bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of Phantom Electrode Stimulation on Vocal Production in Cochlear Implant Users
Authors: Caldwell Meredith T. , Jiradejvong Patpong , Limb Charles J.
Published: December 2018

Objectives:

Cochlear implant (CI) users suffer from a range of speech impairments, such as stuttering and vocal control of pitch and intensity. Though little research has focused on the role of auditory feedback in the speech of CI users, these speech impairments could be due in part to limited access to low-frequency cues inherent in CI-mediated listening. Phantom electrode stimulation (PES) represents a novel application of current steering that extends access to low frequencies for CI recipients. It is important to note that PES transmits frequencies below 300 Hz, whereas Baseline does not. The objective of this study was to explore the effects of PES on multiple frequency-related characteristics of voice production.

Design:

Eight postlingually deafened, adult Advanced Bionics CI users underwent a series of vocal production tests including Tone Repetition, Vowel Sound Production, Passage Reading, and Picture Description. Participants completed all of these tests twice: once with PES and once using their program used for everyday listening (Baseline). An additional test, Automatic Modulation, was included to measure acute effects of PES and was completed only once. This test involved switching between PES and Baseline at specific time intervals in real time as participants read a series of short sentences. Finally, a subjective Vocal Effort measurement was also included.

Results:

In Tone Repetition, the fundamental frequencies (F0) of tones produced using PES and the size of musical intervals produced using PES were significantly more accurate (closer to the target) compared with Baseline in specific gender, target tone range, and target tone type testing conditions. In the Vowel Sound Production task, vowel formant profiles produced using PES were closer to that of the general population compared with those produced using Baseline. The Passage Reading and Picture Description task results suggest that PES reduces measures of pitch variability (F0 standard deviation and range) in natural speech production. No significant results were found in comparisons of PES and Baseline in the Automatic Modulation task nor in the Vocal Effort task.

Conclusions:

The findings of this study suggest that usage of PES increases accuracy of pitch matching in repeated sung tones and frequency intervals, possibly due to more accurate F0 representation. The results also suggest that PES partially normalizes the vowel formant profiles of select vowel sounds. PES seems to decrease pitch variability of natural speech and appears to have limited acute effects on natural speech production, though this finding may be due in part to paradigm limitations. On average, subjective ratings of vocal effort were unaffected by the usage of PES versus Baseline.
The role of febuxostat in gout
Authors: Bardin Thomas , Richette Pascal
Published: December 2018

Purpose of review

Concerns about the cardiovascular safety of febuxostat lead to reconsideration of the place of febuxostat in the management of gout.

Recent findings

The CARES trial is a randomized controlled trial mandated by the FDA to compare the cardiovascular safety of febuxostat and allopurinol in the management of gout. About 6190 patients with gout and major cardiovascular disease, randomly assigned to allopurinol or febuxostat, were prospectively followed up for a median of 32 months. No difference was noted in the occurrence of the primary end-point event, a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or unstable angina with urgent revascularization, but cardiovascular death was significantly more common in the febuxostat group (4.3%) as compared with the allopurinol group (3.2%) (P = 0.03).

Present guidelines on the management of gout should be revised in view of recent findings. Allopurinol could be recommended as the sole first-line urate-lowering drug (ULD) in patients with no contraindication. In patients contraindicated to allopurinol, uricosurics could be preferred to febuxostat as first-line ULDs in patients with cardiovascular disease/risk factors and no history of uric acid stones.
Diagnostic advances in synovial fluid analysis and radiographic identification for crystalline arthritis
Authors: Zell Monica , Zhang Dawen , FitzGerald John
Published: December 2018

Purpose of review

The present review addresses diagnostic methods for crystalline arthritis including synovial fluid analysis, ultrasound, and dual energy CT scan (DECT).

Recent findings

There are new technologies on the horizon to improve the ease, sensitivity, and specificity of synovial fluid analysis. Raman spectroscopy uses the spectral signature that results from a material's unique energy absorption and scatter for crystal identification. Lens-free microscopy directly images synovial fluid aspirate on to a complementary metal-oxide semiconductor chip, providing a high-resolution, wide field of view (∼20 mm2) image. Raman spectroscopy and lens-free microscopy may provide additional benefit over compensated polarized light microscopy synovial fluid analysis by quantifying crystal density in synovial fluid samples. Ultrasound and DECT have good sensitivity and specificity for the identification of monosodium urate (MSU) and calcium pyrophosphate (CPP) crystals. However, both have limitations in patients with recent onset gout and low urate burdens.

New technologies promise improved methods for detection of MSU and CPP crystals. At this time, limitations of these technologies do not replace the need for synovial fluid aspiration for confirmation of crystal detection. None of these technologies address the often concomitant indication to rule out infectious arthritis.
The Total Cost to the Health Care System in Medicare and Medicaid Patients for the Treatment of Cervical Myelopathy
Authors: Schroeder Gregory D. , McKenzie James C. , Casper David S. , Kurd Mark F. , Hilibrand Alan S. , Woods Barret I. , Radcliff Kris E. , Rihn Jeffery A. , Anderson David Greg , Vaccaro Alexander R. , Kepler Christopher
Published: December 2018

Introduction:

Cervical myelopathy is a common indication for spine surgery. Modern medicine demands high quality, cost-effective treatment. Most cost analyses fail to account for complication costs from nonoperative treatment. The purpose is to compare the total health care costs for operative versus nonoperative treatment of cervical myelopathy.

