bluuebunny/crossref_metadata_2025 huggingface dataset:
Management of Orbital Complications of Acute Rhinosinusitis in Pediatric Patients
Authors: Trivić Aleksandar , Cevik Muge , Folić Miljan , Krejovic-Trivić Sanja , Rubino Salvatore , Micić Jelena , Stevanović Goran , Milovanović Jovica , Jotić Ana , Barać Aleksandra
Published: July 2019

Background:

The major clinical dilemma managing acute rhinosinusitis (ARS) in pediatric population is distinguishing uncomplicated rhinosinusitis from a complicated bacterial ARS and orbital complications, the latter requiring antimicrobials and surgical intervention. However, factors associated with severe orbital complications and the optimum management strategy remains controversial. The objectives of this study were to characterize the clinical outcomes of children with orbital complications of ARS and to identify risk factors associated with disease severity.

Methods:

This retrospective cohort analysis evaluated the clinical outcomes of 61 children admitted for orbital complications between January 1, 2002 and December 31, 2017. Descriptive statistics were performed to examine the demographics and clinical findings. We compared groups using Mann-Whitney U test for continuous variables and χ2 for categorical variables.

Results:

Although two-thirds of children had received prehospital antibiotics, half of the cohort presented with post-septal orbital complications. While 83% of isolates obtained from the same patients were susceptible to the prehospital antibiotics given, the majority of those who received prehospital antibiotics nevertheless required surgical intervention. We observed significant association between the age of presentation and disease severity. Children >5 years of age presented with more severe orbital complications despite prehospital antibiotics and were more likely to require surgical intervention (
P
< 0.001).

Conclusions:

In this study, stage II/III orbital complications at presentation and older age were the most important determinants of medical treatment failure. Early referral to eye, nose and throat (ENT) should be considered for children >5 years with ARS due to worse orbital complications despite prehospital antibiotics.
An Interprofessional Geriatric Experiential Learning Experience: Its Impact on Physical and Occupational Therapist Students
Authors: Dockter Mary , Lundeen Heather , Parker Michael G.
Published: July 2019

Introduction.

Accreditation standards for physical therapist (PT) education require the inclusion of interprofessional education (IPE) in order to prepare health care professionals to work in collaborative environments. Additional guidelines document the need to educate PT students in the care of older adults; however, a gap in readiness for entry-level practice exists. Therefore, there were three purposes of this study that were to 1) examine the impact of an IPE experiential learning project on PT and occupational therapist (OT) students' knowledge and attitudes toward each other's professions, 2) examine students' comfort, value, and ability to work with another profession, and 3) assess the project's impact on PT and OT students' attitudes toward older adults.

Methods.

Physical therapist and OT student groups, under the supervision of faculty, evaluated a community dwelling older adult over 3 visits and developed a comprehensive wellness program, which was provided by the students on visit 4. Students completed 2 surveys: the Interprofessional Socialization and Valuing Scale (ISVS) and Kogan's Attitude Towards Old People Scale (KAOP), prior to and at the conclusion of the project.

Results.

The Wilcoxon’s signed rank test showed significant increases after the completion of the IPE project in the total ISVS (P < .001) median scale scores for all students and on the subscales regarding the ability (P < .001), value (P < .001), and comfort (P < .001) in working with others. Significant increases were observed for all students on the total KAOP scale scores (P < .001) and the positive subscale scores (P < .001); significant decreases were observed in the negative subscale scores (P < .001).

Discussion and Conclusion.

This study demonstrates a successful IPE experiential learning project used to enhance PT and OT students' abilities, values, and comfort with collaborative practice and enhancement of PT and OT student groups' attitudes toward older adults.
Idiopathic anaphylaxis: What you do not know may hurt you
Authors: Chan Suzanne , John Rita Marie
Published: July 2019

Idiopathic anaphylaxis (IA), like immunologic and nonimmunologic anaphylaxis, is a life-threatening, sometimes fatal allergic disease. Although the priority is immediate recognition and initiation of treatment, long-term care planning is important to help reduce anxiety and promote healthy growth and development. Learning to recognize, manage, and stabilize the child is an essential part of improving the family dynamics. Despite advancements in the management of anaphylaxis, research has shown a need for continued patient education and training to improve timely recognition and treatment. This article focuses on elucidating the clinical presentation, theories of pathogenesis, and diagnosis, treatment, and management of IA.
Readiness for the epidemic: The adult nonalcoholic fatty liver disease toolkit for primary care nurse practitioners
Authors: Casler Kelly , Trees Karen , Bosak Kelly
Published: July 2019

Background and purpose:

Nonalcoholic fatty liver disease (NAFLD) prevalence has reached epidemic proportions, and the severe form, nonalcoholic steatohepatitis, can result in cirrhosis and liver failure. The growing prevalence requires primary care (PC) providers to be adept at recognition and management; however, they experience significant knowledge gaps that can result in delayed access to interventions that could improve outcomes. This study's aim was to develop and evaluate a toolkit to improve knowledge gaps and support evidence-based practice (EBP) among PC nurse practitioners caring for patients with NAFLD in a midwestern state.

Methods and intervention:

The Adult NAFLD Toolkit was designed using the Knowledge to Action framework and guidelines from the Agency for Healthcare Research and Quality. The success of the toolkit was evaluated by administering the NAFLD survey for general practitioners in a pre–post evaluation design.

