bluuebunny/crossref_metadata_2025 huggingface dataset:
Extracorporeal Life Support for Severe Acute Chest Syndrome in Adult Sickle Cell Disease: A Preliminary Report
Authors: Boissier Florence , Bagate François , Schmidt Matthieu , Labbé Vincent , Kimmoun Antoine , Fartoukh Muriel , Mekontso Dessap Armand
Published: February 2019

Objectives:

Extracorporeal life support could be helpful for severe acute chest syndrome in adults sickle cell disease, because of the frequent hemodynamic compromise in this setting, including acute pulmonary vascular dysfunction and right ventricular failure. The aim of this study was to report the extracorporeal life support experience for severe acute chest syndrome in four referral centers in France.

Design:

The primary endpoint of this multicentric retrospective study was ICU survival of patients with severe acute chest syndrome managed with extracorporeal life support. Secondary endpoints included comparisons between survivors and nonsurvivors.

Setting:

We performed this study between January 2009 and July 2017 in four referral centers in France.

Patients:

We included adult patients (age > 18 yr) with sickle cell disease, admitted for severe acute chest syndrome and who required extracorporeal life support during the ICU stay.

Interventions:

The study was observational.

Measurements and Main Results:

Over the 8-year period, 22 patients with sickle cell disease required extracorporeal life support for severe acute chest syndrome, including 10 (45%) veno-venous and 12 (55%) veno-arterial extracorporeal life support. In-ICU mortality was high (73%). Nonsurvivors had a higher severity at extracorporeal life support implantation, as assessed by their Vasoactive-Inotrope Score and number of organ failures.

Conclusions:

Our study shows that outcome is impaired in sickle cell disease patients receiving extracorporeal life support while in severe multiple organ failure. Further studies are needed to evaluate selection criteria in this setting.
Demyelinating Neuropathy in a Patient Treated With Revusiran for Transthyretin (Thr60Ala) Amyloidosis
Authors: Zanazzi George , Arshad Muhammad , Maurer Mathew S. , Brannagan Thomas H. , Tanji Kurenai
Published: February 2019

Transthyretin amyloidosis patients develop length-dependent peripheral neuropathy, autonomic dysfunction, and restrictive cardiomyopathy associated with deposition of amyloid fibrils in these tissues. Despite advances in management over the past decade, this disorder causes profound debilitation and ultimately proves fatal. In this report, we describe a man with late-onset cardiac amyloidosis due to a transthyretin Thr60Ala mutation who was treated with an investigational RNAi therapeutic, revusiran, which targets hepatic transthyretin production. Sixteen months into treatment, he developed bilateral lower-extremity weakness and numbness, worsening balance, difficulty manipulating objects with his hands, and finger numbness. Nerve conduction studies were consistent with multifocal demyelinating neuropathy. Intravenous immunoglobulin therapy improved sensation in his hands and feet, and improved hand dexterity. A sural nerve biopsy demonstrated demyelination with substantial axonal loss in the absence of histologically detectable endoneurial amyloid deposition. This case expands the clinicopathologic spectrum of transthyretin amyloidosis and may represent complex disease and treatment effects.
Exploring the “Preterm Behavioral Phenotype” in Children Born Extremely Preterm
Authors: Burnett Alice C. , Youssef George , Anderson Peter J. , Duff Julianne , Doyle Lex W. , Cheong Jeanie L.Y. ,   for the Victorian Infant Collaborative Study Group
Published: February 2019

Objective:

To examine whether difficulties in emotional, attention, and peer or social functioning (a proposed “preterm behavioral phenotype”) co-occur within individual children born extremely preterm (EP; <28 weeks of gestation) and/or extremely low birth weight (ELBW; <1,000 g) and whether different behavioral profiles are related to cognitive and academic outcomes.

Methods:

Population-based cohort of all EP/ELBW survivors born in the state of Victoria, Australia, in 2005, and contemporaneous matched controls were recruited at birth. At age 7 to 8 years, parents of 181 EP/ELBW and 185 control children rated their children's behavior on the Strengths and Difficulties Questionnaire problem scales (emotional symptoms, conduct problems, hyperactivity/inattention, and peer problems). Latent profile analysis was used to explore patterns of behavior within individual children.

Results:

Four behavioral profiles were identified: (1) minimal difficulties in all domains; (2) a profile consistent with the preterm behavioral phenotype; (3) elevations in all domains except peer problems; and (4) marked global elevations in all domains. Most preterm children (55%) had a profile of minimal difficulties. Relative to their risk of being in the minimal difficulties group, EP/ELBW children were overrepresented in the preterm behavioral phenotype (20% vs. 12% controls) and the globally elevated symptom groups (8% vs. 3%). Accounting for birth group and demographic variables, profiles with higher levels of behavior symptoms were associated with poorer cognitive and academic performance.

Conclusion:

Although more EP/ELBW children exhibited the proposed preterm behavioral phenotype than controls, it occurred in only 20% of EP/ELBW children. Greater behavior symptoms were associated with poorer cognitive and academic outcomes.
Multilevel Factors Predicting Cardiac Rehabilitation Attendance and Adherence in Underserved Patients at a Safety-Net Hospital
Authors: Bennett Kymberley K. , Smith Andrew J. , Harry Kadie M. , Clark Jillian M. R. , Waters Marcia A. , Umhoefer Amanda J. , Bergland Dennis S. , Eways Kalon R. , Wilson Elizabeth J.
Published: February 2019

Purpose:

This study examined multilevel factors as predictors of cardiac rehabilitation (CR) attendance and adherence among underserved patients at a safety-net hospital (SNH).