Methods:

The Center for Medicare and Medicaid Services Carrier File from 2005 to 2012 was reviewed using the PearlDiver database, representing a 5% sampling of Medicare billings which diagnosed patients with cervical myelopathy by International Classification of Diseases 9 code. Patients were separated into operative and nonoperative cohorts, and the total health care expenditures per patient normalized to 2012 dollars were collected.

Results:

A total of 3209 patients were included, and 1755 (55.87%) underwent surgery. A 6-year cost analysis performed on 309 patients over the age of 65 from 2006 undergoing surgery resulted in a nonsignificant increase in total health care expenditures ($166,192 vs. $153,556; P=0.45). Operative treatment had a net decrease in total health care costs following the first year of surgery.

Conclusions:

There is no significant difference in the total health care expenditures for operative versus nonoperative treatment of cervical myelopathy after 3 years. It is critical to understand that nonoperative treatment of this progressive disease leads to a substantial increase in total health care expenditures with increased risk of falls, injury, and further morbidity.
Recurrence risk of early-stage melanoma of the external ear: an investigation of surgical approach and sentinel lymph node status
Authors: Truong Amanda , Hyngstrom John R. , Andtbacka Robert H.I. , Noyes R. Dirk , Wright Melissa , Snyder John , Winters Alyssa , Sause William T. , Grossmann Kenneth F. , Khong Hung T. , Bowen Glen M. , Hitchcock Ying J. , Grossman Douglas , Bowles Tawnya L.
Published: December 2018

Surgical management of external ear melanoma presents unique technical challenges based on the unique anatomy and reconstruction concerns. Surgical technique, including preservation of cartilage, is variable and impact on recurrence is unclear. Our goal was to investigate surgical approach, including extent of surgical resection and sentinel lymph node biopsy (SLNB), and the impact on recurrence. In this retrospective review of primary clinical stage 1/2 external ear melanoma, demographics, tumor characteristics, surgical resection technique (including cartilage-sparing vs. cartilage removal), and SLNB results were evaluated for recurrence risk. One hundred and fifty-six patients total had an average follow-up of 5.6 years. Twenty-nine (18.6%) patients underwent cartilage-sparing surgery and 99 (63.5%) patients underwent SLNB, 14.1% of whom had micrometastatic disease. Ten (6.4%) patients recurred loco-regionally. Recurrence was associated with Breslow depth, initial stage at diagnosis, and SLNB status. Cartilage-sparing surgery was not associated with increased recurrence. Sentinel lymph node identification rate was 100% based on clinical detection with use of lymphoscintigraphy. In addition to confirming established risk factors for melanoma recurrence, we confirm the feasibility of SLNB in stratifying recurrence risk. Although we did not see an increased recurrence risk with surgical technique and cartilage-sparing approaches, these findings are limited by small sample size.
Relationship between vasomotor symptom improvements and quality of life and sleep outcomes in menopausal women treated with oral, combined 17β-estradiol/progesterone
Authors: Mirkin Sebastian , Graham Shelli , Revicki Dennis A. , Bender Randall H. , Bernick Brian , Constantine Ginger D.
Published: December 2018

Objective:

To characterize the impact of TX-001HR on the relationship between vasomotor symptom (VMS) improvement and quality of life and sleep.

Methods:

REPLENISH (NCT01942668) was a phase 3, randomized, double-blind, placebo-controlled, multicenter trial, which evaluated four daily doses of 17β-estradiol and progesterone (E2/P4) combined in a single, oral, softgel capsule in postmenopausal women (40-65 years) with a uterus and moderate to severe VMS (≥7/day or ≥50/week). In post hoc analyses, growth models were used to examine relationships between linear changes in VMS frequency and severity over 12 weeks and changes from baseline in the Menopause-Specific Quality of Life (MENQOL; total score and VMS domain) and the Medical Outcomes Study-Sleep (total score, sleep problems indices I and II) questionnaire outcomes at 12 weeks with treatment compared with placebo.

Results:

Outcomes with all four E2/P4 doses were combined (n = 591) and compared with placebo (n = 135). In all 5 growth models, the effects of TX-001HR on MENQOL total score and vasomotor domain were significantly associated with changes in VMS frequency and severity observed over 12 weeks (all, P < 0.001). Treatment-mediated effects on MENQOL via VMS frequency and severity models were significant. Similar results were found with Medical Outcomes Study-Sleep total score and sleep problems indices.

