bluuebunny/crossref_metadata_2025 huggingface dataset:
Systemic Inflammatory Response Syndrome as Predictor of Poor Outcome in Nontraumatic Subarachnoid Hemorrhage Patients
Authors: Rass Verena , Gaasch Max , Kofler Mario , Schiefecker Alois Josef , Ianosi Bogdan-Andrei , Rhomberg Paul , Beer Ronny , Pfausler Bettina , Gizewski Elke R. , Thomé Claudius , Schmutzhard Erich , Helbok Raimund
Published: October 2018

Objectives:

Subarachnoid hemorrhage is a life-threatening disease associated with high mortality and morbidity. A substantial number of patients develop systemic inflammatory response syndrome. We aimed to identify risk factors for systemic inflammatory response syndrome development and to evaluate the role of systemic inflammatory response syndrome on patients’ outcome.

Design:

Retrospective observational cohort study of prospectively collected data.

Setting:

Neurocritical care unit at a tertiary academic medical center.

Patients:

Two-hundred and ninety-seven consecutive nontraumatic subarachnoid hemorrhage patients admitted to the neurologic ICU between 2010 and 2017.

Interventions:

Systemic inflammatory response syndrome was diagnosed based on greater than or equal to two criteria (hypo-/hyperthermia, tachypnea, leukopenia/leukocytosis, tachycardia) and defined as early (≤ 3 d) and delayed (days 6–10) systemic inflammatory response syndrome burden (systemic inflammatory response syndrome positive days within the first 10 d). Using multivariate analysis, risk factors for the development of early and delayed systemic inflammatory response syndrome and the relationship of systemic inflammatory response syndrome with poor 3-month functional outcome (modified Rankin Scale score ≥ 3) were analyzed.

Measurements and Main Results:

Seventy-eight percent of subarachnoid hemorrhage patients had early systemic inflammatory response syndrome, and 69% developed delayed systemic inflammatory response syndrome. Median systemic inflammatory response syndrome burden was 60% (interquartile range, 10–90%). Risk factors for early systemic inflammatory response syndrome were higher admission Hunt and Hess grade (odds ratio, 1.75; 95% CI, 1.09–2.83; p = 0.02), aneurysm clipping (odds ratio, 4.84; 95% CI, 1.02–23.05; p = 0.048), and higher modified Fisher Scale score (odds ratio, 1.88; 95% CI, 1.25–2.89; p = 0.003). Hunt and Hess grade and pneumonia were independently associated with delayed systemic inflammatory response syndrome development. Systemic inflammatory response syndrome burden (area under the curve, 0.84; 95% CI, 0.79–0.88) had a higher predictive value for 3-month poor outcome compared with early systemic inflammatory response syndrome (area under the curve, 0.76; 95% CI, 0.70–0.81; p < 0.001).

Conclusions:

Systemic inflammatory response syndrome is common after subarachnoid hemorrhage and independently contributes to poor functional outcome. Systemic inflammatory response syndrome burden more accurately predicts poor outcome than early systemic inflammatory response syndrome.
Evaluation of a Measurement System to Assess ICU Team Performance*
Authors: Dietz Aaron S. , Salas Eduardo , Pronovost Peter J. , Jentsch Florian , Wyskiel Rhonda , Mendez-Tellez Pedro Alejandro , Dwyer Cynthia , Rosen Michael A.
Published: October 2018

Objective:

Measuring teamwork is essential in critical care, but limited observational measurement systems exist for this environment. The objective of this study was to evaluate the reliability and validity of a behavioral marker system for measuring teamwork in ICUs.

Design:

Instances of teamwork were observed by two raters for three tasks: multidisciplinary rounds, nurse-to-nurse handoffs, and retrospective videos of medical students and instructors performing simulated codes. Intraclass correlation coefficients were calculated to assess interrater reliability. Generalizability theory was applied to estimate systematic sources of variance for the three observed team tasks that were associated with instances of teamwork, rater effects, competency effects, and task effects.

Setting:

A 15-bed surgical ICU at a large academic hospital.

Subjects:

One hundred thirty-eight instances of teamwork were observed. Specifically, we observed 88 multidisciplinary rounds, 25 nurse-to-nurse handoffs, and 25 simulated code exercises.

Interventions:

No intervention was conducted for this study.

Measurements and Main Results:

Rater reliability for each overall task ranged from good to excellent correlation (intraclass correlation coefficient, 0.64–0.81), although there were seven cases where reliability was fair and one case where it was poor for specific competencies. Findings from generalizability studies provided evidence that the marker system dependably distinguished among teamwork competencies, providing evidence of construct validity.

Conclusions:

Teamwork in critical care is complex, thereby complicating the judgment of behaviors. The marker system exhibited great potential for differentiating competencies, but findings also revealed that more context specific guidance may be needed to improve rater reliability.
Outcomes of Older Hospitalized Patients Requiring Rapid Response Team Activation for Acute Deterioration
Authors: Fernando Shannon M. , Reardon Peter M. , McIsaac Daniel I. , Eagles Debra , Murphy Kyle , Tanuseputro Peter , Heyland Daren K. , Kyeremanteng Kwadwo
Published: October 2018

Objectives:

Rapid response teams are groups of healthcare providers that have been implemented by many hospitals to respond to acutely deteriorating patients admitted to the hospital wards. Hospitalized older patients are at particular risk of deterioration. We sought to examine outcomes of older patients requiring rapid response team activation.

Design:

Analysis of a prospectively collected registry.

Setting:

Two hospitals within a single tertiary care level hospital system between 2012 and 2016.