Results:

Pre–post survey scores (N = 11) were compared for statistically significant change using the Wilcoxon signed rank test for matched pairs and showed improvement in overall knowledge (p = .011), perceived preparedness to care for NAFLD (p = .007), intention to recommend weight loss for management (p = .008), and intention to use the NAFLD fibrosis score for patient monitoring (p = .008).

Conclusions:

The results of this pilot study demonstrate successful implementation and positive outcomes of an EBP toolkit and support its expanded use. Continued evaluation on a larger scale is needed. Health care providers can use the process described in this article to develop and implement toolkits to support EBP of other PC issues.
An integrative review of system-level factors influencing dementia detection in primary care
Authors: Romano Raymond R. , Carter Michael A. , Anderson Alison R. , Monroe Todd B.
Published: July 2019

Background and purpose:

The incidence of Alzheimer disease (AD) is increasing in the United States, yet more than half of the people with AD are diagnosed late in the course of the disease. Most are identified outside primary care. New approaches to prevention and treatment mean that early detection of AD may improve the quality of life of those affected by the disease. Nurse practitioners (NPs) have an important role in increasing early diagnosis of AD.

The purpose of this systematic literature review is to identify health care system factors that contribute to missed or delayed diagnosis of dementia by primary care providers.

Methods:

Articles were identified through a systematic electronic search of the following databases: MEDLINE, the Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO.

Conclusions and implications for practice:

Results indicate considerable variation in the diagnostic accuracy of dementia by primary care providers. Missed or underdiagnosis of dementia results from organizational, provider, and patient factors. New treatments are under investigation that may slow the progression of AD much better than current therapy, emphasizing the need to improve early detection by clinicians, especially primary care NPs.
HIV, Tuberculosis, and Otogenic Intracranial Sepsis: A Devastating Disease With a Subtle Presentation
Authors: Yakobi Akhona , Porterfield James Zachary , Toman Julia , Spock Todd , Kapil Narain , de Meyer Jenine , Kejner Alex , Rea Peter , Gleeson Michael , Enicker Basil , Michaelides Elias , Saman Yougan
Published: July 2019

Objectives:

To undertake a large-scale review of otogenic intracranial sepsis in an area of highly prevalent HIV and tuberculosis (TB) to re-examine and inform early diagnosis and treatment efforts.

Methods:

Seventy-seven consecutive cases of otogenic intracranial sepsis in KwaZulu-Natal, South Africa were reviewed for demographics, presentation, imaging, HIV status, culture results, and outcomes.

Results:

The most common intracranial complications were intracranial abscess (46.8%), hydrocephalus (31.2%), subdural empyema (28.6%), and epidural empyema (26.0%). Ear discharge (87.0%), postauricular abscess (29.9%), and hearing loss (29.9%) were notable presenting symptoms. Overall mortality was 15.6%. Of the 45.5% of patients with HIV testing, 54.2% were HIV+, Mortality among HIV+ patients was 15.8% but only 6.3% in HIV− patients (p = 0.61, OR = 2.8). Eight patients (10.4%) had culture or histological evidence of TB infection.

Conclusions:

Otogenic intracranial complications continue to present late and are associated with significant mortality and morbidity, despite advances in diagnostic and treatment modalities. This study represents one of the largest case-series in the literature, and the first to specifically evaluate the effects of HIV and TB infection.

Patient presentation and severity of illness varied; however, a majority of patients presented with ear discharge and no focal neurological signs. An effect size for higher mortality among HIV+ patients compared with HIV− patients was noted but was not significant. Tuberculosis infection was prevalent compared with previous studies.

This study reinforces the need for enhanced screening and early treatment of ear disease to minimize associated mortality and morbidity, particularly in immunocompromised patients.
Hypotympanic Sound Baffle for Amelioration of Pulsatile Tinnitus due to Carotid and Jugular Bulb Dehiscence
Authors: Liu George S. , Blevins Nikolas H. , Vaisbuch Yona
Published: July 2019

Objective:

To share our experience with treating pulsatile tinnitus by insulating a dehiscent carotid artery with a hypotympanic sound baffle, and compare outcomes with a similar resurfacing approach for jugular bulb wall anomalies.

Study Design:

Retrospective case series.

Setting:

Tertiary academic medical center.

Patients:

Adult patients with troublesome pulsatile tinnitus with radiologic evidence of carotid artery dehiscence or jugular bulb wall anomaly within the temporal bone.

Intervention:

Hypotympanic exposure of vessel followed by resurfacing using hydroxyapatite cement (carotid dehiscence) or autologous tissue (jugular bulb wall anomalies).

Main Outcomes Measures:

Alleviation or reduction of pulsatile tinnitus.

Results:

Two patients presented with unilateral, debilitating pulsatile tinnitus and history and imaging consistent with carotid dehiscence and underwent hypotympanic resurfacing with hydroxyapatite cement. Both had considerable initial improvement of tinnitus, and 40% resolution of tinnitus with improved quality of life at an average follow-up of 13.5 months. Two patients with jugular bulb dehiscence/diverticulum treated by resurfacing had complete elimination of symptoms at an average follow up of 17.3 months. There were no major adverse outcomes (permanent hearing loss, vascular injury, or intracranial hypertension).

