bluuebunny/crossref_metadata_2025 huggingface dataset:
Treatment of primary and secondary immune thrombocytopenia
Authors: Kado Ruba , McCune W. Joseph
Published: March 2019

Purpose of review

Medical therapies for the treatment of immune thrombocytopenia (ITP) complicating SLE are increasingly being investigated as alternatives to splenectomy and IVIG. The purpose of this review is to highlight the therapies that are utilized in the treatment of primary ITP and ITP secondary to lupus.

Recent findings

Corticosteroids are still the standard initial treatment of ITP, with the addition of IVIG when a rapid response is needed. There are few studies dedicated to assessing the efficacy of disease-modifying antirheumatic (DMARD), biologic, and nonimmunosuppressive agents as treatment for lupus thrombocytopenia/lupus ITP. Rituximab and thrombopoeitin mimetics have been the most extensively studied therapies for primary ITP in recent years. Results of trials show adequate initial responses; however, the duration of therapy and sustainability of responses are variable. Splenectomy is less often utilized.

Although corticosteroids, intravenous immunoglobulin and splenectomy have proven to be effective measures to treat immune thrombocytopenia, newer studies have demonstrated positive outcomes of immunosuppressives and thrombopoeitin mimetics. In most cases, the reported duration of therapy was not prolonged. More studies are needed to fully assess the effect of medical therapy in lupus ITP and to determine how long to continue maintenance therapy.
C-reactive protein: what to expect after bony hip surgery for nonambulatory children and adolescents with cerebral palsy
Authors: Dick Alastair G. , Magill Nicholas , White Thomas C.H. , Kokkinakis Michail , Norman-Taylor Fabian
Published: March 2019

Bony hip reconstruction surgery in children with severe cerebral palsy is associated with high complication rates, usually postoperative chest and urinary tract infections. C-reactive protein (CRP) level is commonly used as an indication of infection; an understanding of its normal postoperative trends is crucial to allow early identification of abnormal levels and possible infection. Our aim was to describe the trends in CRP following bony hip surgery in children who had an uneventful postoperative course, on the basis that the children for whom CRP does not follow this course are likely to have a bacterial infection. A retrospective review was performed of 155 children with CP having bony hip surgery between 2012 and 2016. The median age was 9.9 years (interquartile range: 6.6–12.7). One hundred (64.5%) patients had a Gross Motor Function Classification System rating of V. All CRP levels measured in routine postoperative care were recorded, and medical records were examined for postoperative infective complications. The CRP levels of patients with clinically proven infections were excluded in order to describe what to expect in the absence of infection. Mean CRP peaked on the third postoperative day at 81 mg/l in those who had no postoperative infection. Twenty-five (16.1%) patients had a postoperative infection; their mean CRP was higher on all postoperative days and peaked at 128 mg/l on the third postoperative day. An understanding of the normal postoperative trends in CRP allows identification of those with abnormally raised levels. Postoperative CRP is consistently higher in children with an infective complication. We recommend that the CRP should be routinely checked following bony hip surgery in children with CP, and a careful search for infection undertaken in those with a raised level.
Are CT Scans Overutilized in the Workup of Vertebral Compression Fractures?
Authors: McGowan Shane M. , Ramski David E. , Homcha Brittany , Sokunbi Gbolabo
Published: March 2019

Study Design:

This was a retrospective chart review.

Objectives:

Computed tomography (CT) does not aid in determination of compression fracture chronicity and contributes to higher cost and radiation exposure. An examination of extraneous imaging will help to guide appropriate workup.

Summary of Background Data:

Cost for osteoporotic fracture treatment has been estimated at $17 billion annually; future costs are anticipated to increase by at least 50%.

Materials and Methods:

A chart review evaluated patients who received kyphoplasty or vertebroplasty as part of compression fracture treatment. The primary end point of the study was analysis of unnecessary imaging obtained during workup. The secondary outcome was excess radiation exposure incurred from unneeded imaging studies.

Results:

There were 104 instances (40.2% of n=259 workups) where patients underwent only magnetic resonance imaging (MRI) or bone scan after radiographs. There were 28 instances (10.8%) where patients underwent only radiographs with a comparison study. There were a total of 76 instances (29.3%) where patients underwent extraneous CT scans and 13 instances (5%) where patients underwent both MRI and bone scan, causing an average of 979.4 mGy cm additional radiation exposure.

Conclusions:

We recommend an algorithm that favors radiographs with comparison study or acquiring either MRI or bone scan to determine acuity. If these are available, CT scan becomes unnecessary and incurs increased costs and radiation exposure.
Thromboelastography Predicts Thromboembolism in Critically Ill Coagulopathic Patients*
Authors: Harahsheh Yusrah , Duff Oonagh C. , Ho Kwok M.
Published: March 2019

Objectives:

Critically ill patients with deranged conventional coagulation tests are often perceived to have an increased bleeding risk. Whether anticoagulant prophylaxis for these patients should be withheld is contentious. This study assessed the ability of using in vitro clot strength, as measured by thromboelastography, to predict thromboembolism in patients with abnormal coagulation profiles.

Design:

Prospective cohort study.

Setting:

A tertiary ICU.

Patients:

Two-hundred and fifteen critically ill coagulopathic patients with thrombocytopenia and/or a derangement in at least one conventional coagulation test (international normalized ratio or activated partial thromboplastin time) within 48 hours of ICU admission.

Interventions:

None.

