bluuebunny/crossref_metadata_2025 huggingface dataset:
Variations of the physical parameters of the blazar Mrk 421 based on analysis of the spectral energy distributions
Authors: Yamada Yurika , Uemura Makoto , Itoh Ryosuke , Fukazawa Yasushi , Ohno Masanori , Imazato Fumiya
Published: March 2020

We report on the variations of the physical parameters of the jet observed in the blazar Mrk 421, and discuss the origin of X-ray flares in the jet, based on analysis of several spectral energy distributions (SEDs). The SEDs are modeled using the one-zone synchrotron self-Compton model, its parameters determined using a Markov chain Monte Carlo method. The lack of data at TeV energies means many of the parameters cannot be uniquely determined and are correlated. These are studied in detail. We find that the optimal solution can be uniquely determined only when we apply a constraint to one of four parameters: the magnetic field (B), the Doppler factor, the size of the emitting region, and the normalization factor of the electron energy distribution. We used 31 sets of SEDs from 2009 to 2014 with optical–UV data observed with UVOT/Swift and the Kanata telescope, X-ray data with XRT/Swift, and γ-ray data with the Fermi Large Area Telescope. The result of our SED analysis suggests that, in the X-ray faint state, the emission occurs in a relatively small area (∼1016 cm) with a relatively strong magnetic field (B ∼ 10−1 G). The X-ray bright state shows a tendency opposite to that of the faint state, that is, a large emitting area (∼1018 cm), probably downstream of the jet, and a weak magnetic field (B ∼ 10−3 G). The high X-ray flux was due to an increase in the maximum energy of electrons. On the other hand, the presence of two kinds of emitting areas implies that the one-zone model is unsuitable for reproducing at least part of the observed SEDs.
Rethinking the Order of the Learning Process: A New and Sustainable Path Designed for an RN-to-BSN Education Program
Authors: Jean-Baptiste Anne Marie , Asongwed Elmira
Published: March 2020

The unpredictable and volatile economic context, ever-changing demography, explosion of technology, and rapid disruptive health delivery models are only a few of the factors characterizing the constant flux permeating the health care system. Current educational initiatives are corrective and reactive rather than reflective and proactive. Some renowned nurse educators and educational leaders pioneered the departure from a learning emphasis on what nurses do to what nurses become. To foster students’ creative initiatives, faculty of an RN-to-BSN three-semester program thread five stages of a creativity process of exposure, inquiry, discovery, reflection, and evaluation into three interrelated courses in the program of study.
Toward a Better Understanding of Electrocochleography: Analysis of Real-Time Recordings
Authors: Weder Stefan , Bester Christofer , Collins Aaron , Shaul Chanan , Briggs Robert J. , O’Leary Stephen
Published: March 2020

Objectives:

Real-time electrocochleography (ECochG) has been used as a monitoring tool during cochlear implantation (CI), whereby, amplitude drops have been correlated with postoperative acoustic hearing results. However, no consensus has been reached as to how a single event of an amplitude drop should be characterized. The aim of this study was to identify ECochG events that predict loss of hearing 1 month after surgery.

Design:

Fifty-five patients were included in this prospective cohort study. Real-time ECochG measurements were performed during CI electrode insertion. Single ECochG events were characterized according to their amplitude loss and slope steepness.

Results:

Using receiver operating characteristic analyses, the most efficient cut-off criterion for a relative hearing loss of 25% was an amplitude loss of 61% at a fixed slope steepness of 0.2 µV/sec. Three-quarters of our population had at least one such event during implantation. Most events occurred shortly before full insertion. With increasing number of events, median residual hearing thresholds deteriorated for all frequencies. Larger amplitude drops trended toward worse hearing preservation. Signal recovery after an ECochG event could not be correlated to acoustic hearing outcomes.

Conclusions:

Our data suggest that amplitude drops exceeding 61% of the ongoing signal at a slope steepness of 0.2 µV/sec are correlated with worse acoustic hearing preservation. Clearly defined ECochG events have the potential to guide surgeons during CI in the future. This is essential if a fully automated data analysis is to be employed or benchmarking undertaken.
Antirheumatic medications in pregnancy and breastfeeding
Authors: Birru Talabi Mehret , Clowse Megan E.B.
Published: March 2020

Purpose of review

As active rheumatic and musculoskeletal disease during pregnancy increases the risk for pregnancy loss, preterm birth, and maternal illness, ongoing management with pregnancy-compatible medications can improve these outcomes. Selecting and taking these medications can be challenging for rheumatologists and patients due to limited knowledge about potential risks and benefits.

Recent findings

Fortunately, the American College of Rheumatology, American College of Obstetrics and Gynecology, British Rheumatology Society, and the European League Against Rheumatism have each published recommendations to guide the use of antirheumatic medications in pregnancy and lactation. Each of these groups endorsed the use of hydroxychloroquine, azathioprine, sulfasalazine, corticosteroids, NSAIDs, and tumor necrosis factor inhibitors in pregnancy. They also agreed that methotrexate, mycophenolate, cyclophosphamide, and leflunomide should be avoided in pregnancy. New medications, including small-molecules and biologics, have limited data to support safety in pregnancy and are not currently recommended during this period. Most antirheumatic medications are compatible with lactation.

