bluuebunny/crossref_metadata_2025 huggingface dataset:
Topical application of Heparanase-1 facilitates bone remodeling during the healing of bone defects in a mouse model
Authors: Chiu Po-Yu , HuangFu Wei-Chun , Liu I-Hsuan , Chang Ya-Pei
Published: January 2020

Background:

Although previous studies have suggested a stimulatory role of heparanase in physiological bone turnover, the potential therapeutic role of heparanase in bone healing has not been elucidated. The purpose of this study was to assess the effect of topical application of heparanase-1 on bone healing.

Methods:

Two different dosages of recombinant mouse heparanase-1 and vehicle control were prepared and delivered via an osmotic pump to provide continuous topical infusion of the therapeutic reagent in a mouse bone defect model at the distal femoral metaphysis. The bone healing progress was evaluated by micro-computed tomography and histological examination at 7, 14, and 21 days after the bone defect was created.

Results:

The peak of trabecular bone generation was achieved earlier than anticipated with the use of heparanase as measured by medullary bone volume fraction and trabecular number observed in micro-computed tomography, while the remodeling of trabecular bone to cortical bone was also achieved earlier than anticipated with the use of heparanase as measured by connectivity density. Histopathological observation revealed a higher frequency of the presence of cartilaginous tissue in the heparanase-treated groups. Both bone mineral density and cortical bone volume fraction showed the best healing outcome with low-dose heparanase, implying a biphasic effect of its mode of action.

Conclusion:

These results indicated that with the appropriate dose of topical heparanase-1, the progress of bone healing could be accelerated in vivo.
Psychosocial Factors Related to Adverse Outcomes in Heart Failure Caregivers
Authors: Graven Lucinda J. , Azuero Andres , Abbott Laurie , Grant Joan S.
Published: January 2020

Background

Heart failure (HF) caregivers experience increased demands and burden. Social support and problem solving may influence the effect of these variables on caregiver outcomes.

Objective

The aim of this study was to examine whether social support and problem solving mediate relationships among caregiver demands and burden, self-care, depression, and life changes in heart failure caregivers.

Methods

Using a cross-sectional, exploratory design, heart failure caregivers (n = 530) completed online questionnaires on caregiver demands and burden, social support, problem solving, depression, self-care, and life changes. Path analysis examined a hypothesized mediating role of social support and problem solving in the relationships among caregiver demands and burden and caregiver outcomes. The analysis included (1) a model-development phase (n = 329) to make data-based decisions on measurement indicators and model structure and (2) a confirmatory phase (n = 201) to provide unbiased inference on the model structure resulting from the initial phase.

Results

Participants were 41.39 (±10.38) years old and primarily white (78.3%) men (50.9%) caring for a spouse (44.9%). Per the magnitudes of the estimated path coefficients, social support mediated the relationship between caregiver burden and depression but did not relevantly mediate the relationship between caregiver burden and self-care or caregiver life changes. In the presence of social support as a parallel mediator, problem solving was not a relevant mediator between caregiver burden and demands and caregiver outcomes.

Conclusions

Social support mediates the effects of caregiver burden on depression but has little effect on self-care or life changes. In the presence of social support, problem solving does not mediate the effects of caregiver demands and burden on caregiver outcomes.
Prediction of Heart Failure Symptoms and Health-Related Quality of Life at 12 Months From Baseline Modifiable Factors in Patients With Heart Failure
Authors: Heo Seongkum , Moser Debra K. , Lennie Terry A. , Fischer Mary , Kim JinShil , Walsh Mary N. , Ounpraseuth Songthip , Turrise Stephanie
Published: January 2020

Background

In patients with heart failure (HF), good health-related quality of life (HRQOL) is as valuable as, or more valuable than, longer survival. However, HRQOL is remarkably poor, and HF symptoms are strongly associated with poor HRQOL. Yet, the multidimensional, modifiable predictors have been rarely examined.

Objective

The aim of this study was to examine the baseline psychosocial, behavioral, and physical predictors of HF symptoms and HRQOL at 12 months and the mediator effect of HF symptoms in the relationship between depressive symptoms and HRQOL.

Methods

We collected data from 94 patients with HF (mean ± SD age, 58 ± 14 years). Data included sample characteristics, depressive symptoms, perceived control, social support, New York Heart Association (NYHA) functional class, medication adherence, sodium intake, self-care management, and HF symptoms at baseline, as well as HF symptoms and HRQOL at 12 months. Multiple regression analyses were performed to address the purpose.

Results

Baseline depressive symptoms (P < .001), medication adherence (P = .010), sodium intake (P = .032), and NYHA functional class (P = .040) significantly predicted 12-month HF symptoms, controlling for covariates (F = 7.363, R
2 = 47%, P < .001). Baseline medication adherence (P = .001), NYHA functional class (P < .001), and HF symptoms (P = .013) significantly predicted 12-month HRQOL (F = 10.701, R
2 = 59%, P < .001). Baseline HF symptoms fully mediated the relationship between baseline depressive symptoms and 12-month HRQOL.

Conclusion

Symptoms of HF and HRQOL could be improved by targeting multidimensional, modifiable predictors, such as self-care, depressive symptoms, and NYHA functional class.
Effects of Art and Reminiscence Therapy on Agitated Behaviors Among Older Adults With Dementia
Authors: HSIAO Chiu-Yueh , CHEN Shu-Li , HSIAO Yu-Shuang , HUANG Hsiu-Yun , YEH Shu-Hui
Published: January 2020

Background

Cognitive degeneration and agitated behavior symptoms of dementia in older adults are the main causes of disability and inability and increase the cost of medical care. Agitated behavior symptoms of dementia are the main causes of early institutionalization and make caregivers exhausted.

