bluuebunny/crossref_metadata_2025 huggingface dataset:
New Deletion at Promoter of HBG1 Gene in Sickle Cell Disease Patients With High HbF Level
Authors: Chaouch Leila , Sellami Houssem , Kalai Miniar , Darragi Imen , Boudrigua Imen , Chaouachi Dorra , Abbes Salem , Mnif Samia
Published: November 2019

Objectives:

The 5′ upstream region of the HBG1 gene plays a very important role in the expression of fetal hemoglobin (HbF). In contrast, increased HbF levels can inhibit the deoxygenation-induced polymerization of sickle hemoglobin (α2βS2), which leads to moderation at the clinical level among sickle cell disease (SCD) patients. Thus, we focused on this article on the study of the 5′ upstream region of HBG1 among SCD pediatric patients with high levels of HbF.

Materials and Methods:

Fifteen SCD pediatric patients were chosen during the first time of diagnosis, and the HbF values were determined before hydoxyurea treatment. The ages at entry ranged from 1 to 8 years. The mutational screening of the 5′ upstream region of the HBG1, which extends to −587 bp, was performed by polymerase chain reaction/sequencing.

Results:

HbF values range from 6.9% to 26%. Sequencing results showed the presence of 6 known polymorphisms, which are as follows: RS35993903, RS34844625, RS3020750, RS2860456, RS2860470, and RS12290216. Interestingly, we also found a new deletion of GCAG in the HBG1 promoter at position -273.

Conclusions:

We described a new mutation, which is a deletion of GCAG in the HBG1 promoter at position -273. This deletion could affect a binding site of a transcription factor unknown so far and thus modulate the expression of the HBG1 gene.
Missed Diagnosis of β-Thalassemia Trait in Premarital Screening Due to Accompanying HbA2-Yialousa (HBD: c.82G>T)
Authors: Yilmaz Keskin Ebru , Acar Öznur , Özbas Halil
Published: November 2019

The diagnosis of β-thalassemia (β-thal) trait is usually based on an elevated HbA2 fraction (3.5% to 8%). Co-inheritance of a δ-globin variant along with β-globin gene defects can interfere with the diagnosis of β-thal trait by causing normal HbA2 levels. In this report, we present an infant with β-thal major whose mother’s β-thal trait was missed twice before due to an accompanying δ-globin mutation (HbA2-Yialousa; HBD: c.82G>T), resulting in a borderline HbA2 level. In an individual with microcytosis and hypochromia but an apparently normal HbA2 level, compound heterozygosity for a δ-globin mutation and a β-thal mutation should be remembered in the differential diagnosis.
Platinum-drugs Ototoxicity in Pediatric Patients With Brain Tumors: A 10-Year Review
Authors: Rabiço-Costa David , Gil-da-Costa Maria J. , Barbosa José P. , Bom-Sucesso Maria , Spratley Jorge
Published: November 2019

Purpose:

Platinum-derived chemotherapy is one of the cornerstones in the treatment of central nervous system tumors in children. We aimed to assess the incidence of hearing loss in children after the exposure to platinum drugs.

Material and Methods:

Retrospective study of prospectively collected data on children consecutively diagnosed with brain tumors and treated with platinum derivatives at a tertiary referral hospital between January 2006 and December 2015. We analyzed multiples variables, such as: age at diagnosis, tumor location, hydrocephalus, platinum drug type, radiotherapy, and follow-up time. The final sample size was 51 patients.

Results:

The median age at diagnosis was 6 years. The median overall follow-up time was 75 months. The incidence of ototoxicity was 23.5%. Rates of hearing loss with carboplatinum were lower than with cisplatinum. A statistically significant association occurred between the presence of hydrocephalus, radiotherapy exposure, infratentorial tumor location, and ototoxicity after treatment with platinum derivatives.

Conclusions:

Childhood central nervous system tumors nowadays exhibit improved cure and survival rates. However, the ototoxicity resulting from the chemotherapy treatment may accompany patients for the rest of their lives. This study reveals that this occurrence is not negligible, and the association of radiotherapy and the presence of hydrocephalus can be potentiating factors.
The influence of sleep quality and circadian preferences on upper extremity rehabilitation in stroke patients after constraint-induced movement therapy
Authors: Pereira Debora Dias , Eras-Garcia Rafael , Frange Cristina , de Oliveira Clarissa Barros , Tufik Sergio , Coelho Fernando Morgadinho Santos
Published: November 2019

Our aim was to explore the influence of sleep and circadian preference on upper extremity (UE) rehabilitation in stroke patients after constraint-induced movement therapy (CIMT) in a cross-sectional retrospective observational study. Forty-three patients were selected to complete questionnaires on circadian preference, sleep quality, excessive daytime sleepiness, and risk of obstructive sleep apnea. They had undergone a 10-day standard CIMT program without medical complications and with normal to minimal cognitive dysfunction. All pre- and postrehabilitation scores (patient perception of the quantity and quality of use of the affected UE and self-quantification of motor ability) were analyzed retrospectively. All patients had improved perception of the quantity and quality of use of the affected UE and self-quantified motor ability. Patients with an evening-type chronotype demonstrated less improvement than those with morning and intermediate types. In addition, patients with poor sleep quality showed less improvement in functional ability than those with good sleep quality. Circadian preferences and sleep quality impacted the improvements in motor performance of patients with stroke after CIMT rehabilitation. This is the first study to suggest that rehabilitation sessions must respect the circadian preferences of patients and that sleep quality can affect outcomes. Future studies should investigate the relationship and mechanisms between circadian preference and poor sleep quality and rehabilitation outcomes on a larger scale.
Effect of intensive rehabilitation on improvement of activity of daily living after intracerebral hemorrhage: a retrospective observational study
Authors: Okuda Yoshinobu , Nakata Toshio
Published: November 2019