Because many patients are hesitant to use antirheumatic medications during pregnancy, honest and accurate discussions about pregnancy planning and management are important to help women make decisions that are in their and their offspring's best interest.
Normalization of Forefoot Supination After Tibialis Anterior Tendon Transfer for Dynamic Clubfoot Recurrence
Authors: Mindler Gabriel T. , Kranzl Andreas , Radler Christof
Published: March 2020

Background:

We aimed to evaluate the effect of tibialis anterior tendon transfer (TATT) on foot motion in children with clubfoot recurrence after initial Ponseti treatment.

Methods:

Children with dynamic clubfoot recurrence after initial Ponseti treatment who underwent TATT between 2014 and 2017 were considered for inclusion. Exclusion criteria were neurological disease, split transfer of the tendon, additional bone or joint invasive surgery, and initial treatment abroad. Of 94 children (143 TATT), 36 met the inclusion criteria. Seventeen (47%) of the 36 children with 25 clubfeet and a mean age at the time of surgery of 6.8 years participated in the study. Gait analysis, including the Oxford foot model, was conducted preoperatively and postoperatively. Furthermore, kinematic and kinetic data were compared with those of age-matched healthy children (n=18).

Results:

Forefoot supination in relation to the hindfoot and tibia was reduced during swing and at initial contact after TATT compared with preoperative values. Forefoot supination in relation to the tibia at initial contact decreased from 12.4 to 5.2 degrees after TATT (control group, 6.0 degrees). The heel showed less dynamic varus and adduction movement after TATT compared with preoperatively. Maximum ankle power was reduced preoperatively and postoperatively compared with controls. Maximum ankle dorsiflexion slightly increased after TATT.

Conclusions:

Gait analysis showed normalization of the main components of dynamic clubfoot recurrence after TATT. This joint-sparing surgery efficiently corrects recurrent dynamic deformity.

Level of Evidence:

Level II—therapeutic.
Prophylactic Decompression for Cervical Stenosis in Jeune Syndrome
Authors: Flanders Tracy M. , Franco Alier J. , Lott Carina , Anari Jason B. , Cahill Patrick J. , Storm Phillip B. , Heuer Gregory G.
Published: March 2020

Study Design.

This is a level IV retrospective descriptive study at a single institution.

Objective.

The objective of the study was to determine the preoperative signs or symptoms prompting cervicomedullary imaging in Jeune syndrome.

Summary of Background Data.

Jeune syndrome is a rare autosomal recessive disorder that results in pulmonary compromise from abnormal development of the thorax. Multiple medical comorbidities complicate timely diagnosis of cervicomedullary stenosis, which neurologically jeopardizes this patient population with regards to improper cervical manipulation. Currently, explicit screening of the cervicomedullary junction is not advocated in national guidelines.

Methods.

The User Reporting Workbench and Center for Thoracic Insufficiency Syndrome (CTIS) Safety Registry was queried for patients with Jeune syndrome under the age of 18 with cervicomedullary stenosis with or without suboccipital craniectomy/craniotomy evaluated at the authors’ institution from January 1, 2007 to August 21, 2018. The primary outcome was the clinical reason for cervicomedullary screening. Secondary outcomes were: age at time of surgery, preoperative myelopathy (spasticity, urinary retention), hydrocephalus, postoperative deficits (respiratory, motor, swallowing difficulty), and need for cervical fusion.

Results.

Of 32 patients with Jeune syndrome, four (12.5%) had cervicomedullary stenosis requiring decompression. The average age at surgery was 5.25 months (2–9 mo). Two patients underwent imaging due to desaturation events while the other two patients were diagnosed with cervical stenosis as an incidental finding. No patients exhibited clinical myelopathy. Two patients had baseline preoperative swallowing difficulties. None of the patients postoperatively required cervical fusions, nor did they exhibit respiratory deficits, motor deficits, or worsening swallowing difficulties.

Conclusion.

Jeune patients should be routinely screened for cervicomedullary stenosis and undergo subsequent prophylactic decompression to minimize or eliminate the development of irreversible neurologic compromise.

Level of Evidence: 4
The Relationship Between 3-dimensional Spinal Alignment, Thoracic Volume, and Pulmonary Function in Surgical Correction of Adolescent Idiopathic Scoliosis
Authors: Buckland Aaron J. , Woo Dainn , Vasquez-Montes Dennis , Marks Michelle , Jain Amit , Samdani Amer , Betz Randal R. , Errico Thomas J. , Lonner Baron , Newton Peter O.
Published: March 2020

Study Design.

Retrospective review of a prospective multicenter database.

Objective.

The aim of this study was to study the effects of thoracic kyphosis (TK) restoration in adolescent idiopathic scoliosis (AIS) Type 1 and 2 curves on postoperative thoracic volume (TV) and pulmonary function.

Summary of Background Data.

Surgical correction of AIS is advocated to preserve or improve pulmonary function, prevent progressive deformity and pain, and improve self-appearance. Restoration of sagittal and 3D alignment, particularly TK, has become increasingly emphasized in efforts to improve pulmonary function, TVs, sagittal balance, and prevent adjacent-segment degeneration and deformity.

Methods.

AIS patients 10 to 21years undergoing surgical correction of Lenke Type 1 and 2 curves with baseline, 1st-erect-postoperative, and 5-year (5Y) postoperative visits including stereoradiographic assessment and pulmonary function tests (PFTs) were included. 3D-radiographic analysis was performed to assess spinal-alignment, chest-wall, and rib-cage dimensions at each time point. Outcome variables were analyzed between time points with one-way analysis of variance and between variables with linear regression analysis.

