitis.
Containment of a Large SARS-CoV-2 Outbreak Among Healthcare Workers in a Pediatric Intensive Care Unit
Authors: Knoll Rebecca Luise , Klopp Jonas , Bonewitz Gloria , Gröndahl Britta , Hilbert Katja , Kohnen Wolfgang , Weise Kerstin , Plachter Bodo , Hitzler Walter , Kowalzik Frank , Runkel Stefan , Zepp Fred , Winter Julia , Cacicedo Maximiliano Luis , Gehring Stephan
Published: August 2020

Objective:

Healthcare workers (HCWs) are particularly exposed SARS-CoV-2 because they are critical in preventing viral transmission and treating COVID-19 patients. Within HCWs, personnel of intensive care units (ICUs) are at the forefront of treating patients with a severe course of COVID-19 infection and therefore represent an extremely vulnerable group. Thus, our objective is to contribute to establish means of infection control protecting HCWs in the frontline of the current pandemic.

Design:

An outbreak of SARS-CoV-2 was detected and contained in a pediatric ICU (PICU). The first positive case was identified with a point-of-care diagnostic system on site. Real-time PCR-based testing systems from self-collected nasopharyngeal samples swabs were used to test for viral RNA of SARS-CoV-2 in the follow-up.

Setting:

PICU within a tertiary university hospital in Germany.

Participants:

Healthcare workers of the PICU.

Interventions:

Positive HCWs were sent into quarantine. Containment measures were implemented including wearing of surgical-masks, physical distancing and systematic testing.

Results:

Among 432 HCWs, 91 (25%) were tested. Forty-five percent reported symptoms corresponding to characteristics of COVID-19. Of those, only 19,5% (8 HCWs) were tested positive for SARS-CoV-2. No infection occurred outside the PICU. After the implementation of containment measures, viral transmission was stopped.

Conclusions:

In the present study, a large outbreak within a team of healthcare workers of a PICU, affecting almost one fifth of the entire personnel is documented, along with detailed insights about how the outbreak was contained and how operability of the unit was maintained.
Antibiotic Utilization and Infection Among Infants with Abdominal Wall Defects
Authors: Ravikumar Chandana , Mitchell Ian C. , Cantey Joseph B.
Published: August 2020

Background:

Neonates with abdominal wall defects are at an increased infection risk because of the defect itself and prolonged neonatal intensive care unit (NICU) stays. Antibiotic prophylaxis until closure of the defect is common. However, infection risk and antibiotic use have not been well quantified in these infants.

Methods:

A retrospective cohort study of infants with abdominal wall defects (gastroschisis and omphalocele) admitted to a single-center NICU from 2007 to 2018. Demographic and clinical information, including microbiologic studies, antibiotic dosing and surgical care, were collected. Antibiotic use was quantified using days of therapy (DOT) per 1000 patient-days. Sepsis was defined as culture of a pathogen from a normally sterile site.

Results:

Seventy-four infants were included; 64 (86%) with gastroschisis and 10 (14%) with omphalocele. Median day of closure was 8 days [interquartile range (IQR) 6–10, range 0–31]. All infants received ≥1 course of antibiotics; median antibiotic DOT/infant was 24.5 (IQR 18–36) for an average of 416.5 DOT per 1000 patient-days. Most antibiotic use was preclosure prophylaxis (44%) and treatment of small intestinal bowel overgrowth (24%). Suspected and proven infection accounted for 26% of all antibiotic use. Skin and soft tissue infection (13/74, 18%) and late-onset sepsis (11/74, 15%) were the most common infections; 2 infants had sepsis while on antibiotic prophylaxis. All infants survived to discharge.

Conclusions:

Most antibiotic use among infants with abdominal wall defects was prophylactic. Infection on prophylaxis was rare, but 35% of infants had infection after prophylaxis. Improved stewardship strategies are needed for these high-risk infants.
Association between chronic pain and long-term cognitive decline in a population-based cohort of elderly participants
Authors: Rouch Isabelle , Edjolo Arlette , Laurent Bernard , Pongan Elodie , Dartigues Jean-François , Amieva Hélène
Published: August 2020

Chronic pain (CP) was associated with impaired cognitive performance in several cross-sectional studies conducted in older adults; however, fewer longitudinal studies assessed this link that remains still debated. With a prospective design, the present analysis was aimed at evaluating the relationship between CP and the change in several tests assessing memory, attention, verbal fluency, and processing speed. The study population was selected from the PAQUID study, a cohort of community dwellers aged 65 years and older; 693 subjects receiving a pain assessment were included. Chronic pain was evaluated using a questionnaire administered at 3-year follow-up. Cognitive performances were assessed every 2 to 3 years between 3 and 15 years assessing general cognition (Mini-Mental State Examination), verbal and visual memory (word paired-associate test and Benton test), attention and speed processing (Wechsler Digit Symbol Substitution Test and Zazzo's Cancellation Task), and language skills and executive functions (Isaacs Set Test). The link between CP and the change in cognitive function was assessed with latent process mixed models controlled for age, sex, education, comorbidities, depression, and analgesic drugs. The association between CP and each of the cognitive scores was then tested with the same procedure. A significant relationship was observed between CP and poorer 15-year scores on global cognitive performance (P = 0.004), and specifically, the Digit Symbol Substitution Test (P = 0.002) was associated with a higher slope of decline (P = 0.02). Chronic pain is associated with a higher cognitive decline, particularly in processing speed. This result reinforces the importance of actively treating CP with pharmacological and nonpharmacological strategies to prevent its consequences, including cognitive consequences.
ACE2 and SCARF expression in human dorsal root ganglion nociceptors: implications for SARS-CoV-2 virus neurological effects
Authors: Shiers Stephanie , Ray Pradipta R. , Wangzhou Andi , Sankaranarayanan Ishwarya , Tatsui Claudio Esteves , Rhines Laurence D. , Li Yan , Uhelski Megan L. , Dougherty Patrick M. , Price Theodore J.
Published: August 2020

