bluuebunny/crossref_metadata_2025 huggingface dataset:
Reflux Symptoms in Gastroparesis
Authors: Jehangir Asad , Parkman Henry P.
Published: February 2019

Goal:

The goal of this study was to determine the relationship of reflux with gastroparesis (Gp), looking both at symptoms and objective testing.

Background:

Gp patients often experience gastroesophageal reflux symptoms. How the severity of reflux correlates with the severity of Gp is not known.

Study:

Patients referred to our academic center with symptoms of Gp completed the Patient Assessment of Upper Gastrointestinal Symptoms, Hospital Anxiety and Depression Scale, and Patient Health Questionnaire (PHQ)-15. They underwent 4-hour gastric emptying scintigraphy; and, if indicated, high-resolution esophageal manometry and esophageal pH impedance (EpHI).

Results:

Of 755 patients from July 2013 to May 2018, 432 had Gp with Gastroparesis Cardinal Symptom Index (GCSI) total score of 3.2±0.1 (mean±SEM) and heartburn/regurgitation subscore of 2.0±0.1. A fourth (27.1%) of all Gp patients had moderate to very severe heartburn/regurgitation symptoms. Heartburn/regurgitation subscore had strong correlation with GSCI total score (r=0.56, P<0.01), and weak correlation with 4-hour gastric retention (r=0.11, P=0.02). In total, 103 Gp patients underwent EpHI monitoring; time esophageal pH<4 had no correlation with heartburn/regurgitation subscore. Less than half (41.7%) of the patients undergoing EpHI had gastroesophageal reflux disease by EpHI. Gp patients with gastroesophageal reflux disease had more severe 4-hour gastric retention, and more frequently had decreased lower esophageal sphincter resting pressure and esophageal motility disorders. Heartburn/regurgitation subscore had moderate correlation with somatic symptoms, and weak correlations with anxiety and depression.

Conclusions:

The severity of reflux symptoms in Gp has strong correlation with GCSI total score, weak correlation with gastric retention, and no correlation with esophageal pH monitoring.
Trends in Hospital Utilization After Medicaid Expansion
Authors: Admon Andrew J. , Valley Thomas S. , Ayanian John Z. , Iwashyna Theodore J. , Cooke Colin R. , Tipirneni Renuka
Published: February 2019

Background:

Medicaid expansion was associated with an increase in hospitalizations funded by Medicaid. Whether this increase reflects an isolated payer shift or broader changes in case-mix among hospitalized adults remains uncertain.

Reseearch Design:

Difference-in-differences analysis of discharge data from 4 states that expanded Medicaid in 2014 (Arizona, Iowa, New Jersey, and Washington) and 3 comparison states that did not (North Carolina, Nebraska, and Wisconsin).

Subjects:

All nonobstetric hospitalizations among patients aged 19–64 years of age admitted between January 2012 and December 2015.

Measures:

Outcomes included state-level per-capita rates of insurance coverage, several markers of admission severity, and admission diagnosis.

Results:

We identified 6,516,576 patients admitted during the study period. Per-capita admissions remained consistent in expansion and nonexpansion states, though Medicaid-covered admissions increased in expansion states (274.6–403.8 per 100,000 people vs. 268.9–262.8 per 100,000; P<0.001). There were no significant differences after Medicaid expansion in hospital utilization, based on per-capita rates of patients-designated emergent, admitted via the emergency department, admitted via clinic, discharged within 1 day, or with lengths of stay ≥7 days. Similarly, there were no differences in diagnosis category at admission, admission severity, comorbidity burden, or mortality associated with Medicaid expansion (P>0.05 for all comparisons).

Conclusions:

Medicaid expansion was associated with a shift in payers among nonelderly hospitalized adults without significant changes in case-mix or in several markers of acuity. These findings suggest that Medicaid expansion may reduce uncompensated care without shifting admissions practices or acuity among hospitalized adults.
Impact of Prophylaxis on Bone Mineral Metabolism in Children With Hemophilia
Authors: Culha Vildan , Akpinar Tekgündüz Sibel , Yarali Hüsniye N. , Tunç Bahattin , Özbek Namik Y.
Published: February 2019

In this study, we aimed to investigate changes in calcium (Ca) metabolism in hemophilia patients (PWH). We also aimed to investigate the importance of diagnosis and treatment of factors impairing calcium metabolism and the significance of early diagnosis and prophylaxis with respect to these subjects. For all patients, serum calcium, phosphorus, alkaline phosphatase, 25 hydroxy vitamin D (25-OHD), parathormone (PTH), and calcitonin levels were evaluated. Bone mineral density (BMD) was assessed by dual-energy x-ray absorptiometry. Low BMD scores and 25-OHD deficiency were observed in 29 (74.4%) and 34 (87.2%) patients, respectively. Prophylaxis of PWH did not differ significantly in terms of 25-OHD levels and BMD scores. Patients in the prophylaxis group had significantly higher PTH levels (P=0.042). A negative correlation was found between PTH measurements and Z-score (P=0.008). In summary, our findings, with a small number of PWH in our study group, suggest that biochemical markers of bone turnover may be used to detect bone loss. Follow-up through annual BMD measurements coupled with appropriate exercise programs could be recommended.
Nurses on Boards
Authors: Graystone Rebecca
Published: February 2019

