bluuebunny/crossref_metadata_2025 huggingface dataset:
Breastfeeding Is Associated with a Reduced Risk of Attention-Deficit/Hyperactivity Disorder Among Preschool Children
Authors: Soled Derek , Keim Sarah A. , Rapoport Eli , Rosen Lisa , Adesman Andrew
Published: September 2020

Background:

Breastfeeding has been associated with a lower risk of attention-deficit/hyperactivity disorder (ADHD). However, most studies examining this association have focused on small samples outside the United States or were likely subject to substantial residual confounding. Our objectives were to investigate, in a nationally representative sample of preschool children in the United States, the associations between ADHD and both age of breastfeeding cessation and age of formula introduction, as well as associations between ADHD and exclusive breastfeeding duration.

Methods:

Analysis of data from children aged 3 to 5 years in the 2011/12 National Survey of Children's Health (n = 12,793). Logistic regressions were used to model current medical diagnosis of preschool ADHD as a function of breastfeeding duration, breastfeeding exclusivity, and the timing of formula introduction with adjustment for 12 potential confounders using propensity scores, including sex, age, race, household income, prematurity, insurance, and medical home.

Results:

After adjustment for potential confounders, exclusive breastfeeding for at least 6 months was associated with substantially reduced odds of ADHD (adjusted prevalence odds ratio [aPOR] = 0.38; 95% confidence interval [CI], 0.15–0.99). Breastfeeding duration was also associated with ADHD, with 8% reduced odds of ADHD for each additional month of breastfeeding (aPOR = 0.92; 95% CI, 0.86–0.99). The results for exclusive breastfeeding duration were similar, but the confidence interval included the null (aPOR = 0.92; 95% CI, 0.85–1.00). The age of formula introduction was not associated with ADHD (aPOR = 0.92; 95% CI, 0.81–1.05).

Conclusion:

In a nationally representative sample of preschool children, breastfeeding was associated with a lower prevalence of ADHD. These findings provide evidence in support of the neurodevelopmental benefits of breastfeeding.
Association of Positional Plagiocephaly and Developmental Delay Within a Primary Care Network
Authors: Rohde Jessica F. , Goyal Neera K. , Slovin Sara R. , Hossain Jobayer , Pachter Lee M. , Di Guglielmo Matthew D.
Published: September 2020

Objective:

Previous research has suggested an association between plagiocephaly and developmental delay. However, study samples drawn from children seen in subspecialty clinics increase the potential for selection and referral bias. Our study evaluates the association between plagiocephaly and developmental delay and the timing of these diagnoses in a primary care setting, where plagiocephaly is commonly diagnosed and managed.

Methods:

Our retrospective analysis used electronic medical record data from 45 primary care sites within a children's health system from 1999 to 2017, including children aged 0 to 5 years with diagnoses determined by physician diagnosis codes at primary care visits. Children were classified in the plagiocephaly group if diagnosis occurred by 12 months of age. Primary outcome was any developmental delay. Pearson χ2 test, Fisher exact test, and logistic regression analyses were conducted, with multivariable models adjusted for sex, race, ethnicity, insurance, prematurity status (22–36 weeks' gestation), primary care sites, birth year, and diagnoses of abnormal tone and torticollis.

Results:

Of 77,108 patients seen by 12 months, 2315 (3.0%) were diagnosed with plagiocephaly, with an increase in diagnosis prevalence over the study time frame. Plagiocephaly was independently associated with an increased odds of any developmental delay diagnosis (adjusted odds ratio 1.50, 95% confidence interval 1.32–1.70). The diagnosis of plagiocephaly was recorded before the diagnosis of developmental delay in most cases when both diagnoses were present (374 of 404, 92.6%).

Conclusion:

Data from a large primary care cohort demonstrate an association between plagiocephaly and developmental delay, affirming findings in previous subspecialty literature.
Growing Up Fast: Managing Autism Spectrum Disorder and Precocious Puberty
Authors: Finkle Abigael , Zavertnik Samantha , Myers Susan , Cormier DePorres , Heithaus Jennifer , Augustyn Marilyn
Published: September 2020

CASE:

John is a 4-year-old boy with autism spectrum disorder (ASD) and developmental delay who presented with concerns about increasing aggressive behavior at a follow-up visit with his developmental-behavioral pediatrician. Diagnosis of ASD was made via Diagnostic and Statistical Manual of Mental Disorders, 5th version criteria at initial evaluation at 34 months. Medical history at that time was pertinent for rapid linear growth since the age of 1 and recent pubic hair growth and penile enlargement. Family history was significant for early puberty in a maternal uncle and 4 distant maternal relatives. Standardized testing included administration of the Childhood Autism Rating Scale 2-Standard, which was consistent with severe symptoms of ASD, and the Mullen Scales of Early Learning, which indicated moderate delay in fine motor skills and expressive language and severe delay in receptive language and visual receptive skills.

At initial assessment, John's parents also reported a pattern of aggressive behavior, which included frequent hitting of other children at childcare, consistently forceful play with peers and family members, and nightly tantrums with hitting and throwing at bedtime. Triggers of aggressive behavior included other children taking his toys, transition away from preferred activities, and being told “no.”

