bluuebunny/crossref_metadata_2025 huggingface dataset:
Anesthesia and Cognitive Outcome in Elderly Patients: A Narrative Viewpoint
Authors: Cottrell James E. , Hartung John
Published: September 2019

Better ways to manage preoperative, intraoperative and postoperative care of surgical patients is the bailiwick of anesthesiologists. Although we care for patients of all ages, protecting the cognitive capacity of elderly patients more frequently requires procedures and practices that go beyond routine care for nonelderly adults. This narrative review will consider current understanding of the reasons that elderly patients need enhanced care, and recommendations for that care based on established and recent empirical research. In that latter regard, unless and until we are able to classify anesthetic neurotoxicity as a rare complication, the first-do-no-harm approach should: (1) add anesthesia to surgical intervention on the physiological cost side of the cost/benefit ratio when making decisions about whether and when to proceed with surgery; (2) minimize anesthetic depth and periods of electroencephalographic suppression; (3) limit the duration of continuous anesthesia whenever possible; (4) consider the possibility that regional anesthesia with deep sedation may be as neurotoxic as general anesthesia; and (5) when feasible, use regional anesthesia with light or no sedation.
Interlaminar Endoscopic Lumbar Discectomy Using a New 8.4-mm Endoscope and Nerve Root Retractor
Authors: Shim Hyeong-Ki , Choi Kyung-Chul , Cha Kyung Han , Lee Dong Chan , Park Choon-Keun
Published: September 2019

Study Design:

Surgical technique.

Objective:

Using an 8.4-mm endoscope and endoscopic nerve root retractor, the interlaminar endoscopic lumbar discectomy (IELD) technique is introduced for lumbosacral levels.

Summary of Background Data:

Although spine surgeons are familiar with IELD, this technique is only used for L5–S1 disk herniations and requires a wide interlaminar space.

Methods:

Using an 8.4 mm-endoscope, high-speed drill, and endoscopic Kerrison punches, a nerve-root retractor facilitated the simultaneous medial retraction of the nerve root and removal of the disk fragment by the instrument’s cannula. Clinical parameters such the visual analog scale scores for back and leg pain, modified Macnab criteria, and Oswestry Disability Index were analyzed.

Results:

A total of 101 patients were enrolled. The visual analog scale scores for back and leg pain significantly decreased from 6.8±2.1 and 7.8±1.5 to 2.0±0.6 and 1.78±1.1, respectively, at the 1-year follow up (P<0.01). The Oswestry Disability Index score significantly improved from 28.6±11.7 to 7.4±2.9 (P<0.01). Ninety-nine patients (97.1%) showed good outcomes.

Conclusions:

A new IELD technique and instruments can overcome the drawbacks of existing IELD with adequate bone work and control of the affected nerve root.
The Second Toe-to-Hand Transfer for Full-length Thumb Reconstruction in Congenital Thumb’s Grade IIIb to V Hypoplasia: MTPJ Arthrodesis Instead of Tendon Rebalansing
Authors: Ozols Dzintars , Butnere Marisa M. , Petersons Aigars
Published: September 2019

Congenital thumb hypoplasia is a rare deformity of the upper extremity. The classification of thumb hypoplasia was created by Blauth in 1967 (types I to V). The base of the first metacarpal bone is absent for hypoplasia types IIIb to V, therefore, toe-to-hand transplantation is not recommended. A stable first carpometacarpal joint has been considered a mandatory factor for a successful toe-to-hand transplantation. The aim of this study is to describe a new technique for thumb reconstruction with the second toe transfer and metatarsophalangeal joint (MTPJ) arthrodesis, which can provide a five-digit hand and restore thumb functionality for thumb hypoplasia IIIb to V. We performed second toe-to-hand transplantation with MTPJ arthrodesis for 3 pediatric patients (mean age, 69 mo) with congenital thumb hypoplasia IIIb (n=2), grade V (n=1). Long-term follow-up evaluated the functions and esthetics of the hands for grade IIIb patients (n=2). We believe the second toe transfer with MTPJ arthrodesis transplantation is a promising method for reconstructing a full-length congenital or traumatic thumb absence for the pediatric population.
SSi6 promotes cell death by apoptosis through cell cycle arrest and inhibits migration and invasion of MDA-MB-231 human breast cancer cells
Authors: Luna-Dulcey Liany , da Silva James A. , Cominetti Marcia R.
Published: September 2019

Triple-negative breast cancer subtype is the most aggressive type of breast cancer due to the lack of specific therapeutic targets, having limited treatment options, low survival prognosis and high recurrence rates. In this work, we describe the effects of a semisynthetic derivative of [6]-gingerol (6G) called SSi6, produced by the addition of a 2,4-dinitrophenylhydrazine reagent on several aspects of triple-negative breast cancer biology. Human breast cancer cell lines MDA-MB-231 and MCF-10A were used in the experiments. MTT assays were used to detect cell viability. Cell cycle and apoptosis assay were analyzed using flow cytometer Accuri C6 and analysis of proteins as retinoblastoma Rb and kinases Cdk4/6 were analyzed by western blotting. SSi6 induced cytotoxic effects on triple-negative breast cancer cells, with higher selectivity when compared to the non-tumor MCF-10A cells. In addition, SSi6 inhibited migration and invasion of triple-negative breast cancer cells and was able to arrest cell cycle at the G1-phase, mainly by decreasing Cdk4/6-Rb axis levels. Therefore, SSi6 provoked the induction of apoptosis in triple-negative breast cancer cells. SSi6 was more efficient in producing these effects, compared to the original 6G natural product. This study may contribute to a better understanding of the effects of natural and semisynthetic products on the in-vitro metastatic processes in the MDA-MB-231 triple-negative breast cancer cell line. Additional, it can be useful to understand the effects of chemical modifications on already effective natural compounds aiming at the improvement of their bioactive properties, such as in the increase of the cytotoxic selectivity against tumor cells, compared to non-tumor ones.
Microcannula Injection of Large Gel Particle Hyaluronic Acid for Cheek Augmentation and the Correction of Age-Related Midface Contour Deficiencies
Authors: Jones Derek H. , Hessler Jill , Chapas Anne , Jonas Brandie , Crider Julie , Chopra Raj
Published: September 2019