Results.

Thirty-nine patients (37 females, 14.4 ± 2.2 years) were included. 3D-spinal-alignment analyses demonstrated significant reduction in preoperative to first-erect thoracic and lumbar Cobb-angles, an increase in TK:T2–12 (19.67°–39.69°) and TK:T5–12 (9.47°–28.05°), and reduction in apical vertebral rotation (AVR) (P < 0.001 for all). Spinal-alignment remained stable from 1st-erect to 5Y. 3D rib-cage analysis demonstrated small reductions in baseline to first-erect depth (145–139 mm), width (235–232 mm), and increase in height (219–230 mm, P < 0.01), but no significant change in volume (5161–5222 cm,
3

P = 0.184). From 1st-erect to 5Y, significant increases in depth, width, height, and volume (all P < 0.001) occurred. PFTs showed preoperative to 5Y improvement in first second of Forced Expiratory Volume (FEV1) (2.74–2.98 L, P = 0.005) and forced vital capacity (FVC) (3.23–3.47 L, P = 0.008); however, total lung capacity (TLC) did not change (P = 0.517). Percent-predicted TLC decreased (Pre: 101.3% to 5Y: 89.3%, P < 0.001); however, percent-predicted forced expiratory volume and FVC did not (P = 0.112 and P = 0.068).

Conclusion.

Although TK increases, coronal-Cobb and AVR decrease postoperatively; these do not directly influence TV, which increases from 1st-erect to 5Y due to growth, corresponding with increases in FEV1 and FVC at 5Y; however, surgical restoration of kyphosis does not directly improve pulmonary function.

Level of Evidence: 3
Cervical Spine Balance of Multilevel Total Disc Replacement, Hybrid Surgery, and Anterior Cervical Discectomy and Fusion With A Long-term Follow-up
Authors: Xu Shuai , Liang Yan , Wang Jinyu , Yu Guanjie , Zhu Zhenqi , Liu Haiying
Published: March 2020

Study Design.

Comparative study.

Objective.

The aim of this study was to compare cervical alignment among three-level total disc replacement (TDR), two prosthesis with one cage (2D1C), one prosthesis with two cages (1D2C), and anterior cervical discectomy and fusion (ACDF), then identify the importance of cervical balance of cervical spondylotic myelopathy (CSM).

Summary of Background Data.

There were few long-term comparisons on cervical alignment and cervical balance among three-level TDR, 2D1C, 1D2C, and ACDF for CSM.

Methods.

Twenty-eight patients with TDR, 15 with 2D1C, 36 with 1D2C, and 32 cases with ACDF were included with a mean follow-up of 90.9 ± 8.9 months. C2-C7 cervical lordosis (CL), C2-C7 sagittal vertical axis (SVA), T1 slope (T1S) were measured on x-ray at preoperation, immediate postoperation, and final follow-up, as well as range of motion (ROM), upper/lower adjacent ROM (UROM/LROM), and adjacent segment degeneration (ASD); cervical balance was assessed by T1S minus CL (T1SCL; 20°). Clinical outcomes included neck disability index (NDI) and Japanese Orthopedic Association (JOA) score.

Results.

NDI and JOA improved (P < 0.01)at postoperation and final-visit with no difference among four groups. ROM decreased mostly in ACDF group, although with a comparable inter-group UROM/LROM and ASD. All groups gained equal CL-improvement at final-visit. SVA and T1S together with their change were of no differences among groups (P > 0.05). There was a correlation among alignment parameters and between CL and ROM. The inter-group capacity of balance maintaining and imbalance correction was comparable (P > 0.05). The change of T1SCL was not correlated to NDI and JOA (P > 0.05).

Conclusion.

Adjacent segments were seldom affected. Cervical alignment was equivalently rebuilt among TDR, 2D1C, 1D2C, and ACDF. It was not essential to pay excessive attention to balance.

Level of Evidence: 3
Microstructural Changes in Compressed Cervical Spinal Cord Are Consistent With Clinical Symptoms and Symptom Duration
Authors: Wu Weifei , Yang Zong , Zhang Tingting , Ru Neng , Zhang Fan , Wu Bin , Liang Jie
Published: March 2020

Study Design.

A prospective study.

Objective.

To investigate the association between microstructural changes measured by diffusion tensor imaging (DTI) and clinical symptoms and their duration in patients with cervical spondylotic myelopathy (CSM) affected by single level.

Summary of Background Data.

No report was reported regarding the association between the microstructural changes and the symptoms and their duration at single-level spinal cord compression.

Methods.

Twenty-nine consecutive patients with CSM and 29 normal subjects were enrolled in this study. DTI with tractography was performed on the cervical spinal cord. Clinical symptoms were evaluated using modified Japanese Orthopaedic Association (mJOA) scores for each patient, and the duration of clinical symptoms was noted based on the earliest instance of limb pain or numbness or weakness or bladder dysfunction. Mean fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were calculated from tractography images.

Results.

The mean FA value of the cervical compressed spinal cord was significantly lower than the FA of the normal population (P < 0.001). The mean ADC value in the cervical compressed spinal cord was obviously higher than those of normal cervical spinal cord (P < 0.001). In the CSM patients, a significant positive association was observed between FA values and mJOA scores (P < 0.001). However, there were a notable negative association between mJOA scores and ADC values (P < 0.001), and between mJOA scores and symptom duration (P < 0.001).