Conclusions:

TX-001HR improvements in quality of life and sleep outcomes are associated with and may be mediated through improvements in VMS frequency and severity.
Insights on Multiple Myeloma Treatment Strategies
Authors: Mateos María‐Victoria , Ludwig Heinz , Bazarbachi Ali , Beksac Meral , Bladé Joan , Boccadoro Mario , Cavo Michele , Delforge Michel , Dimopoulos Meletios A. , Facon Thierry , Geraldes Catarina , Goldschmidt Hartmut , Hájek Roman , Hansson Markus , Jamroziak Krzysztof , Leiba Merav , Masszi Tamás , Mendeleeva Larisa , O’Dwyer Michael , Plesner Torben , San‐Miguel Jesús F. , Straka Christian , van de Donk Niels W.C.J. , Yong Kwee , Zver Samo , Moreau Philippe , Sonneveld Pieter
Published: December 2018

The introduction of new agents and management strategies over the past decade has resulted in a major step change in treatment outcomes with deepening responses and increased survival for patients with multiple myeloma. In daily clinical practice, healthcare professionals are now faced with challenges including, optimal treatment sequencing and changing treatment goals. In light of this, a group of experts met to discuss diagnostic and treatment guidelines, examine current clinical practice, and consider how new clinical trial data may be integrated into the management of multiple myeloma in the future.
Evaluation of Patent Blue as the Vital Dye in an Animal Model of Descemet Membrane Endothelial Keratoplasty
Authors: Ho Wei-Ting , Chang Jung-Shen , Chen Tsan-Chi , Chou San-Fang , Wang I-Jong , Chang Shu-Wen
Published: December 2018

Purpose:

To evaluate the safety and feasibility of patent blue (PB) as the vital dye in Descemet membrane endothelial keratoplasty (DMEK).

Methods:

Bovine corneal endothelial cells were incubated with different concentrations (0.02%–2.5%) of PB. The cell viability, which was assessed by Cell Counting Kit-8 assay, was compared with that of untreated control and 0.06% to 0.4% trypan blue. The dyes were also used for graft preparation and implantation in the porcine eye model to evaluate stain quality, dye retention, and the feasibility of using PB in DMEK surgery.

Results:

No obvious increase in cytotoxicity was detected for 0.06% to 0.4% trypan blue and PB at concentrations up to 1.0%, but the cell viability after incubating with 1.5% to 2.5% PB was significantly reduced. PB at 0.5% to 1.0% generated good staining quality that can be used to facilitate graft implantation. Although the staining quality of 0.5% to 1.0% PB faded to an intermediate level after a 30-minute wash in phosphate-buffered saline, dye retention persisted for up to 24 hours.

Conclusions:

PB at 0.5% to 1.0% is biocompatible and can stain the graft sufficiently, making it an alternative for DMEK surgery.
Direct and Indirect Flap Measurements in Femtosecond Laser–Assisted In Situ Keratomileusis
Authors: Crispim Joao , Allemann Norma , Hallak Joelle A. , Azar Dimitri T. , De La Cruz Jose
Published: December 2018

Purpose:

To compare direct and indirect LASIK flap thickness measurements using ultrasound and Scheimpflug technology.

Methods:

Eighty-two eyes treated with laser-assisted in situ keratomileusis refractive surgery using a femtosecond laser (IntraLase FS150) were prospectively included in the study. Flap thickness was set to 115 μm. Corneal flap thickness was measured using the direct method—ie, ultrasound pachymetry immediately after flap construction in the presence of cavitation bubbles—and indirect methods, with subtraction of intraoperative post-lift corneal thickness measured using ultrasound pachymetry (intrastroma) from preoperative central corneal thickness using ultrasound (Indirect-US) or Scheimpflug thinnest pachymetry (Indirect-Scheimpflug).

Results:

Mean flap thickness was overestimated using the indirect methods, Indirect-US and Indirect-Scheimpflug (122.6 ± 24.5 μm and 128.1 ± 26.1 μm, respectively; P < 0.0060 and P < 0.0001, respectively). There were no significant correlations between the direct and indirect methods. Indirect-Scheimpflug was significantly higher (P = 0.0122) than Indirect-US. The closest average flap thickness compared with the set parameter of 115 μm was that of the direct method (115.6 ± 8.6 μm; 95% confidence interval: −1.3 to 2.5; P = 0.5163). The direct method provided the lowest SD of all groups (SD: 8.64).

Conclusions:

The direct method of flap thickness measurement was the most comparable to the set parameter compared with the indirect subtraction methods. Additional studies are needed to determine which method allows for the most accurate measurement of flap thickness.
Late-Onset Sterile Peripheral Ulcerative Keratitis Post-Corneal Collagen Crosslinking
Authors: Chanbour Wassef , Mokdad Israa , Mouhajer Abdallah , Jarade Elias
Published: December 2018

Purpose:

To report the incidence, characteristics, clinical presentations, risk factors, and the available treatment modalities of sterile peripheral ulcerative keratitis (PUK) post-corneal collagen crosslinking (CXL).

Methods:

This study is a retrospective study including 771 eyes of 474 patients operated for keratoconus or ectasia after LASIK between January 2010 and June 2017 at Beirut Eye & ENT Specialist hospital. The average follow-up period was 4.2 years with a minimum of 1 year post-CXL.

Results:

Eleven eyes (1.4%) of 8 patients developed late-onset PUK with or without corneal haze and sterile infiltrates. The complications occurred between 3 months and 6 years postoperatively. Their mean age of 39.6 ± 7.1 years was higher than the age of the noncomplicated patients 21.9 ± 8.8 years (P = 0.0001). Four affected patients had inflammatory and autoimmune conditions. Sex, presence of intrastromal ring segments, mean keratometry, and the thinnest pachymetry were found to be insignificantly different between groups, and photorefractive keratectomy was performed more in patients with keratitis. Duration of ultraviolet light exposure was related to sterile ulcerative keratitis development. All patients responded to steroid treatment, and only one had a relapse which resolved with topical cyclosporine 1% drops.