Purpose

The aim of this study was to examine the effects of art therapy and reminiscence therapy on the alleviation of agitated behaviors in older adults with dementia.

Methods

An experimental research design with two experimental groups and one comparison group was conducted to examine the effects for each group on agitated behaviors. Participants were recruited from two dementia care centers in central and northern Taiwan. The study included 54 older individuals who met the sampling criteria and completed the data collection process. The participants were randomly allocated into the art therapy group (n = 24), the reminiscence therapy group (n = 22), and the comparison group (n = 8). The intervention consisted of 50-minute sessions conducted weekly for 12 weeks. Regular activities were continued in the comparison group. The structured questionnaires were completed, and observations of agitated behaviors were collected before the intervention and at 1 and 6 weeks after the intervention.

Results

Significant differences were found in agitated behavior symptoms at the three time points in the art therapy group, whereas reminiscence therapy was found to have had a clear and immediate effect on decreasing agitated behavior. The generalized estimating equation exchange model test revealed a significant and sustained, postintervention effect of art therapy on agitated behavior. In contrast, no significant and sustained effect on agitated behavior was observed in the reminiscence therapy group.

Conclusions

The findings of this study support that art therapy may have a positive effect on dementia-associated agitated behaviors in institutionalized older adults. Reminiscence therapy activities conducted weekly for 50 minutes each session did not reach statistically significant implications. It is suggested that future studies consider conducting art and reminiscence therapies for a 16-week duration with two weekly sessions to evaluate the effectiveness of the therapy. The duration of follow-up should be extended as well in future studies.
Roles of FGF21 and irisin in obesity-related diabetes and pancreatic diseases
Authors: Xie Ting , Leung Po Sing
Published: January 2020

In the past decades, skeletal muscle has become the focus of numerous studies due to its potential physiological role as an endocrine organ secreting hundreds of myokines. Among these myokines, fibroblast growth factor 21 (FGF21) and irisin are novel hormone polypeptides sending signals to regulate the function of specific organs, like skeletal muscle, liver, pancreas, and adipose tissue. Both hormones have been reported to normalize glucose, improve insulin resistance, and promote lipid homeostasis, thereby preventing the development of metabolic disorders, such as obesity and diabetes. Besides preserving pancreatic β-cell functions, FGF21 also protects pancreatic acini from inflammation and reduces proteotoxic stress via facilitating digestive enzyme secretion. Meanwhile, irisin is found to inhibit the pancreatic cancer cell growth as well. This review attempts to focus on the current knowledge of FGF21 and irisin and their effective roles in pancreas including pancreatic β- and acinar cells under various physiological conditions, its anti-diabetic actions, and the clinical implications.
Improving Microscopic Imaging in Otology and Neurotology
Authors: Saadi Robert , Liaw Jeffrey , Baker Aaron , Isildak Huseyin
Published: January 2020

Objective:

Due to the microscopic nature of otologic surgery, photographic image quality suffers from an inherent inability to maintain all the planes of surgery in focus under binocular microscopy. Our goal was to perform simple editing techniques to create improved imaging for educational and research purposes in the field of Otology and Neurotology.

Patients/Design:

The study was a proof of concept performed with series of cases including patients undergoing transmastoid and transcanal otologic surgery over time period of December 1, 2018 to March 1, 2019 at an academic medical center. The Zeiss OPMI Pentero 800 operating microscope was used with a camera capturing 2.1 megapixel, 1098 × 1080 resolution images.

Intervention:

We created a systematic protocol for capturing images of multiple focal lengths during each surgery. With the image-editing technique of focus-stacking, multiple images of varying focal length, were spliced together to produce high-quality and high-fidelity composite images rendered using the Adobe Photoshop (San Jose, CA).

Outcomes:

Subjective comparisons of pre and post photo-edited photographs.

Results:

Composite, focus-stacked images with comparison to unedited microscopic pictures are reviewed in the manuscript.

Conclusion:

We describe a simple and objectively practical method for improving the quality of medical imaging in the field of Otology/Neurotology. To achieve this enhanced image quality, a relatively expeditious and reliable photographic protocol can be used for image capturing and editing, requiring little to no additional training for a physician in the field.
Performing MRI Scans on Cochlear Implant and Auditory Brainstem Implant Recipients: Review of 14.5 Years Experience
Authors: Tam Yu Chuen , Lee Jennifer W. Y. , Gair Juliette , Jackson Cay , Donnelly Neil P. , Tysome James R. , Axon Patrick R. , Bance Manohar L.
Published: January 2020

Objective:

To assess the complication rate of magnetic resonance imaging (MRI) using 1.5 T scanners on cochlear implant (CI) and auditory brainstem implant (ABI) recipients over 14.5 years.

Methods:

Prospective study conducted in a tertiary referral center for cochlear and auditory brainstem implantation, including patients with neurofibromatosis 2. The primary outcome was complications related to MRI scanning in implant recipients, including failure to complete MRI sessions. The secondary outcome was magnet void size due to MRI scanning with magnet in situ.