John was concurrently evaluated by a pediatric endocrinologist at 34 months. At that assessment, his height Z-score was +2.5, and he had Tanner 2 pubic hair, Tanner 3 genitalia, and 6 cc testicular volumes. Radiograph of the hand revealed a bone age of 6 years (+7.8 S.D.). Laboratory studies revealed a markedly elevated testosterone level and low gonadotropin (luteinizing hormone [LH] and follicle-stimulating hormone) levels and a normal dehydroepiandrosterone sulfate, suggestive of peripheral precocious puberty. Targeted genetic testing with sequencing of theLHCGRgene revealed a heterozygous D578G mutation resulting in the rare condition Familial Male-Limited Precocious Puberty (FMPP), characterized by constitutive activation of the LH receptor.1FMPP, also referred to as testotoxicosis, was attributed as the cause of John's peripheral precocious puberty.

By the age of 4, John's height Z-score was +3.1, his genitalia larger, and his bone age 10 years (+10.3 S.D.). His parents elected to start off-label therapy with bicalutamide (a nonsteroidal antiandrogen) and anastrazole (an aromatase inhibitor), recommended by the endocrinologist. Unexpectedly, as John's hyperandrogenism was treated, John's family reported intensified aggression toward other children and adults, especially at school, in addition to multiple daily instances of biting when upset. What is your next step in John's treatment of his challenging behavior?

REFERENCE

1. Shenker A, Laue L, Kosugi S, et al. A constitutively activating mutation of the luteinizing hormone receptor in familial male precocious puberty. Nature. 1993;365:652–654.
Comparison of 1565-nm Nonablative Fractional Laser and 10600-nm Ablative Fractional Laser in the Treatment of Mild to Moderate Atrophic Acne Scars
Authors: Cheng Xiaoxi , Yang Qing , Su Yingjun , Wu Yanqiu , Ma Xianjie
Published: September 2020

BACKGROUND

The 10,600-nm ablative fractional laser (AFL) is widely used for treating facial atrophic acne scars but with evident side effects. By contrast, the common Er:Glass non-AFL (NAFL) is safer but lacks of comparable outcomes. A novel 1,565 nm Er:Glass NAFL improves thermal energy delivery and could yield better outcomes.

OBJECTIVE

We aimed to compare the effectiveness and safety between the 1,565-nm NAFL and 10,600-nm AFL in treating mild-to-moderate facial atrophic acne scars.

METHODS

Nineteen patients with mild-to-moderate bilateral facial atrophic acne scars were enrolled in a randomized split-face trial, which involved 3-session procedures for each laser. The effectiveness and safety were evaluated by doctors and patients who were blinded to the treatment assignment.

RESULTS

Both lasers improved the acne scar profiles comparably. A marked reduction in erythema, crusting durations, and degree of pain were noted on the sides treated with the 1,565-nm NAFL, relative to those treated with the 10,600-nm AFL.

CONCLUSION

Both 1,565 nm-NAFL and 10,600-nm AFL can improve mild-to-moderate acne scars. Patients should never expect complete resolution. The 1,565-nm NAFL has less side effects.
Intralesional Hyaluronic Acid Injection for Chondrodermatitis Nodularis Helicis: A Novel Treatment for Rapid Relief of Pain and Healing of Ulcerations
Authors: Carey Wayne
Published: September 2020

BACKGROUND

Chondrodermatitis nodularis helicis (CNH) is a common chronic condition characterized by a tender nodule on the helix or antihelix of the ear which may or may not have accompanying crusting, scaling, or ulceration and that is often difficult to treat.

OBJECTIVE

Develop an easy, effective, and durable treatment to reduce the pain and clinical signs including ulcerations associated with CNH using injectable hyaluronic acid (HA).

MATERIALS AND METHODS

Twenty-four patients were injected and followed up in 2 to 4 weeks intervals using 0.2 to 0.3 mL of various HA with a high G-Prime.

RESULTS

Injectable HA significantly improved the symptoms and also the clinical appearance of all patients treated after 1 or 2 injections except 1 patient. Extrusion of the material through a preexisting ulcer usually required a second follow-up injection 2 weeks later. No adverse events were noted with the injections other than the intentional visible bulging of the injected region with HA.

CONCLUSION

Injectable HA provides almost immediate relief from the discomfort of CNH in most cases in less than 1 or 2 weeks, significantly improves the clinical appearance over time and resolves accompanying ulcerations.
Peripapillary and Macular Vessel Density Measurement With Optical Coherence Tomography Angiography in Exfoliation Syndrome
Authors: Gür Güngör Sirel , Sarigül Sezenöz Almila , Öztürk Caner , Gökgöz Gülşah , Akman Ahmet
Published: September 2020

Precis:

Although peripapillary retinal nerve fiber layer thickness (RNFLTs) and vessel density (VD) values were similar to healthy group, eyes with exfoliation syndrome had significantly lower superficial macular VDs and minimum ganglion cell analysis values.

Purpose:

To compare peripapillary and macular perfused capillary densities with optical coherence tomography angiography (OCT-A) between patients with eyes having exfoliation syndrome (XFS) and normal age-matched healthy controls.

Patients and Methods:

This cross-sectional study included patients diagnosed with XFS from December 2017 to January 2020 at the Glaucoma Department. Peripapillary and parafoveal superficial VDs were obtained using OCT-A. The RNFLTs and ganglion cell analysis values were compared.

