bluuebunny/crossref_metadata_2025 huggingface dataset:
Pediatric Hepatitis C Quality Improvement Project Improves Healthcare Access
Authors: Vallabhan Monique K. , Castillo Ricardo , Roldan Patricia , Rhoades Natalie , Kong Alberta S. , Jimenez Elizabeth Y.
Published: February 2023

Objectives:

Incidence of hepatitis C virus (HCV) infection is increasing in women of reproductive age, leading to increased prevalence of HCV infection in children via vertical transmission. This quality improvement (QI) project aimed to increase referrals to and appointments scheduled with a specialty pediatric gastroenterology HCV clinic and the number of eligible children with HCV who completed treatment.

Methods:

From July 2020 to August 2021, the QI team designed a project using the Model for Improvement and completed Plan Do Study Act cycles to test change ideas to improve HCV awareness and education for medical providers and families; standardize the referral process; track patients; increase clinic capacity; and connect families with community resource care coordination. Referrals to the pediatric HCV clinic, appointments scheduled, no shows, and treatment follow‐up were tracked during the project period and a comparison timeframe from July 2019 to June 2020.

Results:

There were improvements in several measures during the project period versus the comparison timeframe, with 80 versus 48 referrals received (66% increase), 115 versus 59 scheduled clinic visits (95% increase), and 7 versus 5 treatment completers (40% increase), along with a small (7%) decline in the proportion of scheduled clinic visits that were no shows.

Conclusion:

Application of QI methodology increased medical provider and caregiver awareness and engagement in accessing HCV healthcare available for at‐risk children. More QI efforts should be accelerated to identify best practices amidst a nationwide HCV epidemic.
A Case of Multifocal Lymphangioendotheliomatosis With Thrombocytopenia and Changes in Coagulopathy
Authors: Nagao Daiki , Ozeki Michio , Nozawa Akifumi , Yasue Shiho , Sasai Hideo , Endo Saori , Kato Takazumi , Hori Yumiko , Ohnishi Hidenori
Published: February 2023

Multifocal lymphangioendotheliomatosis with thrombocytopenia is a rare disease characterized by progressive multiple vascular lesions and is accompanied by thrombocytopenia. The precise diagnosis of this disease is frequently difficult because of the heterogeneity of the clinical symptoms. We report a case of a male infant who presented with severe thrombocytopenia induced by local inflammation. In addition, enlargement of the extremities with soft tissue and bone involvement without gastrointestinal bleeding was observed. The thrombocytopenia resolved after a combination therapy of sirolimus and prednisolone. Our finding that plasma angiopoietin-2 concentrations reflected the disease status suggests its utility as a biomarker of Multifocal lymphangioendotheliomatosis with thrombocytopenia.
Self-perception of cognitive functions in patients with neurological impairments as measured against a translated Cognitive Change Index
Authors: Suster Alja , Mlinaric Lesnik Vesna , Podlesek Anja , Cizman Staba Ursa
Published: February 2023

The primary purpose of the study was to compare the results of neuropsychological assessments with results obtained using a translated Cognitive Change Index (CCI) on patients with diagnosed brain pathology. Our study included 54 patients diagnosed with neurologic pathology (stroke, TBI, or brain tumor) at the University Rehabilitation Institute Soca (average age = 51 years, SD = 15 years). The results of neuropsychological evaluations and anamnestic data were also obtained for the clinical subsample. Confirmatory factor analysis of the translated CCI performed on responses of 151 normative elderly participants supported a one-factor structure of the questionnaire. Cronbach’s α was 0.77 in the clinical sample. A significant correlation was found between lower scores for attention and visual abilities using objective measurement tools and a person’s self-assessment of impairment in their own cognitive functions (score on CCI). Individuals can perceive that their attention and visual abilities are impaired when those abilities also score low in diagnostic tests.
Awareness of Disease Status Among Patients With Cancer
Authors: Finlayson Catherine S. , Rosa William E. , Mathew Shiyon , Applebaum Allison , Squires Allison , Fu Mei R.
Published: February 2023

Background

As the quality of cancer care improves, oncology patients face a rapidly increasing number of treatment options. Thus, it is vital that they are full and active partners in the treatment decision-making process. Awareness of disease status has been investigated in the literature; it has been inconsistently conceptualized and operationalized.

Objective

The aim of this integrative review was to develop a conceptual definition and model of the awareness of disease status among patients with cancer.

Methods

Whittemore and Knafl’s integrative review methodology guided this article. We obtained data through a systematic search of 8 databases. Key terms utilized were awareness, perception, truth disclosure, diagnosis, prognosis, terminal illness, status, neoplasm, and metastasis. Dates through January 2020 were searched to capture all relevant articles. Sixty-nine articles met inclusion criteria.

Results

The integrative review methodology guided the development of a conceptual definition and model. The concept of “awareness of disease status” was defined as the individual patient’s understanding of being diagnosed and treated for cancer based on the multifactorial components of individual patient characteristics and contextually driven communication practices of healthcare providers. This understanding is dynamic and changes throughout the disease trajectory.

Conclusion

These findings will inform consistency in the literature. Such consistency may improve person-centered clinical communication, care planning practices, and, ultimately, cancer-related outcomes.