Results:

Ninety-seven patients (21 ABI recipients, 76 CI recipients of whom 23 were bilateral) underwent a total of 428 MRI sessions consisting of 680 MRI procedures, which generated 2,601 MRI sequences (excluding localizers). Of these, 28/428 (6.5%) MRI sessions were performed with magnet removed, and the remaining 400/428 (93.4%) with the magnet in situ. The overall complication rate per session was 15/428 (3.5%). The majority of complications were accounted for by patient discomfort, in some cases requiring abandoning the scan session, but 5 magnet dislocations were also recorded. There were no cases of implant device failure or excessive demagnetization of the receiver stimulator magnet.

For CI and ABI recipients, the implant caused large voids of around 110 mm × 60 mm with the magnet in situ which reduced to 60 mm × 30 mm when the magnet was removed. However, it was usually possible to visualize the internal acoustic meatus and cerebellopontine angle by positioning the implant package higher and further forward compared with conventional positioning.

Conclusion:

MRI scanning in ABI and CI recipients is generally safe and well tolerated without magnet removal, and carries a low rate of complications. However, patients should be fully informed of the possibility of discomfort, and precautions such as local anesthetic injection and head bandaging may reduce the likelihood of adverse events.
Development of a Preliminary Question Prompt List as a Communication Tool for Adults With Gastroesophageal Reflux Disease
Authors: Kamal Afrin , Katzka David A. , Achkar Edgar , Carlson Dustin , Clarke John , Fass Ronnie , Gyawali Chandra P. , Patel Dhyanesh , Penagini Roberto , Rezaie Ali , Roman Sabine , Savarino Edoardo , Shaheen Nicholas J. , Triadafilopoulos George
Published: January 2020

Background:

Question prompt lists (QPLs) are structured sets of disease-specific questions intended for patient use, encouraging patients to ask questions to facilitate their consultation with their physician.

Aim:

The aim of this study was to develop a QPL specific to adults with gastroesophageal reflux disease (GERD), created by esophageal experts.

Methods:

The QPL content (78 questions) was derived through a modified Delphi method consisting of 2 rounds. In round 1, 18 esophageal experts provided 5 answers to the prompt “What you wish your patients would ask” and “What questions do patients often not ask, that I wish they would ask?” In round 2, the experts rated each question on a 5-point Likert scale, and responses rated as “essential” or “important,” determined by an a priori threshold of ≥4.0, were accepted for the QPL.

Results:

Twelve esophageal experts participated. Of 143 questions from round 1, 110 (76.9%) were accepted for inclusion in the QPL, meeting a median value of ≥4.0, and, subsequently, it reduced to 78, minimizing redundancy. Median values ranged between 4.0 and 5.0, with the highest agreement median (5.0) for questions asking dosing and timing of proton pump inhibitor therapy, and surveillance in Barrett’s. Questions were categorized into the following categories: “What does this illness mean,” “lifestyle modifications,” “general treatment,” “treatment with proton pump inhibitors,” “What I should expect for my future,” and “Barrett’s.” The largest number of questions covered lifestyle modifications (21.8%), with the highest agreement median (5.0) for “How helpful are lifestyle modifications in GERD?”

Conclusions:

A preliminary GERD-specific QPL, the first of its kind, was developed by esophageal experts. Modification after more patient consultation and feedback is planned in subsequent versions to create a GERD-QPL for eventual use in clinical gastroenterology.
The Relative Importance of Clinical and Socio-demographic Variables in Prognostic Prediction in Non–Small Cell Lung Cancer
Authors: He Jiangping , Zhang James X. , Chen Chin-tu , Ma Yan , De Guzman Raymond , Meng Jianfeng , Pu Yonglin
Published: January 2020

Background:

Prognostic modeling in health care has been predominantly statistical, despite a rapid growth of literature on machine-learning approaches in biological data analysis. We aim to assess the relative importance of variables in predicting overall survival among patients with non–small cell lung cancer using a Variable Importance (VIMP) approach in a machine-learning Random Survival Forest (RSF) model for posttreatment planning and follow-up.

Methods:

A total of 935 non–small cell lung cancer patients were randomly and equally divided into 2 training and testing cohorts in an RFS model. The prognostic variables included age, sex, race, the TNM Classification of Malignant Tumors (TNM) stage, smoking history, Eastern Cooperative Oncology Group performance status, histologic type, treatment category, maximum standard uptake value of whole-body tumor (SUVmaxWB), whole-body metabolic tumor volume (MTVwb), and Charlson Comorbidity Index. The VIMP was calculated using a permutation method in the RSF model. We further compared the VIMP of the RSF model to that of the standard Cox survival model. We examined the order of VIMP with the differential functional forms of the variables.

Results:

In both the RSF and the standard Cox models, the most important variables are treatment category, TNM stage, and MTVwb. The order of VIMP is more robust in RSF model than in Cox model regarding the differential functional forms of the variables.

Conclusions:

The RSF VIMP approach can be applied alongside with the Cox model to further advance the understanding of the roles of prognostic factors, and improve prognostic precision and care efficiency.
Trends in Contracting and Common Ownership Between Hospice Agencies and Nursing Homes
Authors: Stevenson David G. , Sinclair Nicholas , Zhang Shiyuan , Meneades Laurie M. , Huskamp Haiden A.
Published: January 2020

Background:

In recent years, policymakers have paid particular attention to the emergence of a robust for-profit hospice sector and increased hospice use by nursing home residents. Previous research has explored financial incentives for nursing home-hospice use, but there has been limited research on nursing home-hospice partnerships and none on the extent of nursing home-hospice common ownership.