Conclusion:

Creation of a hypotympanic sound baffle offers promise as a means of reducing pulsatile tinnitus emanating from a dehiscent carotid artery transmitted to the tympanum, with substantial improvement in reported functional ability. Treatment of venous etiologies of pulsatile tinnitus with similar techniques demonstrates higher success rates, which may be attributable to incomplete resurfacing of carotid artery dehiscence along its extent towards the petrous apex due to safety concerns.
The Efficacy of a Home Treatment Program Combined With Office-Based Canalith Repositioning Procedure for Benign Paroxysmal Positional Vertigo—A Randomized Controlled Trial
Authors: Piromchai Patorn , Eamudomkarn Nuntakarn , Srirompotong Somchai , Ratanaanekchai Teeraporn , Yimtae Kwanchanok
Published: July 2019

Objectives:

To compare the efficacy of the home treatment program combined with office-based canalith repositioning procedure (CRP) versus office-based CRP alone for benign paroxysmal positional vertigo (BPPV).

Study Design:

Randomized controlled trial.

Method:

One hundred six patients with BPPV were randomly assigned to the home treatment program combined with office-based CRP group and the office-based CRP only group. The canalith repositioning procedure was performed in all patients at an out-patient clinic. The patients in the home treatment group were additionally instructed to do the exercise tailored for their affected canal at home every day. The presence of nystagmus was recorded. The symptom of vertigo and its impact on daily life were evaluated by the Dizziness Handicap Inventory (DHI) and a visual analog scale (VAS). All outcomes were evaluated at 1, 2, and 4 weeks after the initial treatment. A cure was defined as a patient having no nystagmus on the appointment date.

Results:

The success rate of the home treatment program combined with office-based CRP group and the office-based CRP only group were 100 and 91.67%, respectively (p = 0.043). The nystagmus duration, latency, DHI, and VAS scores decreased significantly from baseline at 1, 2, and 4 weeks for both groups (p < 0.001). No significant side effects were noted in either of the groups.

Conclusion:

The office-based CRP plus home treatment program was more effective than the CRP only group for BPPV. Both groups were effective in reducing the symptom of vertigo and its impact on daily life.

Trial Registration:

Clinicaltrials.in.th/TCTR20160810001.
Effect of noninvasive ventilation on intubation risk in prehospital patients with acute cardiogenic pulmonary edema: a retrospective study
Authors: Gartner Birgit Andrea , Fehlmann Christophe , Suppan Laurent , Niquille Marc , Rutschmann Olivier T. , Sarasin François
Published: July 2019

Objective

The aim of this study was to assess the effect of prehospital noninvasive ventilation for acute cardiogenic pulmonary edema on endotracheal intubation rate and on ICU admission rate.

Methods

We carried out a retrospective study on patients’ prehospital files between 2007 and 2010 (control period), and between 2013 and 2016 (intervention period). Adult patients were included if a diagnosis of acute cardiogenic pulmonary edema was made by the prehospital physician. Exclusion criteria were a Glasgow coma scale score less than 9 or any other respiratory diagnosis. We analyzed the association between noninvasive ventilation implementation and endotracheal intubation or ICU admission with univariable and multivariable regression models. The primary outcome was prehospital endotracheal intubation rate. Secondary outcomes were admission to an ICU, prehospital intervention length, and 30-day mortality.

Results

A total of 1491 patients were included. Noninvasive ventilation availability was associated with a significant decrease in endotracheal intubation rate (2.6% in the control versus 0.7% in the intervention period), with an adjusted odds ratio (OR) of 0.3 [95% confidence interval (CI), 0.1–0.7]. There was a decrease in ICU admissions (18.6% in the control versus 13.0% in the intervention period) with an adjusted OR of 0.6 (95% CI, 0.5–0.9). There was no significant change in 30-day mortality (11.2% in the control versus 11.0% in the intervention period, P = 0.901).

Conclusion

In our physician-staffed prehospital system, use of noninvasive ventilation for acute cardiogenic pulmonary edema decreased both endotracheal intubation and ICU admission rates.
Effect of Medicaid Disenrollment on Health Care Utilization Among Adults With Mental Health Disorders
Authors: Ji Xu , Wilk Adam S. , Druss Benjamin G. , Cummings Janet R.
Published: July 2019

Background:

Medicaid is an important source of insurance coverage for those with mental health (MH) disorders in the United States. Although disruptions in Medicaid coverage are common, little is known about the dynamic relationship between Medicaid disenrollment and MH care utilization.

Objective:

We estimated changes in all-cause and MH-related health care use post Medicaid disenrollment among a nationwide cohort of adults with MH disorders.

Subjects:

We identified 8841 persons (197,630 person-months) ages 18–64 with MH disorders and Medicaid coverage from Panels 4 to 19 Medical Expenditure Panel Survey.

Methods:

Using a quasi-experimental design and propensity weighting, we estimated logit models examining changes in service utilization per-person-per-month. We used a “post” indicator to estimate average differences in service use postdisenrollment (vs. those with continuous Medicaid coverage) and a count variable measuring total months since coverage loss to estimate changes over time.