Between 2008 and 2012, the intensity of rehabilitation therapy for the recovery phase of stroke was gradually increased at our hospital in line with the policy of Japan’s National Insurance System. Training hours increased from 0.8 to 2.5 hours/day without introducing any new techniques, programs, or equipment. The aim of this study was to investigate the effectiveness of the increased intensity of rehabilitation on the improvement of activity of daily living of patients with intracerebral hemorrhage. We retrospectively compared patient outcomes for the periods 2013–2017 (N = 162) and 2003–2007 (N = 116) using the gain in Barthel Index as an indicator of improvement in activity of daily living. The median (interquartile range) gain was significantly higher in 2013–2017 than in 2003–2007 [30 (20–45) vs. 15 (5–30); P < 0.001]. A stratified analysis showed that this improvement was independent of sex, the patient’s Barthel Index on admission, or the side of the brain lesion, but it varied with age or time to admission from onset of the disease. These results, based on a considerable difference in the intensity of rehabilitation between the two periods, support the consensus that increased time spent on rehabilitation results in better functional outcome in post-stroke patients. The results also suggest that age and the timing of starting rehabilitation are important factors to examine the effectiveness of intense rehabilitation in patients with intracerebral hemorrhage.
Korean Immigrant Women's Postpartum Experiences in the United States
Authors: Han Meekyung , Goyal Deepika , Lee Jiyoung , Cho Hyang , Kim Amber
Published: November 2019

Background:

Postpartum depression (PPD) affects one in seven women in the United States. Korean Americans are one of the six largest Asian American (AA) subgroups, representing 9% of the AA population in the United States. Women of Asian descent have not always been represented in studies of PPD.

Purpose:

The purpose of this study was to understand postpartum experiences, perceptions of PPD, and mental health help-seeking among Korean women living in the United States.

Methods:

Individual, face-to-face, semistructured interviews of Korean immigrant women, over age 18, who were able to read, write, and speak English or Korean, and who had given birth to a live infant within the past 12 months, were conducted using a qualitative exploratory design. Thematic analysis approach was used to analyze qualitative data The Edinburgh Postnatal Depression Screening Scale (EPDS) was used to assess frequency of depressive symptoms over the past week.

Results:

Eleven women participated. Total EPDS scores ranged from 2 to 17 (mean 6.5, SD = 3.2); three women had scores indicating a high risk for developing PPD. Two overall themes, postpartum experiences and perceptions of PPD and professional help-seeking, along with several subthemes were identified. They included postpartum challenges, importance of keeping Korean postpartum traditions, desire for professional Korean postpartum care, “Sanhoo-Joeri” postpartum support and social networking, normalization of PPD symptoms, family first for health seeking attitude and behavior, and stigma attached to mental health care.

Clinical Implications:

Nurses working with Korean women during postpartum can provide culturally competent care by assessing postpartum care needs, respecting cultural practices, and providing resources such as Korean postpartum care centers Sanhoo-Joeriwon, which can be found in major U.S. cities with large Korean communities (e.g., Los Angeles), and in-home postpartum care providers, Sanhoo-Joerisa. Nurses should be comfortable educating women about normal signs and symptoms of PPD and those requiring immediate medical follow-up.
Medicinal Plants Combating Against Insomnia
Authors: Akram Muhammad , Daniyal Muhammad , Munir Naveed , Mohiuddin Ejaz , Sultana Sabira
Published: November 2019

Insomnia is a state defined as trouble with sleep; it is a chronically disabling condition and is now significantly prevalent, imposing enormous health and economic burdens both on individuals and on society. This state includes trouble in falling asleep, problems staying asleep, fragmented sleep (repeatedly awakening at night), and/or awakening before time in the morning. This difficulty in sleeping causes feeling exhausted during the day and trouble with daytime activities including driving, family responsibilities, and completion of valued daily routines. Different types of synthetic sedative drugs are used to handle nervous system changes, but repeated use of sedatives caused tolerance in the human body. After a while, people had to take a heavy dose of sedative to make them feel sleepy, which imposes extra toxic effects on vital organs of the body. Medicinal plants are gaining more and more attention as sedative agents because herbs contained different types of natural bioactive metabolites with not well reported side effects. In addition, medicinal plants have economic, high efficacy and are easy available. So in current review plants possessing sedative activities have been compiled with their constituents responsible to manage insomnia. Review of the literature indicated that medicinal plants from various systems of medicine have been reported to possess sedative activity. This review suggests that medicinal plants are efficacious for insomnia; further laboratory and clinical studies are required.
Usefulness of Abductive Reasoning in Nursing Education
Authors: Mirza Noeman A. , Akhtar-Danesh Noori , Noesgaard Charlotte , Martin Lynn , Byrne Carolyn
Published: November 2019

Background

Hypothetico-deductive reasoning used by novice nurses could limit their ability to explain a presenting care situation in its entirety. Hence, scholars recommend the use of abductive reasoning as an alternative approach.

Purpose

This study explored the effects of abductive reasoning training on baccalaureate nursing students' hypothesis generation abilities.