Conclusion.

These results illustrate DTI can measure the micostructural changes of cervical spinal cord and DTI parameters are potential biomarkers for spinal cord dysfunction in patients with CSM.

Level of Evidence: 3
Association Between Low Back Pain and Biomedical Beliefs in Academics of Physiotherapy
Authors: Gomes Aline Souza , de Sá Ferreira Arthur , Reis Felipe José Jandre , de Jesus-Moraleida Fabianna Resende , Nogueira Leandro Alberto Calazans , Meziat-Filho Ney
Published: March 2020

Study Design.

Observational cross-sectional study.

Objective.

To analyze the association between low back pain and biomedical beliefs in physiotherapy students of the first and last year.

Summary of Background Data.

There is a hypothesis that the presence of low back pain may be a risk factor for biomedical beliefs in physiotherapy academics.

Methods.

Three hundred sixty-five students of first and last year of the physiotherapy course from three universities in city of Fortaleza completed a questionnaire with sociodemographic factors and a Pain Attitude and Beliefs Scale used to determine the orientation (biopsychosocial or biomedical approach) of practitioners to the management of people with low back pain.

Results.

The mean age of participants was 23.57 ± 4.77 years, with a predominance of females (80.27%, n = 239). Approximately 23.84% reported low back pain, 18.9% had undergone imaging tests at the site, and 36.71% reported that family members with low back pain also underwent these examinations. The means of the biopsychosocial subscale of the Pain Attitude and Belief Scale corresponded to 20.19 and 20.63 in the first and last year academics, respectively, whereas the biomedical subscale corresponded to 32.10 and 32.73 in the first and last year academics, respectively. There was no statistical difference between the scores of the first and last year students. Linear regression analyses showed that low back pain was associated with lower levels of biomedical beliefs in the students of the last year (beta coefficient = −2.17, 95% confidence interval = −3.95 to −0.3, P = 0.02). We did not find association between low back pain and levels of biomedical beliefs in academics of both years and with academics of the first year. Also, we did not find association between low back pain and levels of biopsychosocial beliefs.

Conclusion.

First and last year physical therapy students did not present a difference between biomedical and biopsychosocial beliefs. Although biomedical beliefs were prevalent in both groups, the academics of the last year who had low back pain presented lower levels of biomedical beliefs than the academics of the last year without low back symptoms.

Level of Evidence: 4
Incidental Durotomy Is Associated With Increased Risk of Delirium in Patients Aged 65 and Older
Authors: Kazarian Erick R. , Lopez Wylie Y. , Eizember Shane , Blucher Justin A. , Culley Deborah J. , Javedan Houman , Kang James D. , Schoenfeld Andrew J.
Published: March 2020

Study Design.

Retrospective cohort study.

Objective.

To evaluate the impact of incidental durotomy during spine surgery on the development of delirium in patients aged 65 and older.

Summary of Background Data.

Delirium after spine surgery has been shown to increase the risk of adverse events, including morbidity and readmissions. Durotomy has previously been postulated to influence the risk of delirium, but this has not been explored in patients 65 and older, the demographic at greatest risk of developing delirium.

Methods.

We obtained clinical data on 766 patients, including 182 with incidental durotomy, from the Partners healthcare registry (2012–2019). Patients had their medical records abstracted and age, biologic sex, body mass index, smoking status, preoperative diagnosis, use of a fusion-based procedure, and number of comorbidities were recorded. Our primary outcome was the development of delirium. Our primary predictor was incidental durotomy. We used logistic regression techniques to adjust for sociodemographic and clinical confounders. We performed propensity score matching as a sensitivity test. We hypothesized that elderly patients would be at increased risk of delirium following durotomy.

Results.

Delirium was identified in 142 patients (19%). Among patients with an incidental durotomy, 26% were diagnosed with delirium. The incidence of delirium was 16% in the control group. Following adjusted analysis, the likelihood of delirium was significantly greater in patients with a durotomy (odds ratio [OR] 1.91; 95% confidence interval [CI] 1.27, 2.88). After propensity score matching, durotomy remained significantly associated with delirium in multivariable adjusted analyses (OR 1.90; 95% CI 1.07, 3.39).

Conclusion.

This investigation is among the first to specifically evaluate an association between durotomy and delirium in elderly patients undergoing spine surgery. The increased association between durotomy and delirium in this cohort should prompt increased surveillance and interventions designed to minimize the potential for cognitive deterioration or impairment during postoperative management of a durotomy.

Level of Evidence: 3
Optimization of Nursing-Specific Flu Alerts
Authors: Cieslowski Bethany , Brock Laurie , Richesson Rachel L. , Silva Susan , Kim Hyeoneui
Published: March 2020

Clinical decision support interventions, such as alerts and reminders, can improve clinician compliance with practice guidelines and patient outcomes. Alerts that trigger at inappropriate times are often dismissed by clinicians, reducing desired actions rather than increasing them. A set of nursing-specific alerts related to influenza screening and vaccination were optimized so that they would “trigger” less often but function adequately to maintain institutional flu vaccination compliance. We analyzed the current triggering criteria for six flu vaccine–related alerts and asked nurse end users for suggestions to increase specificity. Using the “five rights” (of clinical decision support) as a framework, alerts were redesigned to address user needs. New alerts were tested and implemented and their activity compared in two different flu seasons, preoptimization and postoptimization. The redesigned alerts resulted in fewer alerts per encounter (P < .0001), less dismissals of alerts (P < .0001), and a 2.8% point improvement in compliance rates for flu vaccine screening, documentation, and administration. A focus group confirmed that the redesign improved workflow, but some nurses thought they still triggered too often. The five rights model can support improvements in alert design and outcomes.
Histopathological Features of Subcutaneous Sarcoidosis
Authors: Marcoval Joaquim , Penín Rosa M. , Mañá Juan
Published: March 2020