Nurses are a natural fit for board service. They represent the biggest segment of the healthcare workforce, consistently rank as the nation's most trusted profession, and play a huge role on the frontlines of healthcare. Why, then, are so few nurses serving on boards today? This month's Magnet® Perspectives column examines a nationwide effort to address this gap. We explore the benefits of board service for nurses, their hospitals, and their communities and identify opportunities for chief nursing officers (CNOs) to incorporate board work into their existing programs.
A Call to Action on Point-of-Care Violence in Hospitals and Health Systems
Authors: Boston-Fleischhauer Carol , Herleth Anne , Langr Madeleine
Published: February 2019

Despite deeper investment in security measures, the rate of violence and point-of-care safety threats in healthcare settings is rising. As a result, nurses do not always feel safe while delivering care. In this article, the authors describe strategies for addressing point-of-care violence. This is the 2nd article of a series. The 1st article of this series, Cracks in the Foundation of the Care Environment Undermine Nurse Resilience, in the December 2018 issue (volume 48, issue 12) of The Journal of Nursing Administration, the authors explained how nursing leaders can reduce frontline nurse stress and burnout by addressing 4 “cracks in the foundation” of the care environment that can undermine nurse resilience. This article aims to help leaders address 1 of the foundational cracks: that violence and point-of-care safety threats are now commonplace in healthcare settings.
Targeting the Fear of Safety Reporting on a Unit Level
Authors: Copeland Donna
Published: February 2019

Historically, healthcare has accepted a culture of individual blame and punishment following an adverse event. Blame leads to under-reporting of errors due to the fear of reprisal. Consequently, under-reporting results in missed opportunities for nursing leaders to recognize and improve system breakdowns in mitigating recurrence. A quality improvement effort targeting staff's fear of reporting was launched to improve the culture of safety.
Nurses’ Participation in Clinical and Administrative Decisions in Different Types of Hospital Units
Authors: Bacon Cynthia Thornton , Shrestha Smriti , Jenkins Marjorie
Published: February 2019

OBJECTIVE

This study explored the types of decisions and differences in decision making that nurses made in different types of hospital units.

BACKGROUND

The relationship between nurses’ participation in decision making and the different types of hospital units where they work is not well understood.

METHODS

Nurses’ participation in decision making was explored using the Participation in Decision Activities Questionnaire. The final sample included 307 nurses in 24 nursing units in 6 hospitals.

RESULTS

Nurses overall participated more in clinical than administrative decisions, and there were significant differences based on unit type. Critical care nurses had the highest and general care units the lowest levels of participation in decision making.

CONCLUSIONS

Nurses in critical care units participated in higher amounts and at higher levels of clinical decisions overall than either intermediate or general care units. Nurse leaders should determine barriers to decision making in general care units and explore mechanisms to increase participation by clinical nurses.
Multimodal Pain Management for Major Joint Replacement Surgery
Authors: Goode Victoria M. , Morgan Brett , Muckler Virginia C. , Cary Michael P. , Zdeb Christine E. , Zychowicz Michael
Published: February 2019

Effective pain management for orthopaedic major joint replacement is key to achieving earlier recovery, better functioning, and high rates of patient satisfaction. In an effort to decrease opioid dependency, practitioners are turning to multimodal pain management, which involves the use of multiple analgesic agents and techniques. To utilize this technique, a patient's history of and preoperative consumption of medications to treat pain impacts the success of this regimen. Multimodal pain management involves the use of nonsteroidal anti-inflammatory drugs, acetaminophen, N-methyl-D-aspartate antagonists, gabapentin, serotonin inhibitors, regional techniques, and opioids as needed. It is necessary for the nurse to understand the mechanism of pain and how the multimodal adjuncts target the pain response to benefit the patient's perioperative course as well as his or her postoperative and discharge management.
Using Modern Neuroscience to Inform Opioid Use and Abuse Liability in Adolescents
Authors: Napier T. Celeste , Persons Amanda L.
Published: February 2019

Opioid abuse and overdosing have reached epidemic status in the United States, and this epidemic has profound negative effects on the lives of adolescents and their families. A combination of readily available opioids (including illicit opioids, such as heroin, and overprescribed prescription opioid-based painkillers) and an abuse vulnerability inherent to adolescence drives the problem. The pharmacology of opioids in the context of adolescent brain neurobiology helps explain the enhanced vulnerability to drug abuse experienced by the young. This report overviews these topics as they relate to orthopaedic procedures employed for adolescent patients.
The Tightrope Walk
Authors: Anderson Ida , Alger Jessica
Published: February 2019

Pain and pain management are a major focus for an orthopedic nurse. However, reliance upon opioid monotherapy creates adverse effects for patients and has contributed to the opioid epidemic across the United States. There have been strategies developed locally and nationally to address the epidemic. Nurses, too, have an ethical and moral obligation to balance the management of pain therapies to alleviate the suffering of their patients, all while being good stewards of opioid medications. Nurses must also take the time to properly educate their patients on good stewardship techniques including proper use and disposal of their opioid medications.
Transient Pigmentary Lines of the Newborn in a Postmortem Examination
Authors: Terry Merryl , Marlowe Stewart Donna
Published: February 2019