Objective:

To describe trends in nursing home-hospice contracting and common ownership and to identify potential tradeoffs in care provided by nursing homes and hospice agencies that share common ownership.

Research Design:

Retrospective cohort study of nursing home-hospice patients between 2005 and 2015.

Results:

Between 2005 and 2015, the number of hospice agencies and nursing homes with common ownership grew substantially, now representing almost 1-in-5 providers in each sector. Relative to individuals using hospice in nursing homes without common ownership, adjusted analyses found that individuals receiving hospice from a commonly owned agency had a greater likelihood of having stays of 90 days or more [odds ratio (OR)=1.06; 95% confidence interval (CI), 1.02–1.10], having a stay resulting in a live discharge (OR=1.06; 95% CI, 1.02–1.11), and having at least 1 registered nurse/licensed practical nurse visit during the last 3 days of life (OR=1.17; 95% CI, 1.05–1.29); these individuals also had a lower mean visit hours per day (−0.07; P=0.003).

Conclusions:

Common ownership between hospice agencies and nursing homes is an emerging trend that reflects a broader push toward consolidation in the health care sector. Our analyses highlight potential concerns relevant to Medicare payment policy and are a first step toward improving our understanding of these trends and their implications.
Quality of Care in Chronic Kidney Disease and Incidence of End-stage Renal Disease in Older Patients
Authors: Fukuma Shingo , Ikenoue Tatsuyoshi , Shimizu Sayaka , Norton Edward C. , Saran Rajiv , Yanagita Motoko , Kato Genta , Nakayama Takeo , Fukuhara Shunichi
Published: January 2020

Background:

The quality of care received by a growing number of older patients with chronic kidney disease (CKD) has not been adequately examined.

Objective:

The objective of this study was to assess the quality of CKD care among older patients and to clarify its association with the incidence of end-stage renal disease (ESRD).

Research Design:

This was a population-based cohort study.

Subjects:

Older (65 y and above) CKD patients diagnosed between October 2010 and September 2014 from the National Database of Health Insurance Claims of Japan.

Measures:

A composite quality score (QS) of 3 quality measures for CKD care during the 6 months after CKD diagnosis was computed. The validated quality measures included urine testing for proteinuria, nutritional guidance, and nonsteroidal anti-inflammatory drugs avoidance. To assess the association between the QS and ESRD incidence, we used instrumental variable analysis after stratification for the history of diabetes.

Results:

Among the 890,773 older CKD patients, 2.9% progressed to ESRD (incidence rate of 12.5 per thousand person-years). In total, 59.9% underwent urine testing, 4.5% received nutritional guidance, and 91.2% avoided regular use of nonsteroidal anti-inflammatory drugs. An instrumental variable analysis revealed that a higher QS was associated with—lower ESRD incidence in patients diagnosed with diabetes (hazard ratio: 0.25, 95% confidence interval: 0.24–0.27 for each point higher score) but not in patients without a diagnosis of diabetes (hazard ratio: 0.99, 95% confidence interval: 0.92–1.05).

Conclusion:

Among older CKD patients, quality of CKD care varied between patients, and better quality of CKD care was associated with a lower ESRD incidence in patients with diabetes but not in nondiabetic patients.
French Red Cross Volunteer Rescue Workers
Authors: Meudal Julie , Vandentorren Stéphanie , Simeoni Laurent , Denis Céline
Published: January 2020

Few studies have explored the psychological consequences of terrorism on volunteer rescuers. We examined the psychological characteristics of volunteer rescuers after the January 2015 terrorist attacks in France. We analyzed the results of the IMPACTS study regarding the somatic, psychological, and social characteristics of the French Red Cross volunteer rescuers who intervened during these terrorist attacks. We used a standardized questionnaire during a face-to-face interview, 6 to 9 months after the attacks. Forty-one volunteers were included. Nine were presenting anxiety disorders, 11 were displaying recurrent depressive episodes, and five were displaying abusive alcohol consumption. Twenty-seven were provided with a debriefing after their intervention. Half of the most exposed volunteers had no contact with mental health professional 9 months after their intervention. A healthcare protocol, covering short-, medium-, and long-term care, should be systematically proposed to volunteer rescue workers to minimize the risk of chronic psychic posttraumatic disorders.
Strengths–Weaknesses–Opportunities–Threats Analysis for a Pediatric Anesthesia Program
Authors: Eizaga Rebollar Ramón , García Palacios María Victoria , Fernández Mangas María del Carmen , Arroyo Fernández Francisco Javier , Márquez Rodríguez Carlos Miguel , Carnota Martín Ana Isabel , Morales Guerrero Javier , Torres Morera Luis Miguel
Published: January 2020

Background:

Risk management in healthcare institutions begins by first identifying the potential risks within a certain organization or specific area and then goes on to develop further strategies to reduce harm. The most common tool for this type of analysis is Strengths–Weaknesses–Opportunities–Threats (SWOT).

Methods:

We conducted a SWOT analysis in our pediatric anesthesia program: key factors were identified in a matrix, prioritized in a score table, represented in a graph, and finally analyzed.

Results:

Items obtained partial scores from 20 to 120. The item “lack of clinical protocols” was given greater weight (60) and received a lower value (1), resulting in the highest partial score (60) among the negative key factors and indicating a need for greater efforts to improve this specific aspect.

