bluuebunny/crossref_metadata_2025 huggingface dataset:
Long-term Safety and Efficacy of Conjunctival Pedicle Graft Revision Combined With Repeated Pericardium Allograft for Exposed Glaucoma Drainage Devices
Authors: Guajardo José M. , Lim Kin S.
Published: September 2018

Purpose:

To investigate the safety and long-term results of conjunctival pedicle graft (CPG) technique for revision of exposed glaucoma drainage device (GDD).

Design:

Retrospective noncomparative case series.

Patients and Methods:

All patients with exposed GDD between 2011 and 2016 who underwent tube revision with CPG were included. Data from demographic variables, glaucoma subtype, previous surgeries, GDD type and location, patch graft nature, intraocular pressure, and intraoperative and long-term complications were collected.

Results:

Eight eyes from 7 patients met the inclusion criteria. Median age was 61 years old (range, 51 to 80), median time to erosion was 23.4 months (range, 5 d to 45.1 mo), median number of operations before exposure was 3 (range, 1 to 5), and 6 tubes had an inferior location (75%). Average follow-up after repair was 24.3 months (range, 5.2 to 59.8 mo). No significant intraoperative adverse events were noted and visual acuity, intraocular pressure, and number of medications remained unchanged at 1 month after repair in all cases. We report 1 case of repeated tube exposure 24 months after CPG in a 51-year-old Afro-Caribbean woman with 5 previous operations.

Conclusions:

With an average follow-up of >2 years, we provide additional long-term evidence that CPG is a safe and effective technique for treating exposed tubes. We did not experience any complications and report 1 reexposure case in a young Afro-Caribbean patient with extensive previous conjunctival scarring.
Effect of Antiplatelet/Anticoagulant Use on Glaucoma Progression in Eyes With Optic Disc Hemorrhage
Authors: Lee Jiyun , Sung Kyung R. , Kwon Junki , Shin Joong W.
Published: September 2018

Purpose:

To assess whether the use of antiplatelets (APs)/anticoagulants (ACs) affects glaucoma progression in eyes with optic disc hemorrhage (DH).

Methods:

One hundred and nineteen eyes from 119 patients with primary open-angle glaucoma in whom a DH was observed at least once during the follow-up period (mean follow-up duration: 6.2 y) were included in this retrospective observational study. Cox proportional hazard models were used to identify the association between putative factors, including AP/AC use, and glaucoma progression. Glaucoma progression was assessed on the basis of changes noted on serial optic disc and retinal nerve fiber layer photographs or changes in the visual field.

Results:

Nineteen of the 119 patients took AP/AC drugs daily [AP/AC use group (AG)], while the others did not [no use group (NG)]. The follow-up period to progression was significantly different between the 2 groups (61.2±23.5 mo for the AG and 47.6±22.0 mo for the NG; P=0.016). Kaplan-Meier analysis revealed a greater cumulative probability of glaucoma progression in the NG than in the AG, with borderline statistical significance (P=0.081). Higher mean intraocular pressure during the follow-up period was a risk factor for glaucoma progression (hazard ratio, 1.107; P=0.014), while AP/AC drug use protected against glaucoma progression (hazard ratio, 0.576; P=0.046).

Conclusions:

According to our result, use of AP/AC drugs was associated with lower risk of glaucoma progression in eyes with DH.
Interocular Asymmetry of Minimum Rim Width and Retinal Nerve Fiber Layer Thickness in Healthy Brazilian Individuals
Authors: Zangalli Camila e Silva , Reis Alexandre S. C. , Vianna Jayme R. , Vasconcellos José P. C. , Costa Vital P.
Published: September 2018

Purpose:

To determine interocular differences in Bruch’s membrane opening minimum rim width (BMO-MRW) and retinal nerve fiber layer thickness (RNFLT) in healthy Brazilian individuals.

Materials and Methods:

Both eyes of 220 healthy individuals were included in this observational, cross-sectional study. All individuals had normal clinical examination and visual fields. Global and sectorial interocular BMO-MRW and RNFLT differences, acquired and regionalized relative to the fovea to BMO center (FoBMO) axis, were calculated. The effect of age, axial length, and BMO area asymmetry on the parameters’ asymmetry was evaluated.

Results:

The 95th limits for interocular BMO-MRW and RNFLT global differences were 49 and 9 μm, respectively. BMO-MRW asymmetry was negatively correlated (β=−33.87 μm/mm2, R
2=0.06, P<0.001), whereas RNFLT asymmetry was positively correlated (β= 6.13 μm/mm2, R
2=0.09, P<0.001) with BMO area asymmetry. Neither BMO-MRW nor RNFLT asymmetries were correlated with axial length asymmetry (β=−16.90 μm/mm, R
2=0.00, P=0.15; β=−1.18 μm/mm, R
2=0.00, P=0.52, respectively). Similarly, BMO-MRW and RNFLT asymmetries were not correlated with age (β=0.17 μm/y, R
2=0.01, P=0.22; β=0.02 μm/y, R
2=0.00, P=0.19, respectively).

Conclusions:

Our results suggest that global BMO-MRW and RNFLT interocular differences exceeding 49 and 9 μm, respectively, may indicate statistically abnormal asymmetry, which may suggest early structural damage. Asymmetry in BMO area should be accounted for when considering interocular asymmetry in BMO-MRW and RNFLT.
Heritability of Anterior Chamber Indices in Rural Population
Authors: Hashemi Hassan , Yekta AbbasAli , Heydarian Samira , Ostadimoghaddam Hadi , Aghamirsalim Mohamadreza , Derakhshan Akbar , Khabazkhoob Mehdi
Published: September 2018

Objective:

To examine the heritability of the anterior chamber depth, angle, and volume as well as the corneal volume and diameter using Pentacam in households living in underserved rural areas of Iran.