Methods:

Participants were recruited during hospitalization for a cardiac procedure or event. Participants responded to a questionnaire, and outcome data (including CR attendance and adherence) were extracted from medical records at baseline and 6 mo post-discharge.

Results:

Data were collected from 171 participants, 92 (53.8%) of whom attended CR. On average, participants completed 24 CR sessions (66.7% adherence) and 40 (43.5%) participants fully adhered to the 36 prescribed sessions. Bivariate comparisons showed that participants who attended CR were more likely to have insurance (P = .002), perceive CR as important (P = .008), believe they needed CR (P = .005), and endorsed fewer barriers to CR (P = .005) than their nonattending counterparts. After controlling for insurance status, a regression analysis to predict attendance revealed only 1 predictor; perceived lack of time (P = .04). Bivariate analyses showed that only 1 clinical factor, treatment during hospitalization, was significantly related to adherence (P = .03). Patients with medical management alone (no revascularization) showed less adherence than their counterparts with revascularization.

Conclusions:

Although access to insurance is a significant predictor of attendance, psychological barriers that are amenable to being addressed by CR staff are also important. Findings suggest that perceived lack of time is important in SNH patient decision making to attend CR. This psychological barrier is a subject on which CR staff can intervene to educate patients about the life expectancy increases and decreased personal health care expenditures because of attendance.
Targeting the CaVα–CaVβ interaction yields an antagonist of the N-type CaV2.2 channel with broad antinociceptive efficacy
Authors: Khanna Rajesh , Yu Jie , Yang Xiaofang , Moutal Aubin , Chefdeville Aude , Gokhale Vijay , Shuja Zunaira , Chew Lindsey A. , Bellampalli Shreya S. , Luo Shizhen , François-Moutal Liberty , Serafini Maria J. , Ha Taehwan , Perez-Miller Samantha , Park Ki Duk , Patwardhan Amol M. , Streicher John M. , Colecraft Henry M. , Khanna May
Published: February 2019

Inhibition of voltage-gated calcium (CaV) channels is a potential therapy for many neurological diseases including chronic pain. Neuronal CaV1/CaV2 channels are composed of α, β, γ and α2δ subunits. The β subunits of CaV channels are cytoplasmic proteins that increase the surface expression of the pore-forming α subunit of CaV. We targeted the high-affinity protein–protein interface of CaVβ's pocket within the CaVα subunit. Structure-based virtual screening of 50,000 small molecule library docked to the β subunit led to the identification of 2-(3,5-dimethylisoxazol-4-yl)-N-((4-((3-phenylpropyl)amino)quinazolin-2-yl)methyl)acetamide (IPPQ). This small molecule bound to CaVβ and inhibited its coupling with N-type voltage-gated calcium (CaV2.2) channels, leading to a reduction in CaV2.2 currents in rat dorsal root ganglion sensory neurons, decreased presynaptic localization of CaV2.2 in vivo, decreased frequency of spontaneous excitatory postsynaptic potentials and miniature excitatory postsynaptic potentials, and inhibited release of the nociceptive neurotransmitter calcitonin gene–related peptide from spinal cord. IPPQ did not target opioid receptors nor did it engage inhibitory G protein–coupled receptor signaling. IPPQ was antinociceptive in naive animals and reversed allodynia and hyperalgesia in models of acute (postsurgical) and neuropathic (spinal nerve ligation, chemotherapy- and gp120-induced peripheral neuropathy, and genome-edited neuropathy) pain. IPPQ did not cause akinesia or motor impairment, a common adverse effect of CaV2.2 targeting drugs, when injected into the brain. IPPQ, a quinazoline analog, represents a novel class of CaV2.2-targeting compounds that may serve as probes to interrogate CaVα–CaVβ function and ultimately be developed as a nonopioid therapeutic for chronic pain.
Direct-Acting Oral Anticoagulants and Warfarin-Associated Intracerebral Hemorrhage Protocol Reduces Timing of Door to Correction Interventions
Authors: Olivier Rosemary C. , Gleeson Diane , Skinner Claudia , Cacciata Marysol , Wickman Mary
Published: February 2019

Background: Intracerebral hemorrhage (ICH) is a life-threatening complication of oral anticoagulant therapy that sometimes results in hematoma expansion after onset. Our facility did not have a standardized process for treating oral anticoagulant–associated ICH; this resulted in lag times from order to reversal agent administration. Purpose: The aim of this study was to examine the impact of a rapid anticoagulant reversal protocol, combined with warfarin and direct-acting oral anticoagulant therapy, in decreasing door to first intervention times. Methods: This study used a retrospective quality assessment research approach in examining an oral anticoagulant reversal protocol to compare the control and intervention groups. Phytonadione was the first intervention treatment for most study participants diagnosed with warfarin-associated ICH with an international normalized ratio greater than 1.4. Factor IX was the first intervention treatment for all but one study participant with DOAC-associated ICH. Results: Findings were statistically significant (P < .05) for door to first intervention treatments. Door to phytonadione in minutes decreased from 232.7 (SD, 199.4) to posttest findings of 111.4 (SD, 64.6). Door to factor IX in minutes decreased from 183.9 (SD, 230.2) to posttest findings of 116.6 (SD, 69.1). Conclusion: Study findings support the hypothesis that the new protocol was associated with lower door-to-treatment times for eligible patients.
Effect of Applicant Gender on Multiple Mini-Interview Admissions Score
Authors: Hegmann Theresa
Published: February 2019

Purpose

Admissions criteria for physician assistant (PA) schools vary considerably, but they often involve a combination of academic measures, noncognitive “humanistic” qualities, and mission-related items. To address noncognitive attributes, some PA schools have implemented the multiple mini-interview (MMI) format developed at McMaster University in Canada. This research project looked at differences in interview scores by gender over 3 consecutive admissions cycles at one PA program.