BACKGROUND

There is a growing trend toward the use of blunt-tip microcannulas for the treatment of midface volume loss with injectable hyaluronic acid.

OBJECTIVE

To evaluate the safety and efficacy of large gel particle hyaluronic acid with lidocaine, injected with a blunt-tip microcannula, for cheek augmentation and the correction of age-related midface contour deficiency.

MATERIALS AND METHODS

Sixty subjects with mild to substantial loss of midface fullness were treated to optimal correction. Adverse events (AEs) were obtained during each examination visit. Efficacy was evaluated using the Global Aesthetic Improvement Scale, the Medicis Midface Volume Scale (MMVS), and the FACE-Q subject satisfaction questionnaire through 16 weeks.

RESULTS

Five AEs were reported, with only one being considered injection procedure-related (mild presyncope). No serious AEs were reported. Global aesthetic improvements were reported for the majority of subjects (≥98.3% for investigator-assessed and ≥91.5% for subject-assessed) for up to 16 weeks. At 8 weeks, the MMVS responder rate was 100% and subject satisfaction scores (5/6 questions) in the FACE-Q were ≥91.5%.

CONCLUSION

Hyaluronic acid with lidocaine, injected with a blunt-tip microcannula, has a favorable safety profile and is effective up to 16 weeks for cheek augmentation and the correction of age-related midface contour deficiencies (NCT03160716).
Update in Soft-Tissue Filler–Associated Blindness
Authors: Sorensen Eric P. , Council M. Laurin
Published: September 2019

BACKGROUND

Soft-tissue filler administration is an increasingly popular minimally invasive cosmetic procedure. Simultaneously, there have been a greater number of adverse events reported, including the devastating complication of blindness.

OBJECTIVE

To report cases of filler-related blindness published since 2015.

MATERIALS AND METHODS

The Ovid MEDLINE database was searched from January 1, 2015, to August 1, 2018, using a previously described Boolean string.

RESULTS

Sixty new cases of filler blindness were identified. The most common type of filler reported was hyaluronic acid (HA) (N = 42, 70.0%), followed by autologous fat (N = 7, 11.7%), and calcium hydroxyapatite (CaHA) (N = 7, 11.7%). The most common injection locations were the nose (N = 33, 55.0%), glabella (N = 21, 35.0%), and forehead (N = 11, 18.3%). Ten cases reported vision restoration (16.7%). Four of the successful cases involved hyaluronidase administration, including 1 retrobulbar hyaluronidase injection.

CONCLUSION

Since 2015, there have been 60 newly reported cases of soft-tissue filler blindness. Most recent cases have occurred with HA, which is a shift from previous reports. In HA cases, hyaluronidase injection may be successful in restoring vision if administered promptly. It is imperative for providers to be familiar with strategies for managing soft-tissue filler blindness.
Intralesional Triamcinolone May Not Be Beneficial for Treating Acute Hidradenitis Suppurativa Lesions: A Double-Blind, Randomized, Placebo-Controlled Trial
Authors: Fajgenbaum Kristen , Crouse Lauren , Dong Li , Zeng Donglin , Sayed Christopher
Published: September 2019

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, inflammatory condition characterized by recurrent nodules, sinus tracts, comedones, and scarring. Hidradenitis suppurativa is often associated with pain and decreased quality of life. Limited clinical trial data exist regarding the management of acute HS lesions, but clinical experience and a prospective case series suggest that intralesional triamcinolone may be useful.

OBJECTIVE

To compare the efficacy of intralesional triamcinolone to placebo for the treatment of HS inflammatory lesions.

MATERIALS AND METHODS

This is a double-blind, randomized, placebo-controlled trial comparing intralesional triamcinolone 10 mg/mL, triamcinolone 40 mg/mL, and normal saline (NS). Thirty-two subjects at University of North Carolina Dermatology and Skin Cancer Centers were enrolled for a total of 67 lesions. Subjects reported pain scores, days to resolution, and satisfaction on a standardized survey over a 14-day period.

RESULTS

When intralesional injections of triamcinolone 10 mg/mL, triamcinolone 40 mg/mL, and NS were compared, no significant difference was found for days to HS inflammatory lesion clearance, pain reduction at Day 5, or patient satisfaction.

CONCLUSION

No statistically significant difference was found between varying concentrations of triamcinolone and NS for the treatment of HS lesions. Steroid injections may be less effective for the management of acute HS than typically presumed.
Characteristics of Patients Hospitalized for Cutaneous Squamous Cell Carcinoma
Authors: Tripathi Raghav , Knusel Konrad D. , Ezaldein Harib H. , Bordeaux Jeremy S. , Scott Jeffrey F.
Published: September 2019

BACKGROUND

Knowledge regarding the inpatient burden of cutaneous squamous cell carcinoma (cSCC) is limited.