Materials and Methods:

This cross-sectional population-based study was conducted in randomly selected households living in 2 rural districts in the south and north. The data of subjects above 5 years and households in which at least 2 members (father or mother and a child) had Pentacam data were analyzed. Each subject underwent a comprehensive ophthalmic examination, with emphasis on the measurement of visual acuity and refraction, biomicroscopy, and Pentacam imaging. Heritability was estimated to investigate familial aggregation of anterior chamber indices, and the effects of age, sex, and living area were controlled for as confounding factors.

Results:

Of the 3851 selected individuals, 3314 participated in the study. After applying the exclusion criteria, the data of 1383 subjects from 382 households were included in the analysis. The mean age of the participants was 37.23±19.35 years (range, 6 to 93 y). The highest and lowest heritability estimates were related to the anterior chamber angle (72%) and corneal diameter (28%), respectively. The heritability percentages of the anterior chamber depth, anterior chamber volume, and corneal volume were 47%, 39%, and 57%, respectively.

Conclusions:

The high heritability of the anterior chamber angle points to a high correlation between this phenotype and genetic factors. Further genetic and molecular investigations are suggested to find the related genes and understand the etiology of glaucoma.
Mobile, Population-wide, Hybrid HIV Testing Strategy Increases Number of Children Tested in Rural Kenya and Uganda
Authors: Ayieko James , Chamie Gabriel , Balzer Laura , Kwarisiima Dalsone , Kabami Jane , Sang Norton , Cohen Craig R. , Bukusi Elizabeth A. , Clark Tamara D. , Plenty Albert , Charlebois Edwin D. , Petersen Maya , Kamya Moses , Havlir Diane V. , Ruel Theodore
Published: September 2018

Efficient ways to identify children with HIV in the context of universal test-and-treat policies are needed. We evaluated a hybrid testing strategy combining mobile community and home-based HIV testing in 87,700 children across 32 rural communities in 2 East African countries. This approach resulted in 81% testing coverage of at-risk children and doubled the number of children diagnosed with HIV.
Reactivity of Routine HIV Antibody Tests in Children With Perinatally Acquired HIV-1 in England: Cross-sectional Analysis
Authors: Fidler Katy J. , Foster Caroline , Lim Emma J. , Patel Amie , Welch Steven , Menson Esse , Klein Nigel , Judd Ali
Published: September 2018

We assessed HIV antibody prevalence in children with perinatally acquired HIV in England. Eighteen percent (10/55) of those starting combination antiretroviral therapy <6 months of age were seronegative at median age 9.1 years and had lower viral load at diagnosis and combination antiretroviral therapy start and fewer viral rebounds, than 45 of 55 seropositives. Implications for patient selection for HIV cure research, and interpretation of routine antibody testing, are discussed.
Is Polymerase Chain Reaction in Neonatal Dried Blood Spots Reliable for the Diagnosis of Congenital Cytomegalovirus Infection?
Authors: Vives-Oñós Isabel , Codina-Grau María Gema , Noguera-Julian Antoni , Blázquez-Gamero Daniel , Fortuny Claudia , Baquero-Artigao Fernando , Frick Marie Antoinette , Saavedra-Lozano Jesús , Goycochea-Valdivia Walter , Rives-Ferreiro María Teresa , Montesdeoca-Melián Abián , Calavia-Garsaball Olga , Ferreras-Antolin Laura , Marín-Soria José Luís , Dulín-Íñiguez Elena , Soler-Palacín Pere
Published: September 2018

Background:

Detection of cytomegalovirus (CMV) DNA by real-time polymerase chain reaction (rt-PCR) in dried blood spots (DBSs) collected for newborn screening has been assessed for retrospective diagnosis of congenital CMV (cCMV) infection, with variable results (sensitivities ranging from 34% to 100%). We aimed to assess the accuracy of this technique in Spain in a large patient series.

Methods:

Ambispective, multicenter study including patients with confirmed cCMV from the Spanish Registry of cCMV patients. cCMV was established on the presence of CMV DNA in any body fluid, by positive culture findings or by molecular techniques during the first 2 weeks of life. Children in whom cCMV had been excluded were used as negative controls. Neonatal DBS samples were collected from both groups. The presence of CMV DNA was assessed by rt-PCR (RealStar CMV, Altona, Germany) in a central laboratory.

Results:

One-hundred three patients and 81 controls from 10 hospitals were included. The performance of CMV DNA determination in DBS for the diagnosis of cCMV was as follows (95% confidence interval): sensitivity 0.56 (0.47–0.65), specificity 0.98 (0.91–0.99), positive likelihood ratio 22.81 (5.74–90.58) and negative likelihood ratio 0.45 (0.36–0.56). Sensitivity increased with the birth viral load (bVL) log category. In cCMV patients, lower bVL was the single variable associated with a negative DBS rt-PCR result (P = 0.017).