Methods

Three years of pre-existing de-identified data gathered as part of the routine admissions process were analyzed retrospectively using SPSS-v25.

Results

Data were available for all interviewees for 2015, 2016, and 2017 (N = 350 total). Between-group differences were not statistically significant by gender. Reliability (Cronbach's α) was 0.865 for academic scoring and 0.694 for MMI scoring.

Discussion

Analysis of 3 years of admissions data from a single program did not show evidence for gender bias in MMI scores. Although this result is reassuring, it requires continued monitoring and replication.
Factors That Influence Job Choice at the Time of Graduation for Physician Assistant Students
Authors: Twombly Lauren Anne , Rizzolo Denise , Chen Rong , Kelchen Robert
Published: February 2019

Research and data analysis show that there is a shortage of primary care providers throughout the United States. Physician assistants (PAs) play an important role in health care delivery; however, the percentage of PAs practicing in primary care has dramatically decreased in the past 15 years. The purpose of this study was to identify potential factors that influence PA students' first job choice following graduation from a PA program to determine whether they have a relationship to the choosing of primary care. The 2016 End of Program Survey data were analyzed using a multinominal logistic regression to determine what factors influenced PA students' selections of primary care as their first job choice: individual factors, program factors, and external factors. Of the 3038 subjects, 269 (8.9%) accepted a job in primary care, 847 (27.9%) accepted a specialty job, and 1922 (63.3%) did not accept a job. When comparing no job accepted versus primary care job choice, marital status and racial/ethnic differences influenced first job choice. Financial factors were also found to be significant predictors. In the second model, comparing specialty versus primary care job choice, marital status influenced first job choice along with financial factors. In addition, one program variable (moderate clinical rotation experience) was found to be statistically significant in the model of specialty versus primary care job choice. Financial factors were found to be the greatest predictor in first job choice. Focusing on policy to help reduce student debt and increase reimbursement rates could help increase the number of students choosing primary care.
On the Possibility of Achieving Near-Normal Swing Phase of Walking with Passive Single-Axis and Polycentric Knees: A Simulation Approach
Authors: Sudeesh S. , Sujatha S. , Shunmugam M.S.
Published: February 2019

Introduction

A new passive polycentric knee called IITM polycentric knee (IPK), where IITM stands for the authors' institution, namely, Indian Institute of Technology Madras, was designed to provide better functionality at a reduced cost. The design of the knee was based on stance phase stability criteria and toe clearance during the swing phase for users in developing countries to handle uneven terrain. The present study features a simulation-based dynamic analysis of a passive single-axis knee (SAK) and IPK to understand the swing phase behavior of the IPK with respect to SAK. This study aims at understanding the advantages and disadvantages of the IPK against a passive SAK to improve its design criteria and enable further development to provide better functionality to the existing passive SAK users.

Methods

Lower-limb models of a normal leg and prosthetic legs with SAK and IPK were created, their swing phases were simulated, and gait parameters were analyzed. The passive knees in the present study have only frictional damping and no active knee moments, implying the requirement of compensatory strategies for forward progression of the swinging leg. The required frictional damping at the knee joint to obtain near-normal knee motion and the compensations required while using the SAK and IPK were obtained by simulation. The lower-limb dynamics obtained from the simulations was analyzed to understand the performance of the SAK and IPK during swing.

Results

This study shows that the IPK is superior to an SAK in terms of achieving knee extension in preparation for stance, even without an extension assist and with lower hip effort. The peak hip power during swing with the IPK was 58.7% less than with the SAK. A negative heel clearance was found in terminal swing with the IPK, which demands a compensatory strategy for foot clearance during the swing and shows the necessity for inclusion of a heel clearance parameter in the design of polycentric knees.

Conclusions

The present work focuses on the swing behavior comparison of passive single-axis and polycentric knees. The study provides insight into the compensatory strategies required to achieve successful forward progression of the swinging leg with both types of knees. The analysis shows the potential for a well-designed passive polycentric knee to be a cost-effective alternative to achieve near-normal swing during walking.
Finite Element Analysis of the Jaipur Foot: Implications for Design Improvement
Authors: Wolynski Jakob G. , Wheatley Benjamin B. , Mali Harlal Singh , Jain Anil K. , Haut Donahue Tammy L.
Published: February 2019

Introduction

The Jaipur Foot is a low-cost prosthetic limb developed by Dr. P.K. Sethi and implemented in clinics across India and the world. Although the device is well-suited for many geographic and socioeconomic areas, it suffers from an inconsistent lifespan.

Methods

The purpose of this study was to use finite element analysis to parametrically simulate the Jaipur Foot to determine potential improvements to the prosthesis’ design. The resulting model used varied material properties and internal boundary conditions through two stages of the gait cycle to predict the effects on the likelihood of device failure. Further analysis investigating the effect on device mechanics by the change in material properties due to vulcanization was also completed.

Results

Results suggested that the interface between microcellular rubber blocks is a concern for failure, which agrees with epidemiological studies of the prosthesis. Data further indicated changes in material property to result in substantial alterations to the stresses experienced within the prosthesis.

