bluuebunny/crossref_metadata_2025 huggingface dataset:
Relationship Between the Degree of Iris Pigmentation and Corneal Sensitivity to a Cooling Stimulus
Authors: Ntola Anna M. , Nosch Daniela S. , Joos Roland E. , Murphy Paul J.
Published: April 2019

Purpose:

To explore the relationship between the degree of iris pigmentation and corneal sensitivity threshold (CST) on a variety of different ethnicities, using the air-jet noncontact corneal aesthesiometer and by applying a consistent method of subject iris pigmentation classification.

Methods:

A total of 200 subjects (mean age 23.7 ± 3.1 years, 127 women) participated in this clinical cross-sectional study: 100 whites, 40 Asians, 40 Chinese, and 20 Afro-Caribbeans. CST was assessed within the central cornea using a noncontact corneal aesthesiometer, and the degree of iris pigmentation of each subject was noted according to the Seddon method using a set of graded photographs of iris pigmentation (grades 1–5). Inclusion criteria were absence of ocular disease including dry eye, no contact lens wear, and no use of artificial tears. Statistical testing between ethnicities was made by the pairwise t test with Holm adjustment, and a linear model was set up to analyze the effects of ethnicity and iris grade.

Results:

A moderate trend for increasing CST with increasing iris pigmentation grade for all ethnicities was observed (R = 0.46; P < 0.0001), with CST changing from 0.66 ± 0.16 mbars for grade 1, 0.74 ± 0.18 mbars for grade 2, 0.86 ± 0.31 mbars for grade 3, 0.85 ± 0.32 mbars for grade 4, and 1.08 ± 0.40 mbars for grade 5. This correlation was stronger within the white group, representing the only ethnicity with all iris pigmentation grades (R = 0.50; P < 0.0001).

Conclusions:

There is a moderate relationship between corneal sensitivity and the degree of iris pigmentation, with sensitivity increasing as iris pigmentation decreases. This relationship is stronger within whites.
Comparison of Small Incision Lenticule Extraction Surgery With and Without Cyclotorsion Error Correction for Patients With Astigmatism
Authors: Chen Pei , Ye Yiming , Yu Na , Zhang Xiaoying , He Jiexu , Zheng Hua , Wei Han , Zhuang Jing , Yu Keming
Published: April 2019

Purpose:

To evaluate the add-on effect of manual cyclotorsion error correction by the cornea-marking method over standard small incision lenticule extraction (SMILE) surgery in astigmatic eyes.

Methods:

Consecutive patients (84) who had preoperative myopic astigmatism of −0.75 diopters (D) or more and were seeking surgical refractive correction by SMILE surgery during July 2017 to August 2017 were included in this study and randomized to treatment with standard SMILE surgery (S group: 30 eyes) or cyclotorsion compensated SMILE surgery (CC group: 54 eyes). The visual acuity and refractive outcomes were analyzed preoperatively and postoperatively. Refractive astigmatic changes were analyzed by the Alpins method.

Results:

The S and CC groups were comparable preoperatively regarding age, manifest spherical equivalent, and manifest refractive cylinder. The mean position-related cyclotorsion degree in the enrolled astigmatic eyes for the S and CC groups was 1.7 ± 2.2 degrees (ranging from 0 to 10 degrees) and 2.19 ± 1.74 degrees (ranging from 0 to 10 degrees), respectively. The mean cylinder was −1.67 ± 0.54 D versus −1.72 ± 0.71 D preoperatively. Six months after treatment, the surgical outcomes in the CC group were significantly better than those of the S group, with a postoperative corrected distance visual acuity of −0.07 ± 0.07 versus 0.016 ± 0.13. A vector analysis of astigmatism also yielded better outcomes in the CC group. However, these 2 groups were statistically similar in spherical equivalent.

Conclusions:

SMILE surgery combined with cyclotorsion error compensation yielded a significant improvement in surgical outcomes regarding safety, efficiency, and predictability for patients with astigmatism.
A Unique Case of Burkholderia cepacia Prosthetic Mitral Valve Endocarditis and Literature Review
Authors: Dellalana Laura E. , Byrge Kelly C. , Gandelman Jocelyn S. , Lines Tara , Aronoff David M. , Person Anna K.
Published: April 2019

Burkholderia cepacia prosthetic valve endocarditis (PVE) is extremely rare, with few cases in the literature. A report of a patient with PVE is described, followed by a literature review on B. cepacia PVE. A 38-year-old man with poor dentition and a history of intravenous drug use and mitral valve replacement was found to have a mitral valve vegetation. Five sets of blood cultures on different days grew B. cepacia. Individual sets of blood cultures on different dates also isolated Streptococcus viridans (outside hospital culture), methicillin-resistant Staphylococcus epidermidis (hospital day 1), and Bacillus spp. (hospital day 6). He was successfully treated with ceftazidime and levofloxacin as dual therapy for B. cepacia PVE, in addition to vancomycin for gram-positive coverage. This case report and review highlights the possibility of B. cepacia PVE in immunocompetent patients with poor dentition, with the potential for a successful outcome after combination antimicrobial therapy.
Amoxicillin-Clavulanate in Tuberculosis Disease
Authors: Wheelock Alyse , Iliaki Eirini , Turner Marie T.
Published: April 2019