Conclusions:

The sensitivity of CMV rt-PCR in DBS in our series was low and correlated with the bVL. Thus, a negative DBS result would not rule out cCMV infection, especially in patients with a low viremia level at birth.
Vaccine Strain Varicella Infection in an Infant With Previously Undiagnosed Perinatal Human Immunodeficiency Type-1 Infection
Authors: Farnaes Lauge , Coufal Nicole G. , Spector Stephen A.
Published: September 2018

A 15-month-old infant with a history of developmental delay and weight loss with multiple hospital admissions was diagnosed with a pustular lesion identified as vaccine strain varicella at the vaccination site. He was ultimately determined to be HIV infected following a protracted evaluation, which did not initially include HIV since his mother was confirmed HIV seronegative at 3 months gestation.
Utility of Clinical and Laboratory Decision Rules in Identifying Bacterial Meningitis Among Children with Suspicion of Central Nervous System Infections in a Malaria-Endemic Area, Mbarara, Uganda
Authors: Boum Yap , Nyehangane Dan , Llosa Augusto E. , Saliez Nicolas , Nanjebe Deborah , Kemigisha Elizabeth , Charrel Remi N. , Baron Emmanuel , Mwanga-Amumpaire Juliet , Page Anne-Laure
Published: September 2018

Several decision rules combining clinical and biological parameters have been proposed to distinguish bacterial from aseptic meningitis, but have not been evaluated in Africa. In children hospitalized with suspected central nervous system infections in Uganda, we found that the Bacterial Meningitis Score and Meningitest showed lower performance than in European children, and that a decision rule designed specifically using parameters associated with bacterial meningitis also showed inadequate diagnostic performance for clinical use.
Advanced Practice Nurse Phone Follow-Up Initiative to Reduce Unplanned Returns for Perforated Appendicitis Patients
Authors: Micalizzi Rosella A. , Phinney Caitlin , Lemire Lindsay , O’Donnell Ellen A.
Published: September 2018

Introduction:

Perforated appendicitis is a high-volume diagnosis managed by advanced practice nurses (APNs) in the general pediatric surgery department at an urban hospital in the northeast. This APN-led quality improvement project aimed to determine the impact of APN phone follow-up to prevent unplanned return visits and readmission.

Methods:

Before June 2015, all patients with perforated appendicitis discharged home on antibiotic therapy were provided with APN phone follow-up. The patients were followed for 30-day outcomes regarding unplanned returns to care. The goal was to attempt to identify patients at a higher risk for returns based on symptom analysis so that preventative measures may be instituted. The process of phone follow-up for patients with perforated appendicitis changed in June 2015 because of the decreased number of patients discharged home on intravenous antibiotic therapy, and therefore the phone follow-up was discontinued. This allowed the data from the first cohort (December 2014 to May 2015) to be reviewed by a retrospective chart review and analyzed.

Outcomes:

The preliminary data between the two cohorts, which have comparable patient volumes and return rates, have revealed that the APN phone follow-up did not necessarily change the rate of unplanned return-to-care visits after patient discharge, perhaps because of the call being conducted too soon after discharge. Our findings suggested that the APN phone follow-up call may have been more impactful in reducing unplanned return-to-care visits if completed after the 48-hour time frame.
Pediatric VAD Discharge and Outpatient Care
Authors: Mehegan Mary , Oldenburg Gary , Lantz Jodie
Published: September 2018

The advancement of pediatric ventricular assist devices (VADs) has enabled pediatric centers to discharge VAD patients home and integrate them back into their communities. Creating standard work flow processes to ensure the educational needs of the patient, family, and community are met will enable programs to successfully manage VAD patients at home. Utilizing multidisciplinary teams to support these patients while hospitalized will greatly contribute to the patients and families readiness for discharge. Defining mutual goals and expectations for patients, families, and the VAD team will promote a superior discharge and outpatient experience.
International Analysis of LVAD Point-of-Care Versus Plasma INR: A Multicenter Study
Authors: Schettle Sarah , Schlöglhofer Thomas , Zimpfer Daniel , Schima Heinrich , Kaufmann Friedrich , Salimbangon Anthony , Wolforth Jennifer , Schroeder Sarah , Hards Rachel , Ritchie Brianne , Staley Linda , Pereira Naveen , Kushwaha Sudhir , Maltais Simon , Stulak John
Published: September 2018

International normalized ratio (INR) measurements manage risks of bleeding and clotting sequelae in the population with left ventricular assist device (LVAD). Studies suggest that point-of-care (POC) INR does not significantly differ from plasma INR (P-INR) values in other patient populations, although this has not been validated in a multicenter LVAD study. We sought to determine whether POC-INR and P-INR values differ significantly in the LVAD population and reviewed patients with permanent LVAD implantation at seven institutions internationally. Our cohort comprised of 279 paired POC-INR and P-INR checks in patients supported on average 630 ± 598 days postimplant with predominately HeartWare, HeartMate II, and HeartMate III devices. The population averaged 57.9 years of age, and there were 86.7% male. We found no statistically significant difference between POC-INR and P-INR values. International normalized ratio accuracy correlated weakly with the time between INR measurements (p < 0.001). When the time difference was less than 4 hours, the difference between INR pairs was significantly lower than measurements greater than 8 hours (p = 0.006). There was no statistically significant difference when comparing paired INR values and time after implant to INR check (p = 0.43), age (p = 0.12), known coagulopathy (p = 0.12), bleeding history (p = 0.22), or thrombosis history (p = 0.34). This is the first large multicenter international study comparing POC-INR and P-INR measurements in patients with LVAD and found no statistically significant difference between either methods, particularly when measured within less than 4 hours of each other.
Physiological and Psychological Stress in Patients Living With a Left Ventricular Assist Device
Authors: Abshire Martha , Bidwell Julie T. , Page Gayle , Budhathoki Chakra , Davidson Patricia M. , Russell Stuart D. , Han Hae-Ra , Desai Shashank , Dennison Himmelfarb Cheryl
Published: September 2018