Sudden unexplained death in infancy is a leading cause of death among infants between 1 month and 1 year of age in the United States. The medical examiner is frequently given the difficult task of attempting to rule out other causes of death such as infantile trauma or child abuse. A thorough postmortem examination of the skin is a crucial component of the autopsy, as is sufficient knowledge of both benign and traumatic skin pathologies. In addition to lifesaving interventions performed by medical personnel, traditional remedies may also be performed that could be confused with trauma. Eastern medicinal therapies such as coining, cupping, or spooning may leave unusual markings on the patient. Transient pigmentary lines of the newborn are a rare but benign dermatologic finding of unknown etiology that should also be kept in the differential diagnoses. The authors present a case of this unique skin condition seen on a 1-month-old African American male infant who was found unresponsive, in addition to a current literature review.
Correctly Identifying Deaths Due to Drug Toxicity Without a Forensic Autopsy
Authors: Dye Daniel W. , McGwin Gerald , Atherton Daniel S. , McCleskey Brandi , Davis Gregory G.
Published: February 2019

In 2005, the National Association of Medical Examiners approved the Forensic Autopsy Performance Standards. Standard B3.7 indicates that a forensic pathologist shall perform a forensic autopsy when the death is by apparent intoxication by alcohol, drugs, or poison.

The Jefferson County Coroner/Medical Examiner Office has observed an increase in our caseload by 10% per year since 2012. We designed a study to determine if a pathologist could correctly classify the cause of death (COD) and manner of death (MOD) of suspected drug-related deaths without information from the internal examination. The determination of the COD and MOD was then compared with the case file, which includes information from the internal examination and microscopy, to determine agreement between the case file and the reclassification. The percent correct for COD and MOD was calculated, and kappa values were calculated for MOD.

The pathologists were able to correctly classify the COD in 73% of cases. For MOD, 2 pathologists achieved substantial agreement between the test cases and the actual case file. The third pathologist had moderate agreement. These findings indicate that a full postmortem examination is necessary to correctly classify the COD/MOD in cases of suspected drug toxicity.

Our null hypothesis is that a full autopsy is not necessary to correctly classify the COD and MOD in cases of drug toxicity.
Primary Renal Synovial Sarcomas: PAX 8 Immunostaining and Unusual Molecular Findings
Authors: Rose Laurel , Grignon David , Cheng Liang , Fan Rong , Zhang Shaobo , Alruwaii Fatimah , Chen Shaoxiong
Published: February 2019

Synovial sarcoma (SS) is a high-grade sarcoma that rarely involves the kidney. Eleven renal SS cases were collected in our institution. Immunostaining features and molecular changes of renal SS were further elucidated in this study. PAX 8 was focally positive in 1 monophasic SS and diffusely positive in both the spindled and epithelial components in 1 biphasic SS. These 2 PAX8 expressing renal SS were confirmed by the presence of the classic t(X;18) translocation. Our study also revealed the presence of extra copies of the SS18 in one biphasic SS and one poorly differentiated SS. The SS18 (SYT) gene rearrangement is useful for confirming the SS diagnosis. However, a negative test (FISH or RT-PCR) does not rule out the diagnosis. Although not as common, other chromosomal alterations, such as polysomy 18, indeed occur in renal synovial sarcoma.
Frequent CTNNB1 or PIK3CA Mutations Occurred in Endometrial Endometrioid Adenocarcinoma With High Levels of Microsatellite Instability and Loss of MSH2/MSH6 Expression
Authors: Huang Hsien-Neng , Kuo Chun-Wei , Lin Ming-Chieh , Mao Tsui-Lien , Kuo Kuan-Ting
Published: February 2019

Background:

DNA mismatch repair (MMR) proteins form 2 heterodimers—MutSα formed by MSH2 and MSH6, and MutLα by MLH1 and PMS2. In endometrial endometrioid adenocarcinomas, cases with MMR protein defect also usually harbor other recurrent genetic mutations of the neoplasm. However, it remains unknown whether defects of the 2 functionally different heterodimers are linked to mutations in different genes. We aimed to study the MMR protein expression, microsatellite instability (MSI), and other common genetic mutations of endometrial endometrioid adenocarcinoma.

Materials and Methods:

We investigated the MSI status of 107 endometrial endometrioid adenocarcinoma patients. MMR protein expression, and mutation of KRAS, CTNNB1, and PIK3CA were also evaluated by immunohistochemistry and sequencing.

Results:

An overall 34.6% (37/107) of endometrial endometrioid adenocarcinomas were MSI-H. All MSI-H tumors exhibited loss of MMR protein expression (loss of MLH1, PMS2, MSH6, and MSH2 was noted in 22, 25, 12, and 7 cases, respectively). CTNNB1, PIK3CA, and KRAS mutation were present in 9, 7, and 7 MSI-H tumors. Compared with patients with loss of PMS2 and/or MLH1 expression, patients with loss of MSH6 and/or MSH2 expression were associated with higher frequencies of CTNNB1 mutation (P=0.036) and PIK3CA mutation (P=0.025).