In the treatment of tuberculosis (TB), antibiotics for presumed bacterial pneumonia may be implicated in diagnostic delays. The same antibiotics are sometimes active against TB, the quinolones being a prominent example. We present the case of a patient with multidrug-resistant TB whose symptoms and radiologic studies improved on amoxicillin-clavulanate to treat presumed necrotizing pneumonia, leading to a complicated and prolonged diagnostic course. We then review the literature on effects of amoxicillin-clavulanate in TB disease, including both in vivo and in vitro studies that have been published to date.
Management of Pneumatosis Intestinalis in Neutropenic Acute Leukemia Patients
Authors: Coba George A. , Shahin Alexander , Saba Marian , Greene John N.
Published: April 2019

Pneumatosis intestinalis (PI) is a rare, possibly life-threatening, disorder that results in the buildup of gas within the wall of the gastrointestinal tract. Chemotherapy used to treat hematologic cancer patients results in prolonged neutropenia and mucositis, which increases the risk for a wide range of infections and end-organ damage. There are a few reports of PI in the setting of neutropenia in leukemia patients. Given the potential severity of PI in immunosuppressed patients, we present 3 patients with acute leukemia and review the literature on cancer patients.
Studying Changes to Burn Wound Flora Over Time as an Opportunity for Antimicrobial Stewardship
Authors: Moffa Matthew A. , Walsh Thomas L. , Buchanan Carley , Aballay Ariel , Bremmer Derek N.
Published: April 2019

Background

Empiric antimicrobial selection for burn injury infection is of paramount importance owing to high rates of morbidity and mortality. By studying the time-related burn wound flora of our patient population, we developed an institutional syndrome-specific algorithm for the appropriate selection of empiric antimicrobial agents.

Methods

During the study period of January 1, 2016, through December 31, 2016, all patients with greater than or equal to 5% total body surface area burn injuries were included for analysis. Culture data from surveillance swabs and operative tissue specimens were reviewed, as it related to time after initial burn injury. Antimicrobial prescription was evaluated when used for a suspected burn injury infection.

Results

Isolation of gram-positive organisms predominated the 31 tissue cultures taken during days 1 to 4 postburn injury. A total of 18 (58%) grew a gram-positive organism, and only 2 (6%) grew a gram-negative rod. After 5 days, we saw a distinct change in microbial growth of the 23 tissue cultures taken, as 11 (48%) grew a gram-positive organism, 12 (52%) grew a gram-negative rod, and 9 (39%) grew Candida species. Even though Pseudomonas species was not isolated until at least 5 days postburn injury, the majority (71%) of antimicrobial prescriptions during the first 4 days after burn injury included an antipseudomonal agent.

Conclusions

These findings of time-related burn wound flora changes along with inappropriate antibiotic prescription led to the development of our institutional syndrome-specific algorithm for the appropriate selection of empiric antimicrobial agents.
Speech Perception Outcomes for Adult Cochlear Implant Recipients Using a Lateral Wall or Perimodiolar Array
Authors: Moran Michelle , Vandali Andrew , Briggs Robert J.S. , Dettman Shani , Cowan Robert S.C. , Dowell Richard C.
Published: April 2019

Aim:

To assess the speech perception outcomes of adult CI recipients with significant preimplant low frequency hearing, examining differences between perimodiolar and lateral wall electrode placement in order to provide clinical guidance for clinicians and surgeons.

Methods:

A prospective cohort study was undertaken identifying all adults who received a thin straight electrode array (TSEA) at the Royal Victorian Eye & Ear Hospital (RVEEH) from 2010 to 2015 and who had a preimplant low frequency pure tone median ≤70 dB HL (n = 63). A retrospective review was completed of the RVEEH database to identify a comparison group who had been implanted with a perimodiolar electrode array, comprising adults implanted between 2004 and 2011 (PM Group) with preimplant hearing equivalent to the TSEA group (n = 70). The TSEA Group were further divided into subgroups in which n = 19 used EAS (TSEA-EAS) and n = 44 who used electric-only hearing (TSEA-Standard).

Results:

There was no significant difference in median speech perception outcomes between the TSEA and PM Groups (TSEA 61.7%, PM 67.3%, p = 0.954). A significant difference was found between the TSEA-EAS and TSEA-Standard subgroups for median speech perception outcome (TSEA-EAS median 73.5%, TSEA-Standard median 58.3%, p = 0.043).

Conclusions:

Significant speech perception benefit following cochlear implantation was achieved with both the perimodiolar and lateral wall electrode arrays and no significant difference was found between outcomes with those array types in this population of adults with functional low frequency hearing pre-implant. Those that received a TSEA, had preserved hearing, and utilised an EAS sound processor performed better than their peers with a TSEA and electric-only hearing.
International Survey on Extracorporeal Membrane Oxygenation Transport
Authors: Broman Lars Mikael , Dirnberger Daniel R. , Malfertheiner Maximilian V. , Aokage Toshiyuki , Morberg Pål , Næsheim Torvind , Pappalardo Federico , Di Nardo Matteo , Preston Tom , Burrell Aidan J.C. , Daly Ivonne , Harvey Chris , Mason Phillip , Philipp Alois , Bartlett Robert H. , Lynch William , Belliato Mirko , Taccone Fabio Silvio
Published: April 2019