Implications for Practice

With a greater understanding of the complexity of patients’ awareness of disease status, nurses will be able to guide their patients to make informed decisions throughout their disease trajectory.
“We're Cancer Care Nurses”
Authors: Wright David Kenneth , Ma Grace , Charlebois Kathleen , Gimmig Karine , Hodgson Lyndsay
Published: February 2023

Nurses play a key role in integrating palliative care into oncology. This project sought to better understand oncology nurses' perspectives about palliative care. Nurses from a community hospital were presented with a series of clinical scenarios and asked to comment on the appropriateness of palliative care in each case. A series of focus groups were held, inviting nurses' reflections about palliative care in relation to their practice. Nurses commenting on the clinical scenarios were unanimous that palliative care was appropriate in the most straightforward case: older adult, approaching the terminal phase of a cancer, having exhausted all curative treatment options, accepting death, wanting comfort, and contending with difficult symptoms. However, opinions on appropriateness varied in less straightforward cases, such as when patients did not accept death or when their cancer diagnosis was recent. In focus groups, nurses described a hybrid professional identity that integrates both oncology and palliative care. To them, this integration constituted the meaning of “cancer care.” They further reflected on tensions they experience between their proximity to patients in everyday care and their (in)abilities to meet palliative care needs. Results suggest the need for stronger institutional supports of cancer nurses' palliative practice.
Engagement in Online Communities by New Mothers in Recovery from Opioid Use Disorder
Authors: Mattson Nicole M. , Ohlendorf Jennifer M.
Published: February 2023

Purpose:

The purpose of this study was to examine the role of engagement with online communities by women using medication-assisted treatment (MAT) to manage recovery from opioid use disorder (OUD) during pregnancy and the first year after birth.

Study Design and Methods:

Ten participants were identified through purposive sampling for this secondary data analysis as part of a larger grounded theory study about ways women using MAT for recovery from OUD meet the needs of their mother–infant dyad. Inclusion criteria included: English-speaking, 18 years of age or older, living in the United States, within the first year after birth, using MAT to manage OUD, and identified engaging with online communities during pregnancy and/or postpartum. A categorical-content narrative approach was used.

Results:

Three narratives were identified from the analysis, belonging, collaboration, and expecting success.

Clinical Implications:

Engagement in online communities can be a meaningful adjunct or replacement for in-person support. Online spaces are available 24/7 and allow people to join a community where they will not experience stigma and can find support tailored to their needs. Health care providers could extend their care for mothers affected by OUD by referring them to online communities for support of recovery self-management efforts.
Integrative Review of Methods From Youth Risk Behavior Survey Secondary Data Analyses Examining HIV Syndemic Factors Among Adolescent Gay and Bisexual Men
Authors: Garcia David Ray , Fletcher Jason , Goldsamt Lloyd , Dunn Navarra Ann-Margaret
Published: February 2023

Background

Adolescent gay/bisexual men exhibit the highest prevalence of undiagnosed HIV infections. Ascertaining antecedents of behaviorally acquired HIV infections among adolescent gay/bisexual men can be challenging; however, these challenges can be overcome through the utilization of secondary data, such as the Youth Risk Behavior Survey.

Objective

Syndemics theory suggests that HIV infections are not a singular phenomenon; instead, many infections occur at the intersection of syndemic factors, such as substance use, violence, and mental health. Our objective is to describe and synthesize research methods of secondary data analyses that examine syndemic factors in relation to HIV risk behavior outcomes among subsamples of adolescent gay/bisexual men.

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycInfo were systematically searched. Inclusion criteria were (a) peer-reviewed Youth Risk Behavior Survey secondary data analyses conducted in the United States after 1991, (b) subsamples with adolescent gay/bisexual men, (c) one or more syndemic factor(s), and (d) one or more HIV risk behavior outcome(s). We used the National Institutes of Health Quality Assessment Tools for quality appraisal.

Results

Of 1,036 citations retrieved, nine studies met inclusion criteria. Results included using logistic regression analysis and data from 2015 to 2017 in six studies and underpinnings with minority stress theory in four studies. Eight studies omitted race/ethnicity in subsamples and six grouped lesbians with adolescent gay/bisexual men. Seven studies examined substance use, six examined violence, and five examined mental health. Condom use and number of partners were the most studied HIV risk behavior outcomes in four studies, whereas intercourse in the last 3 months was an outcome in only one study. Protective factors were not present.

Conclusion

Limitations found the need to highlight better inclusion of race/ethnicity and sexual orientation. Adding contemporary survey items is also necessary, such as nonbinary sex and gender identity, access to HIV prevention (condoms, HIV testing, and preexposure prophylaxis), and experiences with stigma, to elucidate risk behaviors among populations disproportionately affected by HIV infections, including Blacks/African Americans and Hispanics/Latinos.
Latent Class Analysis of Depressive Symptom Phenotypes Among Black/African American Mothers
Authors: Perez Nicole Beaulieu , D’Eramo Melkus Gail , Vorderstrasse Allison A. , Wright Fay , Yu Gary , Sun Yan V. , Crusto Cindy A. , Taylor Jacquelyn Y.
Published: February 2023

Background

Depression is a growing global problem with significant individual and societal costs. Despite their consequences, depressive symptoms are poorly recognized and undertreated because wide variation in symptom presentation limits clinical identification—particularly among African American (AA) women—an understudied population at increased risk of health inequity.

Objective

To explore depressive symptom phenotypes among AA women and examine associations with epigenetic, cardiometabolic, and psychosocial factors.

Methods

This cross-sectional, retrospective analysis included self-reported Black/AA mothers from the Intergenerational Impact on Blood Pressure (InterGEN) study (data collected 2015–2020). Clinical phenotypes were identified using latent class analysis. Bivariate logistic regression examined epigenetic age, cardiometabolic traits (i.e., BMI ≥ 30, hypertension, or diabetes), and psychosocial variables as predictors of class membership.