Results:

Thirty-nine eyes of 39 XFS patients (26 women; mean age, 69.0±8.1 y) and 39 eyes of 39 healthy patients (25 women; mean age, 68.0±8.6 y) were enrolled. There were no statistically significant differences in sex or age distribution, central corneal thickness measurements, refractive errors, or intraocular pressures between both groups (all P>0.05). There were no statistically significant differences in the peripapillary VD or peripapillary RNFLT between XFS eyes and healthy eyes (P>0.05 for all). In the macular region, most superficial VD parameters were significantly reduced in the XFS group (P=0.02 for parafoveal VD, P=0.04 for both hemifields). While the average ganglion cell and internal plexiform layer (GCL+IPL) values were similar between groups (P=0.19), the minimum GCL+IPL value was lower in the XFS group than in the healthy group (P=0.03).

Conclusion:

Although structural test results, especially peripapillary RNFLT and mean GCL+IPL, were similar between the healthy and XFS groups, macular VD values were lower in XFS eyes. Our findings implicate microvascular damage can be the mechanism underlying XFS-related changes and indicate that it precedes significant structural damage.
The Effect of Photographic Visual Aids in Preoperative Patient Counseling in Oculoplastic Surgery
Authors: Yom Kelly H. , Shriver Erin M. , Carter Keith D. , Korn Bobby S. , Kikkawa Don O. , Ko Audrey C.
Published: September 2020

Purpose:

To investigate the effect of visual supplementation and its mode of delivery in preoperative counseling of patients undergoing oculoplastic surgery.

Methods:

A prospective randomized controlled trial of consecutive patients undergoing oculoplastic eyebrow and eyelid surgery was conducted. Patients were randomized to an “oral only” group receiving routine preoperative oral counseling or an “oral and visual” group receiving identical counseling visually supplemented with photographs demonstrating common postoperative physical findings. Patients in the “oral and visual” group were further randomized to receive education from the medical team in person versus prerecorded video. Patient emotions and expectations regarding postoperative healing were assessed preoperatively and at 1 week and 2 months postoperatively.

Results:

103 patients were included: 32 received in-person oral education, 33 received in-person oral education with photographs, and 38 received education with photographs via video. There were no significant differences in demographics or preoperative patient fear, anxiety, or preparedness. The “oral and visual” group expected more severe postsurgical discomfort and physical findings at postoperative day 1 and week 1. There were no significant differences between groups in surgery signup, cancellation, or triage call rates; patient expectations of postoperative months 2 and 4; or in anxiety, preparedness, or satisfaction.

Conclusions:

Visual supplementation in preoperative counseling increases patient expectations of postoperative physical findings without escalating fear or anxiety, and has no significant impact on patient emotions, triage call rates, and satisfaction throughout their surgical experience. Preoperative education via video is perceived by patients to be equivalent to counseling in person by the surgeon.
Fungal Infection in an Exenterated Orbit
Authors: Doulis Alexandros E. , Koch Konrad R. , Heindl Ludwig M.
Published: September 2020

A 48-year-old man presented with an Aspergillus fumigatus complex infection of an exenterated orbit. The OS had been exenterated 7 months ago, together with total parotidectomy and neck dissection followed by irradiation due to a massive squamous cell carcinoma with orbital invasion and lymphatic metastasis. The patient was under permanent immunosuppression with oral prednisone and tacrolimus due to a kidney transplantation 5 years ago. The infected skin of the exenterated orbit was cleared using forceps. MRI ruled out any bone infiltration. After systemic treatment with oral voriconazole and topical therapy with bifonazole ointment for 6 weeks, the patient recovered completely.
Orbital Bony Reconstruction With Presized and Precontoured Porous Polyethylene–Titanium Implants
Authors: Blessing Nathan W. , Rong Andrew J. , Tse Brian C. , Erickson Benjamin P. , Lee Bradford W. , Johnson Thomas E.
Published: September 2020

Purpose:

Complex bony orbital defects are reconstructively challenging due to loss of intraoperative anatomical landmarks and adjacent support. Presized and precontoured porous polyethylene–titanium implants (Medpor Titan 3D Orbital Floor Implant) are designed to reestablish normal orbital floor and medial wall anatomy and are modeled after anatomically averaged orbits. This is the first study to report clinical outcomes with this implant.

Methods:

This retrospective case series reviewed clinical data and outcomes for patients undergoing orbital reconstruction with a presized and precontoured porous polyethylene–titanium orbital implant from January 2016 to June 2018.

Results:

A total of 34 orbits of 33 patients were identified (mean age: 43 ± 16 years, 70% men). Most bony defects were a result of trauma and included large orbital floor deformities (100%), medial wall defects (74%), disrupted inferomedial struts (68%), and broken posterior ledges (82%). Symptomatic diplopia (73%) and enophthalmos (89%, mean: 3.7 ± 2.1 mm) were common preoperatively. Many cases were revisions (44%). Mean follow up was 7.8 ± 6.7 months. All patients had improved globe positioning, enophthalmos, and hypoglobus. Seven patients had persistent postoperative diplopia: 6 responded to prism therapy and 1 required strabismus surgery. One patient required retrobulbar hematoma drainage and 1 patient required implant explantation due to chronic infection.