Conclusions:

In MSI-H endometrial endometrioid adenocarcinomas, different types of MMR protein deficiency indicate different molecular genetic alterations.
Undifferentiated Uterine Sarcomas Represent Under-Recognized High-grade Endometrial Stromal Sarcomas
Authors: Cotzia Paolo , Benayed Ryma , Mullaney Kerry , Oliva Esther , Felix Ana , Ferreira Joana , Soslow Robert A. , Antonescu Cristina R. , Ladanyi Marc , Chiang Sarah
Published: February 2019

Undifferentiated uterine sarcoma is a diagnosis of exclusion with limited molecular genetic data available. Recent recognition of high-grade endometrial stromal sarcomas with diverse genotypes suggests that some tumors classified as undifferentiated uterine sarcomas may represent misdiagnosed high-grade endometrial stromal sarcomas. Archival material from 10 tumors diagnosed as undifferentiated uterine sarcomas in 2009 to 2017 were collected. BCOR immunohistochemistry and fluorescence in situ hybridization (FISH) using break-apart probes flanking BCOR, ZC3H7B, CCNB3, YWHAE, NUTM2, JAZF1, and BCORL1 were performed. Tumors lacking or harboring gene rearrangement with no known fusion partner by FISH were subjected to targeted RNA sequencing. Morphology was correlated with FISH and sequencing results. BCOR expression was moderate to strong in ≥50% of cells in 8 tumors, while weak in <5% cells and negative in 2. FISH detected mutually exclusive ZC3H7B-BCOR and YWHAE-NUTM2 fusions in 3 uniform undifferentiated uterine sarcomas; 2 pleomorphic tumors harbored YWHAE rearrangement with no known partner. Targeted RNA sequencing of 5 FISH-negative uniform undifferentiated uterine sarcomas detected BRD8-PHF1 and YWHAE-NUTM2B fusions and BCOR internal tandem duplication in 4 of them. Tumors with YWHAE-NUTM2 fusions and BCOR genetic abnormalities showed morphology characteristic of high-grade endometrial stromal sarcomas. No fusions were detected by sequencing in the tumor with YWHAE rearrangement only by FISH. Most tumors classified as undifferentiated uterine sarcomas represent misdiagnosed high-grade endometrial stromal sarcomas. BCOR expression in ≥50% of cells may help triage tumors for molecular confirmation of high-grade endometrial stromal sarcoma-related genetic abnormalities. Novel YWHAE rearrangements may define a subset of true undifferentiated pleomorphic sarcomas.
Intraductal Oncocytic Papillary Neoplasms
Authors: Wang Tao , Askan Gokce , Adsay Volkan , Allen Peter , Jarnagin William R. , Memis Bahar , Sigel Carlie , Seven Ipek E. , Klimstra David S. , Basturk Olca
Published: February 2019

Background:

Intraductal oncocytic papillary neoplasm (IOPN) of the pancreas is a rare tumor. Recent molecular data indicate that it is distinct from other intraductal neoplasms; however, its clinicopathologic characteristics, especially the frequency/significance of an invasive carcinoma component, and biologic behavior remain to be fully defined.

Design:

Clinicopathologic characteristics and survival of 24 IOPNs were analyzed. By definition, all tumors exhibited intraductal growth and oncocytic morphology.

Results:

The female:male ratio was 1.7, and mean age was 59. In 44% of the patients, the IOPN was discovered incidentally; however, the working diagnosis was “ductal adenocarcinoma” in 42%. Fourteen IOPNs occurred in the head of the pancreas. The median tumor size was 4.5 cm. The tumors often grew along adjacent benign ducts, mimicking invasion, but only 29% exhibited unequivocal invasive carcinoma, mostly in the form of microscopic foci (pT1a=4, pT1b=1, pT2=2), and only 6% had lymph node metastasis. Invasive carcinoma was predominantly composed of small tubular units lined by oncocytic cells, or individual oncocytic cells infiltrating the periductal stroma. Follow-up information was available for 18 patients (median=6.8 y). No patients died from the disease, and the overall 10-year survival was 94%. Patients with invasive carcinoma trended toward a lower 5-year recurrence-free survival than those with noninvasive IOPNs (66% vs. 93%, P=0.066), but overall survival was not impacted by the presence of invasion (P=0.38).

Conclusions:

IOPN is a distinct tumor type in the pancreas. Despite its morphologic complexity and often extensive pagetoid spread to adjacent ducts, conventional invasive carcinoma is seen in only 29% and usually as microscopic foci. Thus, it is not surprising that IOPN exhibits indolent behavior even when invasion is present.
Angiosarcoma of the Liver
Authors: Yasir Saba , Torbenson Michael S.
Published: February 2019