Conclusions:

PUK is a rare but serious complication after CXL. Long-term follow-up is necessary to detect late-onset PUK. It is a treatable condition associated with older age and autoimmune conditions but has a good visual outcome.
Outcomes of Micropulse Transscleral Cyclophotocoagulation in Uncontrolled Glaucoma Patients
Authors: Zaarour Karen , Abdelmassih Youssef , Arej Nicolas , Cherfan Georges , Tomey Karim F. , Khoueir Ziad
Published: December 2018

Purpose:

This study aimed at evaluating the intermediate-term efficacy and safety of micropulse transscleral cyclophotocoagulation (MP-TSCPC) in cases of uncontrolled glaucoma.

Methods:

Patients with moderate to advanced glaucoma and uncontrolled intraocular pressure (IOP) despite maximally tolerable antiglaucoma medications were selected to undergo MP-TSCPC using the MP3 handpiece with the Iridex Cyclo G6 (IRIDEX Laser Systems). Follow-up examinations took place on a regular basis until 15 months postoperatively.

Results:

Seventy-five eyes of 69 patients (53.6% male patients) were included. Mean age was 55.5±22.9 years. Primary open-angle glaucoma was the most common diagnosis. Corrected distance visual acuity at baseline ranged between 0 and 2.1 logMAR. Mean prelaser IOP was 26.0±7.91 mm Hg. This was reduced significantly to 13.8±5.6 mm Hg (44.0% reduction, P<0.001) at week 1, and to 18.0±7.7, 18.4±7.1, 16.7±6.2, 15.1±4.1, 15.7±5.32, and 14.8±5.50 mm Hg at months 1, 3, 6, 9, 12, and 15, respectively. The mean number of antiglaucoma drops decreased significantly up to 12 months of follow-up (P=0.008) and that of oral acetazolamide tablets decreased significantly up to 15 months (P<0.001). The success rate decreased progressively with time, reaching 81.4% at 6 months and 73.3% at 1 year. No major postoperative complications were encountered, and no eye lost vision completely.

Conclusions:

MP-TSCPC is an efficient noninvasive glaucoma treatment that achieves sustained IOP reduction and reduced need for ocular antihypertensive medications for up to 15 months. The optimal laser parameters to achieve the best success rate with the least side effects still need to be determined.
Effects of Exercise Interventions on Breast Cancer Patients During Adjuvant Therapy
Authors: Lee Junga , Lee Man-Gyoon
Published: December 2018

Background

Effects of exercise interventions on patients with breast cancer (BC) have shown benefits regardless of the measured variables, although the type of exercise and its duration during adjuvant therapy are unclear.

Objective

We investigated the effects of exercise interventions on each measurement, physical fitness, quality of life (QL), fatigue, depression, anxiety, and body compositions and found effective exercise interventions during adjuvant therapy for BC.

Methods

Twenty-nine studies were found by searching the databases of MEDLINE and EMBASE from January 2000 to February 2018. Randomized controlled trials that investigated the effects of exercise on physical and psychological outcomes in BC patients during adjuvant therapy were selected in this meta-analysis. The size of the effect for each variable from the selected studies considered the method of measurement and was calculated using the standardized mean difference statistic.

Results

A total of 2989 BC patients were included. Exercise interventions had positive outcomes in physical fitness, handgrip strength, QL, fatigue, depression, anxiety, self-esteem, % body fat, and body mass index. Exercise interventions were an average of 150 minutes, 3 times per week, for 17 weeks and consisted of moderate to vigorous (~60% of VO2peak), aerobic, resistance, or combined exercises.

Conclusions

Interventions that involve moderate to vigorous exercise 150 minutes for 3 times per week and in any modality may provide a better outcome for BC patients during adjuvant therapy.

Implications for Practice

Empowering BC patients to implement these exercise interventions could not only improve their health and QL, but also reduce fatigue, depression, and anxiety during adjuvant therapy.
Childhood Trauma Predicts Cancer Treatment–Related Pain in Breast Cancer Survivors
Authors: Kanzawa-Lee Grace A. , Knoerl Robert , Williams David A. , Clauw Daniel J. , Bridges Celia M. , Harte Steven E. , Kolarik Ellen , Houghtby Janet , Lavoie Smith Ellen M.
Published: December 2018

Background

Childhood trauma has been linked to neuropathic pain in noncancer populations, but its relationship with cancer treatment-related neuropathic pain is unknown.

Objective

This secondary data analysis of a prospective, longitudinal, observational study aimed to explore the relationship of childhood trauma experience with pain severity, pain interference, and neuropathic symptom severity (NSS) 12 months after surgery in women receiving treatment for stage 0 to III breast cancer.

Methods

Women (N = 44) recruited from a comprehensive cancer center self-reported childhood trauma experience, pain severity, pain interference, NSS, co-occurring symptoms, and pain beliefs via questionnaires. Descriptive statistics were used to describe childhood trauma experience. Linear regression was used to model childhood trauma and other predictors on pain variables 12 months after surgery.

Results

Childhood trauma predicted pain severity and pain interference 12 months after surgery (P < .05), as did baseline pain severities and helplessness-pain catastrophizing. Age predicted only NSS. Together, the best models predicted 31.6% to 40.9% of the variance in pain severities at 12 months (P < .001).