Conclusions:

Commercially available presized and precon toured porous polyethylene–titanium implants are useful for complex orbital bony defects and can achieve functional improve ments in diplopia, enophthalmos, and extraocular motility with a low incidence of postoperative complications or revisional surgery.
Risk Factors for Developing Postlumbar Puncture Headache: A Case-Control Study
Authors: Nielsen Lea Normand , Vamosi Marianne
Published: September 2020

BACKGROUND: Postlumbar puncture headache (PLPH) is a common adverse event after lumbar puncture. The specific cause for headache remains uncertain but is assumed to be cerebrospinal fluid leakage. The headache affects the patient, family, and workplace as well as society in general. The aim of this study was to identify risk factors associated with the development of PLPH. METHODS: This quantitative case-control study included 285 patients having undergone diagnostic lumbar puncture at a department of infectious diseases during 2015 to 2016. We examined blood glucose and blood albumin levels as well as systolic, diastolic, and mean arterial blood pressure. Statistical analysis included Student t test, χ2, and logistic regression. RESULTS: Compared with the control group, patients with PLPH tended to have a lower glucose level (5.7 vs 6.4 mmol/L), lower systolic pressure (126 vs 137 mm Hg), and lower mean arterial blood pressure (90 vs 96 mm Hg). Logistic regression analysis showed that lower systolic blood pressure (≤126 mm Hg) significantly increased the risk of PLPH (odds ratio, 0.977 [95% confidence interval, 0.957–0.998]) along with age younger than 40 years (odds ratio, 0.954 [95% confidence interval, 0.935-0.973]). CONCLUSION: Patients with a lower systolic blood pressure had a statistically significantly increased risk of PLPH. Furthermore, younger age was also associated with an increased risk of PLPH.
Calcaneal Bone Bruise After Surgery for Insertional Achilles Tendinopathy
Authors: Kosola Jussi , Maffulli Nicola , Sinikumpu Juha-Jaakko , Pánics Gergely , Niemi Pekka , Orava Sakari , Lempainen Lasse
Published: September 2020

Objective:

Excision of the posterosuperior corner of the calcaneus (EPCC) is routinely undertaken in athletes after failure of conservative management of insertional Achilles tendinopathy. Some patients can experience sharp calcaneal pain during postoperative rehabilitation, a sign of a calcaneal bone bruise (CBB).

Design:

Case series, level of evidence IV.

Setting:

University teaching hospital.

Patients:

This study reports 8 patients who developed postoperative CBB after having started impact training too early.

Intervention:

Patients in whom a diagnosis of CBB had been formulated were followed to return-to-play and resolution of bone edema by MRI.

Main Outcome Measures:

Detection of CBB after EPCC.

Results:

After routine EPCC for insertional Achilles tendinopathy, 8 patients presented with sharp pain for a mean 7.1 weeks (median 6 weeks, range 5-11 weeks) before clinical suspicion of CBB. At that stage, MRI showed clear evidence of a bone bruise, with a diagnosis of CBB formulated at an average of 10.8 postoperative weeks (range 6-16 weeks). Calcaneal bone bruise resolved with modified symptom-free loading. Patients returned to play at average on 5.6 months (range 2-9 months) after the diagnosis of postoperative CBB.

Conclusions:

We describe 8 athletes who developed painful CBB following routine EPCC for insertional Achilles tendinopathy after having increased their level of activities too soon after the index procedure. In these patients, the diagnosis of postoperative CBB can be formulated by MRI and more cautious rehabilitation implemented.
Osteitis Pubis Treated With Platelet-Rich Plasma: A Case Report
Authors: Park David J. , Sussman Walter I.
Published: September 2020

Osteitis pubis is a common source of groin pain in athletes participating in sports requiring kicking, twisting, and pivoting movements. Athletes will present with progressive pain or discomfort in the pubic area or groin. There is usually point tenderness over the pubic symphysis and pain localizing to the adductor or rectus abdominis tendons. Conservative management often includes activity modification, oral medications, progressive rehabilitation, therapeutic ultrasound, steroid injections, and prolotherapy. Osteitis pubis can be refractory to conservative management and can keep an athlete sidelined for as long as 2 years. Platelet-rich plasma (PRP) injections have been used for pubic symphysis pain, but reports have focused on pathology affecting the rectus abdominis or hip adductor muscle tendons. In this article, we present a case of isolated osteitis pubis, without overlapping rectus abdominis or adductor tendon involvement, successfully treated with an ultrasound-guided PRP injection of the fibrocartilage.
Insertional Calcific Tendinopathy of the Achilles Tendon and Dysmetabolic Diseases: An Epidemiological Survey
Authors: Giai Via Alessio , Oliva Francesco , Padulo Johnny , Oliva Gabriella , Maffulli Nicola
Published: September 2020

Objective:

This study reports the incidence of insertional calcific tendinopathy (ICT) of the Achilles tendon in the general population and the percentage of symptomatic patients. The secondary aim is to ascertain whether ICT is associated with diabetes mellitus, thyroid disorders, obesity, and hypercholesterolemia. We hypothesized that metabolic diseases increase the risk of ICT of the Achilles tendon.

Design:

Prospective observational study (level III study).

Setting:

Orthopedic Outpatients Clinic and Emergency Department of Tor Vergata University Hospital, Rome, Italy.

Participants:

Four hundred thirty-three subjects who met the inclusion criteria.