Outcome Measures:

All-cause outpatient visits, MH-related outpatient visits, and acute care visits.

Results:

Becoming uninsured after Medicaid disenrollment was associated with average reductions of 52% [−14.75 percentage-points, 95% confidence interval (CI): −17.59, −11.91] in the likelihood of receiving any outpatient service, 35% (−2.23 percentage-points, 95% CI: −3.71, −0.75) in the likelihood of receiving any MH-related outpatient service, and 52% (−2.44 percentage-points; 95% CI: −3.35, −1.52) in the likelihood of receiving any acute service in a month. Health care use declined the most in the month immediately postdisenrollment, and declines continued over the next half-year (while uninsured).

Conclusions:

Insurance loss after disenrollment from Medicaid led to a persistent disruption in the receipt of health care services for beneficiaries with MH disorders.
Update on the management of craniomaxillofacial trauma in low-resource settings
Authors: Shah Irfan , Gadkaree Shekhar K. , Tollefson Travis T. , Shaye David A.
Published: July 2019

Purpose of review

Craniomaxillofacial (CMF) trauma is a common cause of global morbidity and mortality. Although in high resource settings the management of CMF trauma has improved substantially over the past several decades with internal rigid fixation technology; these advancements have remained economically unviable and have not yet reached low and middle-income countries (LMICs) en masse. The purpose of this review is to discuss the current management of CMF injuries in low-resource settings.

Recent findings

Trauma injuries remain a global epidemic with head and neck injuries among the most common. CMF trauma injuries largely occur in LMICs, with motor vehicle trauma being a common cause. Patients present in a delayed fashion which increases complications. Diagnostic methods are often limited to plain radiographs as computed tomography is not always available. In low-resource settings, CMF trauma continues to be treated primarily by closed reduction, maxillomandibular fixation, and transosseous wiring, yielding acceptable results through affordable methods. With the advent of less expensive plating systems, internal fixation with plates and screws are gradually finding their place in the management of facial trauma in low-resource settings. A shortage of CMF surgeons in LMICs is a recognized problem and is being addressed by targeted curricula.

CMF trauma is a major cause of morbidity and mortality globally that remains poorly addressed. Currently, conventional methods of treating CMF trauma in low-resource settings have evolved to meet resource constraints. The education of CMF surgeons remains a key leverage point in improving CMF trauma care globally.
Hospital Readmissions in Medicare Home Healthcare
Authors: Meadow Ann , Sangl Judith
Published: July 2019

A large sample of all 2011 home healthcare users in traditional Medicare was analyzed to identify the risk indicators at start-of-care that were associated with the highest probability of readmission (N = 597,493). Thirty-five patient characteristics found in Outcome and Assessment Information Set, claims history, or other administrative data were associated with a 30-day readmission risk 30% to 100% above the average in the sample. Most of these characteristics were associated with a 30-day readmission probability of approximately 1 in 5, and several were associated with a readmission probability approaching 1 in 10 during the first 7 days. A majority of the high-risk characteristics were uncommon, and they tended not to occur together, suggesting they can be useful flags for clinicians in prioritizing cases to reduce readmissions. Readmission risk grows most quickly early in the episode of care; typically one-third of the readmissions in the first 30 days occurred by the end of 7 days. High-risk markers at 7 and 30 days were substantially the same, illustrating the importance of the early days at home in influencing the 30-day outcome. A variety of domains and characteristics are represented among the highest-risk markers, suggesting challenges to home healthcare clinicians in maintaining the knowledge and skills needed to address readmission prevention. We suggest possible responses to this problem as strategies to consider, and also discuss implications for assessment practices in home healthcare.
Chronic Heart Failure Treatment With the Left Ventricular Assist Device
Authors: Capriotti Theresa , Micari Morgan
Published: July 2019

The prevalence of chronic heart failure is increasing in the United States due to the increase in the number of older adults and because many people are surviving acute cardiac events and living longer with chronic heart disease. In end-stage heart failure, heart transplant was once the gold standard of treatment and patients had to wait for a matching heart donor. In the past, the left ventricular assist device (LVAD) was a mechanical circulatory support treatment used temporarily for those awaiting heart transplant. However, the LVAD is increasingly becoming the chosen treatment of patients in lieu of heart transplant. Home healthcare nurses and clinicians need to be familiar with LVADs in order to care for patients in end-stage heart failure who are using these devices. This article explains the mechanism, potential complications, and nursing implications of caring for the patient who is using an LVAD.
Feasibility Testing of Health Information Technology
Authors: Nyirenda Joshua , Sun Cynthia , Wright Shanen , Rezek Gary
Published: July 2019

The use of Patient-Reported Outcome Measures (PROMs) to improve patient outcomes, communication, and shared decision-making is of significance to home healthcare. Clinicians have begun to integrate health information technology (HIT) enabled PROM platforms (such as tablets) into routine care to facilitate collection of PROMs. To evaluate the feasibility and suitability of incorporating PROMs into the overall workflow in home healthcare, and integrating data collected with electronic health records (EHRs), we engaged two home healthcare agencies as pilot sites over the course of 4 months. We provided tablets enabled with an app version of the validated Patient-Reported Outcomes Measurement Information System to collect patient data. This was followed by surveys, interviews, and observations on aspects of feasibility, which we analyzed using summary statistics and qualitative analysis. Results show that the implementation of the HIT-enabled PROMs in the home healthcare setting is suitable for workflow, without negatively impacting goals of care. Additionally, the tablets were considered user-friendly by both clinicians and patients. Key to the utility of HIT-enabled PROMs in home healthcare is the integration of the data collected with existing data systems, in order to facilitate quality and improve outcomes, the success of which can depend on EHR platform ownership and the related ability or access to modify EHRs.
End-of-Life Care
Authors: Rochon Therese , Emard Esther
Published: July 2019