Measurements and Main Results:

Thromboelastography was performed for all study patients, and plasma thrombotic biomarkers were measured in a nested cohort (n = 40). Of the 215 patients included, 34 patients (16%) developed subsequent thromboembolism—predominantly among those with a normal (maximum amplitude, 54–72 mm) or increased (maximum amplitude, > 72 mm) in vitro clot strength on thromboelastography (91%; area under the receiver-operating characteristic curve, 0.74; 95% CI, 0.64–0.83). The ability of the maximum amplitude to predict thromboembolism was comparable to plasma P-selectin concentrations (thromboembolism, 78.3 ng/mL vs no thromboembolism, 59.5 ng/mL; p = 0.031; area under the receiver-operating characteristic curve, 0.73; 95% CI, 0.52–0.95). In addition, patients with an increased maximum amplitude were also less likely to receive blood product transfusions within 24 hours of testing compared with those with a subnormal maximum amplitude (12.8% vs 69.2%, respectively; area under the receiver-operating characteristic curve, 0.74; 95% CI, 0.67–0.80).

Conclusions:

In patients with abnormal coagulation profiles, an increased in vitro clot strength on thromboelastography was associated with an increased risk of thromboembolism, and a reduced risk of requiring transfusion compared with those with a normal or reduced in vitro clot strength.
Effect of green tea and lycopene on the insulin-like growth factor system: the ProDiet randomized controlled trial
Authors: Biernacka Kalina M. , Holly Jeff M.P. , Martin Richard M. , Frankow Aleksandra , Bull Caroline J. , Hamdy Freddie C. , Donovan Jenny L. , Neal David E. , Metcalfe Chris , Lane Athene
Published: March 2019

Whether prostate cancer (PCa) may be preventable by dietary interventions can be assessed in randomized trials using intermediate biomarkers of cancer risk or progression. We investigated whether lycopene or green tea modify circulating insulin-like growth factor (IGF) peptides in men at increased risk of PCa. Participants (aged 50–69 years) in one centre in the UK wide PCa testing and treatment trial (ProtecT) with prostate specific antigen between 2.0 and 2.95 ng/ml or negative biopsies, were randomized to daily lycopene (n = 44 assigned 15 mg capsules/day; 44 assigned a lycopene-rich diet; 45 assigned placebo) and green tea (n = 45 assigned 600 mg/day epigallocatechin gallate; 45 assigned green tea drink; 43 assigned placebo) for 6 months. The interventions significantly elevated the primary outcomes, serum epigallocatechin gallate and lycopene at 6 months of follow-up. We report here an exploratory analysis in which serum IGF-I, IGF-II, IGF binding protein (BP)-2 and IGFBP-3 were measured at baseline and 6 months of postintervention. A total of 133 men were randomized (34% of eligible men approached) and 130 had follow-up IGF peptides (98%). In intention-to-treat analyses, there was only weak evidence that lycopene or green tea influenced some aspects of serum IGF-I, IGF-II, IGFBP-2 or IGFBP-3. In men randomized to lycopene supplements, IGFBP-2 was nonsignificantly (50.9 ng/ml; 95% confidence interval: −51.2–152.9, P = 0.3) higher in comparison to placebo, whereas in men randomized to green tea supplements, IGFBP-3 was nonsignificantly (205.2 ng/ml; 95% confidence interval: −583.3–172.9, P = 0.3) lower than with placebo. In this small, pilot randomized controlled trial, there was little evidence that lycopene or green tea interventions influenced serum levels of IGF-I, IGF-II, IGFBBP-3 and IGFBP-2. However, the effects were imprecisely estimates and some observed trends may justify larger trials.
Subcutaneous Panniculitis-Like T-Cell Lymphoma With Granulomas as the Predominant Feature
Authors: Lee Christine , Hsi Andy , Lazova Rossitza
Published: March 2019

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a rare primary cutaneous lymphoma preferentially localized in the subcutaneous adipose tissue and composed of cytotoxic T cells with an α/β immunophenotype. The neoplastic T cells can be variably admixed with other inflammatory cells, including histiocytes, which can rarely form noncaseating granulomas. We present a case of SPTCL in which granulomas are the predominant feature, composing 75%–80% of the inflammatory infiltrate. The top differential diagnoses included infectious and autoimmune etiologies. However, special stains for microorganisms were negative, and immunohistochemical analysis of the atypical lymphocytes showed a CD3+, CD8+, TIA-1+, T-cell receptor (TCR) beta+, and CD4
−
infiltrate with a high Ki67 proliferation index of approximately 30%. TCR gene rearrangement studies by polymerase chain reaction with confirmation by high-throughput sequencing were necessary to exclude an autoimmune etiology, specifically lupus erythematosus panniculitis. To the best of our knowledge, only 1 other case of SPTCL with prominent granulomas has been reported in the literature. It is important for dermatopathologists to recognize this presentation of SPTCL. SPTCL with predominant granulomas should be included in the differential diagnosis of granulomatous panniculitis along with infectious and autoimmune panniculitides as well as other granulomatous lymphomas.
Parent and Provider Perspectives on the Diagnosis and Management of Autism in a Chinese Immigrant Population
Authors: Sakai Christina , Mulé Christina , LeClair Amy , Chang Frances , Sliwinski Samantha , Yau Yoyo , Freund Karen M.
Published: March 2019

Objective:

Minority families experience disparities in the diagnosis and management of autism spectrum disorder (hereafter “autism”). To date, the experiences of Chinese immigrant families in the United States have not been explored. Utilizing parent and provider perspectives, this research sought to identify barriers and facilitators to the diagnosis and management of autism among Chinese immigrant children.