SARS-CoV-2 has created a global crisis. COVID-19, the disease caused by the virus, is characterized by pneumonia, respiratory distress, and hypercoagulation and can be fatal. An early sign of infection is loss of smell, taste, and chemesthesis—loss of chemical sensation. Other neurological effects of the disease have been described, but not explained. It is now apparent that many of these neurological effects (for instance joint pain and headache) can persist for at least months after infection, suggesting a sensory neuronal involvement in persistent disease. We show that human dorsal root ganglion (DRG) neurons express the SARS-CoV-2 receptor, angiotensin-converting enzyme 2 at the RNA and protein level. We also demonstrate that SARS-CoV-2 and coronavirus-associated factors and receptors are broadly expressed in human DRG at the lumbar and thoracic level as assessed by bulk RNA sequencing. ACE2 mRNA is expressed by a subset of nociceptors that express MRGPRD mRNA, suggesting that SARS-CoV-2 may gain access to the nervous system through entry into neurons that form free nerve endings at the outermost layers of skin and luminal organs. Therefore, DRG sensory neurons are a potential target for SARS-CoV-2 invasion of the peripheral nervous system, and viral infection of human nociceptors may cause some of the persistent neurological effects seen in COVID-19.
“Having a Normal Life”
Authors: LaForge Kate , Wros Peggy , Bradley Katherine J. , Beiers-Jones Kristen
Published: August 2020

Client goals within healthcare and social needs navigation programs are neither well understood nor incorporated into ambulatory care practices. This study provides a qualitative analysis of client-established goals within the Interprofessional Care Access Network (I-CAN), a community-based health care and social needs navigation program. One hundred eleven client goal lists were analyzed using conventional content analysis. Twenty-two codes were developed and grouped into 4 main categories including Physical/Mental Health, Social/Social Services, Health Care System, and Daily Living. The results of this study offer insight into client goals within health care and social needs navigation programs and provide suggestions for future research.
MACRA and Accountable Care Organizations
Authors: Abodunde Bukola , Slater Chelsea , Coustasse Alberto
Published: August 2020

The purpose of this study was to examine how the Medicare Access and CHIP Reauthorization Act (MACRA) has improved health care delivery and to determine its impact on Accountable Care Organization (ACO) goals. ACOs have provided quality care through the reduction in readmission rates, coordinated care, and cost savings. With the passage of the MACRA, it has been estimated that it would further decrease Medicare spending on physician and hospital services. Also, ACOs have had a positive impact on improving health care delivery and have played a significant role in providing exceptional quality of care while also managing to increase the cost savings.
Implementing a Protocol of Ankle ROM Goniometry Measurement in the Neuroscience ICU
Authors: Tolland Joseph , Taglieri-Noble Kathleen , McEnroy Kevin , Miccile Lauren A.
Published: August 2020

Background/Purpose:

Prolonged intensive care unit (ICU) admission and symptoms of neurologic injury may increase the risk for joint contracture, negatively affecting function. Clear recommendations for assessing, monitoring, and providing interventions for contractures are limited. The purpose of our study was to determine the effect of implementing an ankle dorsiflexion (DF) measurement protocol in a patient population at risk for ankle contractures. We examined the effect of the measurement protocol on the frequency of measurement, ankle DF range of motion (ROM) from physical therapy (PT) evaluation to hospital discharge, and interventions provided.

Methods:

A measurement protocol of ankle DF ROM was implemented for patients admitted to the neuroscience ICU. A retrospective analysis was conducted of all patients who met eligibility criteria with a total hospital length of stay of more than 15 days and revealed 2 groups. A measurement group (MG) was evaluated by a physical therapist within 72 hours and included in the measurement protocol. A comparison group (CG) was not successfully evaluated per the measurement protocol and not included in the measurement protocol.

Results:

A total of 58 patients were analyzed. The MG (n = 27) received more measurements per week (P < .001) and more total sessions with measurements (P < .001); the CG (n = 31) received more estimated measurements (P = .005). More MG patients were assessed for the need for ROM intervention (P = .02). The CG received more interventions (mean [SD] = 0.94 [2.02]) than the MG (mean [SD] = 0.67 (1.00)], though not statistically significant. A subset of each group had analyzable ROM measurements. The MG subgroup (MGs) ROM change was positive (mean [SD] = 2.88°[8.55°]). The CG subgroup (CGs) was negative (mean [SD] = 4.50° [16.58°]); no significant difference was found.