Patients with a left ventricular assist device (LVAD) commonly experience psychological distress post-implantation, but physiological stress and differences by implant strategy remain unstudied. This study describes indicators of physiological (salivary cortisol, C-reactive protein, sleep quality) and psychological (perceived stress, depression, and fatigue) stress by implant strategy and examines relationships between stress and outcomes (quality of life [QOL] and functional status). Prospective, cross-sectional data were collected from patients ≥3 months post-LVAD implantation (n = 44), and descriptive statistics and logistic regression were used. The study sample was average age 57.7 ± 13 years, mostly male (73%), married (70.5%), and racially diverse. Median LVAD support was 18.2 months. Most had normal cortisol awakening response and fair sleep quality, with moderate psychological stress. There were no differences in stress by implant strategy. Normal cortisol awakening response was correlated with low depressive symptoms. Sleep quality and psychological stress were associated with QOL, whereas cortisol and C-reactive protein levels were associated with functional status. This is the first report of salivary biomarkers and stress in LVAD outpatients. Future research should examine physiological and psychological stress and consider potential clinical implications for stress measurement for tailored approaches to stress management in this population.
Compound heterozygous mutations in IL10RA combined with a complement factor properdin mutation in infantile-onset inflammatory bowel disease
Authors: Jung Eun Suk , Petersen Britt-Sabina , Mayr Gabriele , Cheon Jae Hee , Kang Yunkoo , Lee Seok Joo , Che Xiumei , Kim Won Ho , Kim Seung , Schreiber Stefan , Franke Andre , Koh Hong
Published: September 2018

Objectives

Inflammatory bowel diseases (IBDs) are chronic and multifactorial diseases resulting from a complex interaction of host genetic factors and environmental stimuli. Although many genome-wide association studies have identified host genetic factors associated with IBD, rare Mendelian forms of IBD have been reported in patients with very early onset forms. Therefore, this study aimed to identify genetic variants associated with infantile-onset IBD.

Participants and methods

We obtained genomic DNA from whole blood samples of a male patient with infantile-onset IBD and nonconsanguineous Korean parents. Whole-exome sequencing was performed using trio samples. Then, we analyzed the data using susceptibility genes for monogenic forms of IBD and various immunodeficiencies and protein structural analysis.

Results

The patient who presented with oral aphthous ulcers at the age of 14 days suffered from severe colitis and was refractory to medical treatment. Compound heterozygous mutations in IL10RA (p.R101W; p.T179T) were found in the patient. In addition, a hemizygous mutation in complement factor properdin (CFP) (p.L456V) located on the X-chromosome was detected, inherited from the patient’s mother. Protein structural modeling suggested impaired properdin subunit interactions by p.L456V that may hamper protein oligomerization required for complement activation.

Conclusion

This study identified compound heterozygous mutations in IL10RA combined with a hemizygous CFP mutation in infantile-onset IBD by using whole-exome sequencing. CFP p.L456V may exacerbate symptoms of infantile-onset IBD by disturbing oligomerization of properdin.
Baseline risk assessment of patients with ulcerative colitis: does initial treatment selection influence outcomes?
Authors: Mosli Mahmoud , Alfaer Sultan , Almalaki Turki , Albeshry Abdulrahman , Aljehani Saja , Alshmrani Bashaer , Habib Zaineb , Jawa Hani , Qari Yousif
Published: September 2018

Background and aims

Treatment of ulcerative colitis (UC) typically follows a step-up approach and targets colonic mucosal healing. Although mucosal healing reduces the risk of colectomy, whether or not early treatment of patients with ‘high-risk’ features using tumor necrosis factor (TNF) antagonists reduces the risk of colectomy is not clear. Accordingly, we aim to evaluate the effect of baseline treatment selection according to the risk profile on 5-year outcomes and identify predictors of poor outcomes.

Patients and methods

Adult patients with confirmed UC were retrospectively identified. Baseline clinical and endoscopic data were collected. Patients were assigned a risk profile on the basis of the presence or absence of ‘high-risk’ features within the first 6 months of diagnosis including moderate to severe endoscopic disease, frequent need for steroids, steroid dependency, and disease involving the entire colon according to endoscopy. Treatment discordance was defined as treating ‘high-risk’ patients with medications other than anti-TNF therapy during the first 6 months after diagnosis or treating ‘low-risk’ patients with anti-TNF therapy within 6 months of diagnosis. The associations between discordance and 5-year colectomy and hospitalization rates were statistically calculated through regression analysis, as were predictors of outcomes.

Results

A total of 108 patients were identified and studied. The median age was 36 years (interquartile range=27–50) and the average duration of disease was 6.6 (±3.1) years. Females comprised 62% of the cohort and 30% reported cigarette smoking. Seventy three percent of the patients were placed in the ‘high-risk’ category. The 5-year risk of colectomy was not statistically significantly higher in patients identified as ‘high-risk’ compared with those who were ‘low-risk’ (risk ratio=0.86, 95% confidence interval=0.24–3.1, P=0.81), nor was the 5-year risk of hospitalizations (risk ratio=1.63, 95% confidence interval=0.81–3.30, P=0.15). On the basis of stepwise model selection, colectomy was significantly predicted by discordance (P=0.039), arthritis (P=0.007), baseline stool frequency (P=0.019), Adalimumab use within the first 6 months of diagnosis (P=0.006), and pyoderma gangrenosum (P=0.049); hospitalization was predicted by discordance (P=0.018), baseline albumin concentrations (P=0.005), thromboembolism (P<0.005), thiopurine use within the first 6 months of diagnosis (P<0.005), Adalimumab use within the first 6 months of diagnosis (P=0.003), nationality (P=0.016), endoscopic severity (P=0.007), arthritis (P=0.005), and pyoderma gangrenosum (P=0.025).