Method

Through a pretest-posttest study, we delivered educational training on abductive reasoning and examined hypothesis accuracy, expertise, and breadth. Participants generated scenario-specific hypotheses before and after the training. Academic content experts validated the scenarios, and 2 independent raters scored participants' hypotheses.

Results

Twenty first- and second-year nursing students participated in this pilot study. Posttest scores showed a significant improvement in participants' hypothesis generation abilities: accuracy (P < .001), expertise (P < .001), and breadth (P = .006).

Conclusion

Abductive reasoning training in nursing education may improve students' hypothesis generation abilities.
Design and Evaluation of the Electronic Patient-Generated Index
Authors: Tavernier Susan S. , Beck Susan L.
Published: November 2019

Background

The patient-generated index (PGI) is an individualized measure of health-related quality of life. Previous work testing the PGI in the oncology setting identified threats to content validity due to navigational and computational completion errors using the paper format.

Objective

The purpose of this pilot study was to refine and evaluate the usability and acceptability of an electronic PGI (ePGI) prototype in the outpatient radiation oncology setting.

Methods

This pilot study used adaptive agile web design, cognitive interview, and survey methods.

Results

Three iterations of testing and refining the ePGI were required. Fifteen patients completed the refined ePGI using touch screen tablets with little or no coaching required. Nearly all participants rated the ePGI as “easy” or “very” easy to use, understand, and navigate. Up to one half stated they did not share this type of information with their clinician but felt the information on the ePGI would be useful to discuss when making decisions about their care. Eight clinicians participated, all of whom felt the ePGI was a useful tool to initiate dialogue about quality of life issues, reveal infrequent or unusual effects of treatment, and assist with symptom management.

Discussion

The pilot study indicates the ePGI may be useful for use at the point of care. Larger studies are needed to explore the influence it may have in decision-making and restructuring patient/provider communication.
Intraosseous Administration of Hypertonic Saline in Acute Brain-Injured Patients
Authors: Lawson Thomas , Hussein Omar , Nasir Muhammad , Hinduja Archana , Torbey Michel T.
Published: November 2019

Background:

Central venous catheters are often used to administer hypertonic saline (HTS) but might be associated with serious complications. Intraosseous (IO) access is an alternative method of medication and fluid delivery which is not associated with life-threatening complications and can be inserted faster than CVCs.

Methods:

A prospective case series was conducted on critically ill neurological patients that did not have central venous access, and for whom 3% HTS was indicated. Nonverbal indicators of pain were measured using the critical care pain observation tool. The pain score and serum sodium levels were collected at baseline, at 2, 6, 12, 18, and 24 hours after administration of 3% HTS using IO access. The area surrounding the IO insertion site was monitored for needle placement, extravasation, and tissue damage.

Results:

Five patients were enrolled. Three had an IO placed in the proximal humerus and 2 in the proximal tibia. Most patients did not have nonverbal indicators of pain during insertion and initial bolus. Serum sodium levels increased appropriately, as determined by the care providers. There were no cases of device dislodgement, extravasation, infection, soft tissue injury, or other local complications.

Conclusions:

In this prospective case series, IO administration of 3% HTS was feasible, well-tolerated on the basis of nonverbal indicators of pain in the majority of patients and resulted in an appropriate rise in serum sodium levels. IO fills a niche among vascular access options for HTS, in emergent neurological situations when central venous access is not readily available or peripheral intravenous access is difficult to obtain.
Validity of the Hispanic version of the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Questionnaire in patients with traumatic foot and ankle injuries
Authors: Zelle Boris Alexander , Adcock Christopher Fulton , Francisco Ben Seth , Morton-Gonzaba Nicolas Alexander , Fajardo Roberto José
Published: November 2019

Background:

Hispanics represent the largest minority group in the United States and are projected to represent 29% of the US population by 2060. Enrolling Hispanic patients in clinical outcome trials is critical to study a representative sample of the general population. Lack of translated and validated survey tools has been identified as a major barrier to enrolling Spanish speaking patients. The purpose of this validation study was to study the correlation between the Spanish translation of the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes questionnaire (AAOS-FAOQ) and the Spanish versions of the Foot Function Index (FFI) and the Foot Health Status Questionnaire (FHSQ) in Hispanics from Mexican lineage with traumatic foot and ankle injuries.

Methods:

A cross-sectional validation study in 36 Hispanic patients from Mexican lineage with foot and ankle injuries was performed. The Hispanic version of the AAOS-FAOQ and the Spanish translations of the FAOQ, FHSQ, FFI, and the Short-Form 36 questionnaire (SF-36) were distributed among all patients. Subsequent statistical analysis correlating the Hispanic version of the AAOS-FAOQ to the FFI, FHSQ, and SF-36 was performed. Additional analysis on the Hispanic AAOS-FAOQ included test–retest reliability and internal consistency.

Results:

The Hispanic AAOS-FAOQ Global Foot and Ankle subscale showed statistically significant (P < .05) correlations with 5 of 8 subscales of the FHSQ, the FFI, and the Physical Component Summary subscale of the SF-36. The AAOS-FAOQ Global Foot & Ankle Scale also demonstrated a test–retest reliability of 0.736 and a strong internal consistency.