Methods:

We conducted semistructured qualitative interviews with 16 parents of Chinese children diagnosed with autism and 16 providers who assist in the diagnosis and management of autism. Participant characteristics were analyzed utilizing descriptive statistics. Interviews were audiorecorded, transcribed, translated, and independently coded by 2 researchers until consensus was reached. Coded data were analyzed using a modified grounded therapy approach.

Results:

Parents and providers both identified cultural beliefs as an influence on the understanding and acceptance of autism as a diagnosis. There was a high degree of alignment in themes related to barriers to health care access and parent-provider communication. Recommendations to improve the system of care include (1) supporting communication, (2) cultural sensitivity, and (3) care coordination programming.

Conclusion:

Findings reinforce that diagnosis and treatment of autism should take into account culturally specific beliefs about child developmental norms and should address systems-, provider-, and family-level barriers.
A Case of Velocardiofacial Syndrome With Bilateral Inferior Punctum and Canalicular Agenesis
Authors: Lemaitre Stéphanie , Sarandeses Diez Teresa , Gonzalez-Candial Miguel
Published: March 2019

A 16-year-old girl diagnosed with velocardiofacial syndrome complained of occasional bilateral ocular discharge. Examination revealed an agenesia of the inferior puncti and canaliculi, while the irrigation through the superior puncta was patent on both sides. Dacryocystorhinostomy with insertion of Lester Jones tubes is not considered for the time being because of the absence of epiphora. To the best of the authors’ knowledge, this is the second reported case of lacrimal system agenesia in velocardiofacial syndrome.
Single Suture Müeller Muscle Conjunctival Resection (ssMMCR): A Modified Technique for Ptosis Repair
Authors: Ediriwickrema Lilangi S. , Geng June , Nair Archana A. , Prendes Mark , Gerber Austin L. , Yang Patrick T. , Liu Catherine Y. , Nunery William R. , Harold Lee H.B. , Kikkawa Don O. , Korn Bobby S.
Published: March 2019

Purpose:

To evaluate the efficacy in degree of ptosis correction achieved by single suture Müeller muscle conjunctival resection (ssMMCR) when compared with that of traditional MMCR.

Methods:

A retrospective chart analysis of patients who underwent either ssMMCR or traditional MMCR at 2 institutions. Single suture MMCR was performed after using a ptosis clamp to imbricate conjunctiva and Müeller muscle. Margin-to-reflex distance 1 was measured pre- and postoperatively, and the change in margin-to-reflex distance 1 was analyzed for both groups. Patients were monitored in follow up for postoperative complications including lagophthalmos, corneal abrasions, and change in visual acuity. Statistical analysis was performed using the Microsoft Excel and Stata software programs.

Results:

Twenty-seven and 30 patients underwent single suture and traditional MMCR, respectively. The ssMMCR and MMCR groups were followed postoperatively for approximately 4.2 and 9.7 months, respectively and the average margin-to-reflex distance 1 increased by 2.93 mm and 2.81 mm, respectively. Notably, there was no statistically significant difference in the means identified by t test. Of the 94 eyelid surgeries evaluated, 1 ssMMCR and 3 MMCR eyelids required further surgical revision for persistent ptosis, and 1 ssMMCR developed a transient corneal epithelial abrasion. Surgical revisions were rare with both procedures, and patient satisfaction was high.

Conclusions:

Single suture MMCR is an efficient and effective method for ptosis repair. It results in comparable outcomes including elevation in margin-to-reflex distance 1, safety profile, and reoperation rates, when compared with traditional MMCR.
Improving Operational Efficiency, Effectiveness, and Value in Acute Care Physical Therapy Using the Therapy Value Quotient
Authors: Hull Brian L. , Thut M. Catherine
Published: March 2019

Background and Purpose:

The shift in health care is toward value. However, operational efficiency measurement remains volume driven. Using behavioral economic heuristic theories and the Therapy Value Quotient (TVQ) as a basis for decision-making, the authors hypothesized that clinicians would demonstrate more effective and efficient clinical outcomes compared with the control group outcomes using traditional productivity decision-making heuristics.

Methods:

A quasiexperimental study design with quantitative analysis using the TVQ calculator was used. Also, an anonymous questionnaire on perceived decision-making empowerment and a semistructured focus group discussion with qualitative thematic analysis was used to understand better the heuristic strategies employed while trying to improve the TVQ Value Quotient.

Results:

Overall, the Value Quotient increased 14.7% resulting from a multitude of subcomponent improvements including increasing Activity Measure for Post-Acute Care (AM-PAC) Inpatient Mobility Short Form (IMSF) average change 28% from 2.84 to 3.64 points and decreasing Cost per Visit 8.9%. In addition, TVQ use improved clinician value focus, engagement, and perceived empowerment as evidenced by the 5 identified themes: (1) improved efficiency and staffing, (2) improved teamwork, (3) improved focus on value and not units, (4) improved patient-centeredness, and (5) professional empowerment.

Discussion:

Pursuing the simplicity of basic value-focused goals using the TVQ along with fast and frugal System 1 heuristics was more efficient and provided higher aggregated value compared with baseline management practice of units (Visits, Current Procedural Terminology codes, Relative Value Units) generated per hour. Furthermore, using the TVQ facilitated a paradigm shift from typical acquisition of units per hour worked to promoting an emphasis on delivering the highest overall value. The authors recommend acute care hospitals adopt the TVQ as a primary operational measurement to promote the highest value utilization of acute care physical therapy resources.
Effect of Digital Storytelling on Anxiety in Patients Who Are Candidates for Open-Heart Surgery
Authors: Moghimian Maryam , Akbari Mohammad , Moghaddasi Jafar , Niknajad Rayhaneh
Published: March 2019

Background

Open-heart surgery in persons with cardiovascular disease is associated with high levels of anxiety.