Intervention Methods:

We collected the plain radiographs of the foot and ankle of patients who attended the hospital. Personal data were recorded [age, sex, and body mass index (BMI)], and comorbidities investigated (diabetes mellitus, hypothyroidism, hyperthyroidism, obesity, and hypercholesterolemia). Multivariate regression analyses were performed to study the predictors of the occurrence of Achilles ICT.

Results:

A total of 101 patients (23.3%) showed radiographic evidence of ICT, and 3% (13 patients) were symptomatic. Age [odds ratio (OR) 1.05], diabetes (OR 2.95), hypercholesterolemia (OR 2.27), and hypothyroidism (OR 3.32) were significantly associated with the presence of ICT of the Achilles tendon. Independent predictors of ICT were age, diabetes, hypercholesterolemia, and hypothyroidism. A BMI >30 was associated with a higher incidence of calcifications, and patients with 2 or more comorbidities had more than 10 times higher risk to develop ICT.

Conclusion:

Insertional calcific tendinopathy of the Achilles tendon is common, but few patients are symptomatic. The incidence of ICT increases with age and is significantly higher in patients with diabetes mellitus and hypothyroidism.
Creating inclusive health care environments: Health care stories from the trans population
Authors: Daly Amy , Champion Jane Dimmitt
Published: September 2020

Background:

Transgender people face a multitude of health care access barriers that create wide disparities in health. Transgender people have more untreated acute and chronic conditions than the cisgender population.

Purpose:

The purpose of this study was to describe positive and negative experiences of transgender people when accessing health care.

Methodological orientation:

Qualitative methods including semi-structured interviews and content analysis for identification of themes.

Sample:

Nine transgender people ranging in age from 20 to 35 years who currently reside in a metropolitan area of the Southwestern United States.

Conclusions:

The interviews contained candid stories about the participants' health care experiences and included perspectives about provider knowledge, provider communication, and provider office interactions. Findings identified health care disparities among transgender people related, in part, to negative experiences in the health care environment. Some of these negative experiences arose from the uncertainty of providers' transgender-specific health care knowledge and anxiety about dysphoria-triggering communication in the health care environment.

Implications for practice:

These findings enhance practice by offering insight into how health care providers and personnel interactions influence the experience of transgender patients and help health care providers and personnel understand situations that create anxiety and dysphoria in transgender patients.
Parent-reported toilet training practices and the role of pediatric primary care providers
Authors: Sejkora Ellen K. D. , Igler Eva C. , Davies W. Hobart
Published: September 2020

Background:

Toilet training is a universal developmental milestone and a stressful period for families with few empirically based guidelines.

Purpose:

This study identified currently used methods of toilet training and sources used for parental guidance.

Methodological orientation:

A descriptive, qualitative design was used.

Sample:

Participants included 479 parents of children aged 2–6 years.

Conclusions:

Parents described diverse toilet training strategies, most of which were behavioral and inconsistent with recommendations of the American Academy of Pediatrics. Most children were toilet trained between 24 and 36 months within 5 weeks. Forty-one percent of parents relied on the Internet for toilet training information, and fewer than half reported involvement of their child's primary care provider.

Implications for practice:

Parents in the community would likely benefit from additional education and anticipatory guidance from primary care providers about normative toilet training. Further work is needed to understand the effectiveness of different methods of training and improve adherence to AAP recommendations.
Standardizing mammogram screening in primary care: Integrating an evidence-based approach
Authors: Go Lacrisha , Sandhu Prabjot
Published: September 2020

Background:

Mammogram screening for surveillance and detection of breast cancer has been long recognized as a preventive health measure in primary care for women. However, a clear consensus on when to start screening individual women, based on age and risk factors, lacks guidance. Reputable organizations uphold varying breast cancer screening (BCS) guidelines for women potentiating the risk for fragmented and inconsistent practices among health care providers (HCPs).

Objectives:

This review aims to evaluate the current literature on the possible risks, benefits, and limitations associated with BCS for women between 40 and 49 years and to discuss the need for a more individualized, evidence-based approach to BCS.

Data sources:

A comprehensive systematic review of eight articles, along with five clinical practice guidelines published within the past 10 years that address advantages and disadvantages of receiving mammography for women in their fourth decade was completed.

Conclusions:

There is insufficient evidence to promote adherence to any single clinical practice guideline for the benefit of all patients. Further high-level research is needed, as well as the assessment of individual risk factors influencing breast cancer development and screening outcomes.

Implications for practice:

There is a significant need for further education for HCPs and the development of tools that incorporate a BCS shared decision-making process. Current practice lacks the ability to easily screen individual patients with a method that identifies the appropriate age to screen and addresses the benefits, risks, and limitations of mammography.
How advanced practice registered nurse practice barriers impact health care access in Michigan
Authors: Sheehan Ann , Jones Angella , McNerlin Cindy , Iseler Jackeline , Dove-Medows Emily
Published: September 2020

Despite the Affordable Care Act increasing the number of insured individuals in Michigan, many individuals cannot access care as the state continues to have a provider shortage that is likely to get worse. It is well documented that when individuals lack primary care access, their health suffers. Advanced practice registered nurses (APRN) could help reduce the state's health care shortage, as the care they provide is safe, cost effective, and high quality. Unfortunately, Michigan's APRN practice restrictions limit these professionals from autonomously providing care to the underserved and rural populations that need them the most. Indeed, Michigan is behind other states that offer full practice authority to APRNs, and its health outcomes reflect this stance. Eliminating the restrictive practice environment in Michigan will give citizens better access to primary care.
Exploring novice nurse practitioner job satisfaction
Authors: Auffermann Kristin , O'Keefe Rachael , Smith Tyson , Cohn Tanya
Published: September 2020

Background:

With the continued increase in new nurse practitioners expected over the next 5 years and beyond, more individuals will experience nurse practitioner role transition. It is beneficial to nurse practitioners, patients, and the health care industry to understand factors relating to job satisfaction during role transition.