Conclusions:

This study further validates AAOS-FAOQ in Mexican Hispanics by showing strong correlations with the validated Spanish versions of the FFI and FHSQ.
Themes and gaps in research for opioid use and misuse pertinent to orthopaedic injury patients
Authors: Miller Kaylie , O’Hara Nathan N. , Welsh Christopher J. , Ordonio Katherine , Loughry Nora , Liu Lucy , Slobogean Gerard P.
Published: November 2019

Introduction:

Prescription opioid use and misuse has accelerated rapidly in the United States over the past 2 decades. Orthopaedic surgeons are the third highest prescribers of opioids, and thus are contributing to this problem at a significant rate. Despite a surge in the number of publications on this issue, there has been little emphasis in the literature on disentangling the various factors contributing to opioid use and misuse among fracture patients. The goal of this study was to describe areas of focus and identify knowledge gaps present in the current literature on this important issue.

Methods:

We employed a scoping review technique due to its ability to successfully address a broad research question. In order to better understand the type of information deemed relevant by opioid researchers, we further analyzed our search results by sorting the publications into the following categories: consumer-focused, provider-focused, focus on substitutes, industry-focused, and focus on regulations (at the institution, profession, and government level).

Results:

The search strategies generated 8760 citations; of these, 1166 publications satisfied our inclusion criteria. Around 607 of these final abstracts were marked as “extremely relevant” (52%) and the other 559 (48%) were marked “relevant.” About 36.4% of the total included articles applied to the providers and 19.6% provided information on the consumer. A total of 25.2% of the included papers concerned substitutes for opioids, 15.7% focused on regulatory power in the opioid industry, and 14% considered opioids as an industry, including power of both current stakeholders and potential new entrants.

Discussion:

The present study provides a thorough summary of existing literature on opioid use and misuse relevant to musculoskeletal trauma patients. Furthermore, the categorical division of the literature provides a unique perspective into the drivers contributing to the opioid epidemic, and may assist in development of effective interventions to reduce excessive opioid use following traumatic injuries. Our review allowed us to identify important aspects of the opioid industry and various drivers of abuse that were absent from the literature including involvement of the pharmaceutical industry on the opioid epidemic, the involvement of insurance companies in opioid distribution, and the use of nonopioid alternative medications such as nonsteroidal anti-inflammatory drugs (NSAIDs).
Risk factors associated with mortality after traumatic cervical spinal cord injury
Authors: Higashi Takayuki , Eguchi Hideto , Wakayama Yusuke , Sumi Masakatsu , Saito Tomoyuki
Published: November 2019

Objectives:

To investigate the mortality rate following cervical spinal cord injury (SCI) injury and analyze the associated risk factors.

Design:

Retrospective cohort study.

Setting:

One Level 1 trauma center.

Patients/participants:

A cohort of 76 patients with traumatic cervical SCI was reviewed between January 2010 and May 2015, of which 54 patients were selected for the present retrospective study.

Intervention:

Operative or conservative treatment.

Main outcome measurements:

The following patient parameters were analyzed; age, sex, American Spinal Injury Association (ASIA) impairment scale, neurological impairment level, injury mechanism, radiological findings, treatment, tracheostomy rate, and mortality.

Results:

The mean age of the patient cohort was 65 ± 17 years, with 11 females (20%) and 43 males (80%). A total of 16 (30%), 4 (7%), 22 (41%), and 12 patients (22%) were scored A, B, C, and D, respectively, on the ASIA impairment scale. Most of the injuries were at the C4 (30%) and C5 (33%) levels. Falls from standing (35%) and heights (39%) were the most common injury mechanisms. SCI in 40 patients (74%) occurred without major fracture or dislocation. Surgery was performed on 26 patients. The overall mortality was 19%. Patients in the deceased group were significantly older at the time of injury, compared with those who survived. Paralysis had been more severe in the deceased group. A significantly high number of patients in the deceased group received a tracheostomy. When analyzed using a multivariate logistic regression model, an ASIA impairment scale of A was a significant risk factor for mortality.

Conclusions:

The risk factors associated with mortality were age, tracheostomy, and an ASIA impairment scale of A, the latter had the highest risk.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Comparison of fluoroscopic techniques for assessment of femoral rotational alignment
Authors: Lieberman Elizabeth G. , Jansen Kirsten , Mast Laurel , Brady Jacqueline M. , Yoo Brad J.
Published: November 2019

Objectives:

Anatomic rotational reduction of diaphyseal femur fractures is essential in restoring limb mechanics. Errors in reproducing anteroposterior (AP) or lateral knee reference radiographs of the contralateral limb could result in inaccuracies during rotational reduction. The objective of this study was to examine whether fluoroscopic rotational variation can be observed with the same degree of precision with AP and lateral distal femur projections.

Methods:

AP and lateral radiographs were obtained from intact knees of 7 cadaveric specimens using fluoroscopy. The lateral condylar width and coronal femoral width from the AP images and the posterior condylar offset and sagittal femoral width from the lateral images were measured by 3 reviewers. Interclass correlation coefficients (ICCs) among the 3 reviewers were calculated. The mean data from all reviewers were plotted against angle of rotation, and the slope (M) and regression of the line were then determined.

Results:

ICCs were 0.997 (lateral) and 0.994 (AP), demonstrating excellent interobserver agreement. The mean (±SD) M value for lateral images was 0.016 ± 0.001 and for AP images was 0.009 ± 0.001 (P < .0001). The higher lateral M value represents a more appreciable difference in size of the measured segment for the same rotational change.