Only a few series of patients with systemic sarcoidosis and specific subcutaneous lesions have been reported. We reviewed our patients with systemic sarcoidosis with specific subcutaneous lesions to analyze their histopathological features and their relationship with clinical features of the systemic disease. Patients with systemic sarcoidosis with predominantly subcutaneous sarcoid granulomas diagnosed between 1980 and 2016 in Bellvitge University Hospital were enrolled. We also analyzed patients with clinically and histopathologically identical lesions in whom a diagnosis of systemic sarcoidosis could not be made during follow-up. Twenty-eight patients with systemic sarcoidosis presented specific subcutaneous lesions (23 women and 5 men, mean age 55.64 SD 12.26 years). Dermal involvement was observed in 10 cases, always discrete and limited to deep reticular dermis. The distribution of the granulomatous infiltrate was lobular in 7 cases and lobular and septal in 21. Fibrosis was observed in 21 cases. There were no significant differences in persistence of lesions or persistence of systemic disease activity when comparing patients with and without fibrosis. In conclusion, fibrosis is a frequent finding in subcutaneous sarcoidosis, and although it may be intense, it is not associated with pulmonary fibrosis or with >2 years of persistence of systemic sarcoidosis activity.
Difficult airway management practice changes after introduction of the GlideScope videolaryngoscope
Authors: Avidan Alexander , Shapira Yoel , Cohen Avital , Weissman Charles , Levin Phillip D.
Published: March 2020

BACKGROUND

Introduction of the GlideScope videolaryngoscope caused a change in use of other devices for difficult airway management.

OBJECTIVE

The influence of the GlideScope videolaryngoscope on changes in the indications for and the frequency of use of flexible fibreoptic-assisted intubation and other difficult airway management techniques.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care referral centre.

METHODS

Two periods of equal length (647 days each) before and after introducing the GlideScope were compared. Information about patients who were intubated using nondirect laryngoscopic techniques were analysed. Data were retrieved from the anaesthesia and hospital information management systems.

RESULTS

Difficult airway management techniques were used in 235/8306 (2.8%) patients before and in 480/8517 (5.6%) (P < 0.0001) patients after the introduction of the GlideScope. There was an overall 44.4% reduction in use of flexible fibreoptic bronchoscopy after GlideScope introduction [before 149/8306 (1.8%); after 85/8517 (1.0%), P < 0.0001]. The GlideScope replaced flexible fibreoptic bronchoscopy in most cases with expected and unexpected difficult intubation. In patients with limited mouth opening, flexible fibreoptic bronchoscopy was still mostly the first choice after the introduction of the GlideScope. There was a 70% reduction in the use of other difficult intubation techniques after the introduction of the GlideScope [before 84/8306 (1.0%); after 22/8517 (0.3%), P < 0.0001)].

CONCLUSION

The GlideScope videolaryngoscope replaced flexible fibreoptic bronchoscopy for most patients with expected and unexpected difficult intubation. In the case of limited mouth opening, flexible fibreoptic bronchoscopy was still the first choice after the introduction of the GlideScope. The reduced use of flexible fibreoptic bronchoscopy raises concerns that residents may not be adequately trained in this essential airway management technique. GlideScope use was disproportionately greater than the reduction in the use of flexible fibreoptic bronchoscopy and other difficult intubation techniques. This may be attributed to resident teaching and use in patients with low-to-moderate suspicion of difficult intubation.
European Section/Board of Anaesthesiology/European Society of Anaesthesiology consensus statement on competency-based education and training in anaesthesiology
Authors: Shorten George D. , De Robertis Edoardo , Goldik Zeev , Kietaibl Sibylle , Niemi-Murola Leila , Sabelnikovs Olegs
Published: March 2020

The change from time-based to competency-based medical education has been driven by society's requirement for greater accountability of medical practitioners and those who train them. The European Society of Anaesthesiology and European Section/Board of Anaesthesiology (Anaesthesiology Section of the European Union Medical Specialists) endorse the general principles of competency-based medical education and training (CBMET) outlined by the international competency-based medical education collaborators. A CBMET curriculum is built on unambiguously defined learning objectives, each of which offers a measurable outcome, amenable to assessment using valid and reliable tools. The European training requirements laid out by the European Board of Anaesthesiology define four ‘Generic Competences’, namely expert clinician, professional leader, academic scholar and inspired humanitarian. A CBMET programme should clearly document core competencies, defined end-points, proficiency standards, practical descriptions of teaching and assessment practices and an assessment plan. The assessment plan should balance the need to provide regular, multidimensional formative feedback to the trainee with the need to inform high stakes decisions. A trainee who has not achieved a proficiency standard should be provided with an individualised training plan to address specific competencies or deficits. Programme formats will inevitably differ given the constraints of scale and resource that apply in different settings. The resources necessary to develop and maintain a CBMET programme in anaesthesiology include human capital, access to clinical learning opportunities, information technology and physical infrastructure dedicated to training and education. Simulation facilities and faculty development require specific attention. Reflective practice is an important programme element that supports wellbeing, resilience and achievement of professional goals. CBMET programmes should enable establishment of a culture of lifelong learning for the anaesthesiology community.
Anti-Müllerian hormone as a qualitative marker – or just quantity?
Authors: Kotlyar Alexander , Seifer David B.
Published: March 2020

Purpose of review

In this review, we will summarize research looking into anti-Müllerian hormone (AMH) as a measure of oocyte quality.