In 2010, the Institute of Medicine published the vision for how to transform healthcare to achieve a more seamless patient-centered, high-quality system of care. Among the recommendations were four specifically focused on leveraging nursing which is the largest group of healthcare workers: (1) Ensure that nurses can practice to the full extent of their education and training, (2) Improve nursing education, (3) Provide opportunities for nurses to assume leadership positions and to serve as full partners in healthcare redesign and improvement efforts, and (4) Improve data collection for workforce planning and policy making. At the Care New England Health Care System's Visiting Nurse Association, located in the state of Rhode Island, we redesigned access to end-of-life care by leveraging these recommendations. An experienced palliative care nurse practitioner (NP) leads the program development to improve care delivered by home healthcare nurses and NP specialists. This program was designed to allow patients to remain in their preferred setting of care—their home—until the end of their life. In the 5 years of this program's existence, it has achieved a yearly impact on community-based palliative care and hospice services. The number of documented advance directives increased by 75%, referrals to palliative care and hospice increased by 300% and the length of time on hospice doubled. In addition, NP home visits became an accepted referral source and improvements in both the quality and satisfaction scores for the home healthcare agency were realized.
A Quality Improvement Initiative to Reduce Opioid Consumption after Cesarean Birth
Authors: Burgess Adriane , Harris Amy , Wheeling Julia , Dermo Roni
Published: July 2019

Background:

One in 300 opioid naïve women become addicted to opiates after cesarean birth. After cesarean, women are often prescribed more opiates at discharge than necessary, resulting in increased opportunity for diversion.

Purpose:

To improve use of comfort strategies and nonopioid medications to decrease the amount of opioids required postoperatively and prescribed at discharge, in women who gave birth via cesarean.

Methods:

An interdisciplinary workgroup was convened to assess data on opioid use, prescribing practices at discharge, and nurses' use of alternative comfort strategies from January to March 2018. A comfort bundle was designed to include standardized use of preoperative acetaminophen, postoperative comfort education, simethicone, postoperative gum chewing, and abdominal binders. Nurses and healthcare providers were educated on the initiative. Data were reevaluated and compared with preintervention data assessing for improvement and adherence to the bundle components.

Results:

There was a 61% reduction in morphine milliequivalents given to women after cesarean birth between the first quarter in 2018 and the fourth quarter in 2018. Comparing March with December, 2018 data, adherence to each bundle component improved. The percentage of women receiving less than 20 tabs of oxycodone at discharge increased from 26.3% to 96.7%.

Implications for Nursing Practice:

Nurses should evaluate comfort options provided after cesarean birth and educate women about use of nonopioid pain relief strategies. A standardized process to address pain and comfort after cesarean birth may decrease exposure to opioids while maintaining comfort.
Sex Worker Community-led Interventions Interrupt Sexually Transmitted Infection/Human Immunodeficiency Virus Transmission and Improve Human Immunodeficiency Virus Cascade Outcomes: A Program Review from South India
Authors: Reza-Paul Sushena , Steen Richard , Maiya Raviprakash , Lorway Robert , Wi Teodora Elvira , Wheeler Tisha , Dallabetta Gina
Published: July 2019

Ashodaya Samithi, an organization run by and for female, male, and transgender sex workers in Mysore, India, has worked since 2004 to prevent sexually transmitted infection (STI)/human immunodeficiency virus (HIV) transmission and improve HIV cascade outcomes. We reviewed published and programmatic data, including measures of coverage, uptake, utilization and retention, and relate STI/HIV outcomes to evolving phases of community mobilization. Early interventions designed “for” sex workers mapped areas of sex work and reached half the sex workers in Mysore with condoms and STI services. By late 2005, when Ashodaya Samithi registered as a community-based organization, interventions were implemented “with” sex workers as active partners. Microplanning was introduced to enable peer educators to better organize and monitor their outreach work to reach full coverage. By 2008, programs were run “by” sex workers, with active community decision making. Program data show complete coverage of community outreach and greater than 90% clinic attendance for quarterly checkups by 2010. Reported condom use with last occasional client increased from 65% to 90%. Surveys documented halving of HIV and syphilis prevalence between 2004 and 2009, while gonorrhoea declined by 80%. Between 2005 and 2013, clinic checkups tripled, whereas the number of STIs requiring treatment declined by 99%. New HIV infections also declined, and Ashodaya achieved strong cascade outcomes for HIV testing, antiretroviral treatment linkage, and retention. Program performance dropped markedly during several periods of interrupted funding, then rebounded when restored. Ashodaya appear to have achieved rapid STI/HIV control with community-led approaches including microplanning. Available data support near elimination of curable STIs and optimal cascade outcomes.
Case Report: Perifoveal Exudative Vascular Anomalous Complex in a Chinese Patient with Diabetes Mellitus
Authors: Zhang Zhengwei , Xu Liping , Wu Zhifeng , Zhang Jie
Published: July 2019

SIGNIFICANCE

Perifoveal exudative vascular anomalous complex (PEVAC) is a recently described macular entity, which can be confused with other well-known vascular lesions such as retinal angiomatous proliferation. Perifoveal exudative vascular anomalous complex is more common than previously believed and is usually unresponsive to anti–vascular endothelial growth factor treatment. Clinicians should be aware of this disorder.