OBJECTIVE

To provide nationally representative estimates for hospitalization characteristics due to cSCC and determine predictors for increased length of stay (LOS) and cost of care.

METHODS/MATERIALS

A retrospective cohort study of the 2009 to 2015 National Inpatient Sample. Weighted multivariate logistic/linear regression models were created to evaluate sociodemographic factors associated with cSCC hospitalization and to assess characteristics associated with cost of care and LOS.

RESULTS

This study included 15,784 cSCC and 255,244,626 non-SCC inpatients (prevalence = 6.2/100,000 inpatients). On average, cSCC hospitalizations lasted 5.8 days and cost $66,841.00. Cutaneous squamous cell carcinoma most often occurred on the scalp (30.57%), face (21.08%), and lower limb (11.93%). Controlling for all other factors, cSCC inpatients presented to larger/urban/teaching hospitals and were most often older non-Hispanic white women. More chronic conditions/diagnoses/procedures and nonwhite race were associated with greater cost of care and LOS. Cost of care and LOS significantly differed between cSCCs of different anatomical sites. The most common procedures performed were skin grafts (27.96%), excisions (25.83%), and lymph node biopsies (11.39%).

CONCLUSION

This study highlights the substantial burden of inpatient cSCC in the United States. Further research is necessary to prevent cSCC hospitalizations and improve inpatient dermatologic care for cSCC.
Scientist-led Exercise Testing Is Safe With Diagnostic Interpretation Equivalent to a Cardiologist
Authors: Whitman Mark , Padayachee Cliantha , Tilley Prue , Sear Casey , Rosanoff Shelley , El Shinawi Hadeir , Manolis Christiana , Jenkins Carly , Challa Prasad
Published: September 2019

Background:

The implementation of nonphysician-led exercise stress testing (EST) has increased over the last 30 years, with endorsement by many cardiovascular societies around the world. The comparable safety of nonphysician-led EST to physician-led studies has been demonstrated, with some studies also showing agreement in diagnostic preliminary interpretations.

Objective:

The study aim was to firstly confirm the safety of nonphysician-led EST in a large cohort and secondly compare the interobserver agreement and diagnostic accuracy of cardiac scientist and junior medical officer (JMO)-led EST reports to cardiology consultant overreads.

Methods:

All ESTs performed between 1/7/2010 and 30/6/2013 were included in the study for JMO led tests (n = 1332). ESTs performed for the investigation of coronary artery disease between 1/7/2013 and 30/6/2016 were included for scientist-led testing (n = 1904).

Results:

There was one adverse event, an ST segment myocardial infarction during the recovery phase of a JMO-led EST. Interobserver agreement was superior between the cardiologist and the scientist compared with the cardiologist and the JMO (P < 0.0001). Sensitivity for JMO-led tests differed from the cardiologist overread (86.96% vs. 96.77%, P = 0.03). There were no other significant differences between the cardiologist overread and the JMO- or scientist-led interpretation.

Conclusions:

Scientist-led EST is safe in intermediate risk patients and their preliminary reports are equally diagnostic as cardiologist overreads. While JMO-led ESTs are just as safe, the preliminary reports differ significantly from cardiologist overread particularly with respect to sensitivity.
Novel Application Software for the Semi-Automated Analysis of Infrared Meibography Images
Authors: Shehzad Danish , Gorcuyeva Sona , Dag Tamer , Bozkurt Banu
Published: September 2019

Purpose:

To develop semi-automated application software that quickly analyzes infrared meibography images taken with the CSO Sirius Topographer (CSO, Italy) and to compare them to the manual analysis system on the device (Phoenix software platform).

Methods:

A total of 52 meibography images verified as high quality were used and analyzed through manual and semi-automated meibomian gland (MG) detector software in this study. For the manual method, an experienced researcher circumscribed the MGs by putting dots around grape-like clusters in a predetermined rectangular area, and Phoenix software measured the MG loss area by percentage, which took around 10 to 15 minutes. MG loss was graded from 1 (<25%) to 4 (severe >75%). For the semi-automated method, 2 blind physicians (I and II) determined the area to be masked by putting 5 to 6 dots on the raw images and measured the MG loss area using the newly developed semi-automated MG detector application software in less than 1 minute. Semi-automated measurements were repeated 3 times on different days, and the results were evaluated using paired-sample t test, Bland–Altman, and kappa κ analysis.

Results:

The mean MG loss area was 37.24% with the manual analysis and 40.09%, 37.89%, and 40.08% in the first, second, and third runs with the semi-automated analysis (P < 0.05). Manual analysis scores showed a remarkable correlation with the semi-automated analysis performed by 2 operators (r = 0.950 and r = 0.959, respectively) (P < 0.001). According to Bland–Altman analysis, the 95% limits of agreement between manual analysis and semi-automated analysis by operator I were between −10.69% and 5% [concordance correlation coefficient (CCC) = 0.912] and between −9.97% and 4.3% (CCC = 0.923) for operator II. The limit of interoperator agreement in semi-automated analysis was between −4.89% and 4.92% (CCC = 0.973). There was good to very good agreement in grading between manual and semi-automated analysis results (κ 0.76–0.84) and very good interoperator agreement with semi-automated software (κ 0.91) (P < 0.001).