Conclusions:

The observed rotational change was 1.76 times greater on lateral images compared to AP images; thus, the lateral images may be more precise as a reference for rotation. The routine use of lateral knee radiographs to guide intraoperative rotational alignment of the femur may therefore be justified.
Incidence and Predictors of Chlamydia, Gonorrhea and Trichomonas Among a Prospective Cohort of Cisgender Female Sex Workers in Baltimore, Maryland
Authors: Park Ju Nyeong , Gaydos Charlotte A. , White Rebecca Hamilton , Decker Michele R. , Footer Katherine H.A. , Galai Noya , Silberzahn Bradley E. , Riegger Katelyn , Morris Miles , Huettner Steve S. , Allen Sean T. , Sherman Susan G.
Published: November 2019

Background

Cisgender female sex workers (CFSWs) have elevated rates of sexually transmitted infections (STI) yet are underrepresented in targeted programming and research in the United States. We examined the prevalence, incidence and predictors of chlamydia, gonorrhea, and trichomonas infection among CFSW.

Methods

Two hundred fifty street-based CFSWs were recruited into a prospective observational cohort in Baltimore, Maryland using targeted sampling in 2016 to 2017 and completed surveys and STI testing at baseline, 3, 6, 9, and 12 months. Cox proportional hazards regression was used to model the predictors of STI.

Results

Mean age was 36 years, and 66.5% of respondents were white. Baseline prevalence of chlamydia, gonorrhea, trichomonas was 10.5%, 12.6%, and 48.5%, respectively. The incidence of chlamydia, gonorrhea, and trichomonas was 14.3, 19.3, 69.1 per 100 person-years. Over one year of observation, past year sex work initiation predicted both chlamydia incidence (adjusted hazard ratio [aHR], 2.7; 95% confidence interval [CI], 1.3–6.0) and gonorrhea incidence (aHR, 1.7; 95% CI, 1.0–2.8). Client sexual violence predicted gonorrhea incidence (aHR, 2.9; 95% CI, 1.2–7.1) and having female sexual partners predicted trichomonas incidence (aHR, 3.4; 95% CI, 1.3–8.5). Having a usual health care provider (aHR, 0.6; 95% CI, 0.5–0.7) was inversely associated with trichomonas.

Conclusions

In this study of urban US street-based CFSW, interpersonal and structural factors differentially predicted STIs, and infection rates remained elevated through follow-up despite regular testing, notification, and treatment referral. Focused and multifaceted interventions for sex workers and their sexual partners are urgently needed.
Two Distinct Gonorrhea Trends and Risk Factors Among Women in Australia
Authors: Whitford Kate , Callander Denton , Smith Lucy Watchirs , Guy Rebecca , Kong Marlene , Ward James , Donovan Basil , McManus Hamish , Bell Stephen , McGregor Skye , Menon Arun , Russell Darren , O'Connor Catherine C.
Published: November 2019

Background

In recent years, gonorrhea notifications have increased in women in Australia and other countries. We measured trends over time and risk factors among Australian Aboriginal and Torres Strait Islander (“Aboriginal”) and non-Aboriginal women.

Methods

We conducted a cross-sectional analysis of data from 41 sexual health clinics. Gonorrhea positivity at each patient's first visit (first-test positivity) during the period 2009 to 2016 was calculated. Univariate and multivariate analyses assessed risk factors for first-test positivity in Aboriginal and non-Aboriginal women.

Results

Gonorrhea positivity decreased among Aboriginal women (7.1% in 2009 to 5.2% in 2016, P < 0.001) and increased among non-Aboriginal women (0.6%–2.9%, P < 0.001). Among Aboriginal women, first-test positivity was independently associated with living in a regional or remote area (adjusted odds ratio [aOR], 4.29; 95% confidence interval [CI], 2.52–7.31; P < 0.01) and chlamydia infection (aOR, 4.20; 95% CI,3.22–5.47; P < 0.01). Among non-Aboriginal women, first-test positivity was independently associated with greater socioeconomic disadvantage (second quartile: aOR, 1.68 [95% CI, 1.31–2.16; P < 0.01]; third quartile: aOR, 1.54 [95% CI, 1.25–1.89; P < 0.01]) compared with least disadvantaged quartile: recent sex work (aOR, 1.69; 95% CI, 1.37–2.08; P < 0.01), recent injecting drug use (aOR, 1.85; 95% CI, 1.34–2.57; P < 0.01), and chlamydia infection (aOR, 2.35; 95% CI, 1.90–2.91; P < 0.01). For non-Aboriginal women, being aged 16 to 19 years (aOR, 0.62; 95% CI, 0.49–0.80; P < 0.01) compared with those ≥30 years was a protective factor.

Conclusions

These findings highlight 2 different epidemics and risk factors for Aboriginal and non-Aboriginal women, which can inform appropriate health promotion and clinical strategies.
Health Care Access and Service Use Among Behavioral Risk Factor Surveillance System Respondents Engaging in High-Risk Sexual Behaviors, 2016
Authors: Cuffe Kendra Michelle , Coor Alexandra , Hogben Matthew , Pearson William S.
Published: November 2019

Introduction

Access to health care services such as screening, testing, and treatment of sexually transmitted diseases is vital for those who engage in high-risk behaviors. Studies examining the relationship between high-risk behaviors and health care access and utilization are crucial for determining whether persons at risk are receiving appropriate health services.

Methods

We examined 2016 data from the Behavioral Risk Factor Surveillance System. Our study population included persons aged 18 to 65 years. χ2 and logistic regression analyses were used to examine relationships between high-risk behaviors including drug use and high-risk sexual behaviors, and access to and utilization of health care services.