Conclusions

Childhood trauma exposure was a significant predictor of pain 12 months after breast cancer surgery and adjuvant treatment. Younger and helplessness-pain catastrophizing women are also at risk. Research is needed to identify preventive neuropathic pain interventions for high-risk women.

Implications for Practice

Women receiving breast cancer treatment should proactively be assessed for childhood trauma history, possibly by using discreet previsit questionnaires. Childhood trauma survivors may be at high risk for poor pain outcomes and may benefit from tailored pain interventions.
Accuracy of Messenger RNA Human Papillomavirus Tests for Diagnostic Triage of Minor Cytological Cervical Lesions: A Systematic Review and Meta-Analysis
Authors: Macedo Ana Cristina L. , Bavaresco Daniela Vicente , Gonçalves João Carlos N. , Grande Antônio José , da Rosa Maria Inês
Published: December 2018

Objectives

The main objective of this systematic review and meta-analysis is to specify the accuracy of messenger RNA human papillomavirus (HPV) tests among women with previous minor cervical lesion cytology to detect high-grade squamous intraepithelial lesions (CIN2+ and CIN3+) compared with a histopathological reference standard. The secondary objective is to compare messenger RNA HPV test accuracies and the DNA high-risk HPV test among these women.

Methods

Eligible studies were identified by searching the electronic databases with medical subject headings.

Main Results

Among the 2052 studies identified, 20 primary studies were included. Two tests were mainly identified: Aptima and PreTect HPV-Proofer. Aptima, with 10 studies, had better performance, considering atypical squamous cells of undetermined significance (ASC-US) and low-grade squamous intraepithelial lesion together, with a pooled sensitivity of 90.5% (95% confidence interval [CI], 88.1–92.6) and specificity of 55.1% (95% CI, 53.5–56.8) for CIN2+. For the ASC-US sample, Aptima had a pooled sensitivity of 90.1% (95% CI, 87.1–92.7) and specificity of 59.3% (95% CI, 57.5–61.1).

Conclusions

Messenger RNA HPV tests, mainly Aptima assay, can be recommended to triage women with ASC-US and low-grade squamous intraepithelial lesion because it has higher specificity with a small loss of sensitivity than Hybrid Capture 2 assay; this finding is promising as a means to reduce the overmanagement of minor cytological abnormalities.
Fixation Stability with Bessel Beams
Authors: Bhattarai Dipesh , Suheimat Marwan , Lambert Andrew J. , Atchison David A.
Published: December 2018

SIGNIFICANCE

Ophthalmic imaging instruments that require stable fixation can benefit by using Bessel beams in the form of monitor-based Bessel images.

PURPOSE

The purpose of this study was to investigate fixation stability using laser Bessel and Gaussian beams and monitor-based images of these targets.

METHODS

The right eyes of 16 participants were presented with seven fixation targets: monitor-based images of a bull's eye/cross hair, a Gaussian beam, a Bessel beam with four rings and a Bessel beam with three rings; laser Gaussian beam, laser Bessel beam with four rings, and laser Bessel beam with three rings. Participants fixated target centers for five runs, in which each run presented the seven targets for 20 seconds each. An Eye Tribe tracker sampled eye positions at 30 Hz. Standard deviations along horizontal (σx) and vertical meridians (σy) and areas of bivariate contour ellipses (BCEAs) of fixation positions were calculated, and statistical significances of target differences for these parameters were determined.

RESULTS

Average σx, σy, and BCEAs ranged from 0.26 to 0.35°, 0.38 to 0.55°, and 0.78 to 1.31 degrees2, respectively. Target differences in σx (χ2
6 = 13.0, P = .04), (σy) (χ2
6 = 36.819, P < .001), and BCEA (χ2
6 = 34.406, P < .001) were statistically significant. There were significant post hoc differences between some of the target pairs for σy and BCEA, but not for σx. Monitor-based Bessel beam targets provided significantly smaller σy and BCEAs than the bull's eye/cross hair combination and the monitor- and laser-based Gaussian beam targets.

CONCLUSIONS

Monitor-based images of Bessel beams provided better fixation targets than did a bull's eye/cross hair combination, monitor-based Gaussian images, and laser Gaussian beams, but no claim can be made that laser Bessel beams provide better fixation targets than do laser Gaussian beams. Monitor-based Bessel images should be useful for ophthalmic imaging instruments requiring stable fixation.
Case Report: Management of Corneal Clouding from Lecithin:Cholesterol Acyltransferase Deficiency
Authors: Zemsky Christine J. , Sherman Suzanne W. , Schubert Hermann D. , Suh Leejee H.
Published: December 2018

SIGNIFICANCE

Given that there are few reported cases of lecithin:cholesterol acyltransferase (LCAT) deficiency, recognition of the condition with proper management is notable. Long-term follow-up and contact lens fitting after penetrating keratoplasty provide best possible outcomes.

PURPOSE

The purpose of this study was to report a case of LCAT deficiency successfully treated with penetrating keratoplasty and longer-term follow-up with contact lens fitting.