Conclusions:

For the manual analysis of meibography images, around one hundred dots have to be put around grape-like clusters to determine the MGs, which makes the process too long and prone to errors. The newly developed semi-automated software is a highly reproducible, practical, and faster method to analyze infrared meibography images with excellent correlation with the manual analysis.
Descemet Membrane Endothelial Keratoplasty in Irreversible Corneal Edema Due to Herpes Simplex Virus Endotheliitis
Authors: Basak Samar K. , Basak Soham
Published: September 2019

Purpose:

To report the clinical outcome and postoperative course of Descemet membrane endothelial keratoplasty (DMEK) in irreversible corneal edema due to herpes simplex virus (HSV) endotheliitis.

Methods:

This is a retrospective, noncomparative, interventional case series. Nineteen eyes of 19 patients underwent standard DMEK combined with cataract surgery (triple DMEK) between May 2016 and April 2018. All patients received perioperative oral acyclovir (ACV) and prednisolone. Patients were followed up on day 1, on day 7, at 1 month, and then at 3 monthly intervals. Preoperative and postoperative best spectacle-corrected visual acuity (BSCVA), graft clarity, pachymetry, and endothelial cell loss after 1 year were recorded. Postoperative complications and HSV recurrence were noted until the last follow-up visit.

Results:

All eyes were phakic with variable grades of cataract with a preoperative BSCVA of 1.0 logarithm of the minimum angle of resolution or worse. The mean follow-up period was 19.3 ± 5.4 months. After 1 year, 14 (73.7%) eyes achieved a BSCVA of 0.3 or better. Seventeen (89.5%) patients had a clear graft at the last visit without any rejection episode. One graft failed after 16 months. After 3 months, the mean pachymetry reduced from 667.1 ± 62.1 to 512.8 ± 27.1 μm (P < 0.001). The mean endothelial cell loss after 1 year was 36.7 ± 13.4%. Three (15.8%) eyes had recurrence: one with recurrent endotheliitis and 2 with dendritic keratitis despite oral ACV, which responded to oral valacyclovir and ACV eye ointment. One patient had re-recurrence of endotheliitis after 20 months.

Conclusions:

DMEK in persistent corneal edema after HSV endotheliitis remains challenging but has encouraging outcomes. The postoperative course may be complicated by HSV recurrence. Prophylactic oral antivirals for 1 year or more and topical antivirals are useful for the prevention of recurrence.
Ability of 2 estimation methods of body fat percentage in identifying unfavorable levels of cardiometabolic biomarkers in adolescents: Results from the LabMed study
Authors: Oliveira-Santos José , Mota Jorge , Moreira Carla , Abreu Sandra , Lopes Luís , Agostinis-Sobrinho César , Santos Rute
Published: September 2019

Background:

To assess and compare the ability of body fat percentage (BF%) estimated by 2 methods, bioelectrical impedance analysis (BIA) and by the Slaughter et al equations for triceps and subscapular skinfold thickness (SKF), in identifying unfavorable levels of several biomarkers of cardiometabolic risk.

Methods:

Cross-sectional school-based study with 529 apparently healthy adolescents (267 girls), aged 14.3 ± 1.7 years.

Results:

BF% estimated by both methods always showed higher areas under the curve (AUC) for each biomarker in girls than in boys (with the exception of BIA for leptin). BF% estimated by BIA and by SKF presented a discriminatory ability in identifying unfavorable levels in all biomarkers of cardiometabolic risk in girls; however, BF% estimated by BIA displayed the highest AUC (except for C-reactive protein). In boys, BF% estimated by SKF presented higher AUC for C-reactive protein, fibrinogen and erythrocyte sedimentation rate; and BF% estimated by BIA for complement C3 and leptin. Positive and significant associations between BIA and SKF with all biomarkers (P < .05) were found (except for SKF and complement C4 in girls, and SKF and fibrinogen and erythrocyte sedimentation rate in boys), after adjustments for pubertal stage, cardiorespiratory fitness, adherence to the Mediterranean diet and socioeconomic status.

Conclusions:

Overall, diagnostic performance was more accurate in girls. BF% estimated by BIA presented a slightly better overall discriminatory ability for each biomarker than BF% estimated by SKF in girls, while in boys no method clearly prevailed over the other.
The predictive value of age, creatinine, ejection fraction score for in-hospital mortality in patients with cardiogenic shock
Authors: Çinar Tufan , Hayiroğlu Mert İlker , Şeker Mehmet , Doğan Selami , Çiçek Vedat , Öz Ahmet , Uzun Mehmet , Lütfullah Orhan Ahmet
Published: September 2019

Introduction:

The aim of the present study was to assess the predictive value of the age, creatinine, ejection fraction score for in-hospital mortality in patients with cardiogenic shock secondary to ST-elevation myocardial infarction.

Material and methods:

This single-center, retrospective study was based on a comprehensive analysis of the hospital records of 318 consecutive cardiogenic shock patients. The age, creatinine, ejection fraction score was calculated for each patient using the equation of age/ejection fraction +1 if creatinine level is >2 mg/dl. The study population was stratified into tertiles: T1, T2, and T3, based on the age, creatinine, ejection fraction score. The primary endpoint of the study was the incidence of in-hospital mortality.