Purpose:

The purpose of this study was to contribute to the understanding of the transition period of new nurse practitioners by exploring demographics and job satisfaction during the first 6 months to 2 years of practice.

Methods:

This nonexperimental quantitative study employed convenience sampling with survey methodology. Twenty-one Facebook groups/pages were posted on once a week for 6 weeks. Demographic information was collected, and personal experiences were measured with the Misener Nurse Practitioner Job Satisfaction Scale.

Results:

Practice setting, formal orientation programs, and intent to leave current position were related to overall nurse practitioner job satisfaction during the transition period (p < .05). Satisfaction with time and benefits varied among demographic groups (p < .05).

Implications for practice:

Novice nurse practitioners are mostly satisfied in their new role. However, turnover intention in this population is high and orientation programs are lacking, warranting further study.
Development and testing of an advanced practice clinical advancement program within an academic medical center
Authors: Kapu April N. , Card Elizabeth , Jackson Heather , Kinch Jill , Lupear Buffy Krauser , LeBar Kiersten , Moore Deonna , Terrell Michelle , Dubree Marilyn
Published: September 2020

Background:

Faculty advanced practice registered nurses (APRNs) and physician assistants (PAs) employed by Vanderbilt University Medical Center (VUMC) have historically participated in rank promotion tracks for recognition of professional accomplishments in education, practice, and research. However, there has not been a clinical advancement program for nonfaculty practitioners. Satisfaction, engagement, and health surveys indicated VUMC APRNs and PAs were seeking opportunities for professional growth and development. Many health care organizations have incorporated clinical advancement programs as key recruitment and retention strategies. With a growing number of nonfaculty APRNs and PAs, VUMC began to explore the development, implementation, and evaluation of a clinical advancement program.

Purpose:

A VUMC Clinical Advancement Task Force was created to explore, develop, implement, and evaluate an advanced practice clinical advancement pilot.

Methods:

Two teams were selected to participate in a 6-month pilot. Presurveys and postsurveys were conducted, and postpilot focus groups were held with participating practitioners. A 9-square tool was developed as a rubric for evaluating the practitioner's progress. Applications, leader assessments, and recommendations were housed in a secure database for a selected advancement committee to evaluate.

Results:

Of 23 participants, 47% indicated satisfaction with professional development opportunities, when compared with 84% postpilot. Postpilot focus groups further improved the tool and the process for the program.

Implications for practice:

Opportunities for advancement/professional development positively influence APRN and PA perceptions of job satisfaction. This program could be tested with other APRN and PA teams for impact on job satisfaction, engagement, and retention.
Knowledge, attitudes, and perceptions of nurse practitioners about antibiotic stewardship
Authors: Hamilton Robert M. , Merrill Katreena C. , Luthy Karlen E. , Nuttall Craig
Published: September 2020

Background:

Antibiotic stewardship (ABS) is a set of strategies to optimize antimicrobial use while reducing antibiotic resistance, improving patient outcomes, and decreasing unnecessary costs. Nurse practitioners (NPs) play an essential role in health care education and represent a valuable potential resource for ABS efforts.

Purpose:

The purpose of this study was to describe the knowledge, attitudes, and perceptions of NPs toward ABS.

Methods:

A convenience sample of NPs attending the American Association of Nurse Practitioners annual conference was given a modified descriptive survey. Descriptive statistics were used to assess normality.

Results:

A total of 194 NPs completed the questionnaire (88% female; 70% master's degree). Factors affecting the decisions of antibiotic prescriptions included patient condition (79%) and patient cost (58%). Nurse practitioners based their antibiotic decisions on the antibiogram (63%) in their setting, whereas 56% indicated they start with broad spectrum and tailor antibiotic choices after cultures are received. Nurse practitioners understood that inappropriate antibiotic use causes resistance (97%), harms the patient (97%), and optimum antibiotic use will reduce resistance (94%). Participants also recognized that strong knowledge of antibiotics was important (94%) and felt confident in using antibiotics (86%). However, 94% agreed that antibiotics are overused nationally, and only 62% thought antibiotics were overused in their setting.

Implications for practice:

Nurse practitioners recognize that knowledge about antibiotics is important to their career and would like more education about antibiotics and feedback about their antibiotic choices. Finding effective ways to provide this education could change practice and improve antibiotic use.
Education initiatives in cognitive debiasing to improve diagnostic accuracy in student providers: A scoping review
Authors: Griffith Patricia B. , Doherty Caroline , Smeltzer Suzanne C. , Mariani Bette
Published: September 2020

Background:

The high prevalence of diagnostic errors by health care providers has prompted medical educators to examine cognitive biases and debiasing strategies in an effort to prevent these errors. The National Academy of Medicine hypothesized that explicit diagnostic reasoning education of all health care professionals can improve diagnostic accuracy.