Conclusion:

The SWOT tool proved effective in identifying safety and quality key factors, and it provided information for initiating an improvement program.
Autologous Breast Reconstruction versus Implant-Based Reconstruction: How Do Long-Term Costs and Health Care Use Compare?
Authors: Lemaine Valerie , Schilz Stephanie R. , Van Houten Holly K. , Zhu Lin , Habermann Elizabeth B. , Boughey Judy C.
Published: January 2020

Background:

The authors compared long-term health care use and cost in women undergoing immediate autologous breast reconstruction and implant-based breast reconstruction.

Methods:

This study was conducted using the OptumLabs Data Warehouse, which contains deidentified retrospective administrative claims data, including medical claims and eligibility information from a large U.S. health insurance plan. Women who underwent autologous or implant-based breast reconstruction between January of 2004 and December of 2014 were included. The authors compared 2-year use rates and predicted costs of care. Comparisons were tested using the t test.

Results:

Overall, 12,296 women with immediate breast reconstruction were identified; 4257 with autologous (35 percent) and 8039 with implant-based (65 percent) breast reconstruction. The proportion of autologous breast reconstruction decreased from 47.2 percent in 2004 to 32.7 percent in 2014. The mean predicted reconstruction cost of autologous reconstruction was higher than that of implant-based reconstruction in both unilateral and bilateral surgery. Similar results for mean predicted 2-year cost of care were seen in bilateral procedures. However, in unilateral procedures, the 2-year total costs were higher for implant-based than for autologous reconstruction. Two-year health care use rates were higher for implant-based reconstruction than for autologous reconstruction for both unilateral and bilateral procedures. Women undergoing unilateral implant-based reconstruction had higher rates of hospital admissions (30.3 versus 23.1 per 100; p < 0.01) and office visits (2445.1 versus 2283.6 per 100; p < 0.01) than those who underwent autologous reconstruction. Emergency room visit rates were similar between the two methods. Bilateral procedures yielded similar results.

Conclusion:

Although implant-based breast reconstruction is a less expensive index operation than autologous breast reconstruction, it was associated with higher health care use, resulting in similar total cost of care over 2 years.
Effect of Preoperative Patient Education on Opioid Consumption and Well-Being in Breast Augmentation
Authors: Parsa Fereydoun Don , Pavlosky K. Keano , Harbison Gregory , Yim Nicholas , Cheng Justin , Marison Scott R. , Parsa Alan A.
Published: January 2020

Background:

Perioperative use of opioids is common in surgical practice and frequently results in troublesome opioid-related side effects that often lead to suboptimal postsurgical outcomes. As such, multiple studies have sought to identify alternatives that may reduce reliance on opioid-based perioperative pain management. Recently, it has been shown that patient education and patient involvement in care positively impact surgical outcomes. This study evaluates how patient education regarding the role of endogenous beta-endorphins in reducing pain and the opposing effect of opioid analgesics impacts opioid consumption and mood after surgery.

Methods:

Patients scheduled for breast augmentation were divided into two groups, A and B. Both groups received identical multimodal anesthesia regimens; however, only patients in group B were educated on the role of endogenous beta-endorphins in pain control and mood enhancement, and how opioids block their action.

Results:

Patients in the group receiving preoperative education on the analgesic and mood-enhancing role of endogenous beta-endorphins and how opioids block their action consumed significantly less opioids and had better postsurgical outcomes as determined by self-reported measures of pain level and mood/sense of well-being.

Conclusions:

The findings of this study suggest that opioid use was significantly reduced and patients’ mood/sense of well-being was significantly enhanced when patients received preoperative education on the oppositional relationship between beta-endorphins and opioids. Such patient education may be linked to a significant reduction in opioid use and improved patient mood/sense of well-being, especially when combined with opioid-free multimodal anesthesia.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, II.
Clinical Application of a Patient-Specific, Three-Dimensional Printing Guide Based on Computer Simulation for Rhinoplasty
Authors: Choi Jong Woo , Kim Min Ji , Kang Min Kyu , Kim Sung Chan , Jeong Woo Shik , Kim Don Han , Lee Tae Hoon , Koh Kyung S.
Published: January 2020

Background:

A practical application of three-dimensional printing technology has been considered a difficult area in rhinoplasty. However, the patient-specific three-dimensionally printed rhinoplasty guide based on the simulation program the authors developed could be a solution for minimizing the gap between simulation and actual surgical results. The aims of this study were to determine how a three-dimensional rhinoplasty guide based on three-dimensional simulation would link the patient to the surgeon to investigate its effectiveness.

Methods:

Fifty patients who underwent rhinoplasty between January of 2017 and February of 2018 were included in this study. The patients were consulted about the desired shape of their nose based on preoperative three-dimensional photography. The confirmed three-dimensional simulation was sent to a manufacturing company for three-dimensionally printed rhinoplasty guides. In the guide group, rhinoplasty was performed based on the three-dimensionally printed rhinoplasty guide, and in the control group, procedures were performed based on the surgeon’s intuition.

Results:

The intraclass correlation coefficient test for comparing the simulated and postoperative measurements showed higher correlation in the three-dimensional printing guide group: higher correlation 11.3 percent in nasal tip projection, 21.6 percent in dorsum height, and 9.8 percent in nasolabial angle. The postoperative result of the nasal dorsum had a statistically significant difference between the two groups (p < 0.05).