Objective

The goal of this study was to determine the effect of digital storytelling on anxiety in patients who were candidates for open-heart surgery.

Methods

In this quasi-experimental study, 80 patients were randomly allocated into 2 groups. The intervention group received routine training and digital storytelling. In each group, anxiety was measured by the State-Trait Anxiety Inventory anxiety scale before surgery and 5 days after surgery. The collected data were analyzed using SPSS software V18.

Results

There was no significant difference in the anxiety of both groups during the 2 days before the surgery (P = .40). After the surgery, the mean of anxiety scores in the intervention group was lower than that of the control group (P < .001).

Conclusions

Digital storytelling is an effective method to reduce anxiety in patients who are candidates for open-heart surgery.
Lithium Augmentation Versus Citalopram Combination in Imipramine-Resistant Major Depression
Authors: Navarro Víctor , Boulahfa Ilham , Obach Amadeu , Jerez Dídac , Diaz-Ricart Maribel , Gastó Cristóbal , Guarch Joana
Published: March 2019

Purpose/Background

According to available international clinical guides, tricyclic antidepressants are our first- or second-line treatment of choice for severe unipolar major depression. However, the therapeutic option after an unsuccessful response to a tricyclic antidepressant drug in unipolar major depression is still unclear.

Methods/Procedures

This 10-week randomized open-label study assessed the effectiveness of add-on lithium (adjusted to plasma levels) compared with add-on citalopram (30 mg/d) in 104 severe unipolar major depressive patients after a 10-week unsuccessful imipramine (adjusted to plasma level). Efficacy analyses examined changes in the severity of depression symptoms from baseline visit to endpoint and the comparative remission rate between treatment subgroups.

Findings/Results

The randomized sample consisted of 104 imipramine-resistant severe unipolar major depressed patients. Both, the percentage of remitters (40.4% vs 21.1%, P = 0.034) and the mean reduction of the Hamilton Depression Rating Scale score (58.8% vs 42.5%, P = 0.005) were significantly greater in the add-on citalopram subgroup at endpoint visit.

Implications/Conclusions

Although we should be cautious about generalizing these results to patients with a less severe unipolar major episode, results from the present study suggest that add-on citalopram is a very effective treatment option in unipolar major depressive episodes after an unsuccessful imipramine regimen.
Projected Health Care Associated Costs of Workplace-Related Traumatic Amputation After 10, 15, and 20 Years: Part I: Lower Limb
Authors: Wanamaker Andrea B. , Andridge Rebecca R. , Chaudhari Ajit M.W.
Published: March 2019

Introduction

Previous research has determined the impact of different types of lower-limb prostheses on functional and biomechanical outcomes. Little work, however, has examined the effect of amputation and prostheses on health care costs. The purpose of this investigation was to estimate long-term health care associated costs in individuals with lower-limb amputation of varying limb loss level.

Materials and Methods

An insurance claims database was obtained via a public records request from the Ohio Bureau of Workers’ Compensation for 361 persons who experienced a traumatic injury in the workplace that resulted in lower-limb amputation. Insurance claims included costs associated with prosthetic limbs and equipment, general hospital care, physical therapy, vocational therapy, prescription medication, and additional health care categories. The population was categorized into two limb loss levels: persons with unilateral transtibial amputation and persons with transfemoral amputation. Prosthetic insurance claim codes were examined to determine and classify the type of prostheses prescribed, based on Medicare guidelines for activity levels (K1–K4), to estimate yearly health care costs associated with each type of prosthesis. These data were used to construct Markov decision models to estimate the expected distribution of long-term (10, 15, and 20 years) health care costs after receiving a prosthesis associated with transtibial and transfemoral amputation.

Results

Sixty-two persons with transfemoral amputation and 108 persons with transtibial amputation met our inclusion/exclusion criteria. Average time between prosthesis prescriptions varied based on activity and limb loss levels, and on average, individuals with transtibial amputation received a new prosthesis every 1.3 ± 1.6 years and individuals with transfemoral amputation every 2.3 ± 1.8 years. Annual costs associated with activity and limb loss levels varied greatly over time, ranging from $3,000 to $150,000 per patient. Projected health care associated costs totaled $546,067 ± $293,411 and $253,766 ± $142,206 over 20 years for transfemoral and transtibial amputations, respectively.

Conclusions

The results of this cost investigation provide new information regarding all aspects of health care for individuals with lower-limb amputation, including trends in prosthesis prescription and yearly costs, and how prosthetic prescription may alter these long-term costs.
Implementation of a virtual patient-centered weight loss maintenance behavior competency assessment in adults with obesity
Authors: Brunacini Kevin
Published: March 2019

Background:

Evidence shows that 95%–98% of individuals who undergo a diet for weight loss purposes will gain back their weight within 5 years.

Local problem:

No standardized method exists to assess weight loss maintenance (WLM) behavior competencies in patients who lose weight within a telehealth nutritional counseling private practice. Incorporating this assessment can be used to increase patient self-efficacy and predict a patient's likelihood of long-term weight success.

Methods:

A quality improvement project, implementing four rapid plan-do-study-act cycles, was conducted. Each cycle included tests of change related to team and patient engagement, implementation of a WLM assessment, and an audit adherence. Data were analyzed using run charts to evaluate the impact of interventions on outcomes.

Interventions:

The clinical team submitted a weekly WLM competency survey. A patient intake form was completed to identify behavior risks, followed by implementation of a WLM assessment in weekly follow-ups. A team adherence audit was completed and submitted every week.