Results

All participants were Black/AA and predominantly non-Hispanic. Over half of the sample had one or more cardiometabolic traits. Two latent classes were identified (low vs. moderate depressive symptoms). Somatic and self-critical symptoms characterized the moderate symptom class. Higher stress overload scores significantly predicted moderate symptom class membership.

Discussion

In this sample of AA women with increased cardiometabolic burden, increased stress was associated with depressive symptoms that standard screening tools may not capture. Research examining the effect of specific stressors and the efficacy of tools to identify at-risk AA women are urgently needed to address disparities and mental health burdens.
Physical Exercise Interventions on Quality of Life in Parkinson Disease: A Network Meta-analysis
Authors: Lorenzo-García Patricia , Núñez de Arenas-Arroyo Sergio , Cavero-Redondo Iván , Guzmán-Pavón María José , Priego-Jiménez Susana , Álvarez-Bueno Celia
Published: February 2023

Background and Purpose:

Physical exercise is considered an effective intervention for maintaining or improving quality of life (QoL) in patients with Parkinson disease (PD), but there is no evidence showing which type of physical exercise intervention has more positive effects. This systematic review and meta-analysis aimed to synthesize the evidence regarding the effectiveness of exercise interventions on improving QoL in patients with PD, comparing different types of exercise interventions.

Methods:

A literature search was conducted through January 2022. The methodological quality of the trials was assessed using the Cochrane risk of bias tool RoB2. For the meta-analysis, physical exercise interventions were classified into 5 training categories: resistance, endurance, alternative exercises, dance, and sensorimotor interventions. A standard meta-analysis and network meta-analysis were carried out to evaluate the efficacy of the different types of physical exercise interventions.

Results:

The search retrieved 2451 studies, 48 of which were included in this network meta-analysis with a total of 2977 patients with PD. The indirect effects of the network meta-analysis showed positive results for alternative exercises (−0.46; 95% confidence interval [CI]: −0.76, −0.16), dance (−0.63; 95% CI: −1.08, −0.17), and sensorimotor interventions (−0.23; 95% CI: −0.40, −0.07) versus control comparisons.

Discussion and Conclusions:

More research is needed to determine the types of physical exercise interventions that are most beneficial and for which conditions of the disease they have the most positive effects.

Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A398).
Is Intravenous Immunoglobulin Effective in Reducing the Risk of Mortality and Morbidity in Neuroinvasive West Nile Virus Infection? A Critically Appraised Topic
Authors: Mbonde Amir A. , Grill Marie F. , Harahsheh Ehab Y. , Marks Lisa A. , Wingerchuk Dean M. , O’Carroll Cumara B.
Published: February 2023

Background:

The clinical benefit of intravenous immunoglobulin (IVIG) in adult individuals with neuroinvasive West Nile virus (niWNV) infection is not well substantiated. We sought to critically assess current evidence regarding the efficacy of IVIG in treating patients with niWNV.

Methods:

The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and a content expert in the field of neuro-infectious diseases.

Results:

The appraised study enrolled 62 participants with suspected niWNV, randomized into 3 different arms [37 participants in the Omr-IgG-am group, 12 in the Polygam group, and 13 in the normal saline (NS) group]. Omr-IgG-am and Polygam are different formulations of IVIG. IVIG safety, measured as rates of serious adverse events, was the primary study outcome while IVIG efficacy, measured as rates of unfavorable outcomes, was a secondary endpoint. The estimated rates of SAE were statistically similar in all groups (51.4% Omr-IgG-am, 58.3% Polygam, and 23.1% NS groups). Unfavorable outcomes also occurred at a similar rate between all the groups (51.5% Omr-IgG-am, 54.5% Polygam, and 27.3% NS).

Conclusions:

The appraised trial showed that Omr-IgG-am and Polygam are as safe as NS. Data on efficacy from this trial were limited by a small sample size. Phase III clinical trials on IVIG efficacy in NiWNV infection are needed.
Predominance of High-Level Tetracycline-Resistant Neisseria gonorrhoeae in Kenya: Implications for Global Implementation of Doxycycline Postexposure Prophylaxis for Prevention of Sexually Transmitted Infections
Authors: Soge Olusegun O. , Issema Rodal , Bukusi Elizabeth , Baeten Jared M. , Mujugira Andrew , Celum Connie , McClelland R. Scott , Stewart Jenell ,   for the Partners PrEP Study Team
Published: February 2023

Using archived Neisseria gonorrhoeae samples from 2008 to 2012, the prevalence of tet(M) genemediating high-level tetracycline resistance in N. gonorrhoeae was 96% among 50 Kenyan women. Determining the local and national prevalence of gonococcal tetracycline resistance and surveillance of gonococcal antimicrobial resistance can inform the implementation of doxycycline postexposure prophylaxis for STI prevention.
Case Report: Acquired Brown Syndrome after COVID-19 Vaccination
Authors: Fayed Alaa E. , Rakha Nehal K.
Published: February 2023

SIGNIFICANCE

Brown syndrome, or superior oblique tendon sheath syndrome, is characterized by limitation of elevation on adduction. The disorder is thought to involve the trochlea/superior oblique tendon complex through traumatic, surgical, and inflammatory mechanisms. It could be an indication of multiple underlying immunological or rheumatological disorders.

PURPOSE

This study aimed to report an unusual strabismus after receiving the first dose of a live attenuated coronavirus disease 2019 (COVID-19) vaccine.