Discussion/Conclusion:

The protocol increased the number of measurements performed. Ankle DF ROM was more frequently estimated in the CG. More MG patients were assessed for the need for ROM interventions; however, the number of interventions provided did not differ between groups. Ankle DF ROM goniometric measurements taken at a consistent frequency may affect the number of interventions provided. We were unable to determine the effect of the protocol on ROM measurements due to inconsistent measurement frequency and small sample size. Further studies are needed to assess barriers to consistent ROM measurement, assess the effects of increased measurement on ROM and functional outcomes, and the effect on the provision of intervention and allotment of resources.
Objective Measurement of Carcinogens Among Dominican Republic Firefighters Using Silicone-Based Wristbands
Authors: Caban-Martinez Alberto J. , Louzado-Feliciano Paola , Santiago Katerina M. , Baum Jeramy , Schaefer Solle Natasha , Rivera Geovanny , Miric Marija , Perez-Then Eddy , Kobetz-Kerman Erin N. , Daunert Sylvia
Published: August 2020

Objective:

Characterize objective measurements of carcinogenic exposure using passive sampling silicone-based wristbands among Dominican firefighters.

Methods:

Firefighters from a metropolitan fire service in the Dominican Republic were asked to wear a silicone-based wristband during one typical 24-hour shift. A pre- and post-shift survey collected work shift characteristics. Wristbands were processed for the type and quantity of polycyclic aromatic hydrocarbons (PAHs), a family of known carcinogenic compounds.

Results:

Fifteen firefighters wore a wristband, of which 73.3% responded to a fire with an average of 3.7 calls during the shift. Total PAH exposure was significantly higher among firefighters who responded to a fire versus firefighters with no fire during their shift (261 parts per billion [ppb] vs 117 ppb, P = 0.003).

Conclusions:

Silicone-based wristbands as objective passive samplers documented exposure to carcinogenic compounds during a typical 24-hour firefighter shift.
Stent strut thickness and acute vessel injury during percutaneous coronary interventions: an optical coherence tomography randomized clinical trial
Authors: Vilchez-Tschischke Jean Paul , Salazar Carlos , Gil-Romero Jorge , Mori Ricardo , Nuñez-Gil Ivan , Quirós Alicia , Nombela Luis , del Trigo Maria , Jimenez-Quevedo Pilar , Salinas Pablo , Escaned Javier , Macaya Carlos , Gonzalo Nieves
Published: August 2020

Aims

Compare the degree of acute vascular injury caused by a polymer-free, thin-strut drug-eluting stent (DES) to that caused by a bioresorbable polymer, thick-strut DES using optical coherence tomography (OCT).

Methods and results

Fifty patients requiring nonurgent PCI were randomized to receive either a thin or a thick-strut DES. OCT was performed before and after stent implantation. OCT-based injury score (IS) after implantation was numerically higher within thick-strut stents 0.32 vs. 0.23, but the difference was NS (P = 0.61). Edge dissections were present in 36% of the patients without differences between groups. Tissue prolapse (TP) area was larger with thin-strut stents (2.26 vs. 1.83 mm2, P = 0.04). Stent expansion and symmetry index were similar between the two platforms (85% vs. 94%, P = 0.08; and 0.82 vs. 0.80, P = 0.25). No differences were observed in total malapposition area (1.85 mm2 in thin-strut stents vs. 1.47 mm2, P = 0.48). Regarding the influence of plaque-type, IS tended to be higher (non-significant) with thick strut DES in fibrocalcific plaques. Stent malapposition area was smaller in fibrous plaques, especially with thin strut stents (P = 0.03).

Conclusion

There was no difference in the extent of OCT-based vessel injury associated with thin and thick-strut DES platforms. TP was larger with the thin strut DES, potentially reflecting a deeper stent embedment in the vessel wall.
Fluoroscopy Time During Endoscopic Retrograde Cholangiopancreatography Performed for Children and Adolescents is Significantly Higher With Low‐volume Endoscopists
Authors: Barakat Monique T. , Gugig Roberto , Imperial Joanne , Berquist William E.
Published: August 2020

Background:

Endoscopic retrograde cholangiopancreatography (ERCP) is a fluoroscopy and endoscopy‐based procedure important for diagnosis and management of pediatric pancreaticobiliary disorders. Patient, procedure, endoscopist, and facility characteristics have been shown to influence ERCP complexity and procedure outcomes as well as fluoroscopy utilization in adults; however, the extent to which this is true in pediatric patients remains under‐studied and there are minimal data regarding fluoroscopy utilization in pediatric ERCP.

Methods:

We retrospectively analyzed ERCPs performed on patients <18 years of age at our tertiary care children's hospital from 2002 to 2017 using our institution's paper and electronic medical record system along with a prospectively maintained radiation exposure database. Procedure complexity was graded using the Stanford Fluoroscopy Complexity Score and the American Society of Gastrointestinal Endoscopy Complexity scale. High‐volume endoscopists (HVE) were defined as having a cumulative annual ERCP volume >100 and low‐volume endoscopists (LVE) as <100 (pediatric + adult) ERCPs/year.