Results:

The incidence of in-hospital mortality was significantly greater in patients with a high age, creatinine, ejection fraction score (T3 group) compared with the intermediate (T2 group) or the low score group (T1 group) [86.8% (n = 92 patients) vs. 57.5% (n = 61 patients) vs. 34.9% (n = 37 patients), respectively; P < 0.05 for each]. In multivariable models, after adjusting for all covariables, the risk of in-hospital mortality was 3.21 (95% confidence interval: 2.29–4.58) for patients allocated to the T3 group. The optimal cutoff for the age, creatinine, ejection fraction score for in-hospital mortality was 2.24, with a sensitivity of 74% and a specificity of 77%.

Conclusion:

To the best of our knowledge, this is the first study that has demonstrated a prognostic value of the age, creatinine, ejection fraction score in patients with ST-elevation myocardial infarction-related cardiogenic shock.
Total knee arthroplasty in a patient with ipsilateral hip ankylosis
Authors: Tang XianZhe , Yan ZuYun , Wang Wanchun , Liu Tang
Published: September 2019

Rationale:

There is a large number of people that have knee degeneration in China. Total knee arthroplasty is one of the most effective methods of treatment in the later stages of the disease. However, there are challenges when performing total knee arthroplasty on patients with ipsilateral hip akylosis. So far, there are few reports on postoperative curative effect of total knee arthroplasty for these patients. This case report records how to perform total knee arthroplasty in a patient with ipsilateral hip ankylosis.

Patient concerns:

Due to ankylosing spondylitis, the flexion of the patient's hips are restricted in 10°, which leads to a limited ipsilateral knee flexion to 30° when she is in the supine position.

Diagnoses:

Right knee osteoarthritis; right hip ankylosis.

Interventions:

We modified the traditional surgical position to allow easy exposure of the knee during surgery. After total knee arthroplasty, the patient was included in a planned training program, and was followed for 6 months.

Outcomes:

The patient walked well without ambulation aid and achieved satisfactory knee joint function.

Lessons:

Conversion of a fused hip to a total hip arthroplasty does improve the quality of life of patients, but, given the high incidence of complications and more financial burden to the patient, we modified traditional surgical position of the patient to provide ideal surgical exposure of the knee. We hope that this case can be used as a reference for clinicians to deal with similar situations.
Henoch-Schönlein purpura with intussusception and hematochezia in an adult
Authors: Cui Xiao-Han , Liu Hao , Fu Li , Zhang Chao , Wang Xu-Dong
Published: September 2019

Rationale:

Henoch-Schönlein purpura (HSP) is a common disease in children. However, HSP with intussusception and intestinal obstruction has a low morbidity in children and is occasionally seen in adults. Herein, a rare adult case of HSP complicated with intussusception and hemafecia that was successfully treated with surgery is described.

Patient concerns:

A 19-year-old Chinese man suffered from HSP combined with intussusception and intestinal obstruction and presented with vomiting, diarrhea, abdominal pain, and rash.

Diagnosis:

Henoch-Schönlein purpura with intussusception and intestinal obstruction.

Interventions:

The patient underwent an emergency laparotomy and manual reset.

Outcome:

The patient was discharged 7 days after surgery in stable condition. We followed the patient to the sixth month after surgery. This patient has no long-term complications after surgery.

Lessons:

HSP with intussusception and intestinal obstruction is rarely seen in adults. Patients with HSP often present with abdominal pain as the first symptom, which is easily confused with other diseases. Once the HSP is diagnosed, surgery should be performed as soon as possible, provided there is no absolute contraindication.
Suspected colonic cancer turns out to be disseminated tuberculosis in a kidney transplant recipient
Authors: Schmidt-Lauber Christian , Jacobi Johannes , Polifka Iris , Hilgers Karl F. , Wiesener Michael S.
Published: September 2019

Rationale:

Active tuberculosis constitutes a relevant risk for kidney transplant recipients. In contrast to immunocompetent hosts, kidney transplant recipients often show atypical presentation and course of the disease impeding diagnosis. Especially extrapulmonary or disseminated infection is more frequent and can resemble malignant processes. However, reactivation of tuberculosis mostly develops within the early post-transplant course, whereas malignancies are predominantly long-term complications. We report a case of disseminated abdominal tuberculosis developing 10 years after kidney transplantation and review the underlying literature.

Patient concerns and diagnoses:

A 51-year-old lady presented with epigastric pain, diarrhea, weight loss and night sweats 10 years after deceased-donor kidney transplantation. An epigastric as well as multiple peritoneal masses were found suspicious of a cancer of unknown primary. Colonoscopy revealed a colon tumor with the biopsy showing no dysplasia but histiocytic and granulomatous infiltration with acid-fast bacilli. Mycobacterium tuberculosis was detected in the biopsy and stool and disseminated abdominal tuberculosi was diagnosed.

Interventions and outcomes:

With anti-tuberculosis therapy, the masses regressed, and all cultures became sterile, sparing graft function.

Lessons:

This case emphasizes how variable and unspecific the presentation of tuberculosis in kidney transplant recipients may be and that tuberculosis constitutes a relevant risk also in the long-term post-transplant course.
Improving functional outcome and quality of life for patients with metastatic lesion of acetabulum undergoing cement augmentation
Authors: Yan Taiqiang , Zhao Zhiqing , Tang Xiaodong , Guo Wei , Yang Rongli , Tang Shun , Dong Sen
Published: September 2019

There is an increased enthusiasm in treating osteolytic metastatic acetabulum via injecting polymethyl-methacrylate (PMMA) as a bone filler to provide pain relief and potential structural support. The aim of this respective study is to determine the function and quality of life improvement after cement acetabuloplasty.