CASE REPORT

A 31-year-old female patient presented with painful vertical diplopia and tenderness of the left trochlear area 3 days after the first dose of COVID-19 vaccination. She had a compensatory chin elevation and face turn to the right, as well as a left 10-prism-diopter hypotropia in the primary position, which increased to 15 prism diopters in the right gaze and disappeared in the left gaze. Ocular motility revealed the limitation of elevation on adduction. The patient denied any history of ocular trauma and was consequently investigated for dysthyroid disease and various immunological and rheumatological disorders, which were excluded. A Hess chart was obtained to document the motility disorder.

CONCLUSIONS

We report a case of acquired Brown syndrome in a 31-year-old otherwise healthy woman shortly after COVID-19 vaccination. It is possible that the patient may have developed trochleitis and/or superior oblique tenosynovitis brought on by cross-reacting antibodies generated by the immune response to the vaccine. In the age of the widest vaccination campaign in human history, it is highly likely that we will continue to observe many unexpected potential adverse effects of these vaccines in our clinical practice.
Application of Immunohistochemistry in Cytology
Authors: Shi Yan , Yee-Chang Melissa , Shi Shan-Rong
Published: February 2023

Immunohistochemistry (IHC), also referred to as immunocytochemistry in cytology literature, has revolutionized the practice of cytopathology. Because of the complexity of cytology preparation and limited diagnostic material, performing IHC remains a challenge. Formalin-fixed paraffin-embedded (FFPE) cell block (CB) is the optimal choice for IHC. In this review, the approaches for improving CB preparation will be discussed. When CB material is not available, various cytology specimens can also be used for IHC. With the utilization of Antigen Retrieval (AR) technique, these nonformalin-fixed cytology specimens can achieve successful IHC staining, comparable with the results from FFPE tissue sections. In the last part of this review, we will discuss the use of positive controls and the important role of AR in standardization of IHC in cytology.
The Biomarker Ki-67: Promise, Potential, and Problems in Breast Cancer
Authors: Gown Allen M.
Published: February 2023

Ki-67 is a nuclear protein serendipitously discovered by monoclonal antibody selection in the early 1980s. While it has been applied for decades in the context of breast cancer as a putative prognostic and, more recently, predictive, biomarker, even after all this time there is incomplete agreement as to the validity of the immunohistochemical assays employed for Ki-67 assessment, given possible effects of the disparate methodologies employed and possible confounding preanalytical, analytical, and interpretive variables. In this brief review, the history of Ki-67 and the problems, particularly with the analytical and interpretive variables, are highlighted through a selective review of the published literature. The contributions of the International Ki-67 Breast Cancer Working Group are highlighted, and in particular, the recommendations made by this group are reviewed. The potential of Ki-67 as a biomarker for breast cancer has not yet been fully realized, but an understanding of the power as well as the limitations of the methods of Ki-67 assessment are important if this biomarker can realize its potential.
High Homogeneity of Mesothelin Expression in Primary and Metastatic Ovarian Cancer
Authors: Weidemann Sören , Gorbokon Natalia , Lennartz Maximilian , Hube-Magg Claudia , Fraune Christoph , Bernreuther Christian , Clauditz Till S. , Jacobsen Frank , Jansen Kristina , Schmalfeldt Barbara , Wölber Linn , Paluchowski Peter , Berkes Enikö , Heilenkötter Uwe , Sauter Guido , Uhlig Ria , Wilczak Waldemar , Steurer Stefan , Simon Ronald , Krech Till , Marx Andreas , Burandt Eike , Lebok Patrick
Published: February 2023

To study the extent of heterogeneity of mesothelin overexpression in primary ovarian cancers and their peritoneal and lymph node metastases, a tissue microarray (TMA) was constructed from multiple sites of 220 ovarian cancers and analyzed by immunohistochemistry. One tissue core each was taken from up to 18 different tumor blocks per cancer, resulting in a total of 2460 tissue spots from 423 tumor sites (188 primary cancers, 162 peritoneal carcinosis, and 73 lymph node metastases). Positive mesothelin expression was found in 2041 of the 2342 (87%) arrayed tissue spots and in 372 of the 392 (95%) tumor sites that were interpretable for mesothelin immunohistochemistry. Intratumoral heterogeneity was found in 23% of 168 primary cancer sites interpretable for mesothelin and decreased to 12% in 154 peritoneal carcinosis and to 6% in 71 lymph node metastases (P<0.0001). Heterogeneity between the primary tumor and matched peritoneal carcinosis was found in 16% of 102 cancers with interpretable mesothelin results. In these cancers, the mesothelin status switched from positive in the primary tumor to negative in the peritoneal carcinosis (3 cancers) in or vice versa (2 cancers), or a mixture of positive and negative peritoneal carcinoses was found (11 cancers). No such switch was seen between the mesothelin-interpretable primary tumors and their nodal metastases of 59 cancers, and only 1 mesothelin-positive tumor had a mixture of positive and negative lymph node metastases. In conclusion, mesothelin expression is frequent and highly homogeneous in ovarian cancer.
Lymph Nodes With Increased IgG4-positive Plasma Cells and Patterns Suspicious for IgG4-related Disease
Authors: Chen Ying-Ren , Yu Shan-Chi , Wang Ren-Ching , Lee Chih-Ling , Song Hsiang-Lin , Medeiros L. Jeffrey , Yue Chung-Tai , Chang Kung-Chao
Published: February 2023