Results:

Team WLM competency levels increased 32%, averaging 82% at study conclusion. Completion of the patient intake form reached and held at 100% for the entire duration. Team usage of the WLM assessment peaked at 97%, correlating to increased patient behavior competence by 27.5% as the patient advanced. Team adherence gradually increased, peaking at 100%.

Conclusions:

Patient screening forms and audit logs created a standardized process to collect, deliver, and better coordinate care. The findings suggest that patients who embodied higher behavioral competence will have a greater likelihood of sustaining their weight results and become the successful 2%–5% of weight maintainers.
Omega-3 and ranibizumab for age-related macular degeneration
Authors: Meng Yan , Liu Hong-wei , Sun Peng , Zhou Ping-ping , Wang Jian-jie
Published: March 2019

Background:

Omega-3 and ranibizumab (O3R) has been reported to treat age-related macular degeneration (ARMD) effectively. However, up to the present, no systematic review specifically addressed the efficacy of O3R for the treatment of ARMD. Therefore, in this study, we will propose to assess the efficacy and safety of O3R for the treatment of ARMD.

Methods:

We will search PUMBED, EMBASE, CINAHI, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, Cochrane Library, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, VIP Information, Wanfang Data, as well as the gray literature from inception up to the present. We will accept randomized controlled trials for assessing the efficacy and safety of O3R for ARMD. The primary outcomes include change in best corrected visual acuity and central retinal thickness. The secondary outcomes consist of changes in subfoveal choroidal thickness, macular atrophy, retinal average sensitivity, contrast sensitivity, glare disability, and quality of life. In addition, incidence and severity of adverse events will also be evaluated. Cochrane Collaboration tool will be used to assess the risk of bias for each included study. In addition, Grading of Recommendations Assessment, Development, and Evaluation tool will be utilized to assess the overall strength of the evidence. Two authors will independently carry out all procedures and any divergences will be solved through discussion with a third author. If it is possible, we will conduct meta-analysis and subgroup analysis concerning different interventions, risk of bias, and outcome measurements.

Results:

In this proposed study, we outline details of the aims and methods of efficacy and safety of O3R for the treatment of ARMD.

Conclusion:

The findings of this systematic review will summarize current evidence of O3R for the treatment of patients with ARMD.

Dissemination and ethics:

The results of the present study are expected to be published by peer-reviewed journals. This is a literature-based study. Thus, ethical approval is unnecessary for this study.

Systematic review registration:

PROSPERO CRD42019121177.
Efficacy and safety of adjunctive corticosteroids therapy for patients with severe community-acquired pneumonia
Authors: Huang Jing , Guo Jiquan , Li Hongtao , Huang Weibin , Zhang Tiantuo
Published: March 2019

Background:

The systemic use of corticosteroids for patients in severe community-acquired pneumonia (CAP) remains disputed in clinical practice. We undertook a systematic review and meta-analysis to assess the efficacy and safety of corticosteroids in patients with severe CAP.

Methods:

We searched MEDLINE (1946 to June 2018), EMBASE (1966 to June 2018), and the Cochrane Library database for randomized controlled trials (RCTs) conducted for severe CAP. The endpoints of the study included total mortality, length of intensive care unit (ICU) stay and mechanical ventilation.

Results:

Nine trials which contained 914 patients were included for final meta-analysis. Of the 488 patients in the corticosteroid group, there were 37 deaths (7.58%) and 56 deaths occurred in 426 patients in the control group (13.1%). Corticosteroid therapy was associated with a lower rate of all-cause mortality compared to control (odd ratio [OR] 0.63, 95% confidence interval [CI] 0.42–0.95, P = .03). Subgroup analysis was conducted to show that the drug type modified the effect of steroids for mortality rate: prednisolone or methylprednisolone therapy (OR 0.37, 95% CI 0.19–0.72) reduced total mortality, whereas hydrocortisone use did not (OR 0.90, 95% CI 0.54–1.49). We found the length of ICU stay was significantly shorter in the steroid group compared to control (MD −2.52 days, 95% CI −4.88 to −0.15; P = .04). And there was a reduction trend in the need for mechanical ventilation in corticosteroid group (OR 0.53, 95% CI 0.28–1.02; P = .06). There was no trend towards more adverse events in the corticosteroid arm compared to control (OR 0.92, 95% CI 0.58–1.47; P = .74).

Conclusion:

Overall, adjunctive systemic corticosteroids therapy was effective and safe for patients with severe CAP. In addition, the effects of mortality may differ according to the type of corticosteroids.
miRNAs expression of oral squamous cell carcinoma patients
Authors: Chamorro Petronacci Cintia Micaela , Pérez-Sayáns Mario , Padín Iruegas María Elena , Suárez Peñaranda José M. , Lorenzo Pouso Alejandro Ismael , Blanco Carrión Andrés , García García Abel
Published: March 2019

microRNA expression patterns have provided new directions in the search of biomarkers with prognostic value and even in the search of novel therapeutic targets for several neoplasms. Specifically, miRNAs profiling in oral squamous cell carcinoma (OSCC) represents a web of intrigue in the study of oral carcinogenesis. The objective of the present study was twofold:

The first study phase comprised case-control groups: A) 8 OSCC-affected patients and 8 healthy controls. Microarray technology (Affymetrix miRNA Array Plate 4.1) was used for miRNAs expression profile. Deregulated miRNAs were studied using Diana Tools miRPath 3.0 to associate miRNA targets with molecular pathways via Kyoto Encyclopedia of Genes and Genomes (KEGG). In a second phase, 2 miRNAs chosen for the subsequent RT-qPCR validation were studied in a second OSSC cohort (n = 8).