Patients:

Five-thousand nine-hundred ninety-five patients were analyzed. Comparisons were made between older patients (defined as ≥ 75 yr old) and younger patients.

Interventions:

None.

Measurements and Main Results:

All patient information, outcomes, and rapid response team activation information were gathered at the time of rapid response team activation and assessment. The primary outcome was in-hospital mortality, analyzed using multivariate logistic regression. Two-thousand three-hundred nine were older patients (38.5%). Of these, 835 (36.2%) died in-hospital, compared with 998 younger patients (27.1%) (adjusted odds ratio, 1.83 [1.54–2.18]; p < 0.001). Among patients admitted from home, surviving older patients were more likely to be discharged to a long-term care facility (adjusted odds ratio, 2.38 [95% CI, 1.89–3.33]; p < 0.001). Older patients were more likely to have prolonged delay to rapid response team activation (adjusted odds ratio, 1.79 [1.59–2.94]; p < 0.001). Among patients with goals of care allowing for ICU admission, older patients were less likely to be admitted to the ICU (adjusted odds ratio, 0.66 [0.36–0.79]), and less likely to have rapid response team activation during daytime hours (adjusted odds ratio, 0.73 [0.62–0.98]; p < 0.001).

Conclusions:

Older patients with in-hospital deterioration requiring rapid response team activation had increased odds of death and long-term care disposition. Rapid response team activation for older patients was more likely to be delayed, and occur during nighttime hours. These findings highlight the worse outcomes seen among older patients with in-hospital deterioration, identifying areas for future quality improvement.
Talking Tots and the Terrible Twos: Early Language and Disruptive Behavior in Toddlers
Authors: Roberts Megan Y. , Curtis Philip , Estabrook Ryne , Norton Elizabeth S. , Davis Matthew M. , Burns James , Briggs-Gowan Margaret , Petitclerc Amelie , Wakschlag Lauren S.
Published: October 2018

Objective:

The goal of this article is to investigate the association between the 2 most commonly reported parental concerns about young children—disruptive behavior (e.g., irritable, aggressive, and noncompliant behaviors) and language delay in toddlers. To test for salient subgroup differences, individual differences by the sex of the child and family poverty status were examined.

Methods:

Participants included 1259 mothers of children between 18 and 36 months of age. Mothers completed questions about their child's language development and disruptive behavior. Information regarding poverty status as well as child age and sex were also collected.

Results:

Stronger language skills were associated with fewer disruptive behaviors for children between 18 and 36 months of age. This negative association was stronger for females than for males (b = −0.243; t[1251] = −3.555; p < 0.001) and stronger for children living in poverty than for those above the poverty line (b = −2.04; t[1251] = −2.531; p = 0.011).

Conclusion:

Findings from our study suggest a developmental co-occurrence pattern that begins at a very early age. Individual differences suggest that there is substantial heterogeneity in these patterns; longitudinal investigation is needed to uncover causal pathways and underlying mechanisms. Awareness of the association between these 2 developmental domains, about which parents frequently express concerns, is critical to maximizing early detection and intervention.
The association of an alpha2C adrenoreceptor gene polymorphism with vasomotor symptoms in African American women
Authors: Aharon Devora A. , Friedman Elissa Gretz , Overbey Jessica R. , McLaughlin Maryann , Langaee Taimour , Thurston Rebecca C.
Published: October 2018

Objective:

The alpha2C adrenoreceptor deletion 322-325 (ADRA2C del 322-325) polymorphism has been associated with autonomic activity and thermoregulation, which are implicated in the vasomotor symptom (VMS) mechanism. The ADRA2C del (322-325) has higher prevalence in African American women, a group known to experience more frequent and bothersome VMS. We assessed whether the ADRA2C del (322-325) genotype is associated with increased frequency of VMS in African American women.

Methods:

DNA samples from African American (N = 400) women participating in the Study of Women's Health Across the Nation (SWAN) were genotyped for the ADRA2C del (322-325) polymorphism. Longitudinal data on VMS were obtained from the SWAN repository. The relation of ADRA2C del (322-325) genotypes (deletion/deletion [D/D]; insertion/deletion [I/D]; insertion/insertion [I/I]) with VMS over the menopausal transition for up to 12 years of follow-up was examined using generalized estimating equations. Primary models considered the outcome of frequent VMS (6 or more days in the prior 2 wk vs VMS <6 d in the prior 2 wk) by stage of menopause.

Results:

Four hundred DNA samples from African American women were included. Seventy-five women (18.8%) were found to carry the homozygous variant allele (D/D). There was no significant difference in the trajectory of frequent VMS over the menopausal transition between women with D/D and I/I + I/D genotypes (P = 0.39).

Conclusions:

In this preliminary study among African American women in SWAN, ADRA2C del (322-325) was not significantly related to self-reported VMS. Further studies are warranted to help us understand the role of the adrenergic system in the physiology of VMS to tailor medical therapy to patient needs.
Efficacy of Laser Resurfacing and Facial Plastic Surgery Using Age, Glogau, and Fitzpatrick Rating
Authors: Barrera Jose Enrique , Adame Michael Julian , Lospinoso Josh A. , Beachkofsky Thomas M.
Published: October 2018

Background:

To assess clinical outcomes based on established rating scales in patients who underwent treatment for rhytids using laser resurfacing with and without facial plastic surgery.