Conclusion

Among other clinical parameters, discordance between baseline risk and treatment selection appears to be a significant predictor of outcomes in UC.
Tumor behavior of hepatocellular carcinoma after hepatitis C treatment by direct-acting antivirals: comparative analysis with non-direct-acting antivirals-treated patients
Authors: Abdelaziz Ashraf O. , Nabil Mohamed M. , Abdelmaksoud Ahmed H. , Shousha Hend I. , Hashem Mohamed B. , Hassan Eman M. , Salah Ayman , Omran Dalia A. , Elbaz Tamer M.
Published: September 2018

Introduction

Scarce reports have commented on hepatocellular carcinoma (HCC) behavior after direct-acting antivirals (DAAs).

Aim

To analyze differences in tumor behavior between patients with hepatitis C virus (HCV)-induced HCC and were either treated or not using DAAs.

Patients and methods

This case–control study includes patients with HCV-related HCC who received generic DAAs (group I) and all non-DAA treated patients with HCC who presented to our clinic during the same period (group II). Patient and tumor characteristics, treatment types and outcome were compared between the two groups.

Results

Group I included 89 patients and group II included 207 patients. No significant difference was detected between groups regarding HCC number or size. Group I showed a more infiltrative HCC pattern, whereas group II had more circumscribed and delineated lesions. The incidence of portal vein thrombosis and significant lymphadenopathy was significantly higher in group I (P=0.03 and 0.03, respectively). Serum levels of α-fetoprotein were significantly higher in group I (P=0.02). These factors significantly affected the response to HCC management (P=0.03). Incidence of complete responses were 47.2 and 49.8% for groups I and II, respectively, whereas incomplete responses were 12.4 and 25.1%, respectively. Supportive treatment was applied to 40.4% in group I and 25.1% in group II.

Conclusion

HCC behavior was more aggressive in DAA-treated patients regarding portal vein thrombosis, malignant lymphadenopathy, and HCC imaging characteristics, which affected the chance of ablation and the treatment response.
Increased Cancer Screening for Low-income Adults Under the Affordable Care Act Medicaid Expansion
Authors: Hendryx Michael , Luo Juhua
Published: September 2018

Background:

We tested whether Medicaid expansion under the Affordable care Act was associated with increased screening for cervical, breast, and colorectal cancer among low-income adults.

Methods:

We analyzed Behavioral Risk Factor Surveillance System data, identifying 2012 as preexpansion and 2016 as postexpansion (2014 was treated as a wash-out, and 2013 and 2015 had missing screening data from most states). States (including District of Columbia) either expanded Medicaid in 2014 (n=28) or not (n=18); five states that expanded after 2014 were excluded. Participants included low-income adults aged 18–64 without dependent children. A difference-in-difference approach tested whether expansion was significantly associated with screening, controlling for time, state effects, age, sex, race/ethnicity, education, and urban/rural population. For comparison, we also conducted analyses among the low-income Medicare (aged 65 and above) population, and a higher income population.

Results:

There was a significant expansion effect for women aged 18–64 for cervical cancer screening (N=29,059; odds ratio, 1.04; 95% confidence interval, 1.01–1.08), and for adults 50–64 for colorectal cancer screening (N=32,290; odds ratio, 1.12; 95% confidence interval, 1.03–1.22). Effects for mammography for women aged 40–64, or aged 50–64, were not significant. As expected, there were no significant improvements associated with expansion among the Medicare population, or among a population ineligible due to higher income.

Conclusions:

Medicaid expansion under the Affordable Care Act was associated with increased screening for cervical and colorectal cancer for low-income adults. It will be important to monitor possible adverse cancer outcomes in nonexpansion states among vulnerable populations over time.
Key aspects of PCSK9 inhibition beyond LDL lowering
Authors: Ramin-Mangata Stéphane , Blanchard Valentin , Lambert Gilles
Published: September 2018

Purpose of review

Our primary objective is to review the most recent findings on the biology of PCSK9 and on two key aspects of PCSK9 inhibition beyond LDL control of great clinical relevance: the regulation of lipoprotein (a) circulating levels by PCSK9 inhibitors and the putative diabetogenic effects of these novel therapies.

Recent findings

The reality of two distinct extracellular and intracellular pathways by which PCSK9 decreases the abundance of the LDLR at the surface of many cell types, most importantly hepatocytes, has recently been established. In contrast, the exact mechanisms by which PCSK9 inhibitors lower the circulating levels of lipoprotein (a) remain a point of major dispute. Despite strong indications from genetic studies that PCSK9 inhibition should increase diabetes risk, no such effect has been observed in clinical trials, and in-vitro and in-vivo studies do not clarify this issue.