Results

Among our study population, 6.2% engaged in a high-risk behavior in the past year. Those engaging in high-risk behaviors were more likely to have no health insurance coverage (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.13–1.34), have no personal health care provider (OR, 1.14; 95% CI, 1.06–1.21), have foregone care because of cost (OR 1.54; 95% CI, 1.42–1.65), or have had no routine check-up in the past 2 years (OR 1.16; 95% CI, 1.09–1.25).

Conclusions

Those who engaged in high-risk behaviors had poorer health care access and utilization outcomes. Future studies should incorporate the relationships between changes in behaviors, health care access and utilization, and resulting sexually transmitted disease morbidity.
Clear and Single Binocular Vision in Near 3D Displays
Authors: McCormack Glen L. , Hogan Katherine M.
Published: November 2019

SIGNIFICANCE

Accommodation/convergence mismatch induced by 3D displays can cause discomfort symptoms such as those induced by accommodation/convergence mismatch in clinical vergence testing. We found that the limits of clear and single vision during vergence tests are very different between 3D and clinical tests. Clinical vergences should not be used as substitutes for measures of vergences in 3D displays.

PURPOSE

The purposes of this study were to determine whether the limits of clear and single binocular vision derived from phoropter prism vergence tests match the limits measured in a 3D display and to determine whether vergence mode, smooth versus jump, affected those limits in the 3D display.

METHODS

We tested the phoropter prism vergence limits of clear and single vision at 40 cm in 47 binocular young adults. In separate sessions, we tested, in a 3D display, the analogous 40-cm vergence limits for smooth vergence and jump vergence. The 3D fixation target was a Maltese cross whose visual angle changed congruently with target disparity.

RESULTS

Our mean phoropter vergence blur and break values were similar to those reported in previous studies. The mean smooth divergence limit was less in the 3D display (9.8Δ) than in the phoropter (12.8Δ). Most smooth convergence limits were much larger in the 3D display than in the phoropter, reaching the 35Δ limit of the 3D display without blur or diplopia in 24 subjects. Mean jump vergence limits were significantly smaller than smooth vergence limits in the 3D display.

CONCLUSIONS

The limits of clear and single binocular vision derived from phoropter vergence tests were not a good approximation of the analogous limits in our 3D display.
The Unique and Misunderstood Wound Ballistics in the John F. Kennedy Assassination
Authors: Haag Lucien C.
Published: November 2019

President Kennedy sustained 2 gunshot wounds on November 22, 1963, in Dallas, Texas, while riding in the right-rear seat of the presidential limousine. The convertible top was down, and no special ballistic protection for the occupants was present.

The ballistic events in the assassination and subsequent ballistic evidence were not fully understood then and continue to be misunderstood and often misrepresented today. These facts are largely the consequence of the very uncommon wound ballistic properties of the 6.5-mm Carcano bullets associated with the President's gunshot wounds and the visual responses of the President to his 2 gunshot wounds so often viewed in the 8-mm Zapruder film.

An understanding of the wound ballistic characteristics associated with the John F. Kennedy assassination also applies to certain contemporary bullets. Such an understanding could assist forensic pathologists in future cases in evaluating and correctly interpreting gunshot wounds associated with these types of bullets.
Postmortem Tryptase Level in 120 Consecutive Nonanaphylactic Deaths
Authors: Garland Jack , Philcox Winston , McCarthy Sinead , Mathew Suneeth , Hensby-Bennett Sarah , Ondrushka Benjamin , Woydt Lina , Da Broi Ugo , Palmiere Cristian , Lam Leo , Ahn Yeri , Olds Kelly , Glenn Charley , Morrow Paul , Kesha Kilak , Stables Simon , Tse Rexson
Published: November 2019

Postmortem tryptase is a useful biochemical test to aid the diagnosis of anaphylaxis. Multiple perimortem and postmortem factors have been documented to cause an elevation in postmortem tryptase level. One factor that was recently recognized to have an impact on postmortem tryptase level is correct sampling technique. A recent study recommended aspirating blood samples from a clamped femoral/external iliac vein to be used for reliable postmortem tryptase analysis. This study sampled 120 consecutive nonanaphylactic deaths in which all the peripheral bloods were sampled as recommended. Postmortem interval, resuscitation, different nonanaphylactic causes of death, sex, and age did not show any statistical significant relation to postmortem tryptase level in Studentttest, Pearson correlation, and univariate and multivariate analyses. The mean (SD) postmortem tryptase level was 8.4 (5.2) μg/L (minimum, 1.0 μg/L; maximum, 36.1 μg/L; median, 7.3 μg/L). Using nonparametric methods, the postmortem tryptase reference range in nonanaphylactic death was established as <23 μg/L (97.5th percentile).
Improving Bronchiolitis Care in Outpatient Settings Across a Health Care System
Authors: Tejedor-Sojo Javier , Chan K. Ning , Bailey Martha , Williams Abby , Killgore Maggie , Gillard Laura , Campo Mary , Hua Hannah , Jain Shabnam
Published: November 2019

Objective

This study aimed (1) to reduce use of ineffective testing and therapies in children with bronchiolitis across outpatient settings in a large pediatric health care system and (2) to assess the cost impact and sustainability of these initiatives.