PURPOSE

The purpose of this study was to report a case of PEVAC using multimodal imaging in a Chinese patient with diabetes mellitus but without diabetic retinopathy, followed by a brief review of the relevant literature.

CASE REPORT

A 53-year-old Chinese woman with a 7-year history of diabetes mellitus presented with complaints of a 1-month history of deterioration of visual acuity in her right eye. Complete ophthalmic examination, including fundus examination of the right eye, revealed an isolated lesion immediately temporal to the fovea, accompanied by small hemorrhages and small, hard intraretinal exudates. Fluorescein fundus angiography revealed a well-defined hyperfluorescent lesion in the early phase but with leakage in the late phase. Optical coherence tomography revealed an oval lesion with a hyperreflective wall and relatively dark lumen, intraretinal cystic spaces, and hard exudates. Two intravitreal injections of aflibercept resulted in reduced blood flow in the PEVAC lesion, but with more hemorrhaging and hard exudates and no improvement in visual acuity.

CONCLUSIONS

Perifoveal exudative vascular anomalous complex is an isolated, perifoveal, aneurysmal abnormality. It can occur in healthy patients, in addition to those with diabetes mellitus without retinopathy. In contrast to similar macular vascular anomalies, PEVAC does not typically respond to anti–vascular endothelial growth factor therapy.
Evaluation of Pediatric Cardiac ICU Advanced Practice Provider Education and Practice Variation*
Authors: Justice Lindsey B. , Callow Louise , Loomba Rohit , Harvey Jennifer , FitzGerald Mike , Cooper David S.
Published: July 2019

Objectives:

The education, training, and scope of practice of cardiac ICU advanced practice providers is highly variable. A survey was administered to cardiac ICU advanced practice providers to examine specific variations in orientation format, competency assessment during and at the end of orientation, and scope of clinical practice to determine gaps in resources and need for standardization.

Design:

This study was a cross-sectional descriptive study utilizing survey responses.

Setting:

Pediatric cardiac ICUs in the United States.

Subjects:

The survey was delivered to a convenience sample of advanced practice providers currently practicing in pediatric cardiac ICUs.

Interventions:

A list of pediatric cardiothoracic surgery programs was generated from the Society of Thoracic Surgery database. A self-administered, electronic survey was delivered via email to advanced practice providers at those institutions. Descriptive data were compared using a chi-square test or Fisher exact test depending on the normalcy of data. Continuous data were compared using a Student t test or Mann-Whitney U test.

Measurements and Main Results:

Eighty-three of 157 advanced practice providers responded (53% response rate, representing 36 institutions [35% of institutions]). Sixty-five percent of respondents started as new graduates. Ninety-three to one-hundred percent obtain a history and physical, order/interpret laboratory, develop management plans, order/titrate medications, and respiratory support. Ability to perform invasive procedures was highly variable but more likely for those in a dedicated cardiac ICU. Seventy-seven percent were oriented by another advanced practice provider, with a duration of orientation less than 4 months (66%). Fifty percent of advanced practice providers had no guidelines in place to guide learning/competency during orientation. Sixty-seven percent were not evaluated in any way on their knowledge or skills during or at the end of orientation. Orientation was rated as poor/fair by the majority of respondents for electrophysiology (58%) and echocardiography (69%). Seventy-one percent rated orientation as moderately effective or less. Respondents stated they would benefit from more structured didactic education with clear objectives, standardized management guidelines, and more simulation/procedural practice. Eighty-five percent were very/extremely supportive of a standardized cardiac ICU advanced practice provider curriculum.

Conclusions:

Orientation for cardiac ICU advanced practice providers is highly variable, content depends on the institution/preceptor, and competency is not objectively defined or measured. A cardiac ICU advanced practice provider curriculum is needed to standardize education and promote the highest level of advanced practice provider practice.
Higher Prevalence of Health-Risk Factors Among US Adults With Unmet Health Care Needs Due to Cost, 2016
Authors: Xu Fang , Wheaton Anne G. , Liu Yong , Lu Hua , Greenlund Kurt J.
Published: July 2019

Context:

Adults with unmet health care needs (UHCN) due to cost have fewer opportunities to receive behavioral counseling in clinical settings, which may be associated with a higher likelihood of having health-risk behaviors.

Objective:

This study assessed associations between UHCN and health-risk factors.

Design/Setting:

We used 2016 Behavioral Risk Factor Surveillance System data to calculate age-adjusted weighted prevalence of 5 health-risk factors by UHCN and insurance status and to assess the association of UHCN with these factors using multivariable logistic regression.

Participants:

US adults aged 18 to 64 years who participated in the survey (N = 301 035).