The trafficking pathways by which PCSK9 enhance LDLR degradation via the endolysosomal extracellular route or via the Golgi–lysosomal intracellular route remain to be fully elucidated. The mechanisms by which PCSK9 inhibitors reduce lipoprotein (a) also merit additional research efforts. The role of PCSK9 on glucose metabolism should likewise be studied in depth.
Pancreatic Cancer–Associated Depression
Authors: Barnes Adam F. , Yeo Theresa P. , Leiby Benjamin , Kay Abigail , Winter Jordan M.
Published: September 2018

The prevalence of major depressive disorder (MDD) in pancreatic cancer (PC) has been reported up to 7 times higher than the general population. Despite repeated studies that show worse quality of life, survival outcomes, and treatment compliance in cancer patients with depression, baseline antidepressant use ranges from 15% to 27%. A meta-analysis of 6 prospective trials specific to PC estimates that 43% of patients with PC experience depression after diagnosis. This is especially alarming in patients with PC, who may experience a prodrome of symptoms including depression and loss of drive. In fact, this prodrome of symptoms may very well be due to an overexpression of indoleamine 2,3-dioxgenase, an enzyme in the kynurenine pathway that leads to serotonin depletion and the buildup of cytotoxic metabolites in the brain. In this literature review, we outline all previous studies pertinent to PC and depression, as well as the molecular underpinnings that may contribute to states of depression, and report on previous randomized control trials in cancer populations that investigate the use of antidepressants to treat depressive symptoms and improve quality of life both prophylactically and after the onset of major depressive disorder. In addition, we detail a case report outlining the precipitous decline in health in 1 patient with PC and depression.
Using the Logic Model Framework to Standardize Quality and Rigor in the DNP Project
Authors: Sun Grace H. , Cherry Barbara
Published: September 2018

Background

Since the implementation of the DNP degree, there has been controversy, confusion, and inconsistency about the DNP project. To this day, the profession lacks a consensus of what the DNP project should be.

Problem

Despite much in the literature regarding these issues, there is no systematic approach to the development of DNP project guidelines. Consequently, there is now an escalating interest in increasing the quality and rigor of DNP projects.

Approach

Many issues related to the DNP project can be addressed using a logic model approach and incorporating current best practices.

Conclusions

This article demonstrates how a logic model can be used for the development or improvement of DNP project processes, incorporating best practices and evaluation methods to ensure quality and rigor.
Experience of Robotic Exoskeleton Use at Four Spinal Cord Injury Model Systems Centers
Authors: Heinemann Allen W. , Jayaraman Arun , Mummidisetty Chaithanya K. , Spraggins Jamal , Pinto Daniel , Charlifue Susan , Tefertiller Candy , Taylor Heather B. , Chang Shuo-Hsiu , Stampas Argyrios , Furbish Catherine L. , Field-Fote Edelle C.
Published: September 2018

Background and Purpose:

Refinement of robotic exoskeletons for overground walking is progressing rapidly. We describe clinicians' experiences, evaluations, and training strategies using robotic exoskeletons in spinal cord injury rehabilitation and wellness settings and describe clinicians' perceptions of exoskeleton benefits and risks and developments that would enhance utility.

Methods:

We convened focus groups at 4 spinal cord injury model system centers. A court reporter took verbatim notes and provided a transcript. Research staff used a thematic coding approach to summarize discussions.

Results:

Thirty clinicians participated in focus groups. They reported using exoskeletons primarily in outpatient and wellness settings; 1 center used exoskeletons during inpatient rehabilitation. A typical episode of outpatient exoskeleton therapy comprises 20 to 30 sessions and at least 2 staff members are involved in each session. Treatment focuses on standing, stepping, and gait training; therapists measure progress with standardized assessments. Beyond improved gait, participants attributed physiological, psychological, and social benefits to exoskeleton use. Potential risks included falls, skin irritation, and disappointed expectations. Participants identified enhancements that would be of value including greater durability and adjustability, lighter weight, 1-hand controls, ability to navigate stairs and uneven surfaces, and ability to balance without upper extremity support.

Discussion and Conclusions:

Each spinal cord injury model system center had shared and distinct practices in terms of how it integrates robotic exoskeletons into physical therapy services. There is currently little evidence to guide integration of exoskeletons into rehabilitation therapy services and a pressing need to generate evidence to guide practice and to inform patients' expectations as more devices enter the market.

Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A231).
Effects of a Gaming Platform on Balance Training for Children With Cerebral Palsy
Authors: Hsieh Hsieh-Chun
Published: September 2018

Purpose:

A platform requiring multidimensional trunk movement facilitated postural balance in children with cerebral palsy.

Methods:

The intervention group (n = 20) received 12 weeks of playing personal computer (PC) games using the platform, and the control group (n = 20) played the same games using a computer mouse. Outcomes were center–of-pressure sway, the Berg Balance Scale (BBS), Fullerton Advanced Balance Scale (FAB), and Timed Up and Go (TUG) test scores.

Results:

There were significant interactions between groups and time. There was a significant between-group difference in center-of-pressure sway excursion, BBS test, and TUG test over time. Participants in the intervention group had better balance performance compared with the control group.

Conclusion:

Balance training using a PC gaming platform may improve exercise compliance and enhance recovery of balance in children with cerebral palsy.
Physical Therapist Coaching to Improve Physical Activity in Children With Brain Tumors: A Pilot Study
Authors: Ovans Jessica A. , Hooke Mary C. , Bendel Anne E. , Tanner Lynn R.
Published: September 2018

Purpose:

Children with brain tumors (BTs) experience fatigue and decreased quality of life (QOL). Physical activity (PA) is recommended during and after cancer treatment. We explored whether a fitness tracker intervention combined with tailored coaching by a physical therapist (PT) increased PA and QOL and decreased fatigue in children with BTs.

Methods:

Participants were 7 to 18 years' old, within 2 years of diagnosis, and received a 12-week PA intervention using a fitness tracker combined with 5 PT coaching sessions. Steps/day measured by Fitbit and self-reports of QOL, fatigue, and PA were evaluated at baseline, 12 weeks, and 24 weeks.