Angiosarcoma is a rare malignant neoplasm of the liver. The various morphologic patterns seen with angiosarcomas of the liver have not been systematically studied and their recognition remains a major diagnostic challenge. In order to provide more comprehensive data on the morphologic patterns, angiosarcomas that had been diagnosed between 1996 and 2016 at a large medical referral center were reviewed. The major growth patterns were classified as sinusoidal (non–mass forming) versus mass forming. The mass-forming cases were further subdivided into epithelioid, spindled, or vasoformative. The study identified 21 patients with primary hepatic angiosarcoma: 13 men and 8 women. The ages ranged from 26 to 89 years. Seventeen angiosarcomas were mass-forming tumors, of which 9 showed predominantly vasoformative growth. Most of these vasoformative cases (6/9) were composed of small vessels, 2 cases had slit-like vascular spaces, and one case showed a mixture of small and large vessels. There were 7 mass-forming angiosarcomas without vasoformation: 3 had an epithelioid morphology and 4 were composed primarily of spindled cells. The final mass-forming tumor showed a mixture of vasoformative and nonvasoformative areas. Four of 21 cases were non–mass forming and showed either diffuse sinusoidal infiltration (N=2) or prominent peliotic changes (N=2). Finally, 3 uncommon patterns were identified. One case showed nodules of spindle cells arranged in prominent whorls in a background of loose connective tissue with abundant inflammation. A second case arose in the setting of the Blue Rubber Bleb Nevus Syndrome and showed numerous tumor nodules with an architectural pattern that resembled infantile hemangioma, some with areas of atypia consistent with malignant transformation to angiosarcoma. The third unusual pattern showed multiple nodules of thin walled large caliber vascular proliferations, some of which showed atypia that reached the level of angiosarcoma. The results from this study indicate that the majority of hepatic angiosarcomas are mass forming (two third of cases), a pattern that is recognizable on H&E when vasoformative, but can mimic carcinoma or undifferentatied sarcomas when nonvasoformative (one third of cases). The sinusoidal patterns are particularly challenging and are frequently missed on initial review. Finally, we describe several unsual patterns of angiosarcoma. Awareness of these classic and rare morphologic patterns can help make the diagnosis of angiosarcoma.
A Case of Unintentional Opioid (U-47700) Overdose in a Young Adult After Counterfeit Xanax Use
Authors: Chapman Brittany P. , Lai Jeffrey T. , Krotulski Alex J. , Fogarty Melissa F. , Griswold Matthew K. , Logan Barry K. , Babu Kavita M.
Published: February 2019

We report the case of a young adult who became unresponsive after insufflating what he believed to be “crushed Xanax.” Naloxone was administered, reversing his altered mental status and respiratory depression. Clinicians suspected opioid toxicity; however, the patient adamantly denied opioid use. Because of unclear etiology of his symptoms, blood and urine specimens were obtained. A urine specimen was split and then submitted for a clinical comprehensive drug screen using gas chromatography–mass spectrometry. The blood specimen and the remaining urine specimen were sent to a reference laboratory for analysis using liquid chromatography quadrupole time-of-flight mass spectrometry and liquid chromatography tandem mass spectrometry. The standard, clinical gas chromatography–mass spectrometry urine drug testing procedure only detected caffeine; however, analysis by liquid chromatography quadrupole time-of-flight mass spectrometry and liquid chromatography tandem mass spectrometry confirmed the presence of U-47700 (a high-potency clandestine opioid) and its metabolites in the urine and blood. These findings implicate U-47700 as the agent responsible for the patient's signs of opioid toxicity. In this case, a young adult intending to use alprazolam encountered U-47700 with life-threatening effect. Clinicians must remain vigilant for symptoms consistent with opioid overdose, especially with increasing prevalence of counterfeit drugs containing clandestine opioids. Clinicians must also consider obtaining specimens for appropriate analytical testing to improve surveillance and facilitate public health interventions.
Histopathologic Changes in Placental Tissue Associated With Vertical Transmission of Zika Virus
Authors: Santos Geovane R. , Pinto Clóvis A.L. , Prudente Raphael C.S. , Bevilacqua Estela M.A.F. , Witkin Steven S. , Passos Saulo D.
Published: February 2019

Zika virus (ZIKV) is highly neurotropic after crossing the placenta, inducing teratogenic effects that result in delayed development and microcephaly in infants. The available evidence for vertical transmission of this infection is based on placental studies showing alterations in trophoblastic tissue. However, complete characterization of ZIKV-infected placenta and involved pathways has yet to be fully clarified. This case report of placental ZIKV infection describes morphologic and molecular changes in the placenta. Hyperplasia of placental Hofbauer cells in chorionic villi and numerous histiocyte-like cells in the decidua were observed. The decidua, fibroblasts, and chorion, as well as circulating cells in the intravascular compartment stained positive for ZIKV envelop protein. Deciduitis was present on the maternal surface of the placenta, with a prevalence of lymphocytes associated with vasculitis. A high level of uncommitted CD3+T lymphocytes were present, in addition to CD4+and CD8+cells. Elevated expression of the apoptosis inhibitor, Bcl-2, was observed in syncytiotrophoblasts. These parameters may promote the persistence of ZIKV in placental tissue and transmission to the fetus.
Uterine Inflammatory Myofibroblastic Tumor Showing an Atypical ALK Signal Pattern by FISH and DES-ALK Fusion by RNA Sequencing: A Case Report
Authors: Zarei Shabnam , Abdul-Karim Fadi W. , Chase Dana M. , Astbury Caroline , Policarpio-Nicolas Maria Luisa C.
Published: February 2019