Conclusions

Future work could use this model for alternative designs of the Jaipur Foot.
Fu's subcutaneous needling and constraint-induced movement therapy for a patient with chronic stroke
Authors: Jin Yuanyuan , Jin Xiaoqing , Li Jiangru
Published: February 2019

Rationale:

Spasticity is a common issue in chronic stroke. To date, no study has reported the long-term (up to 1 year) outcomes of Fu's subcutaneous needling in combination with constraint-induced movement therapy in chronic stroke. This report describes the successful addition of acupuncture on spasticity and arm function in a patient with chronic stroke and arm paresis.

Patient concerns:

The patient suffered an infarction in the right posterior limb of the internal capsule 1 year ago, which resulted in hemiparesis in his left (nondominant) hand and arm. The only limitation for constraint-induced movement therapy was insufficient finger extension. The patient was unable to voluntarily extend his interphalangeal or metacarpophalangeal joints beyond the 10 degrees required for constraint-induced movement therapy. However, his muscle tension did not change after the BTX type A injection.

Diagnoses:

A 35-year-old male experienced arm paresis after an infarction in the right posterior limb of the internal capsule 1 year before the intervention.

Interventions:

The BTX type A injection did not work, so the patient received Fu's subcutaneous needling as an alternative therapy before 5 h of constraint-induced movement therapy for 12 weekdays.

Outcomes:

All outcome measures (Modified Ashworth Scale, Fugl-Meyer Assessment, Action Research Arm Test, and Motor Activity Log) substantially improved over the 1-year period. Moreover, during the observation period, the patient's muscle tone and arm function did not worsen.

Lessons:

As a result of a reduction in spasticity, a reduction of learned nonuse behaviors, or use-dependent plasticity after the combined therapy, the arm functions include volitional movements, and coordination or speed of movements in the paretic arm have been improved. However, we cannot rule out the possibility of an influence of the passage of time or the Hawthorne effect. The costs of the treatment of stroke may be reduced, if this combined therapy proved useful in future controlled studies.
The relevance of MTHFR C677T, A1298C, and MTRR A66G polymorphisms with response to male infertility in Asians
Authors: Shi Tian-Lu , Wu Yan , Li Yu , Chen Zhen-Feng , Ma Yi-Ni , Zhang Zhe-Tao , Zhang Yong-Huang , Zhang Lei
Published: February 2019

Although published studies have reported the association between MTHFR C677T (rs 1801133), A1298C (rs 1801131), and MTRR A66G (rs1801394) polymorphisms and male infertility in Asian populations, the results are conflicting. In order to accurately evaluate the relevance, a meta-analysis was performed.

We searched for potential studies in 4 databases, containing PubMed, ScienceDirect, China National Knowledge Infrastructure (CNKI), and Wanfang database until May 31, 2018. The summarized odds ratio (OR) with 95% confidence intervals (95% CI) were calculated to evaluate the relevance in 5 genetic models. The heterogeneity test, sensitivity analysis, and publication bias test was performed by Review Manager 5.3 software.

Overall, 22 case–control studies with 5049 cases and 4157 controls were included in this meta-analysis, which contained 20 studies of MTHFR C677T polymorphism, 12 studies of MTHFR A1298C polymorphism and 4 studies of MTRR A66G polymorphism. The results indicated that MTHFR C677T, A1298C, and MTRR A66G polymorphisms were significantly associated with male infertility in Asian populations (Dominant model: MTHFR CC + CT vs TT: OR = 0.60, 95% CI (0.53, 0.67), P <.00001; MTHFR AA + AC vs CC: OR = 0.62, 95% CI (0.49, 0.79), P = .0001; MTRR AA + AG vs GG: OR = 0.60, 95% CI (0.45, 0.81), P = .001. Recessive model: MTHFR CC vs CT + TT: OR = 0.67, 95% CI (0.61, 0.74), P <.00001; MTHFR AA vs AC + CC: OR = 0.79, 95% CI (0.70, 0.88), P <.0001; MTRR AA vs AG + GG: OR = 0.70, 95% CI (0.56, 0.88), P = .002. Heterozygote model: MTHFR CC vs CT: OR = 0.74, 95% CI (0.67, 0.82), P <.00001; MTHFR AA vs AC: OR = 0.83, 95% CI (0.73, 0.93), P = .002; MTRR AA vs AG: OR = 0.76, 95% CI (0.60, 0.92), P = .02. Homozygote model: MTHFR CC vs TT: OR = 0.48, 95% CI (0.41, 0.56), P <.00001; MTHFR AA vs CC: OR = 0.61, 95% CI (0.39, 0.93), P = .02; MTRR AA vs GG: OR = 0.51, 95% CI (0.36, 0.72), P = .0001. Allele model: MTHFR C vs T: OR = 0.70, 95% CI (0.66, 0.75), P <.00001; MTHFR A vsC: OR = 0.82, 95% CI (0.71, 0.95), P = .01; MTRR A vs G: OR = 0.76, 95% CI (0.66, 0.88), P = .00003). Stratified analyses by geographical location and source of controls showed the same results. Sensitivity analyses indicated that the final consequences of this meta-analysis were stable, and the publication biases test had not found obvious asymmetry.