Results:

Three hundred eighty‐five ERCPs performed on 321 patients were included in this analysis. The mean patient age was 13.4 years (+/− 4.2 years), 77% were index ERCPs (native ampullas), and 81% were performed with therapeutic intent (87% for biliary indication and 13% for pancreatic indication). Fluoroscopy times (FTs) varied between procedures and providers. Median FT was 4.85 (+/− 2.68) minutes. Endoscopist annual ERCP volume was the strongest predictor of FT (P < 0.001). In addition to endoscopist volume, procedure‐specific predictors of increased FT included pancreatic indication for the procedure, biliary or pancreatic duct stricture, patient age <4 years or >16 years at the time of ERCP (P < 0.01 for each), and native ampulla. ERCP complexity rating based on the Stanford Fluoroscopy Complexity Score correlated with FT.

Conclusions:

Radiation exposure is higher than desirable for pediatric ERCP and varies with endoscopist as well as patient and procedure‐specific factors. HVE perform ERCP with lower FT relative to LVE even though HVE procedure complexity was higher. The Stanford Fluoroscopy Score predicted FT for pediatric ERCP, but the ASGE ERCP complexity scale did not. Adaptation and refinement of pediatric‐specific ERCP complexity scales including factors, such as patient size and age and indications/interventions more consistent with those encountered in pediatrics could be beneficial.
Emergency Presentations for Gastrostomy Complications Are Similar in Adults and Children
Authors: Chua Nina , Singh Harveen , Lay Joshua , Murray Megan , McDonald Jennifer , Craig Simon S. , Giles Edward M.
Published: August 2020

Gastrostomy tube (GT) complications are often managed in the Emergency Department (ED). We aimed to characterize and compare the pattern of ED presentations of GT complications in adults and children. A retrospective chart review of patients with GT complications presenting to 3 Australian EDs in 2 years was undertaken. ED visits for GT complications occurred in 70 GT patients (36 adults, 34 children) with 122 presentations. When comparing adults to children, infections occurred in 21% versus 36%, respectively; P = 0.08, mechanical issues in 48% versus 52%; P = 0.86, vomiting in 23% versus 8%; P = 0.02, and other issues in 7% versus 5%; P = 0.7. Presentation to ED within 28 days of initial GT insertion occurred in 3 (8%) adults and 3 (9%) children, predominantly with tube dislodgement. GT complications seen in ED are predominantly infectious and mechanical in nature, with an increased frequency of vomiting in adults when compared with children.
One‐year Outcomes of Congenital Duodenal Obstruction
Authors: Bethell George S. , Long Anna‐May , Knight Marian , Hall Nigel J. ,   BAPS‐CASS
Published: August 2020

Objectives:

Congenital duodenal obstruction (CDO) occurs in 1.2 per 10,000 live births and is frequently associated with other anomalies, most commonly cardiac. The aim of this study was to report important outcomes to 1 year following surgical repair.

Methods:

This was a prospective population‐based study using the British Association of Paediatric Surgeons Congenital Anomaly Surveillance System. Cases were identified at specialist pediatric surgical centres in the United Kingdom during a 12‐month period starting in March 2016. Outcomes were recorded at 1 year following surgical repair.

Results:

There were 100 infants with possible follow‐up at 1 year and follow‐up was achieved in 80 of these (80%) of whom 76 were alive at 1 year. The remainder had been discharged home, although one remained on parenteral nutrition. Five (6.1%) infants underwent repeat surgery for reasons related to CDO and overall 23 (23%) experienced at least 1 central venous catheter‐related complication within 1 year. Overall mortality either before repair or within 1 year following surgical repair was 8.4% (95% CI 2.5%–14.4%), no deaths were related to CDO.

Conclusions:

One year outcomes for CDO are generally very good with poor outcomes typically related to comorbidities. These data are useful for national benchmarking and parental counselling.
Use of Dietary Supplements in Pediatric Liver Disease and Transplantation
Authors: Korotkaya Yelena , Conner Kim , Lau Jen , Mullin Gerard , Harpavat Sanjiv , Miloh Tamir , Mogul Douglas
Published: August 2020

Background:

Dietary supplements are frequently used by healthy individuals and those with chronic medical conditions but may cause damage to the liver. The aim of this study was to examine the prevalence and attitudes of dietary supplement use, and the frequency of disclosure to healthcare providers among parents/caregivers for children with chronic liver disease.

Methods:

We developed an anonymous survey for parents/caregivers of children (<18 years old) with chronic liver disease or liver transplant recipients and distributed the survey through social media groups organized around pediatric liver diseases.

Results:

The survey was completed by 101 parents/caregivers (48 without transplant and 53 posttransplant).

Among respondents, 87% agreed they would use dietary supplements to help their child, but parents/caregivers of transplant recipients were less likely to consider use (77% vs 98%; P = 0.01). In the past 12 months, 83% reported dietary supplement use including 47% who used nonvitamin/mineral supplements. In two‐thirds of parents/caregivers, use was initiated by their personal belief. Although 77% of respondents disclosed their use to their liver team, disclosure varied depending on the supplement with no individual that used cannabinoid products disclosing the use.