Methods

We designed a system-wide quality improvement project for patients with bronchiolitis seen in 3 emergency departments (EDs) and 5 urgent care (UC) centers. Interventions included development of a best-practice guideline and education of all clinicians (physicians, nurses, and respiratory therapists), ongoing performance feedback for physicians, and a small physician financial incentive. Measures evaluated included use of chest x-ray (CXR), albuterol, viral testing, and direct (variable) costs. Data were tracked using statistical process control charts.

Results

For 3 bronchiolitis seasons, albuterol use decreased from 54% to 16% in UC and from 45% to 16% in ED. Chest x-ray usage decreased from 29% to 9% in UC and from 21% to 12% in the ED. Viral testing in UC decreased from 18% to 2%. Cost of care was reduced by $283,384 within our system in the first 2 seasons following guideline implementation. Improvements beginning in the first bronchiolitis season were sustained and strengthened in the second and third seasons. Admissions from the ED and admissions after return to the ED within 48 hours of initial discharge did not change.

Conclusion

A system-wide quality improvement project involving multiple outpatient care settings reduced the use of ineffective therapies and interventions in patients with bronchiolitis and resulted in significant cost savings. Improvements in care were sustained for 3 bronchiolitis seasons.
Acute Cannabis Toxicity
Authors: Wong Kei U. , Baum Carl R.
Published: November 2019

The change in legal status of cannabis (the botanical species Cannabis sativa, commonly known as marijuana) in the United States has had significant impact on pediatric drug exposures. In states with decriminalization of recreational and medicinal use of cannabis, emergency department visits and poison control center calls for unintentional pediatric cannabis intoxication are on the rise in the last few decades. Exploratory or unintentional ingestions of cannabis-containing products (as opposed to those derived from synthetic cannabinoids, which may mimic the structure and/or function of cannabis, but are not the focus of this article) can lead to significant pediatric toxicity, including encephalopathy, coma, and respiratory depression. With the increasing magnitude of the public health implications of widespread cannabis use, clinicians who care for pediatric patients routinely must be adept in the recognition, evaluation, management, and counseling of unintentional cannabis exposure.
Ingested Foreign Body Imaging Using Point-of-Care Ultrasonography
Authors: Kozaci Nalan , Avci Mustafa , Pinarbasili Tansu , Dönertaş Eda , Karaca Adeviyye
Published: November 2019

The ingestion of foreign bodies is a common problem in the pediatric population. Emergent treatment of ingested foreign bodies is dependent on the type of foreign body ingested, patient symptoms, timing of ingestion, and the location of the foreign body. Although X-ray and computed tomography are the imaging techniques used most often to assess for foreign bodies, ultrasonography, which lacks ionizing radiation, may also be useful. This case series describes 8 cases of gastrointestinal tract foreign bodies and the utility of point-of-care ultrasonography for their real-time evaluation.
Mutational and Immunophenotypic Profiling of a Series of 8 Tubo-ovarian Carcinosarcomas Revealed a Monoclonal Origin of the Disease
Authors: Trento Mariangela , Munari Giada , Carraro Valentina , Lanza Cristiano , Salmaso Roberta , Pizzi Sara , Santoro Luisa , Chiarelli Silvia , Dal Santo Luca , Nardelli Giovanni B. , Saccardi Carlo , Nicoletto Ornella , Baldoni Alessandra , Rugge Massimo , Fassan Matteo
Published: November 2019

Carcinosarcomas are rare, highly aggressive neoplasms composed of a combination of carcinomatous and sarcomatous elements. These tumors represent a paradigmatic field for the study of intratumor heterogeneity. A series of 8 tubo-ovarian carcinosarcomas was characterized for the following: (i) immunohistochemical expression of MNF116, epithelial membrane antigen, vimentin, S100, chromogranin, synaptophysin, desmin, myogenin (MYF4), and p53; (ii) mutational profiling of KRAS, BRAF, PIK3CA, NRAS, TP53, and DICER1 genes. Heterologous differentiation was present in 6 of 8 tumors. Cytokeratin MNF116 and epithelial membrane antigen were positive in all the carcinomatous components and in 87.5% and 50.0% of the sarcomatous components, respectively. The sarcomatous components showed positive staining for vimentin in all cases. Two cases demonstrated positivity for neuroendocrine markers in their carcinomatous components. All rhabdomyosarcomas were positive for desmin and MYF-4. Chondrosarcomas were positive for S100. All but one tumor showed similar p53 immunoreactivity in both the carcinomatous and sarcomatous components, and one case showed cytoplasmic p53 expression. Three of 8 cases (37.5%) showed TP53 mutations, and, in 2 cases, the TP53 mutation was shared by both epithelial and mesenchymal components. DICER1 mutation was found in all components of one case. Mutations in KRAS, NRAS, BRAF, and PIK3CA genes were not found in the study cohort. Our results highlight the heterogeneity of ovarian carcinosarcomas at the phenotypic level. A common mutational signature was observed in both components in 3 of 4 informative tumors. More studies are required to dissect different levels of ovarian carcinosarcomas’ heterogeneity in order to define the best therapeutic approaches to these aggressive neoplasms.
Stromal Endocrine Cell Micronests Associated With an Ovarian Mucinous Cystadenoma: Endocrine Cell Preservation (Pseudohyperplasia) Potentially Mimicking Stromal Sex Cord Proliferation or Tumor Microinvasion
Authors: Stewart Colin J.R. , Harding Steve
Published: November 2019