Extracorporeal membrane oxygenation (ECMO) is a lifesaving therapy for severe respiratory and circulatory failure. It is best performed in high-volume centers to optimize resource utilization and outcomes. Regionalization of ECMO might require the implementation of therapy before and during transfer to the high-volume center. The aim of this international survey was to describe the manner in which interhospital ECMO transport care is organized at experienced centers. Fifteen mobile ECMO centers from nine countries participated in this survey. Seven (47%) of them operated under the “Hub-and-Spoke” model. Transport team composition varies from three to nine members, with at least one ECMO specialist (i.e., nurse or perfusionist) participating in all centers, although intensivists and surgeons were present in 69% and 50% of the teams, respectively. All centers responded that the final decision to initiate ECMO is multidisciplinary and made bedside at the referring hospital. Most centers (75%) have a quality control system; all teams practice simulation and water drills. Considering the variability in ECMO transport teams among experienced centers, continuous education, training and quality control within each organization itself are necessary to avoid adverse events and maintain a low mortality rate. A specific international ECMO Transport platform to share data, benchmark outcomes, promote standardization, and provide quality control is required.
Diagnostic value of soluble mesothelin-related peptides in pleural effusion for malignant pleural mesothelioma
Authors: Gao Ruiyue , Wang Feng , Wang Zhen , Wu Yanbing , Xu Lili , Qin Yue , Shi Huanzhong , Tong Zhaohui
Published: April 2019

Background:

Soluble mesothelin-related peptide (SMRP) is a widely studied tumor marker for diagnosing malignant pleural mesothelioma (MPM). This study discussed the diagnostic value of SMRPs in pleural effusion (PE) for MPM.

Methods:

Medline, Embase, Web of Science, and Cochrane library system were systematically searched on the data of SMRPs in PE for MPM diagnosis. Pooled diagnostic sensitivity, specificity, and symmetric receiver operating characteristic curve were calculated.

Results:

Thirteen studies fulfilled the inclusion criteria and a total of 3359 cases including 759 MPM cases, 1061 non-MM (malignant mesothelioma) malignant PE, and 1539 benign PE were brought into this meta-analysis. The pooled results of SMRPs in PE for diagnosing MPM were as follows: sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were 0.68 (95% confidence interval [CI]: 0.64–0.72), 0.91 (95% CI: 0.86–0.94), 7.8 (95% CI: 5.0–12.0), 0.35 (95% CI: 0.31–0.40), and 22 (95% CI: 14–35), respectively. The area under the summary receiver operating characteristic curves (AUC) was 0.75 (95% CI: 0.72–0.80). Subgroup analyzes revealed that the AUC of cohort group using histological diagnosis could be improved to 0.86 (95% CI: 0.83, 0.89). The Deek's funnel plot asymmetry test showed no publication bias.

Conclusion:

Although the sensitivity of SMRPs was low, PE-SMRPs can be a good indicator of the existence of MPM.
Efficacy of fenofibrate for diabetic retinopathy
Authors: Su Xing-jie , Han Lin , Qi Yan-Xiu , Liu Hong-wei
Published: April 2019

Background:

Numerous studies have reported the efficacy of fenofibrate for patients with diabetic retinopathy (DRP). No systematic review has, however, addressed its efficacy for DRP. Thus, this systematic review will firstly evaluate the efficacy and safety of fenofibrate for patients with DRP.

Methods:

This study will search the following databases: PUMBED, EMBASE, CINAHI, ACMD, CENTRAL, CBM, CNKI, VIP, and WANGFANG, along with grey literature from inception to the present. We will accept randomized controlled trials on evaluating the efficacy and safety of fenofibrate for DRP. The primary outcome is the progression of DRP. The secondary outcomes are vision loss, development of diabetic macular edema, aggravation of hard exudates, quality of life, and any adverse events. Methodological quality of each included study will be assessed by using Cochrane Collaboration risk of bias tool. In addition, Grading of Recommendations Assessment, Development and Evaluation tool will also be used to evaluate the overall strength of the evidence. Two independent reviewers will conduct all procedures of study selection, data extraction, and methodological assessment. Any disagreements will be consulted with a third reviewer. RevMan 5.3 software will be used to pool data and to carry out the meta-analysis if it is possible.

Results:

In present study, we anticipate to find a considerable number of published studies presenting evidence on efficacy and safety of fenofibrate for DRP.

Conclusion:

The findings of this systematic review will provide latest evidence of fenofibrate for patients with DRP.

Dissemination and ethics:

The findings of this scoping review will be disseminated in print, conferences, or by peer-reviewed journals. No ethical approval is needed for this systematic review, because it is a literature-based study.

Systematic review registration:

PROSPERO CRD42019121869.
Management of brown tumor of spine with primary hyperparathyroidism
Authors: Hu Jinbo , He Shaohui , Yang Jian , Ye Chen , Yang Xinghai , Xiao Jianru
Published: April 2019

Rationale:

Brown tumor (BT) is a rare benign lesion in skeletal system. It is especially rare secondary to primary hyperparathyroidism (HPT). The differential diagnosis can be misleading due to its diversified clinical characteristics. Final diagnosis mainly relies on excessive elevated parathyroid hormone and biopsy. Treatments include surgical interventions and drugs. Only 19 articles (total 22 cases) reported BT of spine caused by primary HPT.

Patient concerns:

A 50-year-old woman was admitted to our hospital complaining left elbow and thoracodorsal pain with the lower limbs weakness.

Diagnoses:

Multifocal BT.

Interventions:

The patient received intramuscular injection of Miacalcic and incense of Calcitonin (Salmon) Nasal Spray to decrease serum calcium level. Surgery was performed later to excise the ectopia parathyroidoma.

Outcomes:

At 1-year follow-up, the patient was able to lead an independent life in her full capacity, even though she occasionally complained mild weakness of lower limbs.