Recent findings

AMH is a key factor involved in embryogenesis but also in the development of early follicles. Owing to its relatively small inter and intracycle variability, it has become a widely used method of ovarian reserve testing. In the realm of assisted reproductive technology, it has demonstrated a reliable ability to gauge the number of oocytes obtained during an in-vitro fertilization cycle. For these purposes, AMH is a readily measured quantitative tool. However, its qualitative role is as yet undefined.

Although levels of this hormone have been associated with fertilization, blastulation, implantation, and clinical pregnancy rates, there is no clear link with live-birth rates. Furthermore, AMH levels do not appear to correspond with risk of fetal trisomy. AMH does show significant predictive value for the risk of premature ovarian insufficiency and time to onset of menopause.
Role of epigenetic mechanisms regulated by enhancers and long noncoding RNAs in cardiovascular disease
Authors: Das Sadhan , Reddy Marpadga A. , Natarajan Rama
Published: March 2020

Purpose of review

Hyperlipidemia, hypertension, diabetes and related metabolic disorders increase the risk for cardiovascular disease (CVD). Despite significant progress in the identification of key mechanisms and genetic polymorphisms linked to various CVDs, the rates of CVDs continue to escalate, underscoring the need to evaluate additional mechanisms for more effective therapies. Environment and lifestyle changes can alter epigenetic mechanisms mediated by histone modifications and long noncoding RNAs (lncRNAs) which play important roles in gene regulation. The review summarizes recent findings on the role of epigenetic mechanisms in CVD.

Recent findings

Recent studies identified dysregulated histone modifications and chromatin modifying proteins at cis-regulatory elements, including enhancers/super-enhancers, mediating the expression of genes associated with CVD in vascular and immune cells in response to growth factors and inflammatory mediators. Several lncRNAs have also been reported to contribute to pathological gene expression via cis and trans mechanisms involving interactions with nuclear proteins, co-operation with enhancers/super enhancers and acting as microRNA sponges.

Epigenomic approaches in cells affected in CVDs can be exploited to understand the function of genetic polymorphisms at cis-regulatory elements and crosstalk between enhancers and lncRNAs associated with disease susceptibility and progression. The reversible nature of epigenetics provides opportunities for the development of novel therapeutic strategies for CVD.
UDP-glucose 6-dehydrogenase expression as a predictor of survival in patients with pulmonary adenocarcinoma
Authors: Saha Shekhar , Yao Sha , Elakad Omar , Lois Anna-Maria , Henric-Petri Hannah , Buentzel Judith , Hinterthaner Marc , Danner Bernhard C. , Ströbel Philipp , Emmert Alexander , Bohnenberger Hanibal
Published: March 2020

Background:

UDP-glucose-6-dehydrogenase (UGDH) plays an important role in the production of hyaluronic acid, an extracellular matrix component that is responsible for the promotion of normal cellular growth and migration. Increased levels of UGDH have been linked to the progression of epithelial cancers, such as those of the breast, colon and prostate. Therefore we aimed to analyze if the expression level of UGDH does also influence patients survival of lung cancer patients.

Methods:

UGDH expression levels were analyzed by immunohistochemistry in 96 samples of pulmonary adenocarcinoma (AC), 84 cases of squamous cell lung carcinoma (SQCLC) and 33 samples of small cell lung cancer (SCLC) and correlated with clinicopathologic characteristics and patient outcome.

Results:

UGDH was expressed in 62.5% cases of AC, 70.2% cases of SQCLC, and 48.5% cases of SCLC. In AC, expression of UGDH was significantly associated with lymph node metastasis and worse overall survival of the affected patients. However, UGDH expression had no significant correlation to prognosis in SQCLC or SCLC patients.

Conclusions:

In our study, expression of UGDH was associated with worse prognosis of patients with pulmonary adenocarcinoma so that expression of UGDH might help to guide treatment decisions. Furthermore, UGDH might present a potential novel drug target in AC as it displays inhibitable catalytic activity.
Early Postoperative Intraocular Pressure is Associated With Better Pressure Control After XEN Implantation
Authors: Cutolo Carlo A. , Iester Michele , Bagnis Alessandro , Bonzano Chiara , Negri Letizia , Olivari Sara , Cappelli Francesca , Testa Valeria , Sindaco Daniele , Pizzorno Chiara , Scotto Riccardo , Saccheggiani Michela , Traverso Carlo E.
Published: March 2020

Précis:

Gel stent implantation is a bleb-forming surgery designed to achieve predictable pressure drop. An early low intraocular pressure (IOP) is associated with the long-term success of the procedure.

Purpose:

To identify the variables associated with the success of the XEN procedure.

Patients and Methods:

This was part of a prospective, uncontrolled, consecutive case series study. Patients with primary open-angle glaucoma or pseudo-exfoliative glaucoma were included. All the patients underwent surgical XEN implant procedure with mitomycin-C subconjunctival injection 20 minutes before surgery. Success criteria were an off-medication IOP of 6 to 16 mm Hg 12 months after surgery; no additional glaucoma surgery; no visual threatening complications, no visual acuity loss >1 Snellen line. One eye per patient was considered for statistical analysis. A univariate Cox proportional hazard regression analysis was performed to identify potential risk factors for surgical failure. Then, a multivariate Cox model was built.