Endocrine cell micronests (ECMs) have been described only twice previously in the ovary, both in association with mucinous neoplasms exhibiting intraepithelial endocrine cell hyperplasia. We report a 31-yr-old patient with a mucinous cystadenoma in which ECMs were distributed in the stroma surrounding degenerate glandular elements. Immunohistochemistry demonstrated only sparse endocrine cells within the neoplastic glands. We postulate that the ECMs in this case reflected relative preservation of endocrine elements in the context of epithelial atrophy, a process more commonly encountered in gastrointestinal pathology. Ovarian ECMs should also be distinguished from stromal sex cord proliferations and tumor microinvasion.
Educational Attainment and Characteristics of Leaders of Schools of Public Health and State Health Departments
Authors: Gaskins Little N. Ruth , Greer Annette , Moore Justin B.
Published: November 2019

A perceived diversity exists in the educational training of leaders in state and academic public health that isn't observed in other heath disciplines. To assess this perception, the present study describes the training and experience of state health directors and deans of schools of public health. Data were collected in 2017 for deans of schools of public health (n = 56) and state health directors (n = 49) in the United States. Results indicated that 56 deans had at least one terminal degree, while 14 state health directors did not. Women comprised 23 of the dean and 24 state health director positions. Years in current position were 6.91 for deans and 3.51 for state health directors. Thirty-seven deans and 22 state health directors held graduate degrees in public health. As public health leaders advance towards retirement; it is imperative that the public health professionals obtain relevant training necessary to become tomorrow's public health leadership.
Variability of Steady State Oral Baclofen Prescribing Practices in Pediatric Patients With Cerebral Palsy
Authors: McLaughlin Matthew J. , Ratnasingam Denesh , McGhee Emily
Published: November 2019

The aim of the study was to identify oral baclofen dosing variability at steady state based on weight and Gross Motor Function Classification System level using a retrospective cross-sectional study design. The medical records of 500 pediatric aged patients (age 1–21 yrs) were reviewed to obtain 144 pediatric patients who met inclusion criteria. One-way analysis of variance tests revealed increasing mean doses in baclofen (in milligram per kilogram) with higher Gross Motor Function Classification System levels (P = 0.001). Post hoc Tukey analysis showed patients with higher ambulatory ability (Gross Motor Function Classification System I–II) received a lower total daily dosage than did patients with less ambulatory ability (Gross Motor Function Classification System III–V). A moderate correlation was observed with increasing oral baclofen dose as weight increased (r = 0.43, P < 0.0001). Because of the variability in dosing between Gross Motor Function Classification System levels, prescribing oral baclofen for pediatric patients with cerebral palsy may not follow the traditional model of weight-based dosing seen in other pediatric conditions.
Effects of Upper Limb Loss or Absence and Prosthesis Use on Postural Control of Standing Balance
Authors: Major Matthew J. , Stine Rebecca , Shirvaikar Tara , Gard Steven A.
Published: November 2019

Objective

Persons with upper limb loss or absence experience a high prevalence of falls. Although upper limb prostheses help perform upper limb tasks, fall likelihood increases by six times with prosthesis use. The effects of upper limb loss or absence and prosthesis use on postural control are poorly documented.

Design

Static posturography characterized postural control of standing balance between persons with unilateral upper limb loss or absence not wearing a prosthesis and wearing either a customary prosthesis or prosthesis that matched the mass, inertia, and length of their sound limb. Able-bodied controls were also compared to persons with unilateral upper limb loss or absence not wearing a prosthesis. Center-of-pressure anterior-posterior range, medial-lateral range, and sway area, as well as weight-bearing symmetry, were measured.

Results

Persons with upper limb loss or absence display greater standing postural sway than controls. Although wearing a prosthesis improved weight-bearing symmetry, this condition increased postural sway, which was pronounced in the medial-lateral direction.

Conclusions

The presence of upper limb loss or absence increased postural control demands than able-bodied individuals as reflected in greater postural sway, which was further exacerbated with the use of prosthesis. Results suggest that upper limb loss or absence and prosthesis use may affect the internal models that guide motor commands to maintain body center-of-mass position equilibrium. The relatively greater postural control demands might help explain the increase fall prevalence in this patient group.
Active Video Games as an Adjunct to Pulmonary Rehabilitation of Patients With Chronic Obstructive Pulmonary Disease
Authors: Wang Ya-Qing , Liu Xin , Ma Rui-Chen , Yin Ying-Ying , Yang Zhuo , Cao Hui-Ping , Xie Jiao
Published: November 2019

Objective

This review aimed to investigate the effectiveness of active video games as an adjunct to pulmonary rehabilitation for patients with chronic obstructive pulmonary disease.

Design

All entries to the following databases were searched up until April 3, 2019: PubMed, Embase Ovid, the Cochrane Central Register of Randomized Controlled Trials, Web of Science, Wanfang, Weipu, and Chinese National Knowledge Infrastructure databases.

Results

A total of seven articles (three randomized controlled trials and four quasi-experimental studies) with 249 patients were included. Active video games can increase the 6-min walk distance by 30.9 meters on average. Four studies assessed quality of life and showed significant improvement. Four studies have reported that patients with chronic obstructive pulmonary disease found active video games to be enjoyable. Patient adherence was assessed in two studies and showed high adherence with active video games. No adverse events related to active video games were reported.

Conclusions

The review demonstrated that active video games as an adjunct to pulmonary rehabilitation of patients with chronic obstructive pulmonary disease may prove to be useful and enjoyable. Additional studies should explore the differences between different types of active video games in order to create more effective game interventions for pulmonary rehabilitation.