Methods:

Retrospective case review of 48 patients treated by the senior author (J.E.B) between 2009 and 2016. Three reviewers assigned ratings to a total of 48 patients using estimated age and Fitzpatrick, Modified Fitzpatrick, and Glogau scales. Reviewers were blinded to patient demographics and before and after photographs. Patients elected to receive laser-only treatment or combination laser plus facial plastic surgery. Participants included forty-eight patients were selected on the basis that they had either laser treatment alone or laser plus facial plastic surgery and pre- and postoperative photographs.

Results:

Patients with higher Fitzpatrick scores had a greater reduction in Glogau score (ß = 1.66; SE = 0.59;P< 0.01). With respect to modified Fitzpatrick scores after surgery, patients with higher Glogau scores of 3 or 4 before surgery (P< 0.01) had higher scores after surgery ((ß = 0.07; SE = 0.02;P< 0.01). For estimated age, the average change was -1.7 years after laser resurfacing (P= 0.038; 95% CI, 2.96–3.06 years) and -2.07 years when combined with surgery (P= 0.01; 95% CI, 2.89–3.19 years).

Conclusions:

Patients with Fitzpatrick scores of 3, 4, 5, younger patients, and those with less rhytids before surgery tended to have lower Glogau scores after surgery. These findings provide insight on an approach to treating ethnic skin and aging face concerns.
Balancing Distraction Forces in the Mandible: Newton’s Third Law of Distraction
Authors: Shakir Sameer , Naran Sanjay , Lowe Kristen M. , Bartlett Scott P.
Published: October 2018

Vertical mandibular distraction results in translation of both proximal and distal segments. The force exerted on the condylar segment not only places unwanted force on the joint but also rotates the coronoid process into the cranial base. To prevent these sequelae, we investigate the use of a "check plate" on the condylar segment in an attempt to decrease force at the Temporomandibular joint (TMJ) and prevent unwanted rotation of the coronoid. Patients with hemifacial microsomia, seen at our Children's Hospital from 2012 to 2016 having undergone unilateral vertical mandibular distraction with placement of check plate were compared with a sample of those similarly having undergone distraction without use of the plate. Preoperative and postoperative cephalometric measures and 3-dimensional computed tomography imaging were analyzed. Three subjects were identified in each group. Age and Pruzansky-Kaban classification did not differ between groups. Vertical distance from the coronoid process perpendicular to the Frankfort Horizontal did not differ between groups (P < 0.07); however, postoperative distance significantly differed with the coronoid process rotating upward into the cranial base in subjects without a check plate (P < 0.005). Preoperative angle of the coronoid process based on the Frankfort Horizontal did not differ (P < 0.06); however, postoperative angle significantly changed, confirming upward rotation into the cranial base (P < 0.01). Total regenerate did not differ (P < 0.08). Vertical mandibular distraction results in undesirable upward rotation of the proximal segment into the cranial base and superior displacement of regenerate. This can be prevented with the use of a check plate.
Prevalence of Depressive Symptoms in Patients Requesting Cosmetic Breast Surgery in Midwestern Brazil
Authors: de Paula Paulo Renato , Fortes de Arruda Fabiano Calixto , Prado Marcelo , Neves Carlos Gustavo
Published: October 2018

Background:

The prevalence of depressive symptoms (DS) before cosmetic breast surgery was analyzed in the public (PbI) and private (PrI) institutions, comparing types of surgery and patients’ sociodemographic characteristics.

Methods:

A cross-sectional, observational, analytical study to evaluate the prevalence of DS in 185 patients of 18–71 years of age requesting 4 different cosmetic breast surgeries (with and without implants) at public and private institutions. Patients were assessed using the Beck Depression Inventory and analyzed for statistical comparison.

Results:

The most common surgical procedures were reduction mammoplasty in the PbI and augmentation mammoplasty in the PrI. The prevalence of the positive risk for depressive disorder (≥15 points in Beck Depression Inventory) in the PbI was 25.8%, whereas in the PrI: 11.4% (P = 0.012). Moderate and severe DS were, respectively, 120% and 242% higher in the PbI than in the PrI. No patients requesting mastopexy without implants had DS. The highest prevalence (51.4%) of DS occurred in patients with breast implants indications (augmentation mammoplasty and mastopexy with implants). The presence (P = 0.12) or absence (P = 0.33) of implant did not demonstrate a higher risk of DS. Among all patients, 7% answered positively to the statements on suicide ideation, with predominance within the group of implants (54.5%). There were significant differences between the PbI and PrI.

Conclusions:

The prevalence of DS was high (18.9%), with the risk being 2.3 times greater in the PbI. Patients from PbI and PrI showed significant different profiles. Patients for breast implants showed a higher score for suicide ideation.
A Single-visit Approach Using Fillers and Incobotulinumtoxin A: Full Face Enhancement in Asian Patients
Authors: Chao Yates Y. Y.
Published: October 2018

A 3-dimensional, multi-layered approach combining modalities targeting different manifestations is recommended for achieving optimal esthetic outcomes. To date, studies reporting same-day treatment with dermal fillers and botulinum toxin have not been published. This article documents the practical use of a single-visit, pan-facial multimodal approach in addressing the varying esthetic needs of 8 Asian adults. The case series included male or female patients of varying age and degrees of facial fat, who received combination treatment with calcium hydroxylapatite filler, polydensified hyaluronic acid filler, and incobotulinumtoxin A in a single visit in August 2016 at a treatment center in Taiwan. Treatments were individualized based on the needs of each patient, according to guideline recommendations. The agents, with distinctive rheological properties indicated for different purposes, were applied sequentially across different facial tissue planes within a single visit. Patients were monitored for development of side effects after treatment. Photographs taken before treatment and 2 weeks after treatment were evaluated by the treating physicians. For all patients, treatment produced substantial improvements in all treated facial areas. Inherent morphological deficiencies in younger patients were addressed, age-related changes in older patients were corrected, and facial sexual dimorphism was enhanced in male and female patients. No major side effects occurred after treatment. This case series showcases the real-life implementation of a flexible, single-visit, multimodal approach that can be adapted for a variety of indications.
Orbitomaxillofacial Mucormycosis Requiring Complex Multifactorial Management
Authors: Steve Anna K. , Hurdle Valerie A. , Brown Jevon Y.
Published: October 2018