Microarray analysis identified 80 deregulated miRNAs (35 over-expressed and 45 under-expressed). Two miRNAs (miR-497-5p and miR-4417) were chosen for further validation via RT-qPCR. Prognostic analysis did not ascertain relevant relation between miR-497-5p or miR-4417 expression and clinical or pathological parameters, except high miR-4417 in the case of nodular affectation (P = .035) and diminished miR-497-5p radiotherapy-treated patients (P = .05). KEGG analysis revealed that deregulated miRNAs were implicated in several biological pathways such as Proteoglycans in cancer.

Our data suggest an altered miRNAs profiling in OSCC-affected patients. We have verified the altered expression of miR-497-5p and miR-4417 in OSCC samples and related the deregulated miRNAs with the ‘proteoglycans in cancer’ pathway. Further longitudinal studies with large samples are warranted to confirm the present findings.
Evaluation of three-dimensional iterative image reconstruction in C-arm-based interventional cone-beam CT
Authors: Suzuki Shigeru , Katada Yoshiaki , Takayanagi Tomoko , Sugawara Haruto , Ishikawa Takuya , Yamamoto Yuzo , Wada Hiroo
Published: March 2019

We compared images obtained using a three-dimensional iterative image reconstruction (3D-IIR) algorithm for C-arm-based interventional cone-beam computed tomography (CBCT) with that using the customary reconstruction technique to quantify the effect of reconstruction techniques on image quality.

We scanned 2 phantoms using an angiography unit with digital flat-panel system—an elliptical cylinder acrylic phantom to evaluate spatial resolution and a Catphan phantom to evaluate CT number linearity, image noise, and low-contrast resolution. Three-dimensional imaging was calculated using Feldkamp algorithms, and additional image sets were reconstructed using 3D-IIR at 5 settings (Sharp, Default, Soft+, Soft++, Soft+++). We evaluated quality of images obtained using the 6 reconstruction techniques and analyzed variance to test values of the 10% value of each MTF, mean CT number, and contrast-to-noise ratio (CNR), with P < .05 considered statistically significant.

Modulation transfer function curves and CT number linearity among images obtained using the customary technique and the 5 3D-IIR techniques showed excellent agreement. Noise power spectrum curves demonstrated uniform noise reduction across the spatial frequency in the iterative reconstruction, and CNR obtained using all but the Sharp 3D-IIR technique was significantly better than that using the customary reconstruction technique (Sharp, P = .1957; Default, P = .0042; others, P < .0001). Use of 3D-IIR, especially the Soft++ and Soft+++ settings, improved visualization of low-contrast targets.

Use of a 3D-IIR can significantly improve image noise and low-contrast resolution while maintaining spatial resolution in C-arm-based interventional CBCT, yielding higher quality images that may increase safety and efficacy in interventional radiology.
Laparoscopic surgery
Authors: Yu Xiaoming , Cai He , Guan Jing , Zheng Xingbang , Han Hongjing
Published: March 2019

Patients who undergo several in-vitro fertilization (IVF) treatment cycles and fail to conceive present a frustrating problem to the clinician. When 1 cycle of IVF treatment fails, should we offer the couples to choose additional cycle of IVF instead of evaluation of the potential peritoneal factor? In cases of otherwise unexplained infertility, the investigation cannot be considered to be complete until laparoscopy has been performed. The aim of the study is to investigate the fertility outcome of laparoscopic treatment in infertile women with repeated IVF failures.

This is a retrospective case-control study conducted in a tertiary care, academic teaching hospital from January 2012 to December 2015. Patients recruited in this study were classified into 2 groups. Study group (n = 45) were offered laparoscopy for evaluation of infertility, control group (n = 45) elected to proceed to IVF without laparoscopy. Diagnostic laparoscopy and subsequent excision of suspected endometriotic lesions, lysis of adhesion and treatment of tubal pathology were performed when indicated.

Forty-four (97.8%) patients in study had pelvic pathologies and the treatment was performed at the same time. Twenty-four patients in study group conceived including 16 patients conceived spontaneously and 14 patients conceived with additional IVF following laparoscopy management. There was a significant difference in the ongoing pregnancy rates between patients conceived through IVF in study group and control group (41.9% vs 19.6%, P 
< .05).

Laparoscopy in women with normal hysterosalpingography but recurrent IVF failures can detect unrecognized pelvic pathologies. Laparoscopy evaluation prior to additional cycle of IVF seems to improve the subsequent pregnancy rate.
Comparison of laminectomy and fusion vs laminoplasty in the treatment of multilevel cervical spondylotic myelopathy
Authors: Yuan Xiaojun , Wei Chunmei , Xu Wenhua , Gan Xinrong , Cao Shengsheng , Luo Jiaquan
Published: March 2019

Purpose:

The purpose of this study is to evaluate the clinical safety and efficacy between laminectomy and fusion (LF) versus laminoplasty (LP) for the treatment of multi-level cervical spondylotic myelopathy (CSM).

Methods:

The authors searched electronic databases using PubMed, MEDLINE, Embase, Cochrane Controlled Trial Register, and Google Scholar for relevant studies that compared the clinical effectiveness of LF and LP for the treatment of patients with multilevel CSM. The following outcome measures were extracted: the Japanese Orthopaedic Association (JOA) scores, cervical curvature index (CCI), visual analog scale (VAS), Nurich grade, reoperation rate, complications, rate of nerve palsies. Newcastle Ottawa Quality Assessment Scale (NOQAS) was used to evaluate the quality of each study. Data analysis was conducted with RevMan 5.3.