Main Outcome Measures:

Five health-risk factors: obesity, current cigarette smoking, excessive alcohol use, sleeping less than 7 hours per 24-hour period, and no leisure-time physical activity within the past month.

Results:

In 2016, among adults aged 18 to 64 years, 11.2% of those with insurance and 40.1% of those without insurance (both age-adjusted) had UHCN. In both study populations, compared with adults with no UHCN, adults reporting UHCN were more likely to be a current cigarette smoker, report excessive alcohol use, and sleep less than 7 hours per 24-hour period. The prevalence of 3 or more health-risk factors was higher among adults with UHCN than among adults without UHCN (adults with insurance: adjusted prevalence ratio = 1.40; 95% confidence interval = 1.33-1.48; adults without insurance: adjusted prevalence ratio = 1.39; 95% confidence interval = 1.27-1.53).

Conclusions:

Unmet health care needs was associated with more health-risk factors regardless of insurance status. Addressing cost barriers to behavioral counseling may be one approach to consider when seeking to reduce health-risk behaviors among high-risk populations.
Extracellular Vesicles from Human Adipose-Derived Stem Cells for the Improvement of Angiogenesis and Fat-Grafting Application
Authors: Mou Shan , Zhou Muran , Li Yuan , Wang Jiecong , Yuan Quan , Xiao Peng , Sun Jiaming , Wang Zhenxing
Published: July 2019

Background:

The efficacy of autologous fat transplantation is reduced by fat absorption and fibrosis that are closely related to unsatisfactory vascularization. Extracellular vesicles are key components of the cell secretome, which can mirror the functional and molecular characteristics of their parental cells. Growing evidence has revealed that adipose-derived mesenchymal stem cells have the ability to enhance vascularization, which is partly ascribed to extracellular vesicles. The authors evaluated whether adipose-derived mesenchymal stem cell–derived extracellular vesicles improved vascularization of fat grafts and increased their retention rate.

Methods:

To test the angiogenesis ability of adipose-derived mesenchymal stem cell–derived extracellular vesicles, they were isolated from the supernatant of cultured human adipose-derived mesenchymal stem cells and incubated with human umbilical vein endothelial cells in vitro. Then, the vesicles were co-transplanted with fat into nude mice subcutaneously. Three months after transplantation, the retention rate and inflammatory reaction of the grafts were analyzed by histologic assay.

Results:

The experimental group could significantly promote migration and tube formation at the concentration of 20 μg/ml. At 3 months after transplantation, the volume of the experimental group (0.12 ± 0.03 mm3) was larger compared with the blank group (0.05 ± 0.01 mm3). Histology and immunohistology results demonstrated significantly fewer cysts and vacuoles, less fibrosis, and more neovessels in the extracelluar vesicle group.

Conclusions:

The authors co-transplanted adipose-derived mesenchymal stem cell–derived extracellular vesicles with fat into a nude mouse model and found that the vesicles improved volume retention by enhancing vascularization and regulating the inflammatory response.
Free-Breathing Fast Low-Angle Shot Quiescent-Interval Slice-Selective Magnetic Resonance Angiography for Improved Detection of Vascular Stenoses in the Pelvis and Abdomen
Authors: Varga-Szemes Akos , Aherne Emily A. , Schoepf U. Joseph , Todoran Thomas M. , Koktzoglou Ioannis , Edelman Robert R.
Published: July 2019

Objectives

Balanced steady-state free precession-based quiescent-interval slice-selective (bSSFP QISS) magnetic resonance angiography (MRA) is accurate for the noncontrast evaluation of peripheral arterial disease (PAD); however, drawbacks include the need for breath-holding when imaging the abdomen and pelvis, and sensitivity to off-resonance artifacts. The purpose of this study was to evaluate the image quality and diagnostic accuracy in the pelvis and abdomen of free-breathing fast low-angle shot-based QISS (FLASH QISS) techniques in comparison to bSSFP QISS in patients with PAD, using computed tomographic angiography as the reference.

Materials and Methods

Twenty-seven patients (69 ± 10 years, 17 men) with PAD were enrolled in this institutional review board–approved, Health Insurance Portability and Accountability Act–compliant prospective study between April and December 2018. Patients underwent noncontrast MRA using standard bSSFP QISS and prototype free-breathing radial-FLASH and Cartesian-FLASH QISS at 3 T. A subset of patients (n = 22) also underwent computed tomographic angiography as the reference standard. Nine arterial segments per patient were evaluated spanning the abdomen, pelvis, and upper thigh regions. Objective (signal intensity ratio and relative standard deviation) and subjective image quality (4-point scale) and stenosis (>50%) were evaluated by 2 readers and compared using one-way analysis of variance, Wilcoxon, and McNemar tests, respectively.

Results

A total of 179 vascular segments were available for analysis by all QISS techniques. No significant difference was observed among bSSFP, radial-FLASH, and Cartesian-FLASH QISS techniques in signal intensity ratio (P= 0.428) and relative standard deviation (P= 0.220). Radial-FLASH QISS demonstrated the best image quality (P< 0.0001) and the highest interreader agreement (κ = 0.721). The sensitivity values of bSSFP, radial-FLASH, and Cartesian-FLASH QISS for the detection of greater than 50% stenosis were 76.0%, 84.0%, and 80.0%, respectively, whereas specificity values were 97.6%, 94.0%, and 92.8%, respectively. Moreover, FLASH QISS consistently reduced off-resonance artifacts compared with bSSFP QISS.