Mucormycosis is a rare fungal infection caused by ubiquitous fungi in the order Mucorales. It is the most rapidly progressing fulminant fungal infection that mimics necrotizing soft-tissue infections. Overwhelming fungal sepsis develops quickly and mortality rates approach 70%. Culture negative necrotizing infections and cutaneous necrosis following a vascular pattern should raise suspicion for this rare entity. We describe avoiding mortality in a case of orbitomaxillofacial mucormycosis multifactorially treated with: radical serial debridement, topical amphotericin B irrigation and dressings, parenteral amphotericin B, and hyperbaric oxygen therapy. Tissue biopsy was central to confirming the diagnosis and directing multimodal management that ultimately prevented dissemination to the central nervous system and mortality.
Acquisition of analgesic properties by the cholecystokinin (CCK)/CCK2 receptor system within the amygdala in a persistent inflammatory pain condition
Authors: Roca-Lapirot Olivier , Fossat Pascal , Ma Sherie , Egron Karine , Trigilio Gabriella , López-González María-José , Covita João , Bouali-Benazzouz Rabia , Favereaux Alexandre , Gundlach Andrew L. , Landry Marc
Published: October 2018

Pain is associated with negative emotions such as anxiety, but the underlying neurocircuitry and modulators of the association of pain and anxiety remain unclear. The neuropeptide cholecystokinin (CCK) has both pronociceptive and anxiogenic properties, so we explored the role of CCK in anxiety and nociception in the central amygdala (CeA), a key area in control of emotions and descending pain pathways. Local infusion of CCK into the CeA of control rats increased anxiety, as measured in the light–dark box test, but had no effect on mechanical sensitivity. By contrast, intra-CeA CCK infusion 4 days after Complete Freund's Adjuvant (CFA) injection into the hindpaw resulted in analgesia, but also in loss of its anxiogenic capacity. Inflammatory conditions induced changes in the CeA CCK signaling system with an increase of CCK immunoreactivity and a decrease in CCK1, but not CCK2, receptor mRNA. In CFA rats, patch-clamp experiments revealed that CCK infusion increased CeA neuron excitability. It also partially blocked the discharge of wide dynamic range neurons in the dorsal spinal cord. These effects of CCK on CeA and spinal neurons in CFA rats were mimicked by the specific CCK2receptor agonist, gastrin. This analgesic effect was likely mediated by identified CeA neurons projecting to the periaqueductal gray matter that express CCK receptors. Together, our data demonstrate that intra-CeA CCK infusion activated a descending CCK2receptor-dependent pathway that inhibited spinal neuron discharge. Thus, persistent pain induces a functional switch to a newly identified analgesic capacity of CCK in the amygdala, indicating central emotion-related circuit controls pain transmission in spinal cord.
Survival and Functional Status After Bridge-to-Transplant with a Left Ventricular Assist Device
Authors: Suarez-Pierre Alejandro , Zhou Xun , Fraser Charles D. , Grimm Joshua C. , Crawford Todd C. , Lui Cecillia , Valero Vicente , Choi Chun W. , Higgins Robert S. , Kilic Ahmet
Published: October 2018

The use left ventricular assist devices (LVAD) as a bridge-to-transplant (BTT) has become a common modality to treat end-stage heart failure. We sought to examine the impact of BTT on long-term survival and quality of life after heart transplant. The population was all adult patients undergoing isolated heart transplantation in the United States between 2007 and 2017. Inclusion criteria covered BTT patients with a LVAD (only Heartmate II [HMII] or HeartWare Ventricular Assist System [HVAD]) and compared these with patients undergoingde novoheart transplantation. Our primary end-point was survival at 1, 2, and 5 years. Secondary end-points were functional status, return to work, and rates of hospital readmission and graft rejection. Unconditional and conditional survival was estimated with the Kaplan-Meier method. The independent influence of BTT on risk-adjusted mortality was determined using Cox proportional hazards models. In this period, 5,584 patients were bridged with an LVAD and 12,295 underwentde novotransplantation. Unconditional survival was 2% higher inde novopatients at 1, 2, and 5 years. After risk adjustment, BTT was associated with increased mortality at each time point. Unadjusted 5 year survival, conditional on 90 day survival, was similar between groups (82.6%vs.83.4%;p= 0.15). Functional status, return to work, and unadjusted rates of hospital readmission and graft rejection were similar at 1, 2, 5 years. Bridge-to-transplant with LVADs provides excellent survival and similar quality of life to that of patients undergoingde novoheart transplantation. Bridge-to-transplant patients experience a slightly higher mortality rate within 90 days of transplantation.
Bloodstream Infections in Continuous Flow Left Ventricular Assist Device Recipients: Diagnostic and Clinical Implications
Authors: Kyvernitakis Andreas , Pappas Orestis , Farmakiotis Dimitrios , Horn Edward T. , Benza Raymond L. , Bailey Stephen H. , Agarwal Richa
Published: October 2018