This meta-analysis indicates that MTHFR C677T, A1298C, and MTRR A66G polymorphisms are the risk factors with susceptibility to male infertility in Asians.
Vonoprazan versus proton pump inhibitors in treating post-endoscopic submucosal dissection ulcers and preventing bleeding
Authors: Martin  , Zhou Yi , Meng Chun-Xu , Takagi Tatsuya , Tian Yu-Shi
Published: February 2019

Background:

Vonoprazan is a potassium-competitive acid blocker (P-CAB). It is often used in Japan for Helicobacter pylori (H pylori) eradication, gastroesophageal reflux disease, and endoscopic submucosal dissection (ESD) ulcers and bleeding. This meta-analysis aims to evaluate whether vonoprazan has better therapeutic effect on ESD-induced ulcers and bleeding than proton pump inhibitors (PPIs) at different length of treatment periods (2, 4, and 8 weeks).

Methods:

This meta-analysis will include both randomized controlled trials (RCTs) and observational studies discussing the effectiveness of vonoprazan and PPIs on ESD-induced ulcers and bleeding. Information of studies will be collected from PubMed, Cochrane Library, ClinicalTrials.gov, and Google Scholar. Studies will be selected according to the eligibility criteria and data will be extracted by 2 people and compared with each other to keep in consistency. Cochrane risk of bias tool will be used to assess RCTs and the Newcastle-Ottawa Quality Assessment Scale will be used to assess the observational studies. Meta-analysis based on the random-effects model will be conducted to compare the differences of ulcers’ shrinkage ratios (%) and the odds ratios (OR) of scars’ stages and delayed bleeding. Publication bias will be evaluated using funnel plots and Egger's regression test. Heterogeneity will be assessed with the I

2
statistics. Sensitivity analysis will be conducted on follow-up periods. The evidential quality of the findings will be assessed with the Grading of Recommendations Assessment Development and Evaluation (GRADE) profiler.

Discussion:

The findings of the present systematic review will be critical for physicians, patients, and policymakers regarding the use of vonoprazan in ESD-induced ulcers.

Study registration:

PROSPERO registration number: CRD42018116855.
Oral glutamine supplements reduce concurrent chemoradiotherapy-induced esophagitis in patients with advanced non-small cell lung cancer
Authors: Chang Shih-Chieh , Lai Yi-Chun , Hung Jui-Chi , Chang Cheng-Yu
Published: February 2019

Background:

Complications related to concurrent chemoradiotherapy (CCRT) such as acute radiation-induced esophagitis (ARIE) may cause significant morbidity and unplanned treatment delays in patients with advanced non-small cell lung cancer (NSCLC). We designed a prospective randomized study to assess the impact of glutamine (GLN) supplementation in preventing CCRT-induced toxicities of advanced NSCLC patients.

Methods:

From September 2014 to September 2015, 60 patients diagnosed with NSCLC were included to the study. Thirty patients (50%) received prophylactic powdered GLN orally at a dose of 10 g/8 h. The prescribed radiation dose to the planning target volume was 30 Gy in 2-Gy fractions. The endpoints were radiation-induced esophagitis, mucositis, body weight loss, overall survival and progression-free survival.

Results:

The 60 patients with NSCLC included 42 men and 18 women with a mean age ± standard deviation of 60.3 years ± 18.2 (range, 44–78 years).

At a median follow-up of 26.4 months (range 10.4–32.2), all patients tolerated GLN well. A administration of GLN was associated with a decrease in the incidence of grade 2 or 3 ARIE (6.7% vs 53.4% for Gln+ vs Gln-; P = .004). GLN supplementation appeared to significantly delay ARIE onset for 5.8 days (18.2 days vs 12.4 days; P = .027) and reduced incidence of weight loss (20% vs 73.3%; P = .01).

Discussion:

Our study suggests a beneficial effect of oral glutamine supplementation for the prevention from radiation-induced injury and body weight loss in advanced NSCLC patients who receiving CCRT.
Effectiveness of lumbar epidural injection in patients with chronic spinal stenosis accompanying redundant nerve roots
Authors: Lee Jong-Hyuk , Sim Ki-Choon , Kwon Hyun-Jung , Kim Jae-Won , Lee Gunn , Cho Seong-Sik , Choi Seong-Soo , Leem Jeong-Gil
Published: February 2019

Redundant nerve root syndrome (RNRS) is a phenomenon characterized by the presence of elongated, enlarged, tortuous nerve roots in the lumbar subarachnoid space. It is unclear whether RNRS is caused by spinal stenosis or causes these symptoms.

This study evaluated the effects of lumbar epidural steroid injection (LESI) on patients with RNRS and assessed factors associated with RNRS. This retrospective observational cohort study was conducted at a single pain clinic of a university hospital.

The medical records of 172 outpatients presenting with low back and/or leg pain from July to December 2014 were analyzed. Pain intensity (numeric rating scale [NRS]) and functional status were assessed at baseline and 2, 4, and 12 weeks after the LESI. Patients were considered moderate responders if they showed a 3-point or >30% reduction in baseline NRS, or said “better than 30%,” “a little better,” or “I feel an effect.” Patients were considered substantial responders if they showed a 5-point or >50% reduction in baseline NRS, or said “better than 50%,” “very good,” or “much better.” Generalized estimating equation (GEE) analysis was performed to identify the factors associated with moderate response to LESI. Factors associated with RNRS were also determined by logistic regression analysis.

The proportions of both moderate and substantial responders at 2, 4, and 12 weeks were significantly lower in patients with than without RNRS. GEE analysis showed that RNRS were the only factor significantly associated with moderate response to LESI (OR = 0.400; 95% CI, 0.253–0.632; P < .001). The distance from the conus medullaris to the closest level of stenosis was shorter in patients with than without RNRS (P < .001) and was the only independent factor associated with RNRS on multivariate logistic regression analysis (OR = 0.972; P < .001).