Inflammatory myofibroblastic tumors (IMTs) are spindle cell neoplasms of intermediate (borderline) biologic potential with tendency for local recurrence but low risk of metastasis. They affect children more than adults. The most common sites of involvement are the lung, soft tissue, peritoneum, bladder, and less commonly the gynecologic tract. IMTs are characterized by spindle to epithelioid cells with myofibroblastic differentiation, some degree of smooth muscle differentiation, myxoid stroma and usually associated with brisk lymphoplasmacytic infiltrates. In about half of the cases, IMTs are associated with rearrangements of the anaplastic lymphoma kinase (ALK) gene located at chromosome 2p23. The ALK rearrangement can be detected by immunohistochemistry for ALK protein expression (mostly cytoplasmic with or without perinuclear accentuation) or by fluorescent in situ hybridization (FISH) using dual-color break-apart probes for which the typical pattern is seen as split 3′ end (red) and 5′ end (green) probe signals in addition to single normal, unsplit red-green signal pair (yellow). Herein we describe a case of uterine IMT initially misdiagnosed intraoperatively as leiomyoma which showed sparse lymphocytic infiltrates, positive ALK expression by immunohistochemistry, a predominantly atypical FISH signal pattern (1 yellow and 1 red signal only) and few typical signal patterns (1 yellow, 1 red, and 1 green signal) in a smaller population of tumor cells. The RNA sequencing showed a recently described DES-ALK fusion transcript in the tumor cells, suggesting an intrachromosomal inversion and deletion as the likely underlying mechanism for the atypical FISH pattern. Familiarity with the unusual morphology and atypical FISH pattern is crucial given that this tumor has an activating ALK rearrangement and may benefit from targeted tyrosine kinase inhibitors in the future.
Public Health Senior Deputy's Perceptions of State Health Officials' Success Factors: Professional Characteristics, Personal Attributes, and Signs of Derailment
Authors: Boedigheimer Steven F. , Yeager Valerie A. , Chapple-McGruder Theresa , Moffatt Sharon , Halverson Paul K.
Published: February 2019

Context:

Senior deputies work closely with state health officials (SHOs) in state public health agencies and are a valuable resource for understanding their roles, responsibilities, and characteristics.

Objective:

Examine senior deputies' perceptions of SHO success factors.

Design:

Qualitative study including nominal group technique focus groups, a small expert focus group, and interviews.

Setting:

US state public health agencies.

Participants:

Senior deputies in state public health agencies 2016/2017.

Main Outcome Measures:

Perceptions of SHO success factors.

Results:

The most commonly perceived professional characteristics of a successful SHO included the following: credible trusted voice with internal respect/external credibility; improves public health prominence/visibility with an evidence-based agenda; and grows the agency/leaves it stronger. Perceptions of the most common personal attributes for success included excellent listening skills; credibility/honesty/trustworthiness; and public health experience/knowledge. The most commonly perceived signs of SHO derailment included when SHOs have a visible lack of support of elected officials (eg, governor/legislators) and when the SHO is “bypassed” by elected officials.

Conclusions:

A key finding of this study centers on the relationship between the SHO and the governor; meeting the expectations of the governor was identified as a significant professional characteristic of success. Findings highlight the expectation that SHOs have a clear understanding of the governor's priorities and how to relate to the governor's office early in their tenure. This goal should be a priority for transition teams that aid new SHOs as they begin in their new roles. Study insights can help better prepare for orientation/onboarding of new SHOs. Development of key transition documents and tools for rapid onboarding should be considered. Transition teams should assist new SHOs in establishing an understanding of the governor's priorities and how to best communicate with to the governor's office early in their tenure. Strong senior management teams should be prioritized and fostered.
Kids, Cops, and Community: A Qualitative Assessment of Police, Youth, and Parent Perceptions of Each Other
Authors: Harty Nicole M. , Friedman Brett , Tung Gregory J.
Published: February 2019

Context:

Police and communities alike have experienced many traumatic incidents over the last 4 years, prompting police departments across the country to rethink their approach to community programs.

Program:

Aurora's Gang Reduction Impact Program (A-GRIP) launched “Kids, Cops, and Community” (KC&C) in Aurora, Colorado, as a community-based quality improvement project designed to improve community relations by better understanding Aurora police and community members' perceptions of each other and current A-GRIP and Aurora for Youth programs by assessing police, youth, and parents' perceptions of each other.

Implementation:

After a review of current scientific literature on police-community relations, a KC&C advisory group oversaw the creation of key informant interview and focus group guides. A-GRIP recruited participants for 37 interviews (20 police, 8 youth, and 9 parents) and 3 youth focus groups. The community advisory group assisted in the development of salient themes and practical recommendations. The final report outlined 5 major themes (pros/cons of types of police interactions, respectful communication, false uniqueness effect, parenting and police as parents, and youth-police programming awareness) and 2 specific recommendations (sustain/increase opportunities for police-youth interactions and increase community awareness of youth programming).

Evaluation:

A-GRIP members had a rich discussion of the implications of these findings in which there was broad support for identifying a strategy to use these results to improve police-community relations. The coalition was challenged by identifying clear next steps because of turnover in administration and coalition leadership, but they have made progress in increasing information and resource sharing.

Discussion:

This project provides the first model we are aware of that incorporates a systematic assessment of police, youth, and parent perspectives from the same community. Other communities may find value in adapting the KC&C process to identify promising approaches and refine programming elements of police-community engagement activities.
A Cost-Minimization Analysis Evaluating the Use of Liposomal Bupivacaine in Reconstructive Plastic Surgery Procedures
Authors: Little Andrea , Brower Kristin , Keller Deborah , Ramshaw Bruce , Janis Jeffrey E.
Published: February 2019

Background:

Postsurgical pain management is critical to patient satisfaction and value. Several studies have evaluated liposomal bupivacaine in postoperative pain management protocols; however, its economic feasibility remains undefined. This study analyzes the economic impact of liposomal bupivacaine using a national claims database to assess postoperative clinical and financial outcomes in plastic and reconstructive procedures.