Objectives:

The purpose of this scoping review is to identify, analyze, and summarize the existing literature on student health care providers' use of cognitive debiasing strategies to reduce diagnostic error.

Data sources:

The review was guided by the Joanna Briggs Institute methodology for scoping reviews. A systematic search of PubMed, CINAHL, PsychINFO, and Scopus databases for debiasing strategies in student provider education yielded 33 studies.

Conclusions:

The 33 studies included in this review represent four categories of debiasing strategies: increased medical knowledge or experience (seven studies), guided reflection (eight studies), self-explanation of reasoning (nine studies), and checklists to expand diagnosis considerations (seven studies). The studies were inclusive of medical students and residents; no studies included nurse practitioner (NP) students. Guided reflection, the most clearly defined and implemented strategy, showed the most promise for improvement of diagnostic accuracy. Educational interventions were wide ranging in content and delivery but did yield a path for future research.

Implications for practice:

There are myriad debiasing strategies student providers may use to mitigate cognitive bias. Structured reflection and education initiatives demonstrated the most consistent improvements in diagnostic accuracy. Future studies on debiasing strategies must include NP students to understand their response to these initiatives.
Predictors of hemorrhagic stroke in older persons taking nonsteroidal anti-inflammatory drugs: Results from the Food and Drug Administration Adverse Event Reporting System
Authors: McDonald Deborah Dillon , Srisopa Pornpan
Published: September 2020

Background:

Hemorrhagic strokes have not declined in the United States despite a decline worldwide.

Purpose:

To identify hemorrhagic stroke risk associated with nonsteroidal anti-inflammatory drugs (NSAIDs), other medications associated with increased risk for hemorrhagic stroke, and diabetes, cardiovascular disease, gender, and age.

Methods:

A post hoc design was used to examine predictors of hemorrhagic stroke for adults of age 65 years and older from the Food and Drug Administration Adverse Events Reporting System database. The initial sample consisted of all cases reported during the third quarter of 2016 and the second quarter of 2018 with an NSAID as the primary suspect for the adverse drug event (ADE). An additional 397 cases with warfarin as the primary suspect were included in the final sample (N = 3,784) to test for bias from including only NSAID as the primary ADE suspect cases. Extracted data included the primary ADE (hemorrhagic stroke or other ADE), age, gender, primary suspect drug (NSAID or warfarin), and presence of a second NSAID, rivaroxaban, warfarin, clopidogrel, antidepressants (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants), inhaled corticosteroids, diabetes, or cardiovascular medications. Logistic regression was used to predict hemorrhagic stroke.

Results:

Aspirin and warfarin increased the risk for hemorrhagic stroke by 3.458 and 3.059, respectively. Presence of an additional NSAIDs reduced the risk by 48%.

Implications for practice:

Hemorrhagic stroke risk specific to older adults may provide helpful estimates for practitioners as they weigh the risk benefit of prescribing aspirin as an antiplatelet therapy for older adults.
Hearing Loss in Enlarged Vestibular Aqueduct: A Prognostic Factor Systematic Review of the Literature
Authors: Saeed Haroon Shakeel , Kenth Jonny , Black Graeme , Saeed Shakeel R. , Stivaros Stavros , Bruce Iain A.
Published: September 2020

Objective:

There is a need to highlight individual prognostic factors determining hearing loss in enlarged (wide) vestibular aqueduct, as currently clinicians cannot counsel parents about the expected clinical course, nor provide individualized hearing rehabilitation plans following identification at newborn screening. We apply a novel methodology to specifically outline and assess the accuracy of prognostic factors reporting for hearing loss in enlarged vestibular aqueduct.

Data Sources:

A preferred reporting items for systematic reviews and meta-analyses compliant systematic review (Prospero ID: CRD42019151199), with searches applied to Medline, EMBASE, and Cochrane. Studies with longitudinal design were included between 1995 and 2019.

Study Selection:

The CHARMS-PF tool was used to assess robustness of prognostic factor study designs.

Data Extraction:

The QUIPS tool was used to assess for individual study risk of bias.

Data Synthesis & Results:

Seventy papers were suitable for data extraction. In the six studies with low risk of bias, the domains of enlarged vestibular aqueduct (EVA) morphology, age, hearing thresholds, sex, head trauma, and genotype provided exploratory prognostic factors for hearing loss associated with enlarged vestibular aqueduct. Overall, study heterogeneity and risk of bias precluded reporting by forest plots and meta-analysis.

Conclusions:

The majority of exploratory prognostic factor studies for hearing loss associated with enlarged vestibular aqueduct are hampered by risk of bias. However, this systematic review identifies potential independent prognostic factors which should be measured, and adjusted for, in subsequent confirmatory studies utilizing multivariate analysis. This would determine the true independent prognostic effects associated with hearing loss in enlarged vestibular aqueduct, while facilitating prognostic model development and the ability to predict individual hearing loss trajectory.
Audiologic Outcome of Cochlear Implantation in Children With Cochlear Nerve Deficiency
Authors: Yousef Medhat , Mesallam Tamer A. , Garadat Soha N. , Almasaad Ayna , Alzhrani Farid , Alsanosi Abdulrahman , Hagr Abdulrahman
Published: September 2020

Objective/Hypothesis:

The aim of this study was to investigate cochlear implantation (CI) outcome in children with nerve deficiency.