Lymphadenopathy with increased immunoglobulin (Ig) G4+ plasma cells can be a nonspecific finding or a manifestation of immunoglobulin G4–related disease (IgG4-RD). It remains unclear whether there are characteristic pathologic features of IgG4-RD involving lymph nodes, or if IgG4-RD lymphadenopathy can occur without other manifestations of IgG4-RD. In this study, we assessed 55 lymph node biopsy specimens (44 men and 11 women with a mean age of 55 y) with increased IgG4+ plasma cells that had 1 of the 6 well-described pathologic patterns. We also correlated these findings with IgG4 serum levels and followed these patients for 7 to 108 months (mean, 34.9 mo) for the occurrence of extranodal IgG4-RD. We further compared lymphadenopathy in patients who developed other manifestations of IgG4-RD (RD+, n=20, 36%) versus those who did not (RD−, n=35, 64%). We found that there were only minor significant differences between 2 groups, including frequency of receiving treatment (RD+, 90% vs. RD−, 60%, P=0.021) and higher serum levels of C-reactive protein (>8 mg/L, RD+, 53% vs. RD−, 13%, P=0.007). Other differences were either borderline or not significant, including mean age (RD+, 59.8 y vs. RD−, 51.9 y, P=0.097), male-to-female ratio (RD+, 16:4 vs. RD−, 28:7, P=1), constitutional symptoms (RD+, 25% vs. RD−, 9%, P=0.096), multiple enlarged lymph nodes (RD+, 45% vs. RD−, 26%, P=0.143), good response to therapy (RD+, 94% vs. RD−, 94%, P=1); higher serum IgG4 levels (>280 mg/dL, RD+, 75% vs. RD−, 51%, P=0.086), anemia (RD+, 45% vs. RD−, 43%, P=0.877), leukopenia (RD+, 0% vs. RD−, 3%, P=0.446), thrombocytopenia (RD+, 10% vs. RD−, 6%, P=0.556), positivity for antinuclear antibody (RD+, 24% vs. RD−, 29%, P=0.688), elevated serum levels of lactate dehydrogenase (>225 U/L, RD+, 0% vs. RD−, 20%, P=0.064), elevated serum IgE level (>100 IU/mL, RD+, 75% vs. RD−, 92%, P=0.238), and hypergammaglobulinemia (RD+, 90% vs. RD−, 86%, P=0.754). There were also no differences in morphologic patterns (P=0.466), IgG4+ cell location (P=0.104), eosinophil counts (RD+, 10.3±11.3 vs. RD−, 13.4±17.5, P=0.496), Epstein-Barr virus positivity (RD+, 35% vs. RD−, 60%, P=0.074), and Epstein-Barr virus–positive cell location (P=0.351). Our findings suggest that there are minimal differences between stringently defined IgG4-RD lymphadenopathy with versus without other manifestations of IgG4-RD. These findings also suggest the existence of IgG4-RD lymphadenopathy as the sole presentation of IgG4-RD.
Absolute Versus Relative Near-Infrared Spectroscopy in Pediatric Cardiac Patients*
Authors: Iliopoulos Ilias , Cooper David S. , Reagor James A. , Koh Wonshill , Goldstein Bryan H. , Khoury Philip R. , Morales David L. S. , Batlivala Sarosh
Published: February 2023

OBJECTIVES:

Near-infrared spectroscopy (NIRS) has been increasingly accepted as a noninvasive marker of regional tissue oxygenation despite concerns of imprecision and wide limits of agreement (LOA) with invasive oximetry. New generation absolute monitors may have improved accuracy compared with trend monitors. We sought to compare the concordance with invasive venous oximetry of a new generation absolute NIRS-oximeter (FORESIGHT ELITE; CASMED, Branford, CT) with a modern widely used trend monitor (INVOS 5100C; Medtronic, Minneapolis, MN).

DESIGN:

Prospective single-center study.

SETTING:

Tertiary pediatric heart center.

PATIENTS:

Children undergoing elective cardiac catheterization under general anesthesia. Time-paired venous oximetry samples (jugular and renal) were compared with NIRS-derived oximetry by two monitors using regression and Bland-Altman analysis.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

We enrolled 36 children (19 female, 10 cyanotic) with median age 4.1 years (25–75%, 2.5–7.8 yr) and weight 16.7 kg (12.3–29.1 kg). The absolute difference between NIRS-derived and invasive jugular oximetry was less than 10% in 67% of occasions for both monitors. Correlation was fair (Spearman r
s = 0.40; p = 0.001) for the FORESIGHT ELITE and poor (r
s = 0.06; p = 0.71) for the INVOS 5100C. Bias and LOA were +6.7% (+22%, –9%) versus +1.3% (LOA = +24%, –21%), respectively. The absolute difference between NIRS-derived and invasive renal oximetry was less than 10% in 80% of occasions with moderate correlation (r
s = 0.57; p < 0.001) for the FORESIGHT ELITE and in 61% of occasions with moderate correlation (r
s = 0.58; p < 0.001) for the INVOS 5100C; bias and LOA were +3.6% (+19%, –12%) and –1.4 % (+27%, –30%), respectively. NIRS correlation with renal venous oximetry was worse for cyanotic versus noncyanotic patients (p = 0.02).

CONCLUSIONS:

Concordance and LOA of NIRS-derived oximetry with invasive venous oximetry in the cerebral and renal vascular beds was suboptimal for clinical decision-making. Cyanosis adversely affected NIRS performance in the renal site.
The Success of Resident-Associated Lumbar Punctures at a Large, Single-Center Children's Hospital
Authors: Rudloff James , Lendrum Elizabeth , Semenova Olga , Lipshaw Matthew J. , Valentino Caitlin
Published: February 2023

Objectives

The frequency of lumbar punctures (LPs) has declined across US children's hospitals over the past decade, potentially decreasing procedural learning opportunities for pediatric resident trainees. Our study sought to determine whether the proportion of successful LPs performed by our pediatric residents has significantly changed over time.