Conclusions

Free-breathing FLASH QISS MRA techniques provide improved image quality and sensitivity, high specificity, and reduced off-resonance artifacts for vascular stenosis detection in the abdomen and pelvis.
Characterizing and Assessing the Impact of Surgery on Healthcare Spending Among Medicare Enrolled Preoperative Super-utilizers
Authors: Hyer J. Madison , Ejaz Aslam , Diaz Adrian , Tsilimigras Diamantis I. , Gani Faiz , White Susan , Pawlik Timothy M.
Published: July 2019

Objective:

The aim of this study was to characterize preoperative super-utilizers and examine the effect of surgery on service utilization among patients undergoing major elective surgery.

Summary Background Data:

Rising healthcare costs are becoming increasingly burdensome for Medicare. Super-utilizers have been increasingly identified and studied as this subset of patients consume a disproportionate amount of healthcare services compared with the majority of the population.

Methods:

Patients aged 65 or older who underwent any of the following general elective surgeries: abdominal aortic aneurysm repair (AAA), coronary artery bypass graft (CABG), colectomy, or hip replacement were identified using 100% Medicare Inpatient and Outpatient Standard Analytic Files (SAFs) from years 2012 to 2016. Medicare inpatient and outpatient expenditures the year before surgery, around the time of surgery, and the year after surgery were examined.

Results:

Among 603,105 Medicare beneficiaries, 32,145 patients (5.3%) were categorized as super-utilizers. Compared with low-utilizers, super-utilizers were more likely to be male (low-utilizer vs super-utilizer: 47.9% vs 54.2%) and African American (4.0% vs 7.2%), whereas 58.8% (n = 208,080) of low-utilizers presented without any comorbidity [Charlson Comorbidity Index (CCI) = 0] and 49.8% (n = 16,007) of super-utilizers presented with a CCI score of ≥3. Total preoperative spending among super-utilizers was approximately $1.7 billion with a median of $3,159 [interquartile range (IQR): $554–$15,181] per beneficiary. Spending among super-utilizers accounted for 39.6% of total spending for all Medicare beneficiaries versus only 8.4% among low-utilizers. Although the median spending per Medicare beneficiary in the year after surgery was higher for super-utilizers compared with low-utilizers [$1,837 (IQR: $341–$11,390) vs $18,223 (IQR: $3,466–$43,356)], super-utilizers accounted for 13.5% of total postoperative spending. The reduction in adjusted average annual Medicare expenditure ranged from >$15,000 per year for patients undergoing CABG to approximately $30,000 per year for patients undergoing a hip replacement.

Conclusions:

Although super-utilizers accounted for only 5.3% of patients, these patients accounted for 39.6% of total Medicare expenditures in the year before surgery. Among a subset of super-utilizers, surgical intervention was associated with a reduction in annual Medicare expenditure in the year after surgery.
ALPPS Versus Portal Vein Embolization for Hepatitis-related Hepatocellular Carcinoma
Authors: Chan Albert , Zhang Wei Yi , Chok Kenneth , Dai Jeff , Ji Ren , Kwan Crystal , Man Nancy , Poon Ronnie , Lo Chung Mau
Published: July 2019

Objective:

The aim of this study was to evaluate the short- and long-term outcome of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for hepatitis-related hepatocellular carcinoma (HCC).

Summary Background Data:

ALPPS has been advocated for future liver remnant (FLR) augmentation in liver metastasis or noncirrhotic liver tumors in recent years. Data on the effect of ALPPS in chronic hepatitis or cirrhosis-related HCC remained scarce.

Methods:

Data for clinicopathological details, portal hemodynamics, and oncological outcome were reviewed for ALPPS and compared with portal vein embolization (PVE). Tumor immunohistochemistry for PD-1, VEGF, and AFP was evaluated in ALPPS and compared with PVE and upfront hepatectomy (UH).

Results:

From 2002 to 2018, 148 patients with HCC (hepatitis B: n = 136, 92.0%) underwent FLR modulation (ALPPS, n = 46; PVE: n = 102). One patient with ALPPS and 33 patients with PVE failed to proceed to resection (resection rate: 97.8% vs 67.7%, P < 0.001). Among those who had resections, 65 patients (56.5%) had cirrhosis. ALPPS induced absolute FLR volume increment by 48.8%, or FLR estimated total liver volume ratio by 12.8% over 6 days. No difference in morbidity (20.7% vs 30.4%, P = 0.159) and mortality (6.5% vs 5.8%, P = 1.000) with PVE was observed. Chronic hepatitis and intraoperative indocyanine green clearance rate ≤39.5% favored adequate FLR hypertrophy in ALPPS. Five-year overall survival for ALPPS and PVE was 46.8% and 64.1% (P = 0.234). Tumor immunohistochemical staining showed no difference in expression of PD-1, V-EGF, and AFP between ALPPS, PVE, and UH.

Conclusions:

ALPPS conferred a higher resection rate in hepatitis-related HCC with comparable short- and long-term oncological outcome with PVE.