Lessons:

BT of spine with HPT is rarely seen in the clinical practice. Treating the primary parathyroid diseases can be effective. For patients with vertebral fractures and neural deficits, immediately surgical intervention will be necessary to prevent the worse of neurological function.
Primary cardiac angiosarcoma with right atrial wall rupture
Authors: Kim Jinah , Da Nam Bo , Hwang Jung Hwa , Park Soo Bin , Lee Min-Ho , Kim Dong Won , Park Young Woo , Lee Min-Young
Published: April 2019

Rationale:

Cardiac angiosarcoma is the most common malignant tumor of the heart and a rare disease with rapid disease progression and poor prognosis. Cardiac wall rupture is an extremely rare complication.

Patient concerns:

A 32-year-old woman presented with an acute onset of epigastric pain and chest discomfort at first time when she visited an emergency room.

Diagnoses:

A cardiac mass was identified on echocardiography and subsequently performed chest computed tomography and cardiac magnetic resonance imaging revealed the cardiac tumor at right atrium with right atrial wall rupture and hematogenous lung metastasis. Histopathologic diagnosis of metastatic angiosarcoma was done by open lung biopsy.

Interventions:

The patient was treated with palliative chemotherapy for the primary cardiac tumor and hematogenous lung metastasis.

Outcomes:

The follow-up imaging studies revealed treatment response of the primary cardiac tumor and hematogenous lung metastasis.

Lessons:

Clinical and radiologic evaluation of the cardiac angiosarcoma was well performed in our case with various diagnostic imaging modalities including echocardiography, chest computed tomography, cardiac magnetic resonance imaging, and fluorodeoxyglucose-positron emission tomography/computed tomography. This case report well demonstrates typical imaging findings of a rare cardiac tumor and emphasizes importance of early investigation for accurate diagnosis and proper management of the cardiac tumor.
Molecular characteristic analysis for the VP1 region of coxsackievirus A6 strains isolated in Jiujiang area, China, from 2012 to 2013
Authors: Wang Hongtao , Yu Wenmin , Xu Tao , Li Yuyun , Wang Xiaojing , Sun Meiqun
Published: April 2019

Background:

Enterovirus 71 (EV-A71) and Coxsackievirus A16 (CV-A16) are the most common causative agents causing hand, foot, and mouth disease (HFMD). However, coxsackievirus A6 (CV-A6), previously largely ignored, became the predominant pathogen in China in 2012. The objective of this study is to investigate the genetic characteristics and molecular epidemiology of HFMD caused by CV-A6 to guide the diagnosis and treatment of the disease, as well as disease prevention.

Material and methods:

A total of 138 suspected HFMD cases were enrolled in this study and analyses based on complete VP1 nucleotide sequences were performed to determine the evolutionary trajectory of emerging CV-A6.

Results:

Among 138 samples in Jiujiang, 125 (90.58%) were positive for enterovirus, the most frequently presented serotypes were CV-A6 (77, 61.60%), CV-A16 (28, 22.40%), EV-A71 (6, 4.80%) and untyped enteroviruses (14, 11.20%). Seventy-seven CV-A6 positive specimens were analyzed for the complete VP1 sequences by sequencing and 36 representative isolates were selected to perform nucleotide sequence similarity analysis. The results showed that 36 strains isolated from HFMD patients were clustered closely to the mainland China and were far from prototype strain CV-A6/Gdula (AY421764) and other international subtypes. Moreover, phylogenetic analysis of the VP1 gene revealed that 36 circulating strains were not significantly concentrated in one branch, but were widely distributed in each branch.

Conclusions:

Continuous surveillance of HFMD etiological agents other than EV-A71 and CV-A16 is necessary. CV-A6 is emerging as the most common pathogen causing HFMD. Closely monitoring the magnitude and trend of CV-A6 epidemic and the trend of pathogenic spectrum changes can provide scientific basis for this disease prevention and control to the department of disease control.
The role of ERCC1 and AFP gene polymorphism in hepatocellular carcinoma
Authors: Huang Yu-Liang , Wu Jun-Rong , Fang Min , Zhao Hui-Liu , Liu Zhi-Min , Ye Jian , Huang Ling-Sha , Zhu Bo
Published: April 2019

The aim of this study was to evaluate the effects of polymorphisms in excision repair cross-complementation group 1 (ERCC1) and alpha-fetoprotein (AFP) genes and their haplotypes on the susceptibility to hepatocellular carcinoma (HCC), and to decipher the association between single-nucleotide polymorphisms (SNPs) and clinicopathologic characteristics of HCC.

Peripheral blood DNA was extracted from 206 subjects. SNaPshot technique was used for genotyping 5 SNP sites of the ERCC1 rs735482, rs1046282, rs3212948, and AFP rs737241, rs4024 genotypes. Chi-squared test and logistic regression model were used to analyze the relationship of different genotypes or haplotype and the susceptibility and clinicopathologic characteristics of HCC.

The frequency of GG.GA and AA genotypes at the AFP rs737241 site in the case and control groups showed statistically significant differences (P < .05). The risk of HCC in subjects carrying mutated allele A (GA+AA) was increased by 0.543-times (P < .05) compared to that in the subjects with the GG genotype. Significant differences were observed in the linkage disequilibrium between 2 of the five SNPs (P < .05); the frequency of ERCC1 C-C and AFP A-A haplotypes was significantly lower in the case group than in the control group (P < .05). The results of clinicopathologic analysis showed that A allele at the rs737241 locus could increase the expression level of AFP (P = .007), the rs1046282 mutation C allele could increase the AFP expression level (P = .011), rs4024 locus mutation A allele could reduce the risk of vascular invasion (P = .013), rs3212948 locus mutation T allele could reduce the differentiation of liver cancer (P = .022), rs1046282 locus C allele could reduce the DNA load of hepatitis B virus (P = .035), and rs735482 A allele could increase the tumor size in HCC (P = .037).