Conclusions:

This study demonstrated the usefulness of the three-dimensionally–printed rhinoplasty guide, which delivers the preoperative simulated image in the actual clinical practice of rhinoplasty. This approach could cause a paradigm shift in simulation-based rhinoplasty.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Variability of CD4+ Cell Counts in HIV-1–Uninfected Volunteers Who Are Eligible for a Phase I HIV Vaccine Study
Authors: Stafford Kristen A. , Mayer Bryan T. , Fulp William , Chua Joel , Davis Charles , Gilliam Bruce , Dong Dan , Gallo Robert C. , Sajadi Mohammad M.
Published: January 2020

Objective:

Vaccines and biologics containing CD4 molecules or HIV-1 gp120 might induce antibodies targeting CD4. We evaluated temporal variability of CD4 levels in healthy volunteers to quantify declines that could indicate true adverse events.

Design:

Prospective observational cohort study of 100 healthy adults without HIV-1 infection from the Baltimore region.

Methods:

Participants enrolled and consented to blood draws for immunologic laboratory panels performed once every 8 weeks for 48 weeks. The primary CD4+ measurements were CD4+ absolute count (cells/mm3) and CD4 percentage (CD4%, total CD4 cells/total lymphocyte cells). CD4 changes over time were modeled using fold changes for CD4+ absolute counts and differences for CD4 percentages.

Results:

Variation of average CD4+ cell counts and percentages were highly participant-specific (P < 0.001 for both). However, changes in both CD4+ measurements over time were stable in the population. We proposed thresholds to flag unusual drops using 1.5 SD estimates, calculated as 1.5-fold declines for CD4+ count and 6.4% declines for CD4 percentage. In this healthy cohort, flagging simultaneous declines in both measurements corresponded to a low false-positive rate (5.26%).

Conclusions:

Normal biological variation in large lymphocytes should be taken into account to establish thresholds for adverse changes in clinical trials. The inherent subject-specific variability in CD4 levels makes establishing absolute cutoffs difficult. However, this study proposes that thresholds for declines using 1.5 SDs from these data (50% in absolute count and 6.4% for CD4 percentage) allow a small false-positive rate (∼5%) that could maintain sensitivity for true adverse events in a clinical trial.
Safety of Atorvastatin in Patients With Stable Systemic Autoimmune Myopathies
Authors: Pires Borges Isabela Bruna , de Oliveira Diego Sales , Misse Rafael Giovani , dos Santos Alexandre Moura , Hong Valéria Aparecida Costa , Bortolotto Luiz Aparecido , Shinjo Samuel Katsuyuki
Published: January 2020

Background/Objective

Patients with systemic autoimmune myopathies (SAMs) have high prevalence of dyslipidemia and, consequently, possible endothelial dysfunction and vascular stiffness. Our objective was to evaluate the possible benefits on endothelial function and vascular stiffness, as well as adverse effects of atorvastatin in SAMs.

Methods

A pilot longitudinal, double-blind, randomized, placebo-controlled study was conducted. Twenty-four of 242 patients were randomized at a 2:1 ratio to receive atorvastatin (20 mg/d) or placebo for a period of 12 weeks. Demographic data, comorbidities, and clinical and laboratory parameters, as well as endothelial function and arterial stiffness, were evaluated.

Results

Of the 24 randomized patients, 4 patients were excluded, with remaining 20 patients (14 in the atorvastatin group and 6 in the placebo group). The mean age of the patients was 49.0 years, and 75% of the patients were female. At baseline, the demographic data, disease status, treatment, cardiovascular comorbidities, and risk factors were comparable between the atorvastatin and placebo groups. After 12 weeks of follow-up of atorvastatin therapy, no improvements were observed for endothelial function and arterial stiffness in either group (p > 0.05). As expected, a significant reduction in total and low-density lipoprotein cholesterol levels was observed. During the study, no clinical intercurrences or disease relapses were observed in either group.

Conclusions

The atorvastatin drug attenuated low-density lipoprotein cholesterol without worsening clinical outcomes in SAMs. No change was observed for endothelial function and arterial stiffness. Additional studies, with long-term follow-up time and different atorvastatin dosage, are needed to corroborate the results of this study.
The Patients' Perspective of Important Glucocorticoid Effects
Authors: Mirza Serene Z. , Cheah Jonathan T. L. , Ghosh Nilasha , Robson Joanna C. , Hill Catherine L. , Singh Jasvinder , Mackie Sarah L. , Navarro-Millán Iris , Simon Lee S. , Goodman Susan M.
Published: January 2020

Background/Objective

The objective of this cohort study was to understand the positive and negative effects of glucocorticoids (GCs) in patients with systemic lupus erythematosus and myositis from the patients' perspective with the aim of developing a patient-reported outcome measure.

Methods

Included patients were asked to participate in 1 of 5 nominal groups where demographic information and a quality-of-life questionnaire were collected. Patients were asked 2 open-ended questions on (1) benefits and (2) harms related to GC use. We used the Nominal Group Technique, a highly structured consensus method in which responses are generated, shared, and ranked. Descriptive statistics were used to summarize the results. Nominal group sessions took place from April to May 2019.

Results

Of 206 patients who were approached, 21 patients participated, 17 with systemic lupus erythematosus and 4 with myositis, predominantly women with more than 10 years of steroid use. The domains ranked highest for GC benefits were disease control (55 votes), fast onset of action (30 votes), increased energy (10 votes), and pain relief (10 votes). The highest-ranked negative effects were bone loss (38 votes) and weight gain (16 votes); psychological effects and damaged internal organs each received 12 votes.