LESI was less effective in patients with than without RNRS. The only independent factor significantly associated with RNRS was the distance from the conus medullaris to the nearest moderate stenosis.
Acute cholecystitis as a rare and overlooked complication in stroke patients
Authors: Yoo Myung Chul , Yoo Seung Don , Chon Jinmann , Han Young Rok , Lee Seung Ah
Published: February 2019

Acute cholecystitis (AC) is a rare but possible medical complication found in stroke patients. As many stroke patients present with neurologic symptoms, such as altered mental status, motor weakness, global aphasia, or dysarthria, clinical symptoms and signs of AC are often unexpressed or overlooked. As a result, the diagnosis of AC is often delayed with subsequent secondary complications in these stroke patients. This study aims to evaluate the clinical incidence, manifestations, and predictive factors of AC in stroke patients.

A retrospective cohort study was conducted between January 2013 and December of 2017 of all stroke patients (n = 2699) who have been admitted to our stroke center of the university hospital. We evaluated patient demographics, presenting symptoms, vital signs, laboratory results, mean initial consecutive fasting time, mean total fasting time, modified Rankin Scale (mRS), as well as radiological findings of abdominal computed tomography (CT) or ultrasonography.

AC was diagnosed in 28 of the 2699 patients (1.04%). Of these patients with AC, gallbladder stones (calculous cholecystitis) were found in 4 patients (14.3%), and 24 patients (85.7%) were diagnosed with a calculous cholecystitis. Subgroup analysis revealed that of the 28 stroke patients with AC, those who underwent neurosurgical intervention (n = 15) had increased incidence of AC compared with those who did not (2.3% vs 0.6%, respectively, P < .001). Furthermore, the initial consecutive fasting time, total fasting time, and mRS were all predictive factors (P < .05) for developing AC in stroke patients.

The incidence of AC was higher in acute stroke patients who required neurosurgical intervention, with longer initial consecutive fasting time, total fasting time, and higher mRS. We recommend early enteral nutrition and to maintain a high degree of clinical suspicion to make an early diagnosis of AC in stroke patients for improved outcome.
Impact of inflammation-mediated myocardial fibrosis on the risk of recurrence after successful ablation of atrial fibrillation – the FIBRO-RISK study
Authors: Korodi Szilamer , Toganel Rodica , Benedek Theodora , Hodas Roxana , Chitu Monica , Ratiu Mihaela , Kovacs Istvan , Mester Andras , Benedek Imre
Published: February 2019

Introduction:

Interventional ablation has been demonstrated to represent an effective therapy in patients with atrial fibrillation (AF), leading to restoration and maintenance of sinus rhythm in the majority of cases. However, recurrence of AF is encountered in 35% to 40% of cases, and the causes for this frequent complication have not been elucidated so far.

Material and methods:

Here we present the study protocol of the FIBRO-RISK trial, a prospective, single-center, cohort study which aims to investigate the impact of inflammatory-mediated myocardial fibrosis on the risk of recurrence after successful catheter ablation of atrial fibrillation. The level of systemic inflammation in the pre-ablation and immediate post-ablation period will be assessed on the basis of serum levels of inflammatory biomarkers (hsCRP, matrix metalloproteases, interleukin-6), while the level of cardiac fibrosis will be determined based on cardiac magnetic resonance imaging associated with complex post-processing techniques for mapping myocardial fibrosis at the level of left atrium and left ventricle. At the same time, the amount of epicardial fat will serve as an indirect marker of localized inflammation and will be determined at different levels in the heart (surrounding left atrium, right atrium or the entire heart), while ventricular function will be assessed on the basis of serum levels of NT-proBNP prior to the procedure. All these parameters will be investigated in patients with successful ablation of AF, who will be divided into 2 groups: group 1 – patients who develop AF recurrence at 1-year, and group 2 – patients with no recurrence of AF at 1-year. In all patients, the following biomarkers will be determined: serum levels of inflammatory biomarkers and NT-proBNP at 24 hours and 1-year post procedure, the amount of myocardial fibrosis at the level of left atrium and left ventricle at baseline +/− 7 days, and the amount of epicardial fat surrounding left atrium, right atrium and the entire heart at baseline +/− 7 days.

The primary endpoint of the study will be represented by the rate of AF recurrence at 1-year post ablation, documented by either ECG or Holter monitoring. The secondary endpoints of the study will consist in:

In conclusion, FIBRO-RISK will be the first CMR-based study that will investigate the impact of inflammation-mediated myocardial fibrosis and ventricular remodeling on the risk of recurrence after successful ablation of AF, aiming to validate inflammatory biomarkers and myocardial fibrosis as predictors for AF recurrence.
Acute liver failure caused by occupational exposure to HCFC-123
Authors: Choe Hun Jee , Ahn Soomin , Jung Kwangrok , Kim Jin-Wook
Published: February 2019

Rationale:

Hydrochlorofluorocarbon 123 (HCFC-123, Freon123; 2,2-dichloro-1,1,1-trifluoroethane) has been widely used in refrigeration and heat-transfer applications as a substitute for chlorofluorocarbons due to its lower ozone-depleting potentials. Occupational exposure to HCFC-123 may cause mild reversible hepatoxicity, but no fatal cases have been reported yet.