Bloodstream infection (BSI) is a common complication of left ventricular assist device (LVAD) support and particularly difficult to treat. The presentation is often variable because of altered physiology and augmentation of cardiac output by the device. We studied LVAD recipients at a single institution. Multivariate logistic and Cox (with time-varying parameters) regression were implemented. Of 212 patients, 58% experienced infections. Driveline infection (DLI) affected 31%, with 60% of them having deep-tissue involvement. Sixty-six patients (31%) suffered from 135 BSIs. Systemic inflammatory response syndrome (SIRS) was present in 47% of BSIs at presentation and associated with increased mortality. Right heart failure, destination therapy, Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile, morbid obesity, and deep-DLI were independent risk factors for BSI. The BSI was independently associated with mortality. Bridge-to-transplantation (BTT) patients were more likely to receive transplant if they did not have BSIs. Among 104 BTT patients who received heart transplantation, development of BSI was associated with shorter time-to-transplantation. Diagnosis of BSI poses diagnostic and prognostic challenges because of the hemodynamic profile of LVAD patients who may not mount the expected physiologic response to sepsis. Although SIRS criteria lack sensitivity in the LVAD population, SIRS signifies increased risk for death. Deep DLI was the strongest predictor of BSI. Despite the upgrade in listing status of BTT-LVADs with BSIs and shorter time-to-transplantation, BSI remain a major cause of mortality. BSIs are associated with significant mortality and should be regarded as a serious complication, similar to pump thrombosis and stroke.
Blue laser imaging: a new image-enhanced endoscopy for the diagnosis of colorectal lesions
Authors: dos Santos Carlos E.O. , Malaman Daniele , Yoshida Naohisa , Pereira-Lima Júlio C. , Onófrio Fernanda Q. , Furlan Rafaelle G. , Tabushi Fernando I. , Malafaia Osvaldo
Published: October 2018

Background

Image-enhanced endoscopy enables real-time differential diagnosis of colorectal lesions through the observation of microvascular architecture.

Purpose

To evaluate the efficacy of using blue laser imaging (BLI) for capillary pattern analysis in the differential diagnosis of neoplastic and non-neoplastic lesions.

Patients and methods

This prospective study included 920 consecutive superficial lesions diagnosed in 457 patients. The capillary pattern was analysed using BLI-bright magnification on the basis of the Teixeira classification. Histopathology was used as the reference standard.

Results

The adenoma detection rate was 42.3%, with a mean of 0.95 adenomas per patient. Neoplastic lesions were predominant (70.3%), of which 33 (5.1%) had advanced histology. Neoplastic progression was significantly increased in patients aged at least 50 years, in lesions at least 10 mm and in lesions located in the right colon (P<0.01). BLI-based capillary pattern analysis showed 95.5% accuracy, 95.7% sensitivity, 95.2% specificity, 97.9% positive predictive value and 90.3% negative predictive value in the diagnosis of neoplastic lesions. For 672 diminutive lesions (≤5 mm), BLI-based capillary pattern analysis showed 95.7% accuracy, 96.6% sensitivity, 93.6% specificity, 97.2% positive predictive value and 92.2% negative predictive value. Analysing only lesions up to 5 mm in the rectum and sigmoid colon, the values were 95.2, 93.9, 96.5, 95.8 and 94.8%, respectively.

Conclusion

BLI associated with magnification yielded excellent results for the real-time predictive histological diagnosis of colorectal lesions.
Comparative Clinical Outcomes of Edoxaban in Adults With Nonvalvular Atrial Fibrillation
Authors: Aronow Wilbert S. , Shamliyan Tatyana A.
Published: October 2018

Background:

A critical appraisal of all pooled evidence regarding novel oral anticoagulants (NOACs) for stroke prevention regardless of publication status or study design has not been conducted yet. Being the latest addition to NOACs, the data on edoxaban are especially scarce.

Study Question:

What are the comparative clinical outcomes of edoxaban versus warfarin and other NOACs apixaban, dabigatran, or rivaroxaban in adults with nonvalvular atrial fibrillation?

Data Sources:

Randomized controlled trials (RCTs), observational studies, and network meta-analyses were identified in PubMed, EMBASE, the Cochrane Library, Pharmapendium, Elsevier Clinical Pharmacology, and the clinicaltrials.gov trial registry in June 2018.

Study Design:

Rapid review per a priori developed protocol, direct frequentist random-effects meta-analysis of aggregate data, grading the quality of evidence per the Grading of Recommendations Assessment, Development and Evaluation working group approach.

Results:

Direct 4 RCTs (23,021 patients) suggest that edoxaban is noninferior to warfarin in prevention of stroke and systemic embolism [pooled relative risk (RR): 0.65, 95% confidence interval (CI): 0.23–1.81, 2 RCTs] and reduces the risk of cardiovascular mortality (RR: 0.87, 95% CI: 0.78–0.97, 1 RCT), major cardiovascular morbidity (RR: 0.90, 95% CI: 0.82–0.98, 2 RCTs), and major bleeding events (RR: 0.80, 95% CI: 0.71–0.91, 1 RCT) but increases the risk of gastrointestinal bleeding (RR: 1.21, 95% CI: 1.01–1.46, 1 RCT) and anemia (RR: 1.45, 95% CI: 1.05–1.99, 3 RCTs). Edoxaban is superior to warfarin in patients with increased risk of bleeding with warfarin because of variants in CYP2C9 and VKORC1 genes. Indirect evidence does not allow valid conclusions regarding comparative superiority of NOACs. The quality of evidence was downgraded because of reporting bias, small number of events, and indirectness in comparisons.