The SNPs in rs737241 for AFP gene may correlate with the occurrence of HCC. The SNPs in ERCC1 and AFP genes may affect the prognosis of HCC, offering reliable information for early prediction of tumor progression and diagnosis of HCC.
Inflammatory bowel disease and mycobacteria: how much can we trust isoniazid prophylaxis during antitumor necrosis factor therapy?
Authors: Akyuz Filiz , Cavus Bilger , Iliaz Raim , Soyer Ozlem M. , Ormeci Asli , Evirgen Sami , Onder Semen , Koksalan Kaya , Keskin Metin , Karaca Cetin , Demir Kadir , Gulluoglu Mine , Cagatay Tulin , Besisik Fatih , Kaymakoglu Sabahattin
Published: April 2019

Objectives

Isoniazid (INH) prophylaxis is recommended for the prevention of tuberculosis (TB) reactivation before or/and during initiation of treatment with tumour necrosis factor antagonists (anti-TNF agents). Nonetheless, the long-term effectiveness of chemoprophylaxis is not clear. In this study, we aimed to evaluate the characteristics of patients who developed TB reactivation in spite of INH prophylaxis associated with anti-TNF treatment.

Patients and methods

In this retrospective study, medical records of 1263 patients with inflammatory bowel disease were reviewed. Baseline TB screening tests (purified protein derivative test and/or QuantiFERON-TB Gold test) were performed on all patients before initiation of anti-TNF therapy. Patients with purified protein derivative of more than 5 mm and/or a positive result of the QuantiFERON-TB Gold test received INH prophylaxis for 9 months. We analysed the data of patients diagnosed with TB reactivation during the anti-TNF treatment despite INH chemoprophylaxis.

Results

Overall, 175 patients underwent anti-TNF treatment. Sixty of these 175 patients had pretreatment testing showing latent TB infection and therefore were treated concomitantly with INH for 9 months in addition to their anti-TNF treatment. TB reactivation occurred in four of these 60 co-INH/anti-TNF treated patients. Active TB was diagnosed after 37.5±27 (range: 18–84) months of anti-TNF treatment. In two of the four patients that active TB was diagnosed, was also detected other Mycobacterium spp.: M. bovis in one patient and M. genavense in the other one.

Conclusion

INH chemoprophylaxis may not prevent the reactivation of TB during anti-TNF therapy in the long-term. Patients should be carefully and periodically screened for TB reactivation during anti-TNF therapy.
Indication for treatment and severity of disease in treatment-naive patients with chronic hepatitis B virus infection
Authors: Post Gerrit , Shalev Noga , Baumgarten Axel , Shimakawa Yusuke , Lemoine Maud , Krznaric Ivanka , Dupke Stephan , Carganico Andreas , Arastéh Keikawus , Ingiliz Patrick
Published: April 2019

Background and aims

The prevalence of chronic hepatitis B virus (HBV) infection in Europe is poorly defined. Data on the proportion of patients eligible for therapy are lacking but are crucial to meet WHO elimination goals. The aims of our study were to provide an estimate of the need for antiviral treatment and to assess the prevalence of advanced liver disease in treatment-naive, chronic HBV-infected patients.

Patients and methods

We performed a retrospective, cross-sectional analysis of all treatment-naive HBV-infected patients. Baseline clinical assessments included sociodemographic data, hepatitis B-specific analyses, and liver stiffness measurement (LSM).

Results

Between 2010 and 2017, 465 patients with chronic HBV infection were referred, with 301 (64.7%) being eligible for our analysis. Overall, 40% were female, and the mean age was 39.3±13.1 years. Moreover, 61% of patients were born outside Europe, predominantly in the Asia-Pacific region. The median HBV viral load was 1630 IU/ml (interquartile range: 240–35 000 IU/ml), 145 (48.2%) patients had an HBV viral load above 2000 IU/ml, and 14.3% were HBeAg positive.

Median LSM was 5.2 kPa (interquartile range: 4.2–6.6 kPa). LSM indicating clinically significant fibrosis (≥F2) was found in 96/271 (35.0%) patients, including 20/271 (7.4%) patients with suspected advanced fibrosis/cirrhosis. Overall, 26% of patients met EASL 2017 treatment criteria.

Conclusion

In HBV-infected patients referred to one of the largest ID clinics in Berlin, only 26% met EASL treatment criteria and 7% had suspected cirrhosis at presentation. Only in 4% of all patients, a treatment indication could not be determined by a noninvasive approach.
Prevention of Recurrent Ventricular Tachycardia in Patients With Implantable Cardioverter Defibrillators—A Network Meta-analysis
Authors: Malik Aaqib H. , Aronow Wilbert S.
Published: April 2019

Background:

The optimal management for the prevention of recurrent ventricular tachycardia in patients with implantable cardioverter-defibrillators (ICDs) offers a challenge with no set guidelines regarding which therapy offers a best safety and efficacy profile.

Study Question:

Which therapeutic strategy, among antiarrhythmic drugs and catheter ablation (CA), offers the most effective and safe approach in patients with ICDs?

Data Sources:

Randomized controlled trials (RCTs) comparing the efficacy and safety of antiarrhythmic drugs or CA against a placebo group. RCTs were identified from a comprehensive search in PubMed, Embase, and Cochrane library.