Methods

This study is a single-center retrospective study to evaluate our pediatric resident LP success. We evaluated our primary outcome, proportion of overall LP success over time, using linear regression. We similarly used linear regression for proportion of successful resident-associated LPs over time. We calculated the median number of LPs of all pediatric residents during the study period.

Results

We analyzed 3143 LPs from April 2012 to December 2019. Both the overall number of LPs performed and the proportion of LPs that were successful have not significantly changed over an 8-year period (P > 0.05, P > 0.05). Similarly, the number of our resident-associated LPs and the proportion of successful resident-associated LPs have not changed over the study period (P > 0.05, P > 0.05). Our pediatric residents performed a median of 3 LPs (interquartile range: 2–4) in the pediatric emergency department (PED) over residency.

Conclusions

Despite national trends showing decreased LP rates at pediatric hospitals, we demonstrated stable proportions of LPs and success by our pediatric residents. Pediatric residents perform a relatively low number of LPs in the PED setting alone. Future research is needed to demonstrate whether these overall low numbers in the PED translate to procedural competency after residency graduation.
Interactions With Police in the Emergency Care of Children
Authors: Schultz Megan L. , Winn Madeline , Derse Arthur R. , Kaczor Frances , Levas Michael N.
Published: February 2023

Objectives

Emergency medicine providers may interface with law enforcement personnel (LEP) on behalf of their pediatric patients for a variety of reasons, from reporting child abuse to caring for children who are in police custody. Given the unique nature of caring for minors who may not have legal or medical autonomy, interactions with LEP can raise ethical concerns for emergency providers, specifically with regard to legal representation, developmental immaturity, and the civil rights of children and their parents/guardians.

Methods

We review 4 patient scenarios, based on real cases experienced by the authors, to demonstrate the legal and ethical issues that may arise when LEP are involved in the emergency care of a child. These scenarios discuss parental/guardian visitation for children in police custody in the emergency department (ED), the practice of making arrests on hospital grounds, and police interviews of children in the ED.

Results

Using the ethical principles of autonomy, beneficence, and justice, we offer recommendations for emergency providers on how to advocate for their pediatric patients in LEP custody within the constraints and protections of the law. We also suggest best practices for hospital systems to develop policies surrounding LEP activity in the ED.

Conclusions

These nuanced situations require careful advocacy for the child and a collaborative approach between medical providers and LEP to balance the child's well-being with public safety. We offer recommendations here, and we maintain that clear, widely adopted best practices for the care of minors in LEP custody are long overdue.
Cystic Walthard Nests of the Peritoneal Diaphragm: A Report of 3 Cases of a Common Process at an Unusual Site and Occurring in Patients With Endometriosis
Authors: Devins Kyle M. , Wilkinson Nafisa , Barton-Smith Peter , Jaio Long , Young Robert H.
Published: February 2023

Nests of cells resembling urothelium, eponymously named “Walthard nests,” are well-known incidental findings over the fallopian tube and occasionally undergo cystification resulting in clinical detection and surgical removal. Only rarely is this process noted outside the pelvic peritoneum. Herein we describe cystic Walthard nests occurring in the diaphragmatic peritoneum of three patients (aged 25, 36, and 39 yr) undergoing surgical evaluation for presumed endometriosis. In each case, small pearly white nodules on the diaphragmatic peritoneum were noted and biopsied. Microscopic examination revealed cystic spaces filled with pale eosinophilic secretion. The cysts were lined mostly by stratified transitional cells with pale eosinophilic to focally clear cytoplasm. Umbrella cells were focally present in all cases, and 1 showed focal glandular differentiation resembling cystitis glandularis. In areas, the epithelial cells became flattened and attenuated and nuclei were bland. By immunohistochemistry, all were positive for GATA3, cytokeratin 7, and BEREP4 and negative for cytokeratin 20, estrogen receptor, and WT-1. Walthard nests can rarely occur outside the pelvic peritoneum where they may be noted incidentally during surgery for other indications. This should be readily distinguished pathologically from other peritoneal lesions but lack of significant prior comment of them occurring on the diaphragm may result in diagnostic difficulty.
Placental T-Cadherin Correlates With Trophoblastic Invasion Anomalies: Placenta Percreta and Fetal Growth Restriction
Authors: Biyik Ismail , Metineren Huseyin , Ozturk Engin , Simsek Sercan , Oztas Efser , Guldur Muhammed E. , Ince Onur
Published: February 2023