Methods:

The Vizient Clinical Data Base/Resource Manager electronic database was reviewed for plastic surgery procedures (i.e., abdominoplasty, abdominal wall reconstruction, mastectomy with immediate tissue expander placement, mastectomy with direct-to-implant reconstruction, autologous breast reconstruction, and augmentation mammaplasty) at participating hospitals from July 1, 2016, to July 1, 2017. The main outcome measures were the length of stay; 7-, 14-, and 30-day readmission rates; and direct and total costs observed.

Results:

During the study period, 958 total cases met inclusion criteria. Liposomal bupivacaine was used in 239 cases (25 percent). Compared with cases that did not use liposomal bupivacaine, liposomal bupivacaine cases had a decreased length of stay (9.2 days versus 5.8 days), decreased cost (total cost, $39,531 versus $28,021; direct cost, $23,960 versus $17,561), and lower 30-day readmission rates (4 percent versus 0 percent). The 14- and 7-day readmission rates were similar between the two groups.

Conclusions:

The use of liposomal bupivacaine may contribute to a reduction in length of stay, hospital costs, and 30-day readmission rates for abdominal and breast reconstructive procedures, which could contribute to a favorable economic profile from a system view. Focusing on the measurement and improvement of value in the context of whole, definable, patient processes will be important as we transition to value-based payments.
Myth-Busting the DIEP Flap and an Introduction to the Abdominal Perforator Exchange (APEX) Breast Reconstruction Technique: A Single-Surgeon Retrospective Review
Authors: DellaCroce Frank J. , DellaCroce Hannah C. , Blum Craig A. , Sullivan Scott K. , Trahan Christopher G. , Wise M. Whitten , Brates Irena G.
Published: February 2019

Background:

Anatomical variations in perforator arrangement may impair the surgeon’s ability to effectively avoid rectus muscle transection without compromising flap perfusion in the deep inferior epigastric artery perforator (DIEP) flap.

Methods:

A single surgeon’s experience was reviewed with consecutive patients undergoing bilateral abdominal perforator flap breast reconstruction over 6 years, incorporating flap standardization, pedicle disassembly, and algorithmic vascular rerouting when necessary. Unilateral reconstructions were excluded to allow for uniform comparison of operative times and donor-site outcomes. Three hundred sixty-four flaps in 182 patients were analyzed. Operative details and conversion rates from DIEP to abdominal perforator exchange (“APEX”) arms of the algorithm were collected. Patients with standardized DIEP flaps served as the controlling comparison group, and outcomes were compared to those who underwent abdominal perforator exchange conversion.

Results:

The abdominal perforator exchange conversion rate from planned DIEP flap surgery was 41.5 percent. Mean additional operative time to use abdominal perforator exchange pedicle disassembly was 34 minutes per flap. Early postsurgical complications were of low incidence and similar among the groups. One abdominal perforator exchange flap failed, and there were no DIEP flap failures. One abdominal bulge occurred in the DIEP flap group. There were no abdominal hernias in either group. Fat necrosis rates (abdominal perforator exchange flap, 2.4 percent; DIEP flap, 3.4 percent) were significantly lower than that historically reported for both transverse rectus abdominis musculocutaneous and DIEP flaps.

Conclusions:

This study revealed no added risk when using pedicle disassembly to spare muscle/nerve structure during abdominal perforator flap harvest. Abdominal bulge/hernia was nearly completely eliminated. Fat necrosis rates were extremely low, suggesting benefit to pedicle disassembly and vascular routing exchange when required.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Is There a Preferred Incision Location for Nipple-Sparing Mastectomy? A Systematic Review and Meta-Analysis
Authors: Daar David A. , Abdou Salma A. , Rosario Lauren , Rifkin William J. , Santos Pauline J. , Wirth Garrett A. , Lane Karen T.
Published: February 2019

Background:

The incidence of nipple-sparing mastectomy is rising, but no single incision type has been proven to be superior. This study systematically evaluated the rate and efficacy of various nipple-sparing mastectomy incision locations, focusing on nipple-areola complex necrosis and reconstructive method.

Methods:

A systematic literature review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines identifying studies on nipple-sparing mastectomy where incision type was described. Pooled descriptive statistics meta-analysis of overall (nipple-areola complex) necrosis rate and nipple-areola complex necrosis by incision type was performed.

Results:

Fifty-one studies (9975 nipple-sparing mastectomies) were included. Thirty-two incision variations were identified and categorized into one of six groups: inframammary fold, radial, periareolar, mastopexy/prior scar/reduction, endoscopic, and other. The most common incision types were inframammary fold [3634 nipple-sparing mastectomies (37.8 percent)] and radial [3575 nipple-sparing mastectomies (37.2 percent)]. Meta-analysis revealed an overall partial nipple-areola complex necrosis rate of 4.62 percent (95 percent CI, 3.14 to 6.37 percent) and a total nipple-areola complex necrosis rate of 2.49 percent (95 percent CI, 1.87 to 3.21 percent). Information on overall nipple-areola complex necrosis rate by incision type was available for 30 of 51 studies (4645 nipple-sparing mastectomies). Periareolar incision had the highest nipple-areola complex necrosis rate (18.10 percent). Endoscopic and mastopexy/prior scar/reduction incisions had the lowest rates of necrosis at 4.90 percent and 5.79 percent, respectively, followed by the inframammary fold incision (6.82 percent). The rate of single-stage implant reconstruction increased during this period.