Patient concerns:

In this report, we present cases of severe hepatitis with fatal outcome by HCFC-123. Two industrial workers from a manufacturing factory of fire extinguishers which use HCFC-123 were presented with diarrhea, fever, myalgia, and jaundice. Patients had been repeatedly exposed to the liquid form of HCFC-123 for the past three weeks before flare of symptoms.

Diagnosis:

The blood biochemistry tests showed acute cholestatic hepatitis and liver biopsy findings indicated inflammatory hepatocellular injury. The diagnosis of HCFC-123 induced hepatitis was made.

Interventions:

The treatment for both patients were generally supportive. The second patient went through hemodialysis, ventilatory care, and artificial liver support therapy (molecular adsorbent recirculating system) at intensive care unit.

Outcomes:

One patient recovered uneventfully, whereas the other patient showed rapid deterioration leading to acute liver failure complicated with cerebral edema, subdural hemorrhage, and death on hospital day 10.

Lessons:

The HCFC-123-induced hepatitis showed similarities with halothane hepatitis, both of which may share pathophysiologic mechanisms. Exposure to HCFC-123 needs to be listed as a potential cause of acute liver failure, and to be considered in patients with acute hepatitis of uncertain etiology and negative viral serology.
Apatinib treatment of advanced hepatocellular carcinoma with portal vein and inferior vena cava tumor thrombus
Authors: Yang XueGang , Wu Ge , Xu GuoHui
Published: February 2019

Rationale:

Hepatocellular carcinoma (HCC) is a highly invasive cancer associated with vascular invasion. The survival of advanced HCC is very poor. In this case study, we describe the efficacy and safety of apatinib in patient with advanced HCC as the first-line therapy.

Patient concerns:

A 46-year-old male complained of abdominal distention and pain for half a month.

Diagnoses:

HCC patient with portal vein and inferior vena cava tumor thrombus.

Interventions:

The apatinib alone was used as first-line therapy.

Outcomes:

Intrahepatic tumors, portal vein, and inferior vena cava tumor thrombus were diminished. The patient achieved partial response (PR) soon after the treatment, and progression-free survival (PFS) was 12.5 months. During the entire process, the alpha-fetoprotein (AFP) continued to decrease.

Lessons:

Apatinib alone may be a safe and effective therapy for HCC patients with portal vein and inferior vena cava tumor thrombus. However, it is warranted further investigation in the future prospective randomized clinical studies.
Effect of modified laparoscopic hysterectomy on pelvic floor function
Authors: Lee Chung-Yuan , Tseng Chih-Jen , Chang Chia-Hao , Lee Meng-Chih , Ou Yu-Che , Yang Shun-Fa
Published: February 2019

Hysterectomy is a potential risk factor for subsequent surgery for pelvic organ prolapse, especially when the prolapse exists before hysterectomy. Women without prolapse before hysterectomy may also experience prolapse after hysterectomy. This study aimed to describe a surgical modification of laparoscopic colposuspension with round ligaments after hysterectomy in women without preexisting genital prolapse and to evaluate the initial surgical results in these patients.

We reviewed data of 54 patients who underwent laparoscopic hysterectomy with colposuspension with unilateral or bilateral round ligaments after hysterectomy at Chia-Yi Chang Gung Memorial Hospital from July 2012 to March 2015. Vaginal length was measured before and after colposuspension after complete hysterectomy. Preoperative characteristics of the patients, perioperative quality, postoperative outcomes, and vaginal length differences were analyzed.

Vaginal length increased by a mean of 2.59 cm after colposuspension. The mean extra-operative time needed for laparoscopic colposuspension was about 10 minutes. No severe complications were reported in our patients, and we did not find any cystocele after completing vaginal cuff suspension to the round ligament.

The vaginal apex level was maintained in our modified laparoscopic hysterectomy. Therefore, laparoscopic colposuspension with round ligaments is a promising option as a routine, first-line standard procedure in younger women without genital prolapse to maintain an acceptable vaginal length after laparoscopic hysterectomy.
Therapeutic strategies of thromboembolic events in patients with inflammatory bowel diseases
Authors: Zhu Lei , Cheng Jiafei , Gu Peiqing , Liu Yajun , Liu Junlou , Wang Jianhua , Shen Hong
Published: February 2019

Rationale:

Inflammatory bowel disease (IBD), including Crohn disease (CD) and ulcerative colitis (UC), is characterized by chronic inflammatory condition and immunological abnormalities, which probably develop into venous thromboembolic events (VTEs). VTE in IBD patients mostly occurs at deep venous thrombosis (DVT) and pulmonary embolism (PE). The complications are extremely important in clinical practice considering the high mortality rate. Hence, an early diagnosis of IBD and the control of complications play an important role in therapy of thromboembolic events (TEEs).

Patient concerns:

Case 1 was a 31-year-old man with chronic UC who presented with signs of thromboembolism. Case 2 was a 43-year-old woman with CD complicated by fistulas.

Diagnoses:

Computed tomography (CT) and digital subtraction angiography (DSA) of the patient (case 1) suggested a thrombus in cerebral vein. The patient (case 2) developed acute ischemia of her right arm; B ultrasonography revealed a thrombus in the distal of the right subclavian artery accompanied by stenosis.

Interventions:

To lower blood viscosity and overcome the risk of deep thrombosis, the patient (case 1) was treated with a combination of low-molecular-weight heparin and dextran as anticoagulation. For the patient (case 2), anticoagulation treatment with 75 mg qd clopidogrel (plavix) and 1.25 mg qd warfarin was performed.

Outcomes:

In both patients, no further TEE occurred during follow-up 1 year and one and a half years, respectively.