Conclusions:

Edoxaban is a welcome addition to the NOAC's armamentarium. However, the comparative data with other novel NOACs are mostly nonexisting, and urgently needed for better individual patient assessment.
Current and future status of stem cell expansion
Authors: Becnel Melody , Shpall Elizabeth J.
Published: October 2018

Purpose of review

Herein, we seek to describe the current and future role of ex-vivo expansion of cord blood hematopoietic stem cells.

Recent findings

As this field is only in its infancy, there have been many challenges identified. Decreased number of stem cells contained in a cord blood unit and early differentiation of stem cells once expanded have been two overarching challenges faced by the field. Many recent techniques have focused on the properties of the microenvironment and targetable cellular pathways as novel approaches to circumvent these challenges.

Novel discoveries have led to the development of approaches that will increase hematopoietic stem cell yield and will improve engraftment in patients receiving cord blood hematopoietic stem cell transplantation. As a result, patients receiving cord blood hematopoietic stem cell transplantationcontinue to have improved outcomes.
Chemoradiotherapy for Unresectable INI1-negative Chordoma in a Child
Authors: Miyahara Hiroyuki , Nodomi Seishiro , Umeda Katsutsugu , Itasaka Satoshi , Waki Kenji , Imai Tsuyoshi
Published: October 2018

The characteristics of chordomas in children are distinct from those in adults. In particular, the prognosis of patients with INI1-negative chordoma is dismal. The standard treatment for localized chordoma, complete surgical resection with a wide margin, is seldom feasible for chordomas arising at the clivus in children, mainly due to associated complications. Therefore, other treatments for unresectable chordomas in children, including chemoradiotherapy, must be explored. Here, we report a 7-year-old girl with an INI1-negative chordoma of the clivus, who responded to conventional chemotherapy plus radiotherapy. Without surgical resection, she remains alive after 1 year and 7 months of the initial diagnosis.
Associations Between Cannabis Use, Sexual Behavior, and Sexually Transmitted Infections/Human Immunodeficiency Virus in a Cohort of Young Men Who Have Sex With Men
Authors: Gorbach Pamina M. , Javanbakht Marjan , Shover Chelsea L. , Bolan Robert K. , Ragsdale Amy , Shoptaw Steven
Published: October 2018

Background

Among men who have sex with men (MSM) the relationship between sexually transmitted infections (STIs) and cannabis use is not well established. We assessed cannabis use, sexual behavior, and STIs including human immunodeficiency virus (HIV) in a diverse cohort of young MSM.

Methods

In Los Angeles, the mSTUDY cohort conducted visits every 6 months with 512 MSM between 2014 and 2017 collecting demographics, sexual behaviors, and reports of frequency of substance use. Each visit conducted testing for gonorrhea, chlamydia, and syphilis via blood, urine, and pharyngeal and rectal swabs by PCR, Human immunodeficiency virus was assessed using rapid tests for HIV-negatives and viral load for HIV-positives. We analyzed the relationship between cannabis use, sexual behaviors and STIs/HIV across 1535 visits.

Results

Significantly fewer participants tested positive for STIs at visits when reporting the previous 6 months use of only cannabis (11.7%) compared with no drugs (16.3%) or other drugs (20.0%, P = 0.01). Fewer MSM reporting only cannabis use than no or other drug use had been incarcerated, had incarcerated partners, experienced interpersonal violence, and were HIV-positive. In multivariable analyses visits with positive STIs were associated with other drug use (adjusted odds ratio, 1.69; 95% confidence interval, 1.03–2.78) but not use of cannabis only or no drug use after controlling for age, HIV status, new sex partners, and number of sex partners.

Conclusions

When MSM reported using cannabis exclusively fewer STIs were detected and lower risk sexual engagements reported than when MSM reported no drug or other drug use.
Nonrheumatoid Fibrinous Pericarditis
Authors: Gupta Avneesh , Furman Jaclyn , Kesha Kilak , Diaz Francisco , Schmidt Carl J.
Published: October 2018

Classic “bread-and-butter” appearance of fibrinous pericarditis had been described in rheumatic disease and other immunologic diseases such as systemic lupus erythematosus, post–myocardial infarct, uremia, tuberculosis, radiation effects, bacterial, and viral etiology. In most of the described cases, pericarditis occurs as a delayed complication. We present a case of a 21-year-old white woman who was seen in the emergency department to rule out pulmonary embolism for shortness of breath, chest pain, and lightheadedness. The autopsy showed a collection of serous fluid into the pericardial sac with bread-and-butter appearance. Microscopically, the pericardium showed acute inflammation with fibrinous exudates. Sections of the heart showed areas of lymphocytic infiltration with acute fibrinous inflammation of the pericardium. Vasculitis was seen in small blood vessels in the heart and was negative in other organs. No granuloma or necrotizing lesion was seen in microscopic sections of all organs including the heart, ruling out rheumatologic disease. The present study highlights the quest and design of an algorithm for a nonrheumatic disorder as the cause of pericarditis. Molecular studies were performed on heart tissue blocks for identification of cardiotropic viruses. Human parvovirus B19 was isolated from heart tissue blocks. The present case study highlights on updates in pathophysiology and diagnostic criteria for myocarditis along with the use of new molecular techniques for detection of idiopathic cardiomyopathies in a medical examiner setup.
Performance of the Pediatric Index of Mortality 3 Score in PICUs in Argentina: A Prospective, National Multicenter Study
Authors: Arias López María del P. , Boada Nancy , Fernández Analía , Fernández Ariel L. , Ratto María E. , Siaba Serrate Alejandro , Schnitzler Eduardo
Published: October 2018

Objective:

To assess the performance of the Pediatric Index of Mortality 3 score in a population of children admitted to PICUs in Argentina.