Thirty two patients underwent acetabular cement augmentation between May 2014 and March 2018 were respectively reviewed. Isolated percutaneous acetabuloplasty (PA) was performed in 15 patients (group A) while radiofrequency ablation with PA (RFA-PA) in 12 patients (group B). Together with PA, open reconstructive surgery on ipsilateral femur was performed in another 5 cases (group C). Pre- and posttreatment functional evaluation and quality of life (QoL) assessment were carried out.

The average followup duration was 11.5 (range, 3–36) months. None of major complications occurred. 81.2% (26/32) of patients achieved complete pain relief. Reduction of pain intensity and improvement of functional status achieved significantly differences after treatment (P = .00). Significant improvement (P = .00) was observed in scales of global QoL and pain-related restrictions in daily activities. Both isolated PA and RFA-PA procedures were equally effective towards the improvement of function and quality of life (P > .05). Regarding 5 patients in group C, pain intensity decreased when loading the affected limb and they could walk with crutches or cane.

Bone cement acetabuloplasty is an adequate and effective mini-invasive procedure to relieve pain, restore function, and enhance the quality of life of patients for as long as possible in metastatic patients with short life expectancy. Ipsilateral surgery appears to be safe and well tolerated.
Surgery for intra-abdominal abscess due to intestinal perforation caused by toothpick ingestion
Authors: Lim Dae Ro , Kuk Jung Cheol , Kim Taehyung , Shin Eung Jin
Published: September 2019

Rationale:

Failure to pass though the gastrointestinal tract can result in inflammatory response, reactive fibrosis, and intestinal perforation. Fish bones, chicken bones, and toothpicks are the most common types of foreign substances that produce intestinal perforation during ingestion.

Patient concerns:

Case 1: A 49-year-old female was hospitalized with abdominal pain and a fever. The fever lasted for 5 days before hospitalization. Case 2: A 72-year-old male was hospitalized with abdominal pain and fever. The fever lasted for 4 days before hospitalization.

Diagnoses:

Case 1: An abdominal pelvic computed tomography (APCT) scan revealed a large inflammatory mass formation and linear high-density material within the inflammatory mass. The presence of foreign bodies, including acupuncture needles or intrauterine devices was ruled out. Case 2: An APCT scan revealed that there was a small abscess formation measuring about 2.5 cm abutting the abdominal wall and a parasitic infestation was ruled out.

Interventions:

Case 1: An exploratory laparotomy was performed. After removal of the abscess pocket, the sigmoid colon was found to be perforated, and there was a firm, sharp foreign body in the abscess pocket that measured about 5 cm and resembled a toothpick. Case 2: Laparoscopic exploration was then performed. When the abscess was removed from the abdominal wall using a harmony scalpel, a 4 cm foreign body that resembled a toothpick appeared in the abscess pocket.

Outcomes:

The patients recovered well after surgery and were discharged.

Lessons:

Two of the above case reports describe the cases in which the presence of toothpicks was suspected clinically, resulting in the surgery of intra-abdominal abscess caused by intestinal perforations.
Orbital neuroblastoma metastasis
Authors: Yang Wan-Ju , Zhou Yuan-Yuan , Zhao Fang , Mei Zhong-Ming , Li Shuang , Xiang Yi
Published: September 2019

Rationale:

Neuroblastoma is one of the most common tumors found in children, and mostly arises in the adrenal gland and paravertebral regions. Orbital neuroblastoma metastasis is relatively rare, and is associated with poor prognosis. Since the symptoms and signs of orbital neuroblastoma are not specific, its diagnosis remains challenging.

Patient concerns:

A 3-year-old girl presented with periorbital ecchymoses (raccoon eyes) and proptosis for 40 days.

Diagnoses:

Abdominal magnetic resonance imaging (MRI) and sonography analysis revealed a large mass in the left adrenal gland (primary tumor). The computed tomography and MRI further revealed multiple soft tissue masses in the skull and both orbits with erosion of the adjacent bones (the metastasis). The histological analysis of the tumor removed from the right orbit confirmed the diagnosis of neuroblastoma.

Interventions:

The mass on the right face was surgically removed.

Outcomes:

The patient exhibited no deteriorative signs at the 6-month follow-up.

Lessons:

Clinical manifestations, such as periorbital ecchymoses and proptosis, in combination with radiological analysis and histological findings, are important for the diagnosis of orbital neuroblastoma metastasis.
Syphilis and parvovirus B19 co-infection imitating a lupus nephropathy
Authors: Jaunin Eric , Kissling Sebastien , Rotman Samuel , Waeber Gérard , Halfon Matthieu
Published: September 2019

Rationale:

Syphilis can share clinical features with autoimmune diseases, such as cutaneous Lupus or rheumatoid arthritis. Moreover, secondary syphilis can have visceral involvement, thus affecting the kidney. Syphilitic nephropathy causes nephrotic syndrome with a classic membranous pattern. We present a unique presentation of a co-infection by syphilis and parvovirus B19 sharing all the biological and histological features of proliferative lupus nephritis (LN).

Patient concerns:

We present a case of a 71-year-old Caucasian male returning from a trip to Asia presenting with nephrotic syndrome with antinuclear antibodies (ANA) positivity.