Lessons:

It is important to pay attention to IBD patients especially those with high coagulation state.
Successful treatment of a patient with severe thallium poisoning in a coma using Prussian blue and plasma exchange
Authors: Lin Guodong , Yuan Luo , Bai Lili , Liu Yanqing , Wang Yongan , Qiu Zewu
Published: February 2019

Rationale:

This is the first reported severe thallium poisoning patient successfully treated with Prussian blue (PB) and plasma exchange (PE).

Patient concerns:

A 42-year-old woman in a coma owing to severe thallium poisoning was admitted to our department after day 44 of poisoning. At admission, blood and urine thallium concentrations were 380.0 and 2580.0 ng/mL, respectively.

Diagnosis:

The patient was diagnosed with toxic encephalopathy induced by thallium poisoning; in addition, she was also diagnosed with bilateral pneumonia, respiratory failure, moderate anemia, hypoproteinemia, and electrolyte imbalance based on her chest X-ray, blood gas analysis, Hb level, albumin levels, and serum electrolyte results.

Interventions:

The patient was intubated and treated with PB (6600 mg/d, 15 days in total) combined with PE (once daily, 5 days in total) as well as other symptomatic supportive care measures.

Outcomes:

After treatments, her blood and urinary thallium concentrations gradually decreased and on the 13th day after admission, the blood thallium concentration decreased to 0 ng/mL. The oxygenation index gradually improved, meantime, the patient gradually regained consciousness, and on the 50th day of admission, the patient's consciousness reverted to a clear-headed state. The patient recovered mostly after 37 months of follow-up.

Lessons:

Through this case, we learned that the gradual reduction in blood and urine thallium concentration and the patient's improved condition is correlated with PB and PE treatment. For patients with severe thallium poisoning, this treatment method might be effective; but the exact curative effect is unconfirmed, requiring further research to verify.
Diffuse alveolar hemorrhage in a patient with ANCA-associated vasculitis after thyroidectomy
Authors: Wang Kui-Rong , Zhou Yan-Feng
Published: February 2019

Rationale:

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is an autoimmune disease that mainly affects the lungs and kidneys. Limited reports of perioperative management of such patients were primarily concerned with airway stenosis. Here, we report a patient with AAV who developed diffuse alveolar hemorrhage (DAH) early after radical thyroidectomy.

Patient concerns:

A 57-year-old female developed wheezing and dyspnea approximately 30 minutes after radical thyroidectomy, with hemoptysis occurring the following day. The patient had a history of AAV and DAH and was maintained with prednisone.

Diagnosis:

A diagnosis of DAH was made on the basis of the history of AAV, dyspnea, hemoptysis, and chest computed tomography scan results that showed diffuse high-density shadows in the lungs.

Interventions:

The patient was administered high-dose glucocorticoids and cyclophosphamide immunosuppressive therapy. Non-invasive ventilation was needed for 2 days postoperatively due to dysfunction of oxygenation.

Outcomes:

After high-dose glucocorticoids and cyclophosphamide immunosuppressive therapy, DAH improved approximately 2 weeks after the surgery, during which time kidney function was not significantly impaired.

Lessons:

Patients with AAV may develop DAH in the early postoperative period and this may be confused with surgical complications and general anesthetic residues. Therefore, it needs to be identified in an appropriate timeframe.
Prevalence, awareness, and determinants of type 2 diabetes mellitus among commercial taxi drivers in buffalo city metropolitan municipality South Africa
Authors: Adedokun Aanuoluwa Odunayo , Ter Goon Daniel , Owolabi Eyitayo Omolara , Adeniyi Oladele Vincent , Ajayi Anthony Idowu
Published: February 2019

Undiagnosed type 2 diabetes mellitus constitutes a significant threat to the health of commercial taxi drivers, safety of the passengers and other road users. This study determines the prevalence of pre-diabetes and type 2 diabetes mellitus among commercial taxi drivers in Buffalo City Metropolitan Municipality (BCMM), Eastern Cape and examines the factors associated with type 2 diabetes mellitus.

A cross-sectional survey of 403 commercial taxi drivers was undertaken using the World Health Organization (WHO) STEPwise approach. Anthropometric, blood pressure, and blood glucose measurements followed standard procedure. Diabetes status was determined using the fasting blood glucose (FBG) test. Diabetes was defined as a FBG ≥7.0mmol/L or self-reported history of diabetes or current diabetes medication use (treatment), while pre-diabetes was defined as a FBG of 5.6 to 6.9 mmol/L. Awareness of diabetes was defined as a self-reported history of diabetes.

The mean age of the study participants was 43.3 ± 12.5years. Prevalence of pre-diabetes and diabetes were 17% (95% CI: 13.4–20.6) and 16% (95% CI: 12.4–19.6), respectively. Of those who had diabetes (n = 63), the majority were aware of their diabetes status (n = 43) and were on treatment (n = 30). In the unadjusted logistic regression, age, ever married, hypertension, obesity, and driving for more than 5 years were independently associated with diabetes. However, only age >35 (adjusted odds ratio [AOR]= 3.65, CI: 1.17–11.32), ever married (AOR= 3.26, CI: 1.52–6.99) and hypertension (AOR= 3.23, CI: 1.56–6.69) were associated with diabetes in the adjusted logistic regression model.

The prevalence of diabetes among commercial taxi drivers in this study is high, almost twice the national prevalence of diabetes in South Africa. Periodic health screening among this sub-population group is important to bridge the gap of undiagnosed diabetes in South Africa.