Conclusions

The top-ranked GC effects—both benefits and harms—among patients with systemic rheumatic disease are consistent with the top domains associated with GC use reported with other inflammatory diseases. This study informs the development of a comprehensive patient-reported outcome measure that can be used across inflammatory diseases.
Ultrasound Time-Harmonic Elastography of the Pancreas
Authors: Burkhardt Christian , Tzschätzsch Heiko , Schmuck Rosa , Bahra Marcus , Jürgensen Christian , Pelzer Uwe , Hamm Bernd , Braun Jürgen , Sack Ingolf , Marticorena Garcia Stephan Rodrigo
Published: January 2020

Objectives

Pancreatic ductal adenocarcinoma (PDAC) is a very aggressive tumor with a very low 5-year survival rate of 8%. The aims of this study are to determine reference values and physiologic confounders in healthy pancreas and to assess the diagnostic accuracy of ultrasound time-harmonic elastography (THE) in the detection of PDAC.

Materials and Methods

From March 2017 through May 2019, a total of 54 study participants with healthy pancreas (n = 33, CTR) or PDAC (n = 21) were prospectively enrolled. Repeatability of THE was tested in a CTR subgroup (n = 5) undergoing repeat measurement on 4 different days. Interobserver variability was analyzed in 10 healthy volunteers. Age-matched and sex-matched subgroups of CTR (n = 13) and PDAC (n = 13) were compared. In participants with histopathologically proven PDAC, measurements were performed separately in tumorous (PDAC-T) and nontumorous pancreatic tissue (PDAC-NT). Diagnostic performance of pancreatic THE was assessed by receiver operating characteristic curve analysis.

Results

Time-harmonic elastography was highly repeatable (intraclass correlation coefficient, 0.99), and interobserver agreement was excellent (intraclass correlation coefficient, 0.97). Shear wave speed (SWS) of PDAC-T (mean [95% confidence interval] in meters per second, 1.88 ± 0.07 [1.84–1.92]) was higher than SWS of CTR (1.63 ± 0.04 [1.60–1.66], P < 0.001) and PDAC-NT (1.59 ± 0.03 [1.57–1.61], P < 0.001). The exploratory diagnostic performance of THE in separating PDAC-T was excellent (area under the receiver operating characteristic curve, 1.0). Tumorous pancreatic ductal adenocarcinoma was distinguished from CTR and PDAC-NT with cutoff values of 1.73 m/s and 1.70 m/s, respectively.

Conclusions

Pancreatic ultrasound THE has high repeatability and provides excellent imaging contrast based on SWS, allowing detection of PDAC without overlap to nontumorous pancreatic tissue.
Treatment Strategy for Radical Resection of Giant Neurofibroma
Authors: Liu Fei , Din Feixue , Gu Chuan , Lv Lin , Wang Xiuxia , Luo Xusong , Sun Di , Yang Jun
Published: January 2020

The management of giant neurofibroma is a challenge for clinical surgeons. Abundant malformed vessels exist in the tumor, and life-threatening hemorrhage can occur during operation. Moreover, repairing huge defects after radical resection is challenging. Hence, subtotal resection and debulking are more frequently performed than total resection. Although subtotal resection or debulking may reduce morbidity, it inevitably leads to a high rate of recurrence. In addition, subtotal resection or debulking does not decrease surgical risk; on the contrary, when operating on the tumor body, the rate of hemorrhage is much higher in case of subtotal resection and debulking than in radical resection. In this study, 9 patients with giant neurofibroma were retrospectively reviewed. The tumor size ranged from 12 × 9 cm to 60 × 70 cm. Preoperative angiography and magnetic resonance imaging scanning are performed to clarify the tumor features. All patients underwent radical resection, and in-operation blood loss ranged from 300 to 2600 mL. The resection defects were repaired by anterolateral thigh free flap in 2 patients and skin grafts in 7 patients. Partial skin necrosis occurred in 4 patients, and the necrosis area can be repaired with adjacent survived skin by changing the dressing several times. No tumor recurrence was recorded during routine follow-up (range, 12–39 months). The treatment strategy for radical resection of giant neurofibroma proves effective, and the technique of reusing the skin provides sufficient material for covering a large defect without the morbidity associated with a new donor. Thus, tumor removal and wound repair can be accomplished in one stage.
Vocal Cord Paralysis as a Complication of Endotracheal Intubation
Authors: Evman Melis Demirag , Selcuk Ayse Adin
Published: January 2020

Endotracheal intubation is a commonly used method for securing airway. It is considered to be safe but it can still lead to some complications of the airway. Recurrent nerve paralysis due to endotracheal intubation is a rare complication. Pathophysiology is explained as neuropraxia of RLN's compression between the tube and the lamina of the thyroid cartilage or between arytenoid and cricoid cartilages due to tube cuff pressure or tube itself. In literature, unilateral vocal cord paralysis (VCP) due to intubation is more common than bilateral paralysis. In the presented case report, a young patient stayed intubated for only 3 days in intensive care unit who experienced bilateral VCP 2 days after extubation. He had total recovery 5 days after emergency tracheotomy suggesting neuropraxia of the nerve. Neuropraxia of RLN resulting in bilateral VCP due to inappropriate size or excess cuff pressure of the intubation tube may be the underlying reasons. The clinicians must be aware of complications of intubation and should apply appropriate treatment method as soon as possible. Appropriate size and cuff pressure should be chosen for endotracheal intubation.
Identification and Recent Approaches for Evaluation and Management of Dentofacial and Otolaryngologic Concerns for Patients With Freeman-Burian Syndrome: Principles for Global Treatment
Authors: Poling Mikaela I. , Dufresne Craig R.
Published: January 2020