Results:

A total of 14 studies were included in our meta-analysis. No significant difference was observed in terms of postoperative Japanese Orthopaedic Association score (P = .29), visual analog scale neck pain (P = .64), cervical curvature index (P = .24), Nurich grade (P = .16) and reoperation rate (P = .21) between LF and LP groups. Compared with LP group, the total complication rate (OR 2.60, 95% CI 1.85, 3.64, I
2 = 26%, P < .00001) and rate of nerve palsies (OR 3.18, 95% CI 1.66, 6.11, I
2 = 47%, P = .0005) was higher in the LF group.

Conclusions:

Our meta-analysis reveals that surgical treatments of multilevel CSM are similar in terms of most clinical outcomes using LF and LP. However, LP was found to be superior than LF in terms of nerve palsy complications. This requires further validation and investigation in larger sample-size prospective and randomized studies.
SCN1B and SCN2B gene variants analysis in dravet syndrome patients
Authors: Gong Jiao-E. , Liao Hong-Mei , Long Hong-Yu , Li Xiang-Min , Long Li-Li , Zhou Luo , Gu Wen-Ping , Lu Shao-Hua , Qu Qiang , Yang Li-Min , Xiao Bo , Qu Jian
Published: March 2019

Previous research identified SCN1B variants in some cases of Dravet syndrome (DS). We investigated whether SCN1B and SCN2B variants are commonly happened in DS patients without SCN1A variants. A total of 22 DS patients without SCN1A variants and 100 healthy controls were enrolled in this genetic study. DNA from DS patients was sequenced by Sanger method in whole exons of SCN1B and SCN2B genes. We identified two exon variants (c.351C>T, p.G117G and c.467C>T, p.T156M), which were present both in 1000 egenomes database and in healthy controls with a frequency of 0.54% and 4%, 0.06% and 0%, respectively. Additionally, eight intron or 3 prime UTR variants showing benign clinical significance have also been identified. Our results suggest that variants of SCN1B and SCN2B may not be common causes of DS according to our data. Further large sample-size cohort studies are needed to confirm our conclusion.
Neuropeptide Y and dipeptidyl peptidase IV in normally cycling and postmenopausal women
Authors: Kluess Heidi A. , Neidert Leslie E. , Sandage Mary J. , Plexico Laura W.
Published: March 2019

The purpose was to investigate changes in neuropeptide Y (NPY) protein and dipeptidyl peptidase IV (DPP-IV) activity in the plasma and saliva in normally cycling women and women after menopause. We recruited 7 cycling women and 7 postmenopausal women for a cross-sectional, prospective pilot study. Blood via venipuncture and saliva samples were taken at each point in the menstrual cycle (premenopausal) or once per week (postmenopausal) for 2 months. Blood and saliva were analyzed for estrogen, NPY using ELISA and DPP-IV activity using a fluorometric assay. Plasma β-estradiol was an average of 96.45 ± 57.04 pg/mL over 2 cycles in the premenopausal group and 1.72 ± 0.35 pg/mL over 2 months in the postmenopausal group (P < .05). In the cycling group, there were no significant differences in saliva or plasma NPY or DPP-IV over the cycle. For the postmenopausal group, salivary NPY and DPP-IV did not change over 2 months. Plasma NPY was lowest in the middle 2 weeks (average: 0.52 ± 0.10 ng/mL) compared to the first and fourth weeks (average of week 1 and 4: 0.60 ± 0.14 ng/mL;P < .05). Plasma NPY in postmenopausal women was higher overall (0.56 ± 0.13 ng/mL) compared to cycling women (0.30 ± 0.11 ng/mL;P < .05). Plasma DPP-IV activity was unchanged by time in the postmenopausal group. Saliva DPP-IV and saliva NPY in the cycling group had a significant negative correlation (R = −0.95;P < .05). We found that saliva measures of NPY and DPP-IV activity appear to be poor estimates of plasma concentrations and activities, but a larger sample size is required to conform this. Differences in plasma NPY concentrations between the groups and the relationship between salivary NPY and DPP-IV suggests that there may be some unique differences between these groups.
Spontaneous bleeding of thoracoacromial artery mimicking tunneled cuffed catheter-related complication
Authors: Nam Mann Hua , Tsai Ming-Hsien , Fang Yu-Wei , Lin Mi-Chu
Published: March 2019

Rationale:

The chronic complications caused by the tunneled cuffed catheter in chronic dialysis patients are infection and catheter dysfunction. While bleeding due to this access can occur occasionally.

Patient concerns:

We present a 92-year-old woman with a 6-year history of regular hemodialysis (HD). For the past 2 years, she has been receiving HD via a tunneled cuffed catheter placed in the right internal jugular vein. She suffered from a right chest subcutaneous hematoma near the catheter without recent trauma. The increasing size of hematoma after dialysis, and the oozing from the outlet of the catheter were also observed.

Diagnosis:

Computed tomography of chest and angiography were done and showed that the hematoma was caused by thoracoacromial artery bleeding, which was near the puncture site of the tunneled cuffed catheter.

Interventions:

Fluid resuscitation, blood transfusion, surgical drainage, and parenteral antibiotics were prescribed.

Outcomes:

Patient recovered fully without any further sequelae.