CASE REPORT

A 43-year-old white woman of Italian descent presented with corneal clouding and trouble with night vision. The patient had a history of LCAT deficiency, irritable bowel syndrome, gastroesophageal reflux disease, osteoporosis, and hemolytic anemia. Slit-lamp examination demonstrated corneal haze throughout the corneal layers. The corneas had normal pachymetry. Given the opacity of each cornea (right greater than left) and decreased night vision, penetrating keratoplasty was performed on the right eye. At post-operative month 16, the corneal graft remained clear. The patient was able to achieve a best-corrected visual acuity of 20/30+ with a scleral lens.

CONCLUSIONS

Penetrating keratoplasty may be necessary to provide better quality of vision in LCAT deficiency patients, specifically to enhance one's contrast sensitivity, despite relatively good Snellen visual acuity.
Gait Velocity and Joint Power Generation After Stroke
Authors: Mentiplay Benjamin F. , Williams Gavin , Tan Dawn , Adair Brooke , Pua Yong-Hao , Bok Chek Wai , Bower Kelly J. , Cole Michael H. , Ng Yee Sien , Lim Lek Syn , Clark Ross A.
Published: December 2018

Objective

The aim of the study was to assess the degree to which isometric strength of multiple lower limb muscle groups and balance is associated with gait velocity and joint power generation during gait after stroke.

Design

Sixty-three participants in a multisite, multinational, cross-sectional, observational study underwent assessment of gait velocity (10-m walk test), standing balance (computerized posturography), and isometric strength (hand-held dynamometry). Twenty-seven participants had joint power generation assessed (three-dimensional gait analysis). Bivariate associations were examined using Spearman’s correlations. Regression models with partial F tests were used to compare the contribution to gait between measures.

Results

Although all muscle groups demonstrated significant associations with gait velocity (ρ = 0.40–0.72), partial F tests identified that ankle plantar flexor and hip flexor strength made the largest contribution to gait velocity. Ankle plantar flexor strength also had strong associations with habitual and fast-paced ankle power generation (ρ = 0.65 and 0.75). Balance had significant associations with habitual and fast gait velocity (ρ = −0.57 and −0.53), with partial F tests showing that the contribution was independent of strength.

Conclusions

Ankle plantar flexor and hip flexor strength had the largest contribution to gait velocity. Future research may wish to refocus strength assessment and treatment to target the ankle plantar flexors and hip flexors.

To Claim CME Credits

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME

CME Objectives

Upon completion of this article, the reader should be able to: (1) Differentiate the contribution that lower limb strength of each muscle group has on gait velocity after stroke; (2) Appraise the relationship between isometric strength and joint power generation during gait; and (3) Interpret the contribution of both strength and balance to gait after stroke.

Level

Advanced

Accreditation

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)
TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Within-Assessment Variability of the GAITRite System in People With Stroke
Authors: Scully Aileen , Tan Dawn
Published: December 2018

Objectives

The GAITRite is a validated tool for measuring gait. However, no information is available regarding the number of trials required. This study investigated the within-assessment variability of the GAITRite to establish the recommended number of trials.

Design

People with stroke undergoing inpatient rehabilitation were assessed on the GAITRite. Data of individuals admitted from January 2014 to January 2015 were extracted. Five trials were performed. A repeated-measures analysis of variance was used to investigate within-subject differences across the trials. Group means of each variable were plotted against trials. Significance was set at 0.05.

Results

Thirty-six people with stroke (mean [SD] age = 59.6 [13.3] yrs, 61.1% male) were assessed. Significant differences across trials were found for gait speed (P < 0.01), step length on the paretic (P < 0.01) and nonparetic sides (P < 0.01), stance phase time on the nonparetic side (P < 0.01), and single-limb support time of the paretic side (P = 0.02). The differences were found between the first two trials and the other trials.

Conclusions

Depending on the gait variable of interest, the use of two warm-up trials and taking the average of two assessment trials could reduce the within-assessment variability of this instrument in people with stroke.
Exploring assessment of medical students' competencies in pain medicine—A review
Authors: Shipton Elspeth Erica , Steketee Carole , Bate Frank , Visser Eric John
Published: December 2018

Introduction:

Considering the continuing high prevalence and public health burden of pain, it is critical that medical students are equipped with competencies in the field of pain medicine. Robust assessment of student expertise is integral for effective implementation of competency-based medical education.

Objective:

The aim of this review was to describe the literature regarding methods for assessing pain medicine competencies in medical students.

Method:

PubMed, Medline, EMBASE, ERIC, and Google Scholar, and BEME data bases were searched for empirical studies primarily focusing on assessment of any domain of pain medicine competencies in medical students published between January 1997 and December 2016.

Results:

A total of 41 studies met the inclusion criteria. Most assessments were performed for low-stakes summative purposes and did not reflect contemporary theories of assessment. Assessments were predominantly undertaken using written tests or clinical simulation methods. The most common pain medicine education topics assessed were pain pharmacology and the management of cancer and low-back pain. Most studies focussed on assessment of cognitive levels of learning as opposed to more challenging domains of demonstrating skills and attitudes or developing and implementing pain management plans.