Design:

Prospective, national, multicenter study.

Setting:

Forty-nine PICUs located in Argentina belonging to public and private institutions.

Patients:

All children between 1 month and 16 years old admitted to the participating PICUs between May 15, 2016, and February 15, 2017.

Interventions:

None.

Measurement and Main Results:

A total of 6,602 patients were enrolled in the study. The observed mortality was 8% (531/6,602), whereas mortality predicted by Pediatric Index of Mortality 3 was 6.16% (407 deaths). The standardized mortality rate was 1.3 (95% CI, 1.20–1.42). The area under the receiver operating characteristic curve was 0.83 (95% CI, 0.82–0.85). The Hosmer-Lemeshow test showed that the difference between the mortality observed and the mortality predicted by Pediatric Index of Mortality 3 was statistically significant (χ2, 135.63; p < 0.001).

Conclusions:

The Pediatric Index of Mortality 3 score adequately discriminated patients who died from those who survived in our population. However, the observed mortality was higher than predicted by the score. The use of an updated instrument such as Pediatric Index of Mortality 3 will allow an actual comparison between pediatric intensive care provided in the country and care provided internationally. This might also allow future planning of pediatric intensive care services in Argentina.
Infectious Endocarditis Prophylaxis in Children
Authors: Martin James , Lindgren Christina
Published: October 2018

Infectious endocarditis (IE) is a rare illness with high morbidity and mortality. Incidence of IE is on the rise in industrialized countries, particularly as those with congenital heart defects are living longer and the use of indwelling central catheters increases. With the 2007 American Heart Association guidelines, there has been a shift in recommending antibiotic prophylaxis only to high-risk patient populations. This clinical review will highlight the changing epidemiology and etiology of IE, followed by an emphasis on the appropriate indications for antibiotic prophylaxis in high-risk populations undergoing specific procedures.
County-Level Socioeconomic Disparities in Use of Medical Services for Management of Infections by Medicare Beneficiaries With Diabetes—United States, 2012
Authors: Chang Man-Huei , Beckles Gloria L. , Moonesinghe Ramal , Truman Benedict I.
Published: October 2018

Objective:

To assess county-level socioeconomic disparities in medical service usage for infections among Medicare beneficiaries with diabetes (MBWDs) who had fee-for-service health insurance claims during 2012.

Design:

We used Medicare claims data to calculate percentage of MBWDs with infections.

Setting:

Medicare beneficiaries.

Participants:

We estimated the percentage of MBWDs who used medical services for each of 3 groups of infections by sex and quintiles of the prevalence of social factors in the person's county of residence: anatomic site-specific infections; pathogen-specific infections; and HHST infections (human immunodeficiency virus/acquired immunodeficiency syndrome, viral hepatitis, sexually transmitted diseases, and tuberculosis).

Main Outcome Measures:

Using quintiles of county-specific socioeconomic determinants, we calculated absolute and relative disparities in each group of infections for male and female MBWDs. We also used regression-based summary measures to estimate the overall average absolute and relative disparities for each infection group.

Results:

Of the 4.5 million male MBWDs, 15.8%, 25.3%, and 2.7% had 1 or more site-specific, pathogen-specific, and HHST infections, respectively. Results were similar for females (n = 5.2 million). The percentage of MBWDs with 1 or more infections in each group increased as social disadvantage in the MBWDs' county of residence increased. Absolute and relative county-level socioeconomic disparities in receipt of medical services for 1 or more infections (site- or pathogen-specific) were 12.9 or less percentage points and 65.5% or less, respectively. For HHST infections, percentage of MBWDs having 1 or more HHST infections for persons residing in the highest quintile (Q5) was 3- to 4-fold higher (P < .001) than persons residing in the lowest quintile (Q1).

Conclusions:

Infection burden among MBWDs is generally associated with county-level contextual socioeconomic disadvantage, and the extent of health disparities varies by infection category, socioeconomic factor, and quintiles of socioeconomic disadvantage. The findings imply ongoing need for efforts to identify effective interventions for reducing county-level social disparities in infections among patients with diabetes.
Rehabilitation Approach After Surgical Repair of Spontaneous Bilateral Quadriceps Tendon Rupture in a Healthy Mason
Authors: Portugal Diogo Manuel , Capelo João A. , Martins Bárbara Dantas , Ribeiro Inês M. , Ataíde Sofia R. , Vera-Cruz Carla V.
Published: October 2018

Quadriceps tendon rupture is a rare lesion, occurring most frequently in males older than 60 yrs after a fall or trauma and associated with systemic diseases and risk factors. Bilateral injury is even more uncommon and disabling. The authors report a case of spontaneous bilateral quadriceps tendon rupture, nonsimultaneous (8 days apart), in a healthy 54-yr-old black male mason, that may be work related. The patient was included in a 6-mo rehabilitation program after surgical repair. Pain control and gait reacquisition were particularly difficult. Following the customized and phased rehabilitation program, the patient achieved the 6-mo functional outcomes reported for unilateral rupture. The authors highlight the rehabilitation specificities and challenges of the bilateral lesion and discuss the pathophysiological role of prolonged periods of working in repetitive quadriceps overuse postures on quadriceps tendon rupture.
The Effectiveness of Group-Based Physiotherapy-Led Behavioral Psychological Interventions on Adults With Chronic Low Back Pain
Authors: Zhang Qi , Jiang Shujun , Young Lufei , Li Feng
Published: October 2018