Results:

One hundred twenty-three patients were recruited in this study: 93 patients underwent XEN implantation alone whereas 30 the combined procedure with phacoemulsification and intraocular lens implantation. Univariate Cox regression showed that the day after surgery intraocular lens>9 mm Hg was associated with surgical failure (P=0.02) and a postoperative number of needlings ≥2 in the follow-up was also predictive of surgical failure (P<0.01). These data were confirmed by a multivariate model too. At 1 year the surgical success criteria were 76% in the group with 24-hour IOP≤9 mm Hg, whereas it was 43% when above 9 mm Hg (P=0.026).

Conclusions:

Our study shows that an early IOP≤9 mm Hg is predictive of the efficacy of the procedure during 1-year follow-up, whereas more than 2 needlings are predictive of failure.
Femtosecond laser–assisted cataract surgery for bilateral anterior lenticonus
Authors: Hipólito-Fernandes Diogo , Elisa-Luís Maria , Alves Nuno , Maduro Vitor
Published: March 2020

Anterior lenticonus is a characteristic ocular feature of Alport syndrome, leading to progressive vision deterioration. Surgical lens removal may be an option in such cases, and the role of femtosecond laser–assisted cataract surgery (FLACS) has been recently described. Herein, we report the third described case, to our knowledge, of bilateral anterior lenticonus surgically approached through FLACS. A 25-year-old man with X-linked Alport syndrome complained of bilateral progressive vision loss. Ophthalmological evaluation revealed a corrected distance visual acuity of 20/63 in both eyes and bilateral anterior lenticonus associated with anterior polar cataract. FLACS was performed, followed by IOL placement on the capsular bag, without any intraoperative complications. One month postoperatively, uncorrected distance visual acuity was 20/20 in both eyes. Considering these results and the information published so far, this technology might be a good option for these patients.
“No one wants to look after the fibro patient”. Understanding models, and patient perspectives, of care for fibromyalgia: reviews of current evidence
Authors: Doebl Stefanie , Macfarlane Gary J. , Hollick Rosemary J.
Published: March 2020

Fibromyalgia is a common and complex long-term pain condition. Despite advancements in our understanding and treatment of fibromyalgia, patients report patchy health care provision and frustrating journeys through the health care system. To inform how best to deliver care, we undertook 2 narrative reviews examining existing evidence on (1) models of care for fibromyalgia and (2) patients' experiences, preferences, and unmet needs regarding their health care. Seven databases were systematically searched. Quantitative data was narratively synthesised and qualitative data thematically analysed. No evidence-based model of care covering the patient journey through the entire health care system was identified. Limited evidence suggests no clear benefit for ongoing care in secondary care settings. Patients with fibromyalgia report difficult interactions with the health care system that might equally be expressed by those with other long-term conditions, such as inconsistent and poorly coordinated care. However, they also face unique problems; fibromyalgia was often not viewed as a real condition, resulting in difficult encounters with health care staff, in particular not feeling believed or listened to. Significant delays in diagnosis were commonplace. Positive care experiences such as being listened to and shared decision-making made patients feeling better informed, well supported, and more satisfied. There is little evidence to inform how best to organise health care for patients with fibromyalgia and ensure care is delivered in a coordinated and consistent way. These findings provide a strong rationale for developing a new model of care for fibromyalgia.
Sex differences in the development of anxiodepressive-like behavior of mice subjected to sciatic nerve cuffing
Authors: Cardenas Andrea , Caniglia John , Keljalic Denis , Dimitrov Eugene
Published: March 2020

We investigated the contribution of nucleus locus ceruleus (LC) to the development of pain-associated affective behavior. Mice of both sexes were subjected to sciatic nerve cuffing, a model of peripheral nerve injury, and monitored for 45 days. Although the thermal and mechanical thresholds were equally decreased in both males and females, only the male mice developed anxiodepressive-like behavior, which was complemented by suppressed hippocampal neurogenesis. Furthermore, the LC activity was lower in males when compared with females subjected to sciatic cuffing. Next, we used a chemogenetic approach to modulate the activity of LC projections to the dentate gyrus of the hippocampus in females without cuffs and in males with sciatic cuffs. Sustained inhibition of the LC projections to the dentate gyrus for 15 days induced anxiodepressive-like behavior and reduced the hippocampal neurogenesis in females. Activation of the LC projections to the dentate gyrus for 15 days prevented the development of anxiodepressive-like behavior and increased the hippocampal neurogenesis in males with cuffs. In sum, we demonstrated that the LC projections to the hippocampus link the sensory to the affective component of neuropathic injury and that the female mice are able to dissociate the nociception from affect by maintaining robust LC activity. The work provides evidence that sex differences in LC response to pain determine the sex differences in the development of pain phenotype.
“I'll Change His Sexual Orientation, I Don't Think About HIV”: A Qualitative Study to Explore Attitudes, Behaviors, and Experiences Among Wives of Men Who Have Sex With Men in Mainland China
Authors: Yan Fang , Shi Cynthia X. , Zhang Ye , Chen Jia , Williams Ann Bartley , Li Xianhong
Published: March 2020