Study Design:

Our outcomes of interest were reductions in appropriate ICD shocks, inappropriate ICD shocks, and overall mortality. We used the event rates in both groups, and then using a frequentist approach employing a graph theory methodology, we constructed a network meta-analysis model.

Results:

Fourteen RCTs with 3815 participants and 6 different interventions treatments were included in our network meta-analysis. The most effective treatment for the prevention of recurrent ventricular tachycardia after ICD is amiodarone followed by CA. Amiodarone is most effective in the reduction of appropriate and inappropriate ICD shocks with an odds ratio (OR) of 0.29 [95% confidence interval (CI), 0.11–0.74] and 0.15 (95% CI, 0.04–0.60), respectively. CA was effective in the reduction of appropriate ICD shocks (OR, 0.41; 95% CI, 0.20–0.87), whereas sotalol was effective in the reduction of inappropriate ICD shocks (OR, 0.46; 95% CI, 0.22–0.95). There was no significant reduction in the overall mortality from any therapy. There was a trend of increased mortality associated with amiodarone therapy (OR, 2.40; 95% CI, 0.92–6.26).

Conclusions:

Amiodarone remains the most efficacious therapy for the reduction of appropriate and inappropriate shocks in patients with ICD. No therapy resulted in mortality reduction, but amiodarone showed a trend toward increased mortality.
The lung microbiome and transplantation
Authors: Mitchell Alicia B.
Published: April 2019

Purpose of review

Lung transplantation survival is still limited compared with other solid organ transplant modalities, due to a range of factors that are continuing to be elucidated. However, new research is emerging which indicates that the microbiome of the lungs, and of other organs, may have important implications for immune response and mediating transplant outcomes. Pathogenic bacterial and viral species are known to have deleterious effects on the allograft, but taking a more global view, and considering the overall composition of the community of microbial species may undercover a greater understanding of the complex interplay involved in allograft dysfunction.

Recent findings

The microbiome appears to have an important modulatory role on immune response in both normal development, and after transplantation. A range of microbial species contributes to the resident microscopic community, with the gut and blood microbiomes having a significant impact on the function of the lungs and resistance to infection. Movement of species from within and outside the respiratory tract occurs in the early transplant period, leading to a modified donor microbiome in the recipient. There is evidence to suggest that chronic lung allograft dysfunction may be facilitated by the respiratory microbiome and interactions with immune cells within the allograft.

Further investigation of the respiratory microbiome, interactions with the microbiome of other organs and impact on immune and allograft function posttransplantation is needed. Promising insights are being gained regarding certain microbial profiles which may be associated with negative outcomes, and the mechanisms through which this occurs. As our understanding expands, the ability to modify the microbiome offers novel treatment strategies for combating allograft dysfunction.
Community-acquired respiratory viruses
Authors: Gottlieb Jens
Published: April 2019

Purpose of review

Incidence of community-acquired respiratory viruses (CARVs) after lung transplantation (LTx) is 10–68 cases per 100 patient-years. Infected patients may develop graft failure and there seems to be an association between CARV infection and development of chronic lung allograft dysfunction (CLAD). This review summarizes the impact of CARV infection after LTx and potential treatment strategies.

Recent findings

Detection rate of CARV depends on diagnostic methods. CARV infections after LTx are reported more frequently probably attributed to improved diagnostic methods, especially nucleic acid testing. Paramyxoviridae and picornaviridae are most frequent. For paramyxoviridae, the association with CLAD is reported in various single-center observational studies. Neuraminidase inhibitors are approved for influenza and can be safely used in flu-infected LTx patients. There is no approved treatment for paramyxoviruses, most centers use ribavirin in the infected LTx recipient.

Antivirals against CARV in LTx recipients have not yet demonstrated reduced morbidity in randomized clinical trials. Agents against CARV under development are inhibiting viral attachment and use silencing mechanisms of viral replication. The cohort of lung transplant recipients is a focus of intense research because of the high morbidity of CARV infection and intense surveillance of LTx recipeints.
A Consensus Study of the Grading and Typing of Intraductal Papillary Mucinous Neoplasms of the Pancreas
Authors: Furukawa Toru , Fukushima Noriyoshi , Itoi Takao , Ohike Nobuyuki , Mitsuhashi Tomoko , Nakagohri Toshio , Notohara Kenji , Shimizu Michio , Tajiri Takuma , Tanaka Mariko , Yamaguchi Hiroshi , Yanagisawa Akio , Sugiyama Masanori , Okazaki Kazuichi
Published: April 2019

Objective

The grading and typing of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are challenging for pathologists. We aimed to clarify the points of consistency and disagreement in assessing the grades and types of IPMNs.

Methods

Digital slide images of 20 IPMNs were independently assessed by 10 Japanese pathologists, who then held a consensus meeting to discuss the points of disagreement and develop a consensus and recommendations.

Results

The average agreement rates for grade and type were 83.5% (range, 100%–40%) and 82.5% (range, 100%–50%) and the Fleiss' κ values were 0.567 and 0.636, respectively.