Study Design:

Retrospective chart review.

Methods:

A total of seven children with prelingual profound deficiency (hypoplasia or aplasia) were included. A control group of 10 CI children with no cochlear nerve anomalies was also included. In addition to implant stimulation levels, children's performance on pure-tone audiometry, speech reception measure, and auditory and speech skills ratings were compared across groups. Additionally, pre- and postoperative audiologic results were evaluated for the group with nerve deficiency.

Results:

In general, children with nerve deficiency performed poorer than those without nerve deficiency on all tested measures. Stimulation levels were considerably higher and more variable than the control group. Results further showed that performance was dependent on the diameter of the internal auditory canal.

Conclusion:

Overall, cochlear implantation outcome in children with auditory nerve deficiency is poorer and extremely more variable than those without nerve deficiency. However, three of the patients had a noticeable improvement in auditory performance postimplantation suggesting that CI is a viable option in this population but expected benefit can be dependent on the status of the cochlear nerve.
Liver Stiffness Measured by Either Magnetic Resonance or Transient Elastography Is Associated With Liver Fibrosis and Is an Independent Predictor of Outcomes Among Patients With Primary Biliary Cholangitis
Authors: Osman Karim T. , Maselli Daniel B. , Idilman Ilkay S. , Rowan Daniel J. , Viehman Jason K. , Harmsen William S. , Harnois Denise M. , Carey Elizabeth J. , Gossard Andrea A. , LaRusso Nicholas F. , Lindor Keith D. , Venkatesh Sudhakar K. , Eaton John E.
Published: September 2020

Goals:

We aimed to describe the diagnostic and prognostic performance of transient elastography (TE) and magnetic resonance elastography (MRE) in patients with primary biliary cholangitis (PBC).

Background:

The diagnostic performance of TE and MRE in detecting advanced fibrosis in PBC and in predicting outcomes independent of existing serologic prognostic markers is incompletely understood.

Materials and Methods:

Five hundred thirty-eight consecutive patients with PBC at 3 centers with liver stiffness (LS) measurements by TE (n=286) or MRE (n=332) were reviewed. LS cutoffs for predicting fibrosis stages were determined by receiver operating characteristic curves among those with a liver biopsy (TE, n=63; MRE, n=98). Cox proportional hazard regression modeling was used to identify associations between covariates and hepatic decompensation.

Results:

The optimal LS thresholds for predicting histologic stage F4 were 14.40 kPa (area under the curve=0.94) for TE and 4.60 kPa (area under the curve=0.82) for MRE. Both TE and MRE outperformed biochemical markers for the prediction of histologic advanced fibrosis. Optimal LS thresholds to predict hepatic decompensation were 10.20 kPa on TE and 4.30 kPa on MRE. LS by TE and MRE (respectively) remained predictors of hepatic decompensation after adjusting for ursodeoxycholic acid responsiveness [hazard ratio (HR), 1.14; 95% confidence interval (CI), 1.05-1.24 and HR, 1.68; 95% CI, 1.28-2.19] and the GLOBE score (HR, 1.13; 95% CI, 1.07-1.19 and HR, 2.09; 95% CI, 1.57-2.78).

Conclusion:

LS measurement with either TE or MRE can accurately detect advanced fibrosis and offers additional prognostic value beyond existing serologic predictive tools.
Procedural bleeding risk, rather than conventional coagulation tests, predicts procedure related bleeding in cirrhosis
Authors: Janko Natasha , Majeed Ammar , Commins Isabella , Kemp William , Roberts Stuart K.
Published: September 2020

Background

Standard coagulation parameters are used to guide prophylactic blood product transfusion prior to invasive procedures in cirrhotic patients despite limited high-quality evidence.

Aims

We aimed to describe coagulation parameters and prophylactic blood product use in cirrhotic patients having invasive procedures, and the influence of both on periprocedural bleeding.

Methods

We conducted a cohort study of cirrhotic patients undergoing invasive procedures at a referral hospital. Procedures were classified into low or moderate-high bleeding risk. Prophylactic blood component was defined as fresh frozen plasma, cryoprecipitate or platelet transfusion prior to procedures. Univariate and multivariate logistic regression was performed to identify factors associated with procedure-related bleeding.

Results

We identified 566 procedures in 233 cirrhotic patients. Prophylactic blood product was given before 16% of high-risk and 11% of low-risk procedures (P = 0.18). Eight (8.3%) high-risk procedures were complicated by postprocedural bleeding, six of which occurred in patients without significant coagulopathy. The bleeding rate for low-risk procedures was 0.4%. For patients with international normalized ratio >1.5, platelet count <50 x 109/L, or both, the rate of bleeding was comparable between those given and not given prophylactic blood products (3.1 vs. 1.9%; P = 0.63). After adjusting for age, sex, platelet count, international normalized ratio, acute kidney injury, sepsis and model of end-stage liver disease, the only factor significantly predicting procedure-related bleeding was the procedural bleeding risk category (P < 0.01).

Conclusions

Procedure-related bleeding in cirrhotic patients cannot be accurately predicted by INR or platelet count, nor prevented by blood component prophylaxis using these parameters. Procedure-related bleeding is best predicted by the bleeding risk status of procedures.