In mainland China, HIV prevalence among men who have sex with men (MSM) has risen sharply in the past decade. However, few HIV studies have directly addressed the female spouses' (tongqi) experiences, a population estimated at 14 million [Cheng, F. K. (2016). I want to come forward: Voices from Chinese tongqi. Cogent Social Sciences, 2(1), 1158343. doi:10.1080/23311886.2016.1158343; Zhu, J. (2018). “Unqueer” kinship? Critical reflections on “marriage fraud” in mainland China. Sexualities, 21(7), 1075-1091. doi:10.1177/1363460717719240]. We conducted this exploratory qualitative study to understand tongqi's attitudes toward same-sex sexuality and HIV risk as well as their sexual history. Semistructured interviews were conducted with 24 tongqi between October 2015 and September 2016. Data were coded and analyzed using thematic analysis. We identified four primary themes: (a) surprise, initial disbelief, and negative attitudes toward their husbands' same-sex sexuality; (b) maintenance of regular sexual contact, particularly before pregnancy; (c) unprotected sex with marital and extramarital partners; and (d) low perception of HIV risk. Strategies to increase HIV knowledge and testing uptake are urgently needed among these vulnerable women but must be implemented with caution to avoid exacerbating high levels of homophobia.
Exercise in patients on chronic hemodialysis: current evidence, knowledge gaps and future perspectives
Authors: Regolisti Giuseppe , Sabatino Alice , Fiaccadori Enrico
Published: March 2020

Purpose of review

Physical inactivity is common in hemodialysis patients, and is associated with disability and poor outcomes. We summarize the effects of aerobic, resistance or mixed exercise training on aerobic capacity, muscle mass and strength, dialysis efficiency, quality of life and cardiovascular adaptation according to clinical studies on this population, also focusing on knowledge gaps as topics for future research. Finally, we put evidence into clinical context deriving practical indications for exercise implementation in these patients.

Recent findings

In hemodialysis patients, aerobic or mixed exercise training increases predominantly aerobic capacity, whereas resistance training seems more effective in increasing muscle strength. Data concerning dialysis efficiency are equivocal, although phosphate and potassium clearances seem to be improved. There is also inconclusive evidence concerning changes in cardiovascular risk factors. All types of exercise improve patients’ quality of life. However, there is a need for protocol standardization and selection of easily measurable endpoints. In clinical practice, it is advised that exercise implementation be performed gradually, and goals be tailored to individual pretraining fitness levels to maximize patient adherence and clinical benefits.

The overall evidence suggests that exercise training is beneficial and well tolerated in hemodialysis patients, although heterogeneity across studies hinders generalization of results. In any case, a gradual and individualized approach should be used to implement exercise in these patients.
Pharmacogenetics of antitumor necrosis factor therapy in severe sarcoidosis
Authors: Crommelin Heleen , Vorselaars Adriane , van der Vis Joanne , Deneer Vera , van Moorsel Coline H.M.
Published: March 2020

Purpose of review

Antitumor necrosis factor (TNF) treatment is an effective third-line treatment option in severe sarcoidosis. But not all patients respond to treatment. Pharmacogenetics studies the influence of genetic variations on treatment response.

Recent findings

In sarcoidosis, only one study reported on a relationship between genetic variation in TNF and response to anti-TNF therapy. In immune-mediated inflammatory diseases (IMIDs) other than sarcoidosis, several genetic variants were associated with response to anti-TNF therapy. Genes related to TNF, the target of this group of drugs, and the pathway by which TNF exerts its effect, TNF receptor, were studied most extensively. Recent findings related genetic variations in the human leukocyte antigen region to development of antidrug antibodies.

We also included new original data on genetic variations and response to anti-TNF therapy in severe sarcoidosis. We found that TNFRSF1A rs1800693 AA genotype, TNFRSF1B 196T and absence of HLA-DRB1

∗

03 associate with better response after infliximab treatment in severe sarcoidosis.

Data on pharmacogenetics of anti-TNF therapy in severe sarcoidosis are scarce. Findings in other IMIDs indicate there may be a role for pharmacogenetics in predicting response and adverse events in anti-TNF therapy, also in sarcoidosis. Future studies are needed to evaluate pharmacogenetics as a predicting marker in anti-TNF therapy in sarcoidosis.
Comorbidity Assessment Is Uneven Across Veterans Health Administration and Medicare for the Same Patient
Authors: Gidwani-Marszowski Risha , Boothroyd Derek , Needleman Jack , Illarmo Samantha , Asch Steven M.
Published: March 2020

Objective:

Compare comorbidity identification in Medicare and Veterans Health Administration (VA) data for the purposes of risk adjustment.

Data Sources:

Analysis of Medicare and VA datasets for dually-enrolled Veterans receiving care in both settings, fiscal years 2010–2014.

Study Design:

A retrospective analysis of administrative data for a national sample of cancer decedents.

Data Extraction Methods:

Comorbidities were evaluated using Elixhauser and Charlson coding algorithms.

Principal Findings:

Clinical comorbidities were more likely to be recorded in Medicare than in VA datasets. Of 42 comorbidities, 36 (86%) were recorded at a different frequency. For example, congestive heart failure was recorded for 22.0% of patients in Medicare data and for 11.3% of patients in VA data (P<0.001).

Conclusion:

There are large differences in comorbidity assessment across VA and Medicare administrative data for the same patient, posing challenges for risk adjustment.