Conclusions

The disagreement points and recommendations were as follows: destructed ductal walls with desquamated neoplastic epithelia or mucin lakes partially lined with neoplastic cells could be invasion; intraductal stromal invasion could be dismissed unless vascular or lymphatic invasion existed; elastica staining may help visualize ducts in colloidal nodules; high-grade can be distinguished from low/intermediate grade by marked nuclear disarrangements and complex architecture in the intestinal papillae; oncocytic papillae are characterized by eosinophilic cells with round disoriented nuclei; high-grade gastric papillae can be distinguished from pancreatobiliary papillae by relatively low but complex architecture; and the most dysplastic papillae should be used to assess type in mixed papillae types.
Paediatric Endoscopy Global Rating Scale
Authors: Narula Priya , Broughton Raphael , Howarth Lucy , Piggott Anna , Bremner Ronald , Tzivinikos Christos , Gillett Peter , Henderson Paul , Rawat David , Cullen Mick , Loganathan Sabari , Devadason David , Afzal Nadeem A. , Maginnis Janis , McKenna Sharon , Thomson Mike , Green John , Johnston Debbie
Published: April 2019

Introduction and Objectives:

The endoscopy Global Rating Scale (GRS) is a web‐based self‐assessment quality improvement (QI) tool that provides a framework for service improvement. Widespread use of the GRS in adult endoscopy services in the United Kingdom (UK) has led to a demonstrable improvement in quality. The adult GRS is not directly applicable to paediatric endoscopy services. The objective of this study is to develop and pilot a paediatric endoscopy Global Rating Scale (P‐GRS) as a QI tool.

Methods:

Members of the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) Endoscopy Working Group collaborated with the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) to develop the P‐GRS. After a period of consultation, this was piloted nationally at 9 centres and data were collected prospectively at 2 census points, May and December 2016.

Results:

The P‐GRS mirrors the adult GRS by dividing care into 4 domains and includes 19 standards with several measures that underpin the standards. Eight services completed the online P‐GRS return in May 2016 and 6 in December 2016. All pilot sites identified areas that needed improvement and post‐pilot reflected on the key challenges and developments. Several positive developments were reported by the pilot sites.

Conclusions:

The national pilot helped ensure that the P‐GRS developed was relevant to the paediatric endoscopy services. The pilot demonstrated that even in the first year of engaging with this QI tool, services were starting to identify areas that needed improvement, share best practice documents, put in place QI plans, and support greater patient involvement in services.
TakingAIM
Authors: Sullivan Suzanne S.
Published: April 2019

Advance care plans (ACP) align care with individual values and goals for the end of life, yet their rates are low. Communication barriers are a primary reason for these low rates. Precision health approaches that target individuals based on personal needs, behaviors, or choices may improve communication and positively influence rates of advance care plans. A framework to guide these efforts is needed. The purpose of this study is to develop a framework that guides clinicians in identifying individuals who will benefit from targeted advance care planning conversations. Walker and Avant’s theory derivation strategy integrates concepts of social marketing theory, population segmentation, the marketing mix, and the transtheoretical model of behavior change into a novel framework. The Aligning Individuals with Meaningful End-of-Life Discussions to Promote ACP (TakingAIM) model promotes population segmentation by integrating social marketing theory and the marketing mix into conceptual definitions within the context of ACP: plan (product), perception (price), preference (promotion), and pathway (place). The transtheoretical model of behavior change further guides ACP conversations at the individual level. Identifying at-risk groups and targeting their specific needs may improve the rates of advance care plans. This framework is appropriate for use in any clinical setting and is ready for empirical testing.
Adverse Tracheal Intubation-Associated Events in Pediatric Patients at Nonspecialist Centers: A Multicenter Prospective Observational Study*
Authors: Matettore Adela , Ramnarayan Padmanabhan , Jones Andrew , Randle Elise , Lutman Daniel , O’Connor Maeve , Chigaru Linda
Published: April 2019

Objectives:

In tertiary care PICUs, adverse tracheal intubation-associated events occur frequently (20%; severe tracheal intubation-associated events in 3–6.5%). However, pediatric patients often present to nonspecialist centers and require intubation by local teams. The rate of tracheal intubation-associated events is not well studied in this setting. We hypothesized that the rate of tracheal intubation-associated events would be higher in nonspecialist centers.

Design:

Prospective observational study.

Setting:

We conducted a multicenter study covering 47 local hospitals in the North Thames and East Anglia region of the United Kingdom.

Patients:

All intubated children transported by the Children’s Acute Transport Service from June 2016 to May 2018.

Interventions:

None.

Measurements and Main Results:

Data were available in 1,051 of 1,237 eligible patients (85%). The overall rate of tracheal intubation-associated events was 22.7%, with severe tracheal intubation-associated events occurring in 13.8%. Younger, small-for-age patients and those with difficult airways had a higher rate of complications. Children with comorbidities and difficult airways were found to have increased severe tracheal intubation-associated events. The most common tracheal intubation-associated events were endobronchial intubation (6.2%), hypotension (5.4%), and bradycardia (4.2%). In multivariate analysis, independent predictors of tracheal intubation-associated events were number of intubation attempts (odds ratio for > 4 attempts compared with a single attempt 19.1; 95% CI, 5.9–61.4) and the specialty of the intubator (emergency medicine compared with anesthesiologists odds ratio 6.9; 95% CI, 1.1–41.4).

Conclusions:

Tracheal intubation-associated events are common in critically ill pediatric patients who present to nonspecialist centers. The rate of severe tracheal intubation-associated events is much higher in these centers as compared with the PICU setting. There should be a greater focus on improving the safety of intubations occurring in nonspecialist centers.
Does an Antimicrobial Time-Out Impact the Duration of Therapy of Antimicrobials in the PICU?*
Authors: Adams Susan M. , Ngo Linh , Morphew Tricia , Babbitt Christopher J.
Published: April 2019

Objectives:

Our aim was to perform an antimicrobial time-out 48–72 hours after commencing therapy in order to achieve a decrease in days of therapy per 1,000 patient days for vancomycin, meropenem, and piperacillin/tazobactam in all PICU patients during an 8-month period.