Conclusions:

For nipple-sparing mastectomy, the periareolar incision maintains the highest necrosis rate because of disruption of the nipple-areola complex blood supply. The inframammary fold incision has become the most popular incision, demonstrating an acceptable complication profile.
Body Contouring Surgery after Massive Weight Loss: Excess Skin, Body Satisfaction, and Qualification for Reimbursement in a Dutch Post–Bariatric Surgery Population
Authors: Monpellier Valerie M. , Antoniou Evangelia E. , Mulkens Sandra , Janssen Ignace M. C. , Jansen Anita T. M. , Mink van der Molen Aebele B.
Published: February 2019

Background:

Body contouring surgery improves quality of life, weight loss, and body image after bariatric surgery. It is unclear why only a minority of the post–bariatric surgery population undergoes body contouring surgery. This study assesses overhanging skin, body satisfaction, and qualification for reimbursement of body contouring surgery in a Dutch post–bariatric surgery population.

Methods:

Post–bariatric patients were selected from a prospective database. Electronic questionnaires evaluated demographics, desire for body contouring surgery, excess skin, and satisfaction with their body.

Results:

A total of 590 patients were included: 368 patients (62.4 percent) desired body contouring surgery, 157 (26.6 percent) did not and 65 (11.0 percent) had undergone body contouring surgery. There were no significant differences between the groups regarding the percentage of patients who met the qualifications for reimbursement. Patients who desired body contouring surgery had more body parts affected by overhanging skin and more often rated the overhanging skin with a Pittsburgh Rating Scale grade 3 compared with patients without a desire to undergo body contouring surgery. The plastic surgeon was never consulted by 39.1 percent of the “desire” population; 44.1 percent of these patients met the weight criteria.

Conclusions:

Post–bariatric patients who desired body contouring surgery had more excess skin than patients without a desire and were less satisfied with their body. Almost half of these patients never consulted a plastic surgeon, partly because of incorrect assumptions regarding reimbursement. Plastic surgeons (together with bariatric teams) should better inform these patients about body contouring surgery possibilities.
Aging of the Upper Lip: Part II. Evidence-Based Rejuvenation of the Upper Lip—A Review of 500 Consecutive Cases
Authors: Tonnard Patrick L. , Verpaele Alexis M. , Ramaut Lisa E. , Blondeel Phillip N.
Published: February 2019

Background:

Findings from photometric analysis of soft tissue on cranial magnetic resonance imaging demonstrate that the aging upper lip shows significant lengthening, thinning, volume loss, and deepening of the nasolabial folds. In this study, these findings are implemented in a review of 500 cases of upper lip rejuvenation to propose an evidence-based strategy for surgical rejuvenation of the upper lip.

Methods:

The charts of 500 consecutive surgical perioral rejuvenation patients treated by the senior authors (P.L.T. and A.M.V.) from 2014 until 2018 were reviewed. The surgical methods of lip lift and fat grafting were described in relation to the cases and the metric data.

Results:

Of the 500 patients, 51 had an isolated procedure such as a lip lift (3 percent), lip augmentation (3 percent), augmentation of the nasolabial folds (2 percent), or skin resurfacing (2 percent). The remaining 449 patients underwent combinations of lip lift, augmentation of the lip and nasolabial fold (32 percent), lip lift with augmentation of the lip and nasolabial fold with resurfacing (30 percent), lip augmentation and resurfacing (14 percent), or lip lift and resurfacing (14 percent).

Conclusions:

Rejuvenating the upper lip needs to address both lengthening and volume loss. This requires a combination of surgical shortening of the upper lip by a precisely designed lip lift and a differential filling of certain upper lip regions by microfat grafting. The combination of these two modalities works synergistically.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Improving the Measurement of Transactional Sex in Sub-Saharan Africa: A Critical Review
Authors: Wamoyi Joyce , Ranganathan Meghna , Kyegombe Nambusi , Stoebenau Kirsten
Published: February 2019

Background:

Transactional sex, or informal sexual exchange, is considered to be an important contributing factor to the disproportionately high HIV infection rates experienced by adolescent girls and young women in sub-Saharan Africa. Nonetheless, confusion remains over how best to define and measure this practice, hindering efforts to mitigate the role of transactional sex in the epidemic. We critically review current measures and offer evidence-based recommendations for improvement.

Setting:

Although transactional sex is practiced around the world, we focus attention on the definition and measurement of this practice in sub-Saharan Africa, given the role it plays in young women's risk of HIV in this region.

Methods:

We relied on both secondary and primary data sources. We draw on a systematic review of literature on transactional sex from sub-Saharan Africa and interview data from both key informants and cognitive interviews (n = 160) with young women (ages 14–24) and men (ages 18–35) in Uganda and Tanzania.

Results:

We find current measures are inconsistent, conflate transactional sex with sex work, and fail to capture the gendered nature of the practice. We provide an evidence-based definition of transactional sex that guides our measurement recommendations. We then detail the development of improved measures through cognitive interviews. Finally, we offer recommended approaches to improved measurement of transactional sex for women and men in large-scale surveys.

Conclusions:

Improved measures are critical for accurate estimation of the prevalence of transactional sex and assessment of the extent to which transactional sex determines HIV risk.