Conclusions:

Dietary supplements are frequently used by children with liver disease and may exceed use in other pediatric conditions. Though most parents report use to their liver team, disclosure may vary depending on the specific supplement. Providers should take extra measures to review use of supplements with their patients and work to develop trust with their families to obtain accurate disclosure of use.
An Innovative Application of End-of-Life Nursing Education Consortium Curriculum to Increase Clinical Nurses' Palliative Care Knowledge
Authors: DeSanto-Madeya Susan , Darcy Ann Marie Grillo , Barsamian Jennifer , Anderson Annmarie , Sullivan Lauren
Published: August 2020

Clinical nurses are in a crucial position to provide primary palliative care by advocating for patients and families at the end of life, collaborating with the health care team to optimize quality of life, and contributing to enhanced symptom management. Most clinical nurses, however, have not received the comprehensive palliative care education needed to provide high-quality palliative care. The End-of-Life Nursing Education Consortium curriculum can bridge this gap by providing nurses with the knowledge needed to promote palliative care. Following completion of an End-of-Life Education Consortium train-the-trainer program, 6 nurses from a large, metropolitan academic medical center designed and implemented a series of 20-minute educational sessions informed by a hospital-wide needs assessment and based on the End-of-Life Nursing Education Consortium curriculum. The educational sessions, Palliative Care Conversations, provide clinical nurses with the core palliative care knowledge and skills needed to advocate for and provide patient-/family-centered care throughout the serious illness trajectory and at end of life. This article describes the process, design, and content of the palliative care educational sessions.
Adolescent Endometriosis
Authors: Gubbels Ashley , Spivack Lauren , Lindheim Steven R. , Bhagavath Bala
Published: August 2020

Importance

Endometriosis is a major health concern in the adolescent population and significantly impacts daily physical and psychosocial functioning. Endometriosis can have differing presentations in this population, and the diagnosis often involves long delays and multiple visits to specialists.

Objective

The aim of this review is to discuss adolescent endometriosis, factors specific to this population, accurate diagnosis, and evidence-based surgical and medical management.

Evidence Acquisition

Computerized searches on the topic of endometriosis and adolescent endometriosis were completed. References from identified sources were then searched manually to allow for a thorough review. Data from relevant sources were synthesized to create the review.

Results

The literature supports endometriosis as a frequent cause of secondary dysmenorrhea. The characteristics of adolescents with endometriosis are shown to differ from those of adults. Initial medical therapy includes nonsteroidal anti-inflammatory drugs and combined hormonal contraceptives, but laparoscopy does have a role in the adolescent population, particularly those who have inadequate response to these treatments. Adolescent endometriosis may have a different appearance and be of all stages. Medical therapies are similar to that of the adult population; however, the benefits of medical and surgical management must be tailored to the adolescent patient.

Conclusions and Relevance

Adolescent endometriosis is likely a more prevalent cause of dysmenorrhea than currently appreciated. A high index of suspicion combined with recognition of risk factors and history-based markers of endometriosis may help identify adolescent endometriosis earlier and avoid delays in diagnosis. Expert opinion supports earlier laparoscopic evaluation in patients with symptoms unresponsive to oral medications, those who have failed initial medical therapy, or those who have evidence of deeply invasive disease, such as an endometrioma. Surgeons should be familiar with the unique appearance of lesions in the adolescent and understand the evidence as it relates to surgical therapy. Postoperative medical management is generally advocated by many, although the efficacy remains unclear at present.

Target Audience

Obstetricians and gynecologists, family physicians

Learning Objectives

After completing this activity, the learner should be better able to describe the nature of adolescent endometriosis as a disease entity, along with risk factors and clinical markers; identify the role of laparoscopic evaluation in diagnosis and management; and explain the evidence-based medication options available to this patient population.
Adjuvant Human Papillomavirus Vaccine to Reduce Recurrent Cervical Dysplasia in Unvaccinated Women: A Systematic Review and Meta-analysis
Authors: Lichter Katie , Krause Danielle , Xu Jingwen , Tsai Sung Huang Laurent , Hage Camille , Weston Erica , Eke Ahizechukwu , Levinson Kimberly
Published: August 2020

(Abstracted from Obstet Gynecol 2020;135:1070–1083)

Persistent infection with human papillomavirus (HPV) oncotypes 16 and 18 accounts for up to 70% of all HPV-associated cervical cancer cases. Although the majority of HPV infections are cleared quickly by the immune system, a subset of approximately 10% to 20% of infections will persist, leading to disease progression and invasive cancer.
Effectiveness of Nitrous Oxide in External Cephalic Version on Success Rate: A Randomized Controlled Trial
Authors: Dochez Vincent , Esbelin Julie , Misbert Emilie , Arthuis Chloé , Drouard Anne , Badon Virginie , Fenet Olivier , Thubert Thibault , Winer Norbert
Published: August 2020

(Abstracted from Acta Obstet Gynecol Scand 2020;99:391–398)

Approximately 4% of all singleton pregnancies are breech at term. These births are associated with an increased risk of maternal and neonatal morbidity and mortality compared with births with cephalic presentations.
ALK-positive Histiocytosis of the Breast
Authors: Kashima Jumpei , Yoshida Masayuki , Jimbo Kenjiro , Izutsu Koji , Ushiku Tetsuo , Yonemori Kan , Yoshida Akihiko
Published: August 2020