Results:

Participants had nonsignificant increase in steps/day. Total fatigue, general, and sleep/rest subscales improved while cognitive fatigue and QOL remained unchanged. Higher steps/day were associated with lower fatigue.

Conclusion:

This is a feasible intervention that may contribute to an increase in PA and improve fatigue in children with BTs.
Adapted Motivational Interviewing to Promote Exercise in Adolescents With Congenital Heart Disease: A Pilot Trial
Authors: McKillop Adam , Grace Sherry L. , Ghisi Gabriela Lima de Melo , Allison Kenneth R. , Banks Laura , Kovacs Adrienne H. , Schneiderman Jane E. , McCrindle Brian W.
Published: September 2018

Purpose:

To assess a motivational interviewing (MI) intervention to improve moderate-to-vigorous physical activity (MVPA) in adolescents with congenital heart disease.

Methods:

Intervention participants received one-on-one telephone-based adapted MI sessions over 3 months. Outcomes were acceptability, change mechanisms (stage of change and self-efficacy), and limited efficacy (physical activity, fitness, and quality of life).

Results:

Thirty-six participants were randomized. Intervention participants completed 4.2 ± 1.2/6 MI sessions, with no improvements in the high self-efficacy or stage of change observed. Participants accumulated 47.24 ± 16.36 minutes of MVPA/day, and had comparable outcomes to peers without heart disease (except for functional capacity). There was no significant difference in change in any outcome by group.

Conclusions:

The intervention was acceptable, but effectiveness could not be determined due to the nature and size of sample.

Clinical Relevance:

Pediatric cardiac rehabilitation remains the sole effective intervention to increase MVPA in this population.
Transcranial Direct-Current Stimulation on Motor Function in Pediatric Cerebral Palsy: A Systematic Review
Authors: Hamilton Angela , Wakely Luke , Marquez Jodie
Published: September 2018

Purpose:

To determine effects of transcranial direct-current stimulation (tDCS) on motor function for children with cerebral palsy.

Methods:

Six electronic databases were searched using terms related to tDCS, combined with functional deficits/associated clinical measures. Results were filtered, including randomized controlled trials in English and children with cerebral palsy. Data were extracted using standardized procedures, and the PEDro scale was used to assess quality and meta-analyses conducted.

Results:

From 135 articles, 9 studies with moderate quality met inclusion criteria. Six were included in 7 separate meta-analyses supporting a benefit of tDCS for static balance, only at follow-up. Benefits of tDCS on dynamic balance, step length, and mobility were not established.

Conclusions:

The findings from meta-analyses suggest that tDCS may provide improvements in static balance at follow-up in children with cerebral palsy and positive effects on gait velocity; however, there was heterogeneity. Further research is needed before this therapy can be endorsed.
Evaluation of an AI-Based Detection Software for Acute Findings in Abdominal Computed Tomography Scans
Authors: Winkel David J. , Heye Tobias , Weikert Thomas J. , Boll Daniel T. , Stieltjes Bram
Published: September 2018

Objective

The aim of this study was to test the diagnostic performance of a deep learning-based triage system for the detection of acute findings in abdominal computed tomography (CT) examinations.

Materials and Methods

Using a RIS/PACS (Radiology Information System/Picture Archiving and Communication System) search engine, we obtained 100 consecutive abdominal CTs with at least one of the following findings: free-gas, free-fluid, or fat-stranding and 100 control cases with absence of these findings. The CT data were analyzed using a convolutional neural network algorithm previously trained for detection of these findings on an independent sample. The validation of the results was performed on a Web-based feedback system by a radiologist with 1 year of experience in abdominal imaging without prior knowledge of image findings through both visual confirmation and comparison with the clinically approved, written report as the standard of reference. All cases were included in the final analysis, except those in which the whole dataset could not be processed by the detection software. Measures of diagnostic accuracy were then calculated.

Results

A total of 194 cases were included in the analysis, 6 excluded because of technical problems during the extraction of the DICOM datasets from the local PACS. Overall, the algorithm achieved a 93% sensitivity (91/98, 7 false-negative) and 97% specificity (93/96, 3 false-positive) in the detection of acute abdominal findings. Intra-abdominal free gas was detected with a 92% sensitivity (54/59) and 93% specificity (39/42), free fluid with a 85% sensitivity (68/80) and 95% specificity (20/21), and fat stranding with a 81% sensitivity (42/50) and 98% specificity (48/49). False-positive results were due to streak artifacts, partial volume effects, and a misidentification of a diverticulum (each n = 1).

Conclusions

The algorithm's autonomous detection of acute pathological abdominal findings demonstrated a high diagnostic performance, enabling guidance of the radiology workflow toward prioritization of abdominal CT examinations with acute conditions.
SUV Harmonization Between Different Hybrid PET/CT Systems
Authors: Rubello Domenico , Colletti Patrick M.
Published: September 2018

Aim

Current PET/CT lutetium oxyorthosilicate (LSO) or lutetium-yttrium oxyorthosilicate crystal scanners are equipped with sophisticated softwares including point-spread function (PSF) and time-of-flight (TOF) image reconstruction. These softwares are associated with increased SUVs compared with 3D-OSEM reconstructions associated with older BGO PET/CT scanners. The European Association of Nuclear Medicine (EANM) identified the problem of SUV harmonization since 2010 through the EANM Research Ltd European Association of Nuclear Medicine Research Ltd [EARL] FDG PET/CT accreditation program. This required processing 2 reconstructions, one optimized for maximum spatial lesion detection and one for harmonized quantitation. We investigated an alternative single reconstruction method for both qualitative and quantitative analysis optimized to maximize spatial lesion detectability, followed by an intrinsic postreconstruction algorithm for SUV harmonization.