Group-based physiotherapy-led behavioral psychological interventions (GPBPIs) are an emerging treatment for chronic low back pain, but the efficacy of these interventions is uncertain. A review of relevant randomized controlled trials and a meta-analysis was conducted to evaluate the effectiveness of GPBPIs on pain relief in adults with chronic low back pain. Literature databases, Google Scholar, bibliographies, and other relevant sources were searched. Thirteen intervention studies (13) published from 1998 to 2013 were included. The meta-analysis was conducted using RevMan software in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. In reviewing the short- (<6 mos), intermediate- (≥6 and <12 mos), and longer-term (≥12 mos) effects of GPBPIs, long-term follow-up evaluations showed large and significant effect sizes (standardized mean difference = −0.25, 95% confidence interval = −0.39 to −0.11, I
2 = 38%, P < 0.01). Subgroup analysis indicated that patients from GPBPIs group had the greater short-, intermediate-, and long-term pain reduction than patients on waiting listing or usual care group. Compared with other active treatments, GPBPIs showed a small but significant long-term pain reduction in patients with chronic low back pain (standardized mean difference = −0.18, 95% confidence interval = −0.35 to −0.01, I
2 = 32%, P = 0.04). In general, GPBPIs may be an acceptable intervention to relieve pain intensity.
Detectability of Brain Metastases by Using Frequency-Selective Nonlinear Blending in Contrast-Enhanced Computed Tomography
Authors: Bongers Malte N. , Bier Georg , Schabel Christoph , Fritz Jan , Horger Marius
Published: October 2018

Purpose

The aim of this study to evaluate the role of frequency-selective nonlinear blending (FS-NLB) for the detectability of brain metastases with contrast-enhanced computed tomography (CECT) using magnetic resonance imaging (MRI) as standard of reference.

Materials and Methods

A retrospective patient data search at our institution yielded 91 patients who underwent both brain CECT and MRI for screening of brain metastases (n = 173) between 2014 and 2016 (mean time interval, 29 ± 37 [malignant: 15 ± 16/benign: 42 ± 47] days). A recently introduced FS-NLB postprocessing technique was applied to CECT images. Two readers interpreted all CT images in an independent fashion. The conventional, linear blending (LB) CT images were evaluated first. After a washout period, the same readers evaluated the FS-NLB CT images. The standard of reference was established by a consensus interpretation of the brain MRI studies. Outcome variables included determination of best performing FS-NLB settings, region of interest (ROI)–based calculation of contrast-to-noise ratios (CNRs), size, and number of brain metastases. Based on the number of metastases, we classified patients in 5 therapeutically relevant categories (0, no metastasis; 1, singular metastasis; 2, less than 4 metastases; 3, >4 and <10 metastases; 4, >10 metastases). Statistical comparison and diagnostic performance tests were applied.

Results

A center of 47 Hounsfield units (HU), delta of 5 HU, and slope of 5 resulted in the best delineation of hyperdense brain metastases, whereas for hypodense brain metastases, a center of 32 HU, delta of 5 HU, and slope of 5 showed best delineation. Frequency-selective nonlinear blending significantly increased CNR in hyperdense cerebral metastases (CECT: 9.11 [6.9–10.9], FS-NLB: 18.1 [11.9–22.8]; P < 0.0001) and hypodense cerebral metastases (CECT: 6.3 [5.2–8], FS-NLB: 17.8 [14.5–19.7]; P < 0.0001). Sensitivity, specificity, negative predictive values, positive predictive values, and accuracy for LB, and FS-NLB were 40%, 98%, 99%, 31%, and 52%, and 62%, 94%, 97%, 40%, and 69%, respectively. Magnetic resonance imaging, LB, and FS-NLB classification of metastatic patients were group 0 (47, 47, 46), group 1 (14, 8, 11), group 2 (16, 12, 15), group 3 (8, 7, 8), and group 4 (6, 4, 6).

Conclusions

Frequency-selective nonlinear blending postprocessing of CECT significantly increases the detection of brain metastases over conventional CECT; however, the sensitivity remains lower than MRI. Frequency-selective nonlinear blending is slightly inferior in the categorization of patients into therapeutically relevant groups, when compared with MRI.
Epithelioid Hemangioma of the Face
Authors: Sedran Luca , Bonaso Mila , Mettus Arianna , Roccia Fabio
Published: October 2018

An epithelioid hemangioma is a very rare lesion arising from vascular structures. We encountered 2 cases in atypical locations, one in the orbital and the other in the nasal region. We performed preoperative angiography in addition to the diagnostic imaging recommended in the literature. Angiography highlighted the lesions well, and in one case, it was possible to embolize the arterial trunk of a high-flow lesion. Angiography underscored how such lesions may differ from the vascular perspective, emphasizing the importance of histology in correct diagnosis. Management of both hemangiomas yielded good functional and cosmetic outcomes with no disease recurrence.
Optic Disc Deformation and Orbital Bone Erosion Secondary to a Huge Neglected Orbital Cavernous Hemangioma
Authors: Bagheri Abbas , Shahraki Kourosh , Tavakoli Mehdi
Published: October 2018

Cavernous hemangioma (CH) is the most common benign tumor of the orbit which can expand the bony orbit by gradual growth of a large tumor. In this article, the authors report a 28-year-old man presented with a longstanding unilateral proptosis secondary to a huge orbital CH which also caused optic disc deformation and bone erosions in the adjacent orbital walls. The optic disc deformities resolved after the tumor removal.