Design:

This is a pre- and postimplementation quality improvement study.

Settings:

A 30-bed PICU at a tertiary children’s hospital.

Patients:

Patients less than 21 years old admitted to the PICU from July 1, 2015, until March 31, 2016, or from July 1, 2016, until March 31, 2017, who received antibiotics for greater than 48 hours were eligible for inclusion.

Intervention:

An antimicrobial time-out was performed after 48–72 hours of antimicrobials for all patients in the PICU during postimplementation.

Measurements and Main Results:

The primary outcome measure was days of therapy per 1,000 patient-days for three target antibiotics: vancomycin, meropenem, and piperacillin/tazobactam. Ninety-five patients meeting inclusion criteria were admitted to the PICU during the pre–time-out period and 95 patients during the post–time-out period. The cohort that underwent time-outs had lower days of therapy for vancomycin (81.3 vs 138.1; p = 0.037) and meropenem (34.7 vs 67.1; p = 0.045). Total acquisition cost was 31 % lower for piperacillin/tazobactam and vancomycin and 46% for meropenem post implementation. Time-outs led to antimicrobial duration being defined 63% of the time and deescalation or discontinuation of antimicrobials 29% of the time.

Conclusions:

A 48–72-hour time-out process in rounds is associated with a reduction in days of therapy for antibiotics commonly used in the PICU and may lead to more appropriate usage. The time-outs are associated with discontinuation, deescalation, or duration being defined, which are key elements of Centers for Disease Control and Prevention–recommended antimicrobial stewardship programs.
Chromhidrosis
Authors: Suessman Anna , Srinivasan Saranya
Published: April 2019

Chromhidrosis is a rare condition characterized by the secretion of colored sweat. We report a case of a preadolescent healthy girl presenting with acute, recurrent blue discoloration of her armpits. The blue discoloration can be wiped off but recurs. As providers, it is useful to be familiar with this diagnosis and course of disease.
Utility of Neuroimaging in Children Presenting to a Pediatric Emergency Department With Ataxia
Authors: Luetje Maureen , Kannikeswaran Nirupama , Arora Rajan , Wang Bo , Farooqi Ahmad , Sivaswamy Lalitha
Published: April 2019

Objectives

The aim of this study was to evaluate the utility of neuroimaging in children who present to the pediatric emergency department with acute-/subacute-onset ataxia. Neuroimaging is performed in many children with ataxia to rule out serious intracranial pathology. There is, however, limited evidence to support such practice.

Methods

This was a retrospective review of electronic medical records of children who presented to the emergency department with ataxia between 2007 and 2013. Patient demographics, historical features, physical examination findings, laboratory results, and neuroimaging results were collected. Neuroimaging studies that were classified as abnormal by a neuroradiologist were further reviewed and classified by the study neurologist as clinically significant or not.

Results

The records of 141 subjects were analyzed. The most common causes of ataxia were infectious/postinfectious (36.2%) and ingestion (15.6%). Neuroimaging was performed in 104 children (73.8%). Neuroimaging was abnormal in 63 children (60.6%). However, these abnormalities were clinically significant in only 14 children (13.5%). Focal neurological findings were noted in 12 of 14 children (85.7%) with clinically significant neuroimaging.

Conclusions

Clinically significant neuroimaging was noted in a minority of children who presented with acute/subacute ataxia. The majority of patients with clinically significant neuroimaging had focal neurological findings on examination. Neuroimaging may not be required in all children presenting to the ED with acute ataxia, but further large-scale studies are needed to validate these findings and identify a subset of patients with ataxia in whom imaging can be deferred.
A rare complication of knee hematoma after genicular nerve radiofrequency ablation
Authors: Strand Natalie , Jorge Paolo , Freeman John , D'Souza Ryan S.
Published: April 2019

Background:

Genicular nerve radiofrequency ablation (RFA) is an intervention to treat patients with chronic knee pain who have failed previous conservative, pharmacologic, and surgical interventions. Vascular complications following interventional procedures of the knee are extremely rare. A delay in diagnosis may be detrimental for the viability of the affected limb and may ultimately require amputation.

Case Presentation:

A 76-year-old man with a history of severe bilateral knee osteoarthritis and grade 4 chondromalacia presented to our clinic with refractory, severe bilateral knee pain and received a bilateral genicular nerve RFA. He returned 4 days later with right medial thigh pain and a magnetic resonance imaging study revealing a hematoma along the anteromedial aspect of the right distal femoral diaphysis measuring 13.3 × 4.5 × 3.0 cm. After collaboration between pain medicine and orthopedic surgery services, decision was made to treat patient conservatively with rest, compression, elevation, ice application, tramadol, and gabapentin, but with close follow-up and a low threshold to intervene with diagnostic and therapeutic angiography with embolization if bleeding worsened; he reported resolution of his pain after a 4-day and 1-month follow-up.

Conclusion:

This is the first report describing iatrogenic vascular injury in the knee after a genicular RFA procedure. Pain medicine physicians should be aware of the vascular anatomy of the knee, particularly paying close attention to variations after previous surgeries. Future trials should investigate modalities that minimize vascular complications including concomitant use of ultrasonography with fluoroscopy and other forms of RFA including pulsed or cooled RFA.