Methods

Phantom and “in vivo” patient data analysis were acquired and analyzed on (a) a Siemens Biograph mCT system with LSO crystals and PSF and TOF algorithms, and on (b) a General Electric Discovery STE system with BGO crystals, without PSF and TOF. A dedicated algorithm (EQ.filter) was tested to harmonize SUV between the 2 scanners compared with EANM/EARL specifications. NEMA IQ phantom and a Jaszczak cylindrical phantom equipped with small fillable spheres (lesion to background ratios of 8:1 and 4:1) were used. Phantom data were validated on 7 oncologic patients with 39 hyperactive lesions ranging from 3 mm to 26 mm.

Results

The main benefit of PSF + TOF LSO PET/CT systems was increased contrast for small active lesions. Recovery coefficients measured according to NEMA standards exceeded those obtained by 3D-OSEM reconstruction. SUVmax discrepancies between the 2 PET/CT systems were as high as 149%, dropping to below 10% when optimized by EQ.filter.

Conclusions

A single reconstruction optimized by EQ.filter for maximum spatial lesion detectability is an easy and precise solution to harmonize SUVs between different PET/CT scanners, avoiding a second reconstruction with an additional smoothing filter as requested by EANM/EARL.
Long-term Quality of Life and Gastrointestinal Functional Outcomes After Pancreaticoduodenectomy
Authors: Allen Casey J. , Yakoub Danny , Macedo Francisco Igor , Dosch Austin R. , Brosch Jessica , Dudeja Vikas , Ayala Ronda , Merchant Nipun B.
Published: September 2018

Objective:

To perform a comprehensive assessment of long-term quality of life (QOL) and gastrointestinal (GI) function in patients following pancreaticoduodenectomy (PD).

Summary of Background Data:

Survival after PD has greatly improved and thus has resulted in a larger population of survivors, yet long-term QOL and GI function after PD is largely unknown.

Methods:

Patients were identified from a global online support group. QOL was measured using the Short Form-36, while GI function was assessed using the Gastrointestinal Symptom Rating Scale. QOL and GI function were analyzed across subgroups based on time after PD. QOL was compared with preoperative measurements and with established values of a general healthy population (GHP). Multivariate linear regression was used to identify predictors of QOL.

Results:

Of the 7605 members of the online support group, 1102 responded to the questionnaire with 927 responders meeting inclusion criteria. Seven hundred seventeen (77.3%) of these responders underwent PD for malignancy. Mean age was 57 ± 12 years and 327 (35%) were male. At the time of survey, patients were 2.0 (0.7, 4.3) years out from surgery, with a maximum 30.7-year response following PD. Emotional and physical domains of QOL improved with time and surpassed preoperative levels between 6 months and 1 year after PD (both P < 0.001). Each GI symptom worsened over time (all P < 0.001). Independent predictors of general QOL in long-term survivors (> 5 years) included total GSRS score [β = −1.70 (−1.91, −1.50)], female sex [β = 3.58 (0.67, 6.46)], and being a cancer survivor [β = 3.93 (0.60, 7.25)].

Conclusions:

Long-term QOL following PD improves over time, however never approaches that of a GHP. GI dysfunction persists in long-term survivors and is an independent predictor of poor QOL. Long-term physical, psychosocial, and GI functional support after PD is encouraged.
Long-term Immunosuppression Adherence After Kidney Transplant and Relationship to Allograft Histology
Authors: Lorenz Elizabeth C. , Smith Byron H. , Cosio Fernando G. , Schinstock Carrie A. , Shah Nilay D. , Groehler Paul N. , Verdick Jayson S. , Park Walter D. , Stegall Mark D.
Published: September 2018

Background

Nonadherence to immunosuppression after kidney transplant is an important contributor to graft failure. Little is known about how nonadherence changes 3 years posttransplant when Medicare coverage of immunosuppression ends and how that nonadherence impacts allograft histology. The goal of this study was to compare rates of nonadherence during posttransplant years 1 to 3 to years 3 to 5 and examine the relationship between nonadherence during years 3 to 5 and 5-year allograft histology.

Methods

We retrospectively analyzed 552 conventional kidney allografts in patients transplanted at our center between January 1, 1999, and June 1, 2010, who used the Mayo Clinic Specialty Pharmacy for the first 5 years posttransplant. Nonadherence was defined as less than 80% proportion of days covered. Overall adherence to immunosuppression appeared to be higher during years 3 and 5 compared to between years 1 and 3 (89.4% vs 82.9%, respectively; P < 0.0001 [paired t test]).

Results

Overall nonadherence during posttransplant years 3 to 5 appeared to be associated with fibrosis and inflammation on 5-year allograft biopsy but not with transplant glomerulopathy (16.9% vs 5.9%, P = 0.004; 10.4% vs 8.5%, P = 0.61, respectively). After adjusting for nonadherence to calcineurin inhibitor and prednisone therapy, only nonadherence to antimetabolite therapy remained significantly associated with 5-year fibrosis and inflammation (odds ratio, 10.6; 95% confidence interval, 1.5-76.1; P = 0.02).

Conclusions

Efforts to improve long-term adherence, possibly through the use of specialty pharmacies and increased adherence to antimetabolite therapy, may improve long-term allograft histology and survival, although further studies are needed to confirm these findings.