Diagnoses:

Because of nephrotic syndrome a kidney biopsy was performed. It demonstrated a membranous nephropathy with extracapillary proliferation and a full house pattern (presence of IgA, IgG, IgM and C1Q deposits) on immunofluorescence (IF), highly suggestive of LN class III and V. However, several atypical clinical features notably the age, sex of the patient and the history of travel prompt us to search for another cause of nephropathy.

Interventions:

A serology was positive for syphilis and a PCR in the renal biopsy was also positive for parvovirus B19. Thus, a co-infection by syphilis and parvovirus B19 was funded to be the cause of the renal lesions.

Outcomes:

The proteinuria improved; a course of antibiotic was administrated because of neurologic syphilitic involvement (presence of headache with positive syphilis serology in the CSF).

Lessons:

A co-infection by syphilis and parvovirus B19 can share all the biological and histological features of proliferative LN and must be recognized as a cause of pseudo-lupus nephritis.
Squamous cell carcinoma of the renal pelvis presenting as an integumentary neoplasm of the flank
Authors: Kim Jung Ryul , Jeong Young Beom , Lee Nae Ho , Wang Sung Il
Published: September 2019

Rationale:

Although chronic pyelonephritis and urolithiasis are established risk factors for squamous cell carcinoma (SCC), only a minority of patients with chronic urolithiasis eventually develop SCC. It is believed that the chronic irritation leads to squamous cell metaplasia that may subsequently develop into SCC. Although studies show that SSC generally spreads locally with associated symptoms of lymphadenopathy, metastasis to the lungs and liver have also been reported. However, cases spreading to the flank have yet to be reported. Therefore, the use of reconstructive techniques for the repair of extensive soft tissue defects in the flank region after extended retroperitoneal resection, is unknown.

Patient concerns:

We report a 54-year-old man who presented with a 1-month history of an enlarged skin mass on the right flank.

Diagnoses:

The patient was subsequently diagnosed with metastatic SCC involving the patient's integumentary system near the flank region proximal to the right kidney following percutaneous nephrostomy.

Interventions:

The skin mass and the surrounding muscle tissue of the right flank were excised with a wide resection margin including radial nephrectomy. The soft tissue defect after resection was reconstructed using a unilateral gluteus maximus myocutaneous V-Y advancement flap.

Outcomes:

No recurrence of the SSC was found on follow-up CT performed 12 months postoperatively.

Lessons:

In patients with long-standing nephrolithiasis complicated by staghorn stone-related infections, biopsies from suspicious lesions detected during percutaneous nephrolithotomy may facilitate early diagnosis. The modified gluteus maximus V-Y advancement flap may be a useful technique for the reconstruction of extensive soft-tissue defects involving the flank region.
Efficacy and safety of different doses of azilsartan medoxomil in patients with hypertension
Authors: Zhang Yan , Yu Huijin , Shao Kangmei , Luo Xinyue , Wang Jiancheng , Chen Gen
Published: September 2019

Background:

Hypertension is one of the most common chronic diseases and an increasingly public-health challenge worldwide. Previous meta-analyses evaluated the effects of azilsartan medoxomil compared to placebo or other antihypertensive drugs in patients with hypertension. However, it is still unclear which dose of azilsartan is optimal. This study will perform a network meta-analysis to assess the efficacy and safety of different doses of azilsartan medoxomil in patients with hypertension.

Methods:

PubMed, EMBASE.com, the Cochrane library, Scopus, and Web of Science were searched from inception to May 2019. Randomized controlled trials reporting efficacy and safety of different doses of azilsartan medoxomil on hypertension will be included if they compared 1 dose of azilsartan medoxomil with another dose of azilsartan medoxomil or with a placebo. Risk of bias of the included trials will be evaluated according to the Cochrane Handbook 5.1.0. NMA will be performed in a Bayesian hierarchical framework using WinBUGS 14.

Results:

The results will be submitted to a peer-reviewed journal for publication.

Conclusion:

This study will summarize all the available data to provide reliable evidence of the value of different doses of azilsartan medoxomil for the treatment of hypertension.

PROSPERO registration number:

CRD42019136882.
Subacute combined degeneration associated with vitamin E deficiency due to small bowel obstruction
Authors: Jung Jong Burm , Kim Yuntae , Oh Kiyoung , Kim Soo A , Doh Joung Hyun , Oh Hye Jeong , Seok Jin Myoung
Published: September 2019

Rationale:

There have been a few reported cases of subacute combined degeneration (SCD) associated with vitamin E deficiency, but the period of intestinal malabsorption was more than several years. We present a rare case of acute onset SCD that occurred in a relatively short period of several weeks with vitamin E deficiency related to small bowel obstruction.

Patient concerns:

A 50-year-old woman had abdominal pain. A small bowel obstruction was suspected and conservative treatment was performed. She underwent bowel surgery after 2 weeks without any improvement. Following the operation, she was in a state of reduced consciousness. She was treated in an intensive care unit. Her consciousness level gradually recovered to alert in a week, but other symptoms such as ataxia, weakness on limbs, severe dysarthria, and dysphagia occurred. Since then, she had spent nearly 6 weeks in a bed-ridden state without improving.

Diagnosis:

SCD associated with vitamin E deficiency was confirmed by laboratory investigations, electrophysiologic test, and whole spine magnetic resonance imaging scans.

Interventions:

For vitamin E supplementation, she was administered a dose of 1200 mg/d. Physical therapy was focused on strengthening exercise, balance, and walker gait training. Occupational therapy was focused on activities of daily living training and dysphagia rehabilitation.