Freeman-Burian syndrome (FBS), formerly Freeman-Sheldon syndrome, is a complex myopathic craniofacial syndrome. Functional craniofacial deformities resulting in respiratory, eating, auditory, or speech impairments often are present to varying degrees in this unique population. There are few references in the literature addressing diagnosis, evaluation, operative counseling, and craniofacial management of FBS, and guidance was absent. As part of a clinical practice guideline development process for FBS, the authors have reviewed dental and oral health concerns, hearing loss, paranasal sinusitis, dysphagia, and dysphasia management for patients with FBS. Searching PubMed and Google Scholar has yielded 14 results describing dentofacial and otorhinolaryngologic concerns in FBS. There is a significant paucity of scholarship on FBS, presenting considerable knowledge gaps. Craniofacial muscles may be preferentially impacted by fibrous tissue replacement. The lack of available objective data should not reduce clinical vigilance to the possibility that fibrous tissue replacement may influence almost any aspect of the patient's presentation, thus necessitating nonstandard treatment deviations. Based on the decades of experience with this challenging patient population, the authors feel much can be done to afford patients with FBS a good and productive quality of life through exquisite medical surveillance, rapid intervention in acute upper respiratory disturbances, conservative operative intervention, and longitudinal lifestyle structuring by the patients.
Educational Resources in Craniofacial Surgery: The Case for User-Friendly Digital Simulators
Authors: Kantar Rami S. , Alfonso Allyson R. , Ramly Elie P. , Diaz-Siso J. Rodrigo , Flores Roberto L.
Published: January 2020

Introduction:

Digital simulators are potential solutions to challenges facing surgical education. The authors sought to evaluate the reach and utilization of a freely-accessible craniofacial surgery digital educational simulator. More importantly, we compare usage patterns between web-based and mobile-based platforms.

Methods:

A 3-way collaboration between academic, non-profit (myFace, New York, NY), and biotechnology (Biodigital, New York, NY) stakeholders in 2015 produced the Craniofacial Interactive Virtual Assistant Pro (CIVA-Pro). CIVA-Pro is a freely-accessible craniofacial surgery digital educational simulator. In addition to the web-based platform, a mobile-based platform was launched in 2017. Usage analytics were collected and analyzed.

Results:

Since its launch, 751 registered users from 117 countries had accessed CIVA-Pro. The total number of sessions was 9531, including 7500 web and 2031 mobile sessions. The total screen time was 403.9 hours, 290.3 for the web and 113.6 for the mobile platform. Comparison of the mean monthly screen time and number of monthly sessions between platforms since 2017 demonstrated a significantly higher mean monthly screen time (60.1 ± 33.2 versus 29.4 ± 16.5 hours; P = 0.002) and number of sessions (110.2 ± 36.1 versus 58.1 ± 31.9; P < 0.0001) for the mobile-based platform. The mean screen time per session was comparable (P = 0.86).

Conclusion:

A freely available digital craniofacial surgery educational simulator designed for surgical trainees can achieve significant global reach. Significantly higher utilization of the mobile-based platform of the simulator as compared to the web-based platform reinforces the need to invest in user-friendly, easily accessible, and widely available digital educational resources by key stakeholders to ensure optimal plastic surgery trainee education.
BK Polyomavirus-specific T Cells as a Diagnostic and Prognostic Marker for BK Polyomavirus Infections After Pediatric Kidney Transplantation
Authors: Ahlenstiel-Grunow Thurid , Sester Martina , Sester Urban , Hirsch Hans H. , Pape Lars
Published: January 2020

Background.

After kidney transplantation, uncontrolled BK polyomavirus (BKPyV) replication causes kidney graft failure through BKPyV-associated nephropathy (BKPyVAN), but markers predicting outcome are missing. BKPyV-specific T cells may serve as a predictive marker to identify patients at risk of persistent DNAemia and BKPyVAN.

Methods.

Out of a total of 114 pediatric kidney recipients transplanted between 2008 and 2018, 36 children with posttransplant BKPyV-DNAemia were identified. In a prospective noninterventional study, BKPyV-specific CD4 and CD8 T cells were measured in 32 of 36 viremic pediatric kidney recipients using intracellular cytokine staining and flow cytometry. The course of the BKPyV replication was monitored with regard to duration of BKPyV-DNAemia and need of therapeutic intervention and diagnosis of proven BKPyVAN.

Results.

Levels of BKPyV-specific T cells negatively correlated with subsequent duration of BKPyV-DNAemia. Patients with BKPyV-specific CD4 T cells ≥0.5 cells/µL and/or BKPyV-specific CD8 T cells ≥0.1 cells/µL had transient, self-limiting DNAemia (PPV 1.0, NPV 0.86). BKPyV-specific CD4 and CD8 T cells below these thresholds were found in children with persistent BKPyV-DNAemia and biopsy-proven BKPyVAN with need for therapeutic intervention. After reducing immunosuppressive therapy, levels of BKPyV-specific CD4 T cells increased while plasma BKPyV-DNAemia declined.

Conclusions.

This study found that BKPyV-specific T cell levels may help to distinguish patients with transient, self-limiting BKPyV-DNAemia from those with persisting BKPyV-DNAemia and biopsy-proven BKPyVAN, who would benefit from individualized therapeutic interventions such as reduced immunosuppression. Thereby the risk for rejection because of unnecessary reduction of immunosuppression in case of self-limiting BKPyV-DNAemia can be minimized.