Originally described as a systemic self-limiting disease in infancy, the spectrum of ALK-positive histiocytosis has recently been broadened to include localized diseases in older children and young adults. Despite different manifestations, these tumors share histologic characteristics and a highly recurrent KIF5B-ALK fusion. ALK-positive histiocytosis is poorly characterized in the breast. In this study, we report 3 cases of ALK-positive histiocytosis of the breast. The patients were Asian women, aged 16 to 45 years. Two patients presented with an isolated breast mass, while 1 exhibited multiorgan involvement. The latter patient received ALK inhibitor after surgery, which led to complete remission. Histologically, well-circumscribed tumors displayed fascicular and storiform growth of uniform, nonatypical spindle cells admixed with lymphocytic infiltrates. Fewer conventional epithelioid histiocytes with lobulated or clefted nuclei were observed within the same breast tumors in 2 cases or within a concomitant brain tumor in the third case. Touton-type giant cells were focally present in 2 cases. Immunohistochemically, tumor spindle, and epithelioid cells were diffusely positive for CD163 and ALK in all cases and focally positive for S100 protein in 1 of the cases. CD1a and langerin were negative. Actin-positive myofibroblasts were admixed within the tumor in 2 cases, and their reactive nature was highlighted using double immunostaining. Break-apart fluorescence in situ hybridization assay demonstrated gene rearrangements involving KIF5B and ALK in all the 3 cases. ALK-positive histiocytosis rarely occurs as a spindle cell breast tumor, and should be distinguished from other diseases such as inflammatory myofibroblastic tumors and spindled histiocytic reaction.
Clinicopathologic Features of Varicella Zoster Virus Infection of the Upper Gastrointestinal Tract
Authors: Mostyka Maria , Shia Jinru , Neumann William L. , Whitney-Miller Christa L. , Feely Michael , Yantiss Rhonda K.
Published: August 2020

Reactivation of latent varicella zoster virus (VZV) may be limited to a dermatome or involve multiple organs, including the gastrointestinal tract. Although gastrointestinal manifestations of disseminated zoster have been likened to those of herpes simplex virus (HSV), histologic features of VZV-related injury to the tubular gut are not well-documented. We performed this study to describe the clinicopathologic features of VZV-related gastrointestinal injury. We identified 6 such patients with VZV infection. All involved the upper gastrointestinal tract, affecting the esophagus (n=3), stomach (n=2), or both (n=1). All patients were immunocompromised adults with hematologic malignancies (n=5) or a heart transplant (n=1); 3 with hematologic malignancies had received stem cell transplants. Five patients had cutaneous and gastrointestinal zoster; 1 had gastrointestinal disease alone. When compared with 14 HSV-related esophagitis controls, there were several notable differences. VZV caused hemorrhagic ulcers with nodularity or erythema, whereas HSV produced round, shallow ulcers on a background of nearly normal mucosa (P=0.01). VZV-related ulcers featured fibrin-rich, pauci-inflammatory exudates compared with the macrophage-rich exudates of HSV (P=0.003). The cytopathic changes of VZV were present at all levels of the squamous epithelium, especially in a peripapillary distribution. In contrast, HSV inclusions were located in the superficial layers (P=0.003) and detached keratinocytes. Unlike HSV, VZV involved the stomach, producing hemorrhage accompanied by striking apoptosis in the deep glands. We conclude that VZV produces unique patterns of gastrointestinal injury that facilitate its diagnosis. Recognition of gastrointestinal VZV infection is important because it heralds potentially life-threatening disseminated disease.
Host Genomics of the HIV-1 Reservoir Size and Its Decay Rate During Suppressive Antiretroviral Treatment
Authors: Thorball Christian W. , Borghesi Alessandro , Bachmann Nadine , Von Siebenthal Chantal , Vongrad Valentina , Turk Teja , Neumann Kathrin , Beerenwinkel Niko , Bogojeska Jasmina , Roth Volker , Kok Yik Lim , Parbhoo Sonali , Wieser Mario , Böni Jürg , Perreau Matthieu , Klimkait Thomas , Yerly Sabine , Battegay Manuel , Rauch Andri , Schmid Patrick , Bernasconi Enos , Cavassini Matthias , Kouyos Roger D. , Günthard Huldrych F. , Metzner Karin J. , Fellay Jacques ,   the Swiss HIV Cohort Study
Published: August 2020

Background:

The primary hurdle for the eradication of HIV-1 is the establishment of a latent viral reservoir early after primary infection. Here, we investigated the potential influence of human genetic variation on the HIV-1 reservoir size and its decay rate during suppressive antiretroviral treatment.

Setting:

Genome-wide association study and exome sequencing study to look for host genetic determinants of HIV-1 reservoir measurements in patients enrolled in the Swiss HIV Cohort Study, a nation-wide prospective observational study.

Methods:

We measured total HIV-1 DNA in peripheral blood mononuclear cells from study participants, as a proxy for the reservoir size at 3 time points over a median of 5.4 years, and searched for associations between human genetic variation and 2 phenotypic readouts: the reservoir size at the first time point and its decay rate over the study period. We assessed the contribution of common genetic variants using genome-wide genotyping data from 797 patients with European ancestry enrolled in the Swiss HIV Cohort Study and searched for a potential impact of rare variants and exonic copy number variants using exome sequencing data generated in a subset of 194 study participants.