Lessons:

Spontaneous bleeding of thoracoacromial artery is rare and clinicians should keep in mind as a differential diagnosis in patient with new-onset hematoma over anterior chest wall. Early diagnosis and treatment are important in such cases.
Treatment of a patient with breast cancer and glucose 6-phosphate dehydrogenase deficiency
Authors: Chung Wei-Pang , Hsu Ya-Tin , Chen Ya-Ping , Hsu Hui-Ping
Published: March 2019

Rationale:

Glucose 6-phosphate dehydrogenase (G6PD) deficiency is the most common enzymatic disorder of red blood cells that cause hemolytic anemia. Some anticancer drugs are reported to trigger oxidative stress; however, events of hemolysis are rarely discussed in patients with G6PD deficiency required oncologic treatments.

Patient concerns:

Here we reported a young woman with G6PD deficiency safely undergoing breast cancer treatment.

Diagnosis:

A 29-year-old patient was diagnosed with advanced cancer of the right breast with tumors positive for hormone receptor and human epidermal growth factor receptor 2.

Interventions:

The patient received chemotherapy with doxorubicin, cyclophosphamide, and docetaxel. During the administration of docetaxel, trastuzumab was concurrently administered and was continued after the completion of docetaxel. The patient underwent adjuvant radiotherapy; meanwhile, tamoxifen was administered as adjuvant endocrine treatment.

Outcomes:

The treatment process was smooth. There was no evidence of hemolytic anemia. Except for hot flushes, the patient lives without remarkable side effects from ongoing or previous treatments.

Lessons:

Some patients have both G6PD deficiency and malignancy in a geographic area with relatively high incidence of the enzymatic disorder and certain types of cancer. We suggest that our report can contribute to the concern regarding the safety of patients with G6PD deficiency undergoing cancer treatment.
Diagnostic accuracy of pediatric atypical appendicitis
Authors: Wang Zhi-hua , Ye Jing , Wang Yu-shui , Liu Yan
Published: March 2019

Rationale:

Acute appendicitis is one of the most common causes of acute abdomen in children, yet it is difficult to diagnose in young children because its clinical manifestations may be atypical. Here, 3 atypical clinical cases associated with appendicitis in children are reported.

Patient concern:

The 1st case corresponds to a 5-year-old male patient who presented with abdominal discomfort, intermittent fevers, and vomiting, have increased white blood cell (WBC) count and C-reactive protein (CRP). The second case is a 7-year-old male patient who began with intermittent fevers and lower quadrant abdominal pain, showing increased WBC count and CRP. The 3rd case corresponds to a 7-year-old female patient who presented with intermittent fevers, abdominal pain, and forebreast discomfort, demonstrating increased WBC count and CRP.

Diagnoses:

Abdominal computed tomography (CT) scan presented data suggestive of enlarged appendix in diameter, and stercolith, corroborated through surgery.

Intervention:

Two patients were treated by appendectomy, and 1 patient was treated conservatively with antibiotics.

Outcomes:

Three patients were treated successfully. At 3-month follow-up, the patients had no complaints of discomfort with no relapse of appendicitis.

Lessons:

Due to atypical symptoms of children, the diagnosis of appendicitis is often delayed, suggesting that the clinicians should be aware of this disease when encountering gastroenteritis patients with elevated WBC and CRP. Furthermore, abdominal CT scan should be taken into consideration when patients showed high level of WBC and CRP, whose appendix is not seen on ultrasound.
Adrenocortical hypofunction with simultaneous primary aldosteronism
Authors: Liang Kaiyong , Ou Xiaojuan , Huang Xukai , Lan Qunfang
Published: March 2019

Rationale:

Cases of adrenocortical hyperfunction combined with primary aldosteronism have been reported in the literature, and the underlying mechanism involves the secretion of aldosterone and glucocorticoids by a tumor or an adenoma. However, adrenocortical hypofunction and coexisting primary aldosteronism have not been reported until now. Herein, we report a case of adrenocortical hypofunction combined with primary aldosteronism.

Patient concerns:

A 66-year-old Chinese woman with rheumatoid arthritis who had been diagnosed with secondary adrenal insufficiency and was taking prednisone acetate tablets for replacement treatment presented to our department. She also had type 2 diabetes mellitus, osteoporosis, bilateral knee osteoarthritis, and lumbar vertebral compression fracture. She had previously developed tuberculosis, which had been cured.

Diagnosis:

The cortisol and adrenocorticotropic hormone rhythm indicated cortisol dysfunction in the patient. A 64-slice computed tomography and magnetic resonance imaging both showed bilateral adrenal hyperplasia. A postural stimulation test indicated a high level of aldosteronism and a high aldosterone-to-renin ratio (ARR, supine position: aldosterone 1788.73 pg/mL, ARR 146.62; upright position: aldosterone 2916.21 pg/mL, ARR 92.29). The captopril test showed the aldosterone level decreased by 364.70 pg/mL 1 hour after administration of captopril (from 2153.28 to 1788.58 pg/mL). The decline in aldosterone level was approximately 16.90% (i.e., <30%), and the ARR was still >40. Based on the above-mentioned findings, we diagnosed the patient with adrenocortical hypofunction with primary aldosteronism.

Interventions:

We administered spironolactone 20 mg twice daily and continued the glucocorticoid replacement therapy.

Outcomes:

One week after diagnosis, the patient had an aldosterone level of 2201.16 pg/mL, plasma renin activity of 3.88 ng/mL/h, and an ARR of 56.7 (upright position). Her blood pressure was maintained within the normal range.

Lessons:

Although adrenocortical hypofunction with primary aldosteronism is rare, cases of primary aldosteronism complicated with hypercortisolism are occasionally encountered. Hence, whenever possible, we recommend testing both aldosterone and cortisol levels in all patients with adrenal dysfunction.