In this study, we compared the placental T-cadherin staining intensity of pregnant women with placenta percreta (PP) and asymmetrical fetal growth restriction (FGR) compared with healthy control pregnancies. Placental T-cadherin levels of the placenta of 86 pregnant women in total, 25 with FGR, 30 with healthy pregnant subjects, and 31 with PP, were examined using monoclonal anti-T-cadherin (CDH13) antibody for immunohistochemical examination. In immunohistochemistry, H-scores were used for each group to compare the expression of T-cadherin in extravillous trophoblast (EVT) cells. T-cadherin H-score of EVTs was highest in the FGR group and the lowest in the PP group. The difference in H-score between the FGR group and the control group was not statistically significant (P=0.344). The difference between the PP group and the other 2 groups was significant (P<0.0001). Multivariable linear regression analysis with a stepwise elimination method was performed in order to identify demographic and clinical parameters with significant effects on the T-cadherin H-score of EVTs. The estimation results identified only the disease group as a significant predictor of the H-score of EVTs (R
2=0.340, P<0.0001). The highest T-cadherin H-score of EVTs was found in the FGR group and the lowest in the PP group. The low T-cadherin H-score values in the PP group suggest that low T-cadherin EVTs may be associated with increased placental invasion. Likewise, despite the statistical insignificance, a higher T-cadherin H-score of EVTs in FGR compared with controls implies a decreased invasiveness of the placenta in FGR.
Evaluation of Lineage/Site-specific Nuclear Immunohistochemical Markers SATB2, Cyclin D1, SALL4, and BCOR in High-grade Endometrial Carcinomas
Authors: Dyhdalo Kathryn S. , Ababneh Emad , Lanigan Christopher , Bowers Kathleen , Zhang Susan , McKenney Jesse K. , Joehlin-Price Amy S.
Published: February 2023

Poorly differentiated malignant neoplasms involving the gynecologic tract routinely include a poorly differentiated endometrial carcinoma (EC) in the differential diagnosis. Some nuclear lineage/site-specific immunohistochemical markers are utilized in this diagnostic setting including SATB2, cyclin D1, SALL4, and BCOR, but their specificity and use in small samples are not clear across the spectrum of ECs. Cases of undifferentiated/dedifferentiated endometrial carcinomas (UEC/DDEC), clear cell carcinoma (CCC), uterine serous carcinoma (USC), FIGO grade 3 endometrial endometrioid carcinoma (EEC), and uterine carcinosarcoma (UCS) were identified and diagnoses confirmed. Whole-section immunohistochemical stains for SATB2, cyclin D1, SALL4, BCOR, and PAX8 were performed. A total of 113 cases were utilized: 15 CCC, 26 EEC, 19 UCS, 22 USC, and 31 UEC/DDEC. Cases were distributed across both low (49%) and high (51%) FIGO clinical stages. SATB2 was expressed by UCS (8/19, 42%), EEC (10/26, 38%), UEC/DDEC (11/30, 37%), and USC (6/22, 27%). Cyclin D1 was expressed by EEC (24/26, 92%), USC (17/22, 77%), UEC/DDEC (15/20 EEC component, 75%; 22/30 UEC, 73%), UCS (10/16 carcinoma, 63%; 11/19 sarcoma, 58%), and CCC (8/15, 53%). SALL4 was expressed most frequently by UEC/DDEC (12/30, 40%), but also USC (7/22, 32%), EEC (5/26, 19%), and UCS (4/16 carcinoma, 25%; 3/19 sarcoma, 16%). BCOR was expressed at low levels in 2 USC, 2 UEC/DDEC, and 2 UCS. PAX8 was generally positive but showed lower expression in UEC/DDEC (17/30, 57%) and in the sarcomatous portions of UCS (6/19, 32%). SATB2, cyclin D1, SALL4, and BCOR stain variable numbers of poorly-differentiated EC and must be carefully interpreted within morphologic and clinical context.
Correlative Assessment of p53 Immunostaining Patterns and TP53 Mutation Status by Next-Generation Sequencing in High-Grade Endometrial Carcinomas
Authors: Matsumoto Nana , Manrai Padmini , Rottmann Douglas , Wu Xinyu , Assem Hisham , Hui Pei , Buza Natalia
Published: February 2023

TP53 mutations are frequently identified in the copy number-high molecular subgroup of endometrial carcinomas (ECs). P53 immunohistochemistry (IHC) is a widely used surrogate marker reflecting the mutational status of TP53, and recent reports have shown ~95% concordance between the two methods in ECs. While these results are promising, studies evaluating the correlation between different p53 IHC staining patterns and comprehensive next-generation sequencing results are still limited. We compared the p53 IHC staining patterns, scored as wild-type, diffuse nuclear overexpression, null/complete absence, and cytoplasmic, to next-generation sequencing results reported by FoundationOneCDx in 43 high-grade ECs: 20 serous ECs, 9 mixed ECs with a serous component, 4 carcinosarcomas with a serous component, and 10 grade 3 endometrioid ECs. The concordance of p53 IHC and TP53 mutation status was 100% (43/43) overall, including 100% (33/33) concordance in tumors with a serous component and 100% (10/10) in endometrioid ECs. Among the 35 tumors with aberrant p53 expression the most commonly observed pattern was diffuse nuclear overexpression seen in 69% (24/35), followed by cytoplasmic staining in 17% (6/35), and complete absence of staining (null) in 14% (5/35) of tumors. Of the 6 tumors with cytoplasmic staining, 4 corresponded to missense mutations within the DNA binding domain (V157F in 2 tumors, and S127P and R280S, in 2 tumor each), while 2 corresponded to nonsense mutations in the tetramerization domain (p.E339*). Our results further support that p53 IHC can serve as an accurate predictor of TP53 alterations in ECs to aid the molecular-based tumor classification and the distinction between tumor histotypes, both of which play an important role in the assessment of clinical prognosis and therapeutic decision making. In addition, our data suggest, that the type and position of TP53 mutation may not directly correlate with the observed p53 IHC pattern in all tumors, and that there may be alternative mechanisms for cytoplasmic localization (other than mutations involving the nuclear localization domain), possibly due to conformational changes or posttranslational modifications of the aberrant p53 protein.
Climate Change Adaptation Activities and Needs in US State and Territorial Health Agencies
Authors: Errett Nicole A. , Dolan Kathleen , Hartwell Cat , Vickery Jamie , Hess Jeremy J.
Published: February 2023

Objective:

To characterize US State and Territorial Health Agencies' (S/THA) climate change adaptation activities and priorities to facilitate appropriate investments, skills development, and support that will strengthen health sector capacity in response to a changing climate.