Results:

Genome-wide and exome-wide analyses did not reveal any significant association with the size of the HIV-1 reservoir or its decay rate on suppressive antiretroviral treatment.

Conclusions:

Our results point to a limited influence of human genetics on the size of the HIV-1 reservoir and its long-term dynamics in successfully treated individuals.
Brief Report: Discrepancies Between Self-Reported Adherence and a Biomarker of Adherence in Real-World Settings
Authors: Hebel Shane , Kahn-Woods Elijah , Malone-Thomas Sheryl , McNeese Marlene , Thornton Lupita , Sukhija-Cohen Adam , Patani Henna , Engeran Whitney , Daughtridge Giffin
Published: August 2020

Background:

Pre-exposure prophylaxis (PrEP) is only effective in preventing new HIV infections when taken consistently. In clinical practice, asking a patient about their adherence (self-report) is the predominant method of assessing adherence to PrEP. Although inexpensive and noninvasive, self-report is subject to social desirability and recall biases. Several clinical trials demonstrate a discrepancy between self-reported adherence and biomarker-based recent adherence. Less is known about the accuracy of self-report in real-world clinical settings. This brief report addresses this knowledge gap and describes the concordance between self-reported adherence and biomarker-based adherence in real-world clinical settings.

Methods:

A liquid chromatography–mass spectrometry urine test for tenofovir was developed and used clinically to detect recent nonadherence (no dose in at least 48 hours) for each individual. Two clinics' standard operating procedures recommend utilization of the urine-based adherence test for patients who self-report that they are not struggling with adherence. Those who self-report struggling with adherence receive enhanced adherence support without the need for additional testing. The number of results indicating recent nonadherence from these 2 clinics were analyzed to assess the concordance between self-reported adherence and biomarker-based adherence.

Results:

Across 2 clinics, 3987 tests were conducted from patients self-reporting as “adherent,” and 564 [14.1%; 95% confidence interval (CI): 13.1% to 15.2%] demonstrated recent nonadherence with the liquid chromatography–mass spectrometry test. At clinic #1 in Florida, 3200 tests were conducted, and 465 (14.5%; 95% CI: 13.3% to 15.8%) demonstrated recent nonadherence. At clinic #2 in Texas, 787 tests were conducted, and 99 (12.6%; 95% CI: 10.4% to 14.9%) demonstrated recent nonadherence.

Conclusions:

Utilization of biomarker-based adherence monitoring at these 2 clinics resulted in 564 additional patients receiving enhanced adherence support who otherwise would not have been identified as nonadherent to their prescribed PrEP regimen. These findings suggest that objective adherence monitoring can be used clinically to enable providers to identify nonadherent patients and allocate support services accordingly.
Ranking United States Plastic Surgery Residency Programs Based on Academic Achievement of Faculty Members
Authors: Boyd Carter J. , Davis Claire , Lindsey John T. , Ananthasekar Shivani , Kurapati Srikanth , King Timothy W.
Published: August 2020

Introduction

The Doximity Residency Navigator is currently the only resource that ranks plastic surgery residency programs. Given the paucity of objective program rankings, in this study, we devised a new algorithm to rank plastic surgery programs based on academic achievement of faculty members.

Methods

The Fellowship and Residency Electronic Interactive Database was used to obtain the following information on plastic surgery programs: the amount of 2017 National Institute of Health and Veterans Administration funding, lifetime and 5-year faculty h-indices, and the number of faculty on editorial boards of journals. Based on all of this information, an overall ranking of the top 25 plastic surgery programs was created.

Results

The top program for annual National Institutes of Health and Veteran Affairs funding was the University of Southern California (integrated and independent). The top programs for faculty lifetime h-index were the University of Michigan (integrated) and New York University (independent). The top program for faculty 5-year h-index was the University of Pennsylvania (integrated and independent). The top program for the number of faculty members who are on the editorial boards of major journals was Harvard University (integrated and independent). The top program overall was Harvard University (integrated and independent).

Conclusion

We ranked plastic surgery residency programs based on objective data related to faculty academic achievement. Academic achievement rankings are just one of numerous other factors that medical students should synthesize when making informed decisions when applying to residency.
Fractionated Ablative Carbon Dioxide Laser Therapy Decreases Ultrasound Thickness of Hypertrophic Burn Scar
Authors: Kemp Bohan Phillip M. , Cooper Laura E. , Lu Khang N. , Raper David M. , Batchinsky Maria , Carlsson Anders H. , Cancio Leopoldo C. , Chan Rodney K.
Published: August 2020

Introduction

Carbon dioxide (CO2) laser treatment is routinely used to treat hypertrophic burn scars (HBS). Although prior research has documented subjective improvement in HBS after treatment, there is little data evaluating objective changes in scar characteristics after therapy. The aim of our process improvement project was to evaluate changes to scar thickness (ST) using high-frequency ultrasound in patients with HBS undergoing CO2 laser therapy.

Methods

Ultrasound measurements of ST were obtained from patients with HBS before initial and at each subsequent treatment. ST, reduction in ST per treatment, and percentage reduction in ST from baseline were tabulated. Post hoc analyses examining the effect of initial ST and scar maturity on outcome were performed. First, patients were grouped by baseline ST into thicker (group 1, initial ST ≥ median value) and thinner (group 2, initial ST < median value) scar groups. Second, patients were divided into quartiles based on time from injury to treatment. Outcomes at each time point were compared with either Mann-Whitney U or Kruskal-Wallis tests, with Bonferonni corrections performed for post hoc subgroup analyses. Significance was set at P < 0.05.