Conclusion:

This review highlights the need for more robust assessment tools that effectively measure the abilities of medical students to integrate pain-related competencies into clinical practice. A Pain Medicine Assessment Framework has been developed to encourage systematic planning of pain medicine assessment at medical schools internationally and to promote continuous multidimensional assessments in a variety of clinical contexts based on well-defined pain medicine competencies.
Survival after Digit Replantation and Revascularization Is Not Affected by the Use of Interpositional Grafts during Arterial Repair
Authors: Lee Z-Hye , Klifto Christopher S. , Milone Michael T. , Cohen Joshua M. , Daar David A. , Anzai Lavinia , Thanik Vishal D. , Hacquebord Jacques H.
Published: December 2018

Background:

Interpositional grafts can be used to reconstruct the digital artery during revascularization and replantation when primary repair is not possible. The purpose of this study was to determine the effect of using interpositional grafts on the rate of digit survival.

Methods:

A retrospective review of all patients from 2007 to 2016 that required revascularization and/or replantation of one or more digits was performed.

Results:

One hundred twenty-seven patients were identified with 171 affected digits (118 digital revascularizations and 53 digital replantations). A graft was used to repair the digital artery in 50 percent of revascularizations (59 of 118) and in 49 percent of replantations (26 of 53). There was no difference in digit survival with use of an interpositional graft for arterial repair versus primary repair in revascularization (91.5 percent in both groups) or replantation (48.1 percent versus 46.2 percent; p = 0.88). Regression analysis demonstrated no association between the use of interpositional grafts and digit survival. Interpositional grafting was more likely to be used in crush (62.5 percent) and avulsion injuries (72.2 percent) compared with sharp laceration injuries (11.1 percent), with a relative risk of 5.6 (p = 0.01) and 6.5 (p = 0.006), respectively.

Conclusions:

There was no difference in the survival rate of amputated digits that required interpositional grafting for arterial repair. The need for an interpositional graft in a large zone of injury should not be considered a contraindication to performing revascularization or replantation. Furthermore, hand surgeons should have a low threshold for using interpositional grafts, especially in crush or avulsion injuries.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Multimodal Characterization of the Mature Septal Deformity and Airspace Associated with Unilateral Cleft Lip and Palate
Authors: Marcus Jeffrey R. , Brown David A. , Carpenter David , Glener Adam , Allori Alexander , Frank-Ito Dennis
Published: December 2018

Background:

The nasal deformity that accompanies cleft conditions is often acknowledged as the most difficult obstacle to restoring facial balance in affected children. Despite considerable progress in the treatment of cleft lip and palate, the outcomes of cleft septorhinoplasty have proven variable and difficult to predict, possibly because of incomplete understanding of the underlying anatomical deformities. The authors sought to characterize unilateral cleft septal and dorsal deformities through a detailed morphologic model based on photogrammetric, qualitative, and quantitative computerized tomographic image analysis.

Methods:

Twenty-five consecutive patients with a unilateral cleft nasal deformity without prior septorhinoplasty were included.

Results:

Dorsal angulation, as measured by the nasal dorsal angle, consistently deviated away from the cleft side at a mean angle of 8.9 degrees. In a majority of patients, the septal deformity was complex and consistent in the anterior and middle regions of the airspace, but variable in the posterior region. Finally, discrete sites of potential nasal obstruction were noted in the anterior, middle, and posterior regions along the acoustic axis. Considerable variation was seen in the anterior and posterior regions, with potential obstructions variably on both the cleft and noncleft sides.

Conclusion:

The authors’ results underscore the importance of subject-specific analysis in cleft septorhinoplasty to address multiple potential sites of nasal obstruction.
Round versus Anatomical Implants in Primary Cosmetic Breast Augmentation: A Meta-Analysis and Systematic Review
Authors: Cheng Fengrui , Cen Ying , Liu Chuanqi , Liu Ruolin , Pan Cheng , Dai Shuiping
Published: December 2018

Background:

Choosing implant shape (round or anatomical) is one of the most essential yet controversial decisions in cosmetic breast augmentation. Many surgeons choose implant shape based on personal experience or expert opinion. This is the first systematic review and meta-analysis comparing the aesthetic effect between anatomical and round implants in primary cosmetic breast augmentation.

Methods:

The authors searched the PubMed, MEDLINE, Embase, ScienceDirect, Web of Knowledge, Scopus, and Cochrane Central Register of Controlled Trials databases for studies that compared anatomical and round implants in primary cosmetic breast augmentation. Primary outcomes were postoperative aesthetic effect and correct identification rate of implant shape. Random effects models were used to obtain pooled standardized mean difference and 95 percent confidence intervals.

Results:

One randomized comparative and four observational comparative studies met the inclusion criteria. No aesthetic superiority was found in the anatomical implant group with regard to overall appearance (standardized mean difference, 0.06; 95 percent CI, −0.40 to 0.53), naturalness (standardized mean difference, 0.18; 95 percent CI, −1.51 to 1.15), projection, upper pole contour, and lower pole contour. Pooled correct identification rate of implant shape by plastic surgeons was 52 percent (95 percent CI, 0.46 to 0.58).

Conclusions:

Generally, anatomical implants do not seem to have an aesthetic superiority compared to round implants. Plastic surgeons seemed to be unable to accurately differentiate the two implant shapes in vivo. Further studies should focus on identifying the specific indications for the use of anatomical implants.
Concurrent Joint Hypermobility Syndrome and Spondyloarthropathy
Authors: Shur Natalie F. , Shur Joshua D. , Rennie Winston J. , Moorthy Arumugam
Published: December 2018

Background

The coexistence of joint hypermobility syndrome (JHS) and spondyloarthropathy (SpA) presents a challenging clinical conundrum due to the contradictory clinical signs that may be present. Classic features such as restricted spinal movement or early morning back stiffness may not be present. Timely diagnosis and appropriate management of these patients are difficult as they tend to have lower scores on validated objective measures.