Outcomes:

After 6 weeks, her muscle strengths and functional level were substantially improved. The vitamin E level was recovered to normal range.

Lessons:

This case suggests that if neurological symptoms occur in patients with intestinal obstruction, clinicians need to consider a deficiency of micronutrients such as vitamin E and vitamin B12. Patients with short clinical courses suffer less neurological damage and achieve faster recovery.
Resident performance in basic perioperative transesophageal echocardiography
Authors: Weber Ulrike , Zapletal Bernhard , Base Eva , Hambrusch Michael , Ristl Robin , Mora Bruno
Published: September 2019

Background:

Training in transesophageal echocardiography (TEE) is based on hands-on training in the operating room, which is time consuming and therefore limits its experience among anesthesiologists. Medical simulations have been successfully used for training of invasive procedures in many areas.

This paper compares the difference in effectiveness of teaching the 11 basic TEE views using either e-learning, simulation based training or hands-on training in the operating room in 3 groups of residents.

Methods:

We included 51 anesthesia and intensive care residents of all training levels but no prior training in echocardiography in this prospective randomized single-center study.

Residents received a tutorial about theoretical knowledge followed by 2 practical study sessions either by e-learning using an online simulator (www.pie.med.utoronto.ca/TEE), with the simulation mannequin (CAE Vimedix Simulator) or in the operating room. Both, a theoretical multiple choice test (0–50 points) and a practical exam test (0–110 points) on the simulation mannequin had to be completed.

The primary endpoint was the post-training scores in the practical and theoretical exams after all training sessions.

Results:

Residents received significantly higher test scores in both practical and theoretical examinations after training with the simulation mannequin (108.41 ± 2.09, 40.6 ± 5.23, n = 17) compared with e-learning (106.88 ± 4.53, 36 ± 4.76, n = 17) or hands-on training (106.82 ± 2.01, 34.94 ± 4.72, n = 17).

Conclusions:

Simulation based TEE training provides more effective training than other teaching methods. It is therefore especially suitable for the initial stages of TEE training to acquire psychomotor skills and knowledge of echo-anatomy.
The effect of insoles on symptomatic flatfoot in preschool-aged children
Authors: Chen Kun-Chung , Chen Yueh-Chi , Yeh Chih-Jung , Hsieh Ching-Lin , Wang Chun-Hou
Published: September 2019

Flatfoot is a common reason for parents to seek help from health care professionals, and limited evidence is available regarding the effects of insoles on preschool-aged children. This study mainly investigated the effect of insoles on symptomatic flatfoot in preschool-aged children and followed up the changes in footprints after 1 year.

This study was a prospective, observational cohort study. Children aged 3 to 5 years old who exhibit the signs of flatfoot feet were recruited from the kindergartens in the central Taiwan between March 2010 and December 2013. The Chippaux-Smirak index (CSI) was used to determine whether the footprints of children were associated with flatfoot. The children were divided into an insole group and a no-insole group according to diagnoses by doctors. This study used the modified shoe insole as the intervention, and the CSI measured and followed up the changes in footprints after 1 year.

A total of 466 preschool-aged children aged 3 to 5 years old with flatfoot completed the 1-year follow-up study. Of these, 123 children (men 77; women 46) were in the insole group and 343 children (men 187; women 156) were in the no-insole group. After the insoles were worn for 1 year, the CSI values of the children with symptomatic flatfoot decreased by 9.7%, and the 5-year-old children had the biggest change (effect size = 1.25). In the insole group, 34.1% of the footprints were determined as normal at 1-year follow-up, and CSI values decreased by 17.5%. High prevalence of joint laxity was found in both groups (insole group: 34.5%; no-insole group: 35.1%). Of the children in the insole group, the proportion of joint laxity was significantly higher in the flatfoot group (43.1%) than in the normal group (17.7%).

This study showed that wearing insoles indeed can reduce the signs of flatfoot in preschool-aged children, and the effect is better in 5-year-old children. It is suggested that insoles can be provided as a conservative treatment for preschool-aged children with symptomatic flatfoot.
Reducing Discomfort After Cesarean Birth Using Abdominal Binders
Authors: Tussey Christina , Kelly Lesly A. , Oja Kenneth J. , Bay R. Curtis , Makarova Natasha
Published: September 2019

Purpose:

The purpose of this study was to evaluate potential benefits of use of an abdominal binder after cesarean birth.

Study Design and Methods:

A randomized controlled trial was conducted at a Magnet-designated, academic medical center in the southwest United States. English- and Spanish-speaking adult women scheduled for an elective cesarean birth were randomized to the intervention or control group. Outcomes were measured for the first 48 hours postoperatively, including pain, medication use, and self-reported symptom distress.

Results:

Randomization resulted in balanced groups. Women who used the abdominal binder after cesarean birth reported a decrease in pain after ambulation, whereas women in the control group reported an increase in pain after ambulation (p < .001). Women in the binder group reported less distress on the Breathe and Cough items of the Symptom Distress Scale than those in the control group. On postoperative day 2, women in the binder group used more ibuprofen (p = .002) and acetaminophen (p = .027) than the control group.

Clinical Implications:

Use of an abdominal binder by women after cesarean birth can decrease pain, potentially enhancing speed of postoperative recovery. As a nursing intervention, abdominal binders may offer women a safe nonpharmacologic option to provide postoperative comfort.