Results

Twenty-one consecutive patients with HBS treated with CO2 laser were included. All patients completed 1 or more treatment, 48% completed 2 or more treatments, and 28% completed 3 treatments. Median initial ST was 0.71 cm (0.44–0.98 cm), and median scar maturity was 7.5 months (4.9–9.8 months). Overall, ST decreased over the treatment course (P < 0.001), with post hoc analysis demonstrating that 2 treatments were required to achieve a significant ST reduction (P < 0.01). On subgroup analysis comparing initial ST, ST decreased significantly in group 1 (thicker scars) overall (P < 0.001) but not in group 2 (P = 0.109). ST reduction was greatest after 1 treatment in group 1 (P = 0.022) and group 2 (P = 0.061). Percent reduction was greater in group 1 relative to group 2 after 1 treatment (P = 0.016). On subgroup analysis of scar maturity, there were no significant differences in either baseline ST or ST at any subsequent visit.

Conclusions

Fractionated ablative CO2 laser treatment improved ST after 1 to 2 treatments. Patients with thicker scars demonstrated greater ST reduction than those with thinner scars. Ultrasound adequately assessed treatment response.
Mitigating Ischemia-Reperfusion Injury Using a Bilobed Partial REBOA Catheter: Controlled Lower-Body Hypotension
Authors: Necsoiu Corina , Jordan Bryan S. , Choi Jae H. , Moon James J. , Espinoza Mark D. , Gremmer Brandon J. , Batchinsky Andriy I. , Cancio Leopoldo C.
Published: August 2020

Background:

Non-compressible torso hemorrhage (NCTH) is the leading cause of potentially preventable death on the battlefield. Resuscitative endovascular balloon occlusion of the aorta (REBOA) aims to restore central blood pressure and control NCTH below the balloon, but risks ischemia-reperfusion injury to distal organs when prolonged. We tested a bilobed partial REBOA catheter (pREBOA), which permits some of the blood to flow past the balloon.

Methods:

Female swine (n = 37, 6 groups, n = 5–8/group), anesthetized and instrumented, were exponentially hemorrhaged 50% of estimated blood volume (all except time controls [TC]). Negative controls (NC) did not receive REBOA or resuscitation. Positive controls (PC) received retransfusion after 120 min. REBOA groups received REBOA for 120 min, then retransfusion. Balloon was fully inflated in the full REBOA group (FR), and was partially inflated in partial REBOA groups (P45 and P60) to achieve a distal systolic blood pressure of 45 mm Hg or 60 mm Hg.

Results:

Aortic occlusion restored baseline values of proximal mean arterial pressure, cardiac output, and carotid flow in pREBOA groups. Lactate reached high values during occlusion in all REBOA groups (9.9 ± 4.2, 8.0 ± 4.1, and 10.7 ± 2.9 for P45, P60, and FR), but normalized by 6 to 12 h post-deflation in the partial groups. All TC and P60 animals survived 24 h. The NC, PC, and P45 groups survived 18.2 ± 9.5, 19.3 ± 10.6, and 21.0 ± 8.4 h. For FR animals mean survival was 6.2 ± 5.8 h, significantly worse than all other animals (P < 0.01, logrank test).

Conclusions:

In this porcine model of hemorrhagic shock, animals undergoing partial REBOA for 120 min survived longer than those undergoing full occlusion.
Immunomodulatory and Therapeutic Effects of Mesenchymal Stem Cells on Organ Dysfunction in Sepsis
Authors: Khosrojerdi Arezou , Soudi Sara , Hosseini Ahmad Zavaran , Eshghi Fateme , Shafiee Abbas , Hashemi Seyed Mahmoud
Published: August 2020

Sepsis is a life-threatening disorder that is caused by a dysregulated inflammatory response during an infection. The disease mostly affects pregnant women, newborns, and patients in intensive care units. Sepsis treatment is a significant part of a country's health budgets. Delay in the therapy causes irreversible failure of various organs due to the lack of blood supply and reduction of oxygen in the tissues and eventually increased mortality. The involvement of four or five organs by sepsis has been attributed to an increased risk of death to over 90%. Although antibiotics are at the first line of sepsis treatment, they do not possess enough potency to control the disease and prevent subsequent organ failure. The immunomodulatory, anti-inflammatory, anti-apoptotic, and anti-microbial properties of mesenchymal stem cells (MSCs) have been reported in various studies. Therefore, the application of MSCs has been considered a potentially promising therapeutic strategy. In preclinical studies, the administration of MSCs has been associated with reduced bacterial load and decreased levels of pro-inflammatory factors as well as the improved function of the different vital organs, including heart, kidney, liver, and lungs. The current study provides a brief review of sepsis and its pathophysiology, and then highlights recent findings in the therapeutic effects of MSCs and MSC-derived secretome in improving sepsis-induced organ dysfunction. Besides, eligible sepsis candidates for MSC-therapy and the latest clinical findings in these areas have been reviewed.