Methods

We performed a medical records review study to identify patients with both JHS and SpA who had presented to the Leicester Spondyloarthropathy clinic. Patients were diagnosed with axial SpA if they met the Assessment of SpondyloArthritis international Society classification criteria.
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Their imaging was reviewed by a consultant musculoskeletal radiologist.

Results

Four cases were identified from the patient database (female; average age, 37.5 years). All patients presented with lower back pain or sacroiliac joint pain but preserved spinal movement with a negative Schober's test. Two had a history of symptoms for more than 10 years. All had a Beighton score of greater than 6. Three of the patients were HLA positive, and 3 had a positive family history. All patients thus far have had their symptoms adequately controlled on nonsteroidal anti-inflammatory drugs and physiotherapy.

Conclusions

The coexistence of JHS and SpA is rare but important to recognize. These patients are difficult to diagnose as they may present late because of preserved spinal movements. It is unclear whether the preserved flexibility masks the true extent of disease or whether clinically they represent a less severe disease phenotype.
The Contribution of the Omentum to the Outcome From Sepsis: An Experimental Animal Study
Authors: Wang Andrew W. , Cauvi David M. , Hawisher Dennis , Reyes Tony , Coimbra Raul , Bickler Stephen , De Maio Antonio
Published: December 2018

The omentum is a large mesenchymal fibro-fatty tissue with remarkable healing capability. It is also rich in immune cells, including macrophages and lymphocytes, within particular structures named milky spots. Clinical observations indicate a high incidence of peritonitis after the removal of the omentum suggesting that it may play a role in sepsis. To test this possibility, male CD-1 mice underwent simultaneous omentectomy and cecal ligation and puncture (CLP), omentectomy-sham operation and CLP alone, and mortality was documented within 72 h post the insults. A significant increase in mortality was observed in mice subjected to omentectomy and CLP in comparison with CLP alone. Mortality was correlated with an increase in cytokine gene expression within the lung after omentectomy and CLP as opposed to CLP alone. However, no differences in bacterial load were observed within the peritoneum or blood between groups. To test the long-term effect of omentectomy, mice were subjected to omentum removal or sham operation, allowed to recover from surgery for 14 or 28 days, and then both were subjected to CLP. In these cases, no differences in mortality were observed between the groups suggesting that the lack of omentum triggers a compensatory mechanism. Finally, omentectomy and sham operation altered the composition of peritoneal immune cells with the disappearance of F4/80high macrophages and the appearance of a new population of F4/80low macrophages within 1 or 14 days post-surgery. The F4/80high positive cells reappeared after 28 days following the procedures. All of these observations suggest that the omentum plays an early role in the outcome from sepsis.
Modulation of CCL2 Expression by Laparoscopic Versus Open Surgery for Colorectal Cancer Surgery
Authors: Duque Patricia , Garutti Ignacio , Terradillos Estrella , Ledesma Beatriz , Rancan Lisa , Simon Carlos , Vara Elena
Published: December 2018

It is well known that surgery provokes an inflammatory response. However, the induced inflammatory response to laparoscopic compared with open surgery under combined anesthesia has never been compared following colorectal cancer surgery. We hypothesize that laparoscopic technique under general anesthesia results in a decreased proinflammatory state. We compared cytokines plasma secretion after laparoscopic technique under general anesthesia (LG), open surgery under combined anesthesia (thoracic epidural and general anesthesia) (OGE), and open surgery under general anesthesia as the control group (OG). Proinflammatory cytokines measured postoperatively were significantly increased in the OG group (n=19), compared with the LG (n=18) and OGE (n=20) groups. Post hoc analysis showed that CCL2 levels were significantly lower in LG at all times postoperatively (P<0.01), while interleukin-4, an anti-inflammatory cytokine, was increased in the OGE group (P<0.01). Laparoscopic technique blunts the postoperative proinflammatory response from the very early stages of the inflammatory cascade, whereas combined anesthesia is a more anti-inflammatory approach.
Communication involving special populations: older adults with cancer
Authors: Adelman Ronald D. , Greene Michele G. , Phongtankuel Veerawat , Silva Milagros D.
Published: December 2018

Purpose of review

Cancer has a high incidence and death rate among older adults. The objective of this article is to summarize current literature about communication between older adults and medical professionals in cancer care. Our article addresses four categories related to communication: first, ageism; second, screening; third, treatment; and fourth, end of life (EoL) care.

Recent findings

Current literature suggests that cancer treatment for older patients may be influenced by ageist biases. Older patients prefer that clinicians incorporate health status to individualize screening decisions although some patients don’t consider life expectancy to be an important factor in screening. Patients often agree with the oncologists’ treatment recommendations but want to be involved in the decision-making process. Lastly, work is being conducted to associate quality communication of EoL issues with hospital performance measures.

Patients are at risk of age-based disparities in cancer screening, treatment, and EoL care. Older adults are not a homogenous group and all elderly cancer patients need to have an individualized approach to care. Medical professionals must understand patients’ goals and values and involve them in shared decision-making and preparation for EoL.