Design:

In 2021, we conducted an online survey of S/THA staff requesting information on current activities related to climate change and health, the state of climate and health programming, and anticipated needs and priorities for assistance. We analyzed survey results using descriptive statistics.

Setting:

US State and Territorial Health Agencies.

Participants:

We received responses from 41 of 59 S/THAs (69.5%).

Main Outcome Measures:

Implementation of S/THA climate and health programs (CHPs); engagement in climate and health activities; maintenance of hazard early warning systems and action plans; employment of climate and health communications strategies; capability to assess risks and adaptation needs related to various climate-sensitive conditions; priorities and plans for climate change adaptation in relation to climate-sensitive health risks; climate change adaptation-related partnerships and collaborations; requests of the Association of State and Territorial Health Officials (ASTHO) for advancing climate change adaptation activities; and the impacts of the COVID-19 pandemic on climate change work.

Results:

Nineteen S/THAs reported having CHPs, the majority of which are federally funded. On average, S/THAs without CHPs reported engagement in fewer climate and health activities and more early warning activities. The S/THAs reported the highest levels of concerns regarding non–vector-borne infectious disease (66%), vector-borne infectious diseases (61%), and extreme heat (61%) hazards.

Conclusions:

As S/THAs with CHPs report substantially greater climate and health capacity than those without, additional federal and state investments (eg, Building Resilience Against Climate Effects [BRACE]) are urgently needed to catalyze climate and health capacity.
The Novel Design and Implementation of an Integrated Burn Rehabilitation Clinical Fellowship
Authors: Jean Stephanie , Shahrokhi Shahriar , Godleski Matthew
Published: February 2023

Postgraduate medical burn rehabilitation training has been limited, with very few academic physiatrists specializing in burn rehabilitation. As a result, there are no existing models for post-graduate burn rehabilitation education. A 12-month comprehensive clinical fellowship in burn rehabilitation was offered through a tertiary burn center with formal university accreditation. In this article, the clinical, educational, and skill-based goals developed and implemented for this novel fellowship was outlined to serve as a blueprint for future fellowships in burn rehabilitation, as well as reflections on the experience.
Extracorporeal Shock Wave Therapy vs. Corticosteroid Local Injection in Shoulder Impingement Syndrome
Authors: ElGendy Mohamed H. , Mazen Mohamed M. , Saied Ahmed Mostafa , ElMeligie Mohamed M. , Aneis Yasser
Published: February 2023

Objective

The aim of this study was to examine the effects of combining extracorporeal shock wave therapy or local corticosteroid injections with a conventional physical therapy (CPT) program for patients with shoulder impingement syndrome.

Design

This was a prospective single-blinded, randomized controlled study.

Methods

Sixty patients with unilateral shoulder impingement syndrome >3 mos were allocated to group A (a 4-wk program of CPT plus a single local corticosteroid injection of 40 mg triamcinolone acetonide mixed with 1% xylocaine, n = 20), group B (CPT only, n = 20), and group C (CPT plus extracorporeal shock wave therapy, 2000 impulses, 0.2–0.3 mJ/mm2, one session per week for 3 wks, n = 20). Subacromial space, shoulder pain and disability index, and shoulder range of motion were assessed at baseline and 4 and 12 wks posttreatment.

Results

There were no between-group differences at 4 wks. At the 12-wk follow-up, no significant differences were found between groups A and B. There was a significant difference in favor of group C compared with group A with the expectation of shoulder internal rotation and subacromial space. Group C was also superior to group B in all outcomes except for subacromial space.

Conclusion

The addition of extracorporeal shock wave therapy to CPT induced more noticeable intermediate-term effects than CPT plus local corticosteroid injection or CPT alone.
Benefit of Outpatient Musculoskeletal Medicine Experience Early in Physical Medicine and Rehabilitation Residency
Authors: Cipriano Kevin , Desale Sameer , Chou Jiling , Malmut Laura
Published: February 2023

Musculoskeletal care for persons with disabilities is an important competency in Physical Medicine and Rehabilitation (PM&R) training. The optimal timing of musculoskeletal medicine rotations in the PM&R residency curriculum is unknown. The objective of this study is to determine if outpatient experience in musculoskeletal medicine increases resident use of musculoskeletal examination skills in the inpatient setting. An 8-item multiple-choice questionnaire was administered monthly to 19 PM&R residents rotating on inpatient services inquiring about number and types of musculoskeletal examinations performed on each inpatient rotation. 71 surveys were collected with a 90% response rate. Significant increases were noted in number of knee examinations and shoulder examinations performed on inpatient rotations after residents completed two months of outpatient musculoskeletal medicine. Most PGY-2 residents (76%) felt that they would perform more musculoskeletal examinations on their inpatient rotations if they had more outpatient musculoskeletal experience at that point in their training. The results suggest that outpatient musculoskeletal experience increases resident use of musculoskeletal examination skills in the inpatient setting. Earlier outpatient musculoskeletal experience in combination with a greater focus on teaching musculoskeletal examination skills in the inpatient setting can support residents in learning how to provide comprehensive musculoskeletal care to individuals with disabilities.