bluuebunny/crossref_metadata_2025 huggingface dataset:
Nutritional Status as an Adjunct Risk Factor for Early Postoperative Complications Following Posterior Cervical Fusion
Authors: Lee Nathan J. , Kothari Parth , Kim Jun S. , Phan Kevin , Di Capua John , Shin John , Cho Samuel K.
Published: February 2017

Study Design.

Retrospective study on prospectively collected data.

Objective.

The aim of this study was to study the impact of nutritional status, as measured by serum albumin level, on patient outcomes following posterior cervical fusion (PCF) surgery.

Summary of Background Data.

Malnutrition is a potential modifiable risk factor that has garnered an increasing amount of attention within orthopedics in recent years. There is evidence to suggest the role of nutritional status in lumbar and ACDF surgery, yet the data for PCF are still lacking.

Methods.

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was queried by current procedure terminology (CPT) from 2010 to 2014. Bivariate analyses were performed to compare the preoperative characteristics between those with normal albumin and hypoalbuminemia. Postoperative complications and outcomes were similarly analyzed for those with and without low albumin levels. Stepwise multivariate logistic regression models were employed to determine whether hypoalbuminemia was an independent risk factor for short-term patient outcomes and complications.

Results.

There were 1573 cases with measured albumin levels (42.4%). The mean (standard deviation) serum albumin level was 3.9 (0.6). Among these patients, 265 (16.8%) cases had hypoalbuminemia. The adjusted analyses demonstrated that patients with hypoalbuminemia had a significantly higher risk for length of stay >5 days (odds ratio [OR] = 3.8; 95% confidence interval [CI] = 2.8–5.1; P < 0.0001). In addition, hypoalbuminemia was an independent risk factor for any complications (OR = 2.7; 95% CI = 1.9–3.7; P < 0.0001), pulmonary complications (OR = 2.3; 95% CI = 1.2–4.5; P = 0.010), intra/postoperative blood transfusions (OR = 3.2; 95% CI = 2.1–4.9; P < 0.0001), sepsis (OR = 4.0; 95% CI = 1.7–9.2; P = 0.001), and venous thromboemoblism (OR = 3.6; 95% CI = 1.5–8.5; P = 0.004).

Conclusion.

These findings implicate that a baseline serum albumin <3.5 g/dL may serve as a valuable prognostic measure for the development of several complications following PCF surgery.

Level of Evidence: 3
Mutational Status of NRAS and BRAF Genes and Protein Expression Analysis in a Series of Primary Oral Mucosal Melanoma
Authors: Hsieh Ricardo , Nico Marcello M. S. , Camillo Cláudia M. C. , Oliveira Kátia K. , Sangueza Martin , Lourenço Silvia V.
Published: February 2017

Primary oral mucosal melanoma is an extremely rare and aggressive tumor arising from melanocytes located in the mucosal epithelium of the oral cavity. Although malignant melanoma of oral mucosa shares some clinical features with its cutaneous counterpart, it has been associated with a worst prognosis; its etiopathogenesis are still only partially unraveled as there is no influence of UV radiation. It is known that the mitogen-activated protein kinase pathway mediates cellular responses to growth signals and its activation is an important phenomenon in melanoma. The aim of this study was to evaluate NRAS and BRAF genes, both components of mitogen-activated protein kinase molecular pathway, and compare with their protein expression. Point mutations of NRAS (codons 12, 13, and 61) and BRAF (codon 600) were screened by pyrosequencing method, and its results were associated to the protein expression of RAS and BRAF performed by immunohistochemistry. The authors observed mutation in BRAF 600 (3/14), NRAS codons 12 and 13 (2/14), and NRAS codon 61 (2/8). One case showed positive RAS protein expression, but no mutation was observed. Twelve in 14 cases showed positive BRAF protein expression: 3 cases showed BRAF mutation; 2 cases showed NRAS codon 61 mutation; 2 cases showed NRAS codons 12 and 13 mutation but not simultaneously. Although NRAS and BRAF mutation frequency and RAS protein expression are low, BRAF protein expression was intense; probably, NRAS and BRAF mutations are independent events and alternative molecular mechanisms in the primary oral mucosal melanoma tumorigenesis.
Zosteriform Mycosis Fungoides: A New Clinical Presentation With a Dermatomal Distribution
Authors: Rieger Kerri E. , Kim Jinah , Kim Youn H.
Published: February 2017

Classic mycosis fungoides (MF) presents with patches and plaques on the trunk and proximal extremities. However, numerous clinicopathologic variants have been described, making diagnosis challenging. Here, the authors report a 21-year-old woman with immunophenotypically and molecularly confirmed MF occurring in a dermatomal distribution. Awareness of this and other rare variants of MF is critical to avoid misdiagnosis.
Lichenoid Dermatologic Toxicity From Immune Checkpoint Blockade Therapy: A Detailed Examination of the Clinicopathologic Features
Authors: Tetzlaff Michael T. , Nagarajan Priyadharsini , Chon Susan , Huen Auris , Diab Adi , Omar Pacha , Aung Phyu P. , Torres-Cabala Carlos A. , Mays Steven R. , Prieto Victor G. , Curry Jonathan L.
Published: February 2017

Immunotherapy targeting the programmed cell death 1 (PD-1) receptor has demonstrated tremendous promise in the treatment of advanced solid tumors. Dermatologic toxicities, however, are an emerging consequence of this therapy and have been clearly associated with immune checkpoint blockade antibodies. Distinctive clinical and histologic subtypes of dermatologic toxicity secondary to immunotherapy are emerging and include rare autoimmune bullous reactions (eg, bullous pemphigoid) and lichenoid eruptions. We report three patients who developed lichenoid dermatitis while receiving anti-PD-1 antibody therapy. The mean time to onset of lichenoid dermatologic toxicity was 42 days (range: 1–75 days) from initiation of anti-PD-1 antibody therapy. Lesions most frequently presented on the extremities and trunk as pustules, papules, and plaques. The face was not commonly involved. Of the five skin biopsies examined, all demonstrated dense band-like lymphocytic infiltrate, hyperkeratosis, hypergranulosis, saw-tooth rete ridge pattern, and dyskeratosis. Acanthosis was a feature in all of the skin biopsies, and in one, epidermal hyperplasia was prominent. In several skin biopsies, histologic features supporting a lichenoid drug eruption were present, including parakeratosis, spongiosis, periadnexal/perivascular inflammation, and eosinophils. Furthermore, the histologic features varied in skin biopsy specimens taken from the same patient at different sites, supporting a drug reaction. All patients' skin lesions improved with use of steroids: two were treated with topical steroids and one with systemic steroids. Recognition of the histopathologic patterns of dermatologic toxicities resulting from immune checkpoint blockade therapy will become increasingly important for ensuring appropriate management of dermatologic toxicities and optimal patient care.
Dermatophytic Pseudomycetoma of the Scalp
Authors: Castro-Echeverry Eduardo , Fiala Katherine , Fernandez Martin P.
Published: February 2017

Dermatophytic pseudomycetoma represents a chronic infection characterized by a tumor-like growth containing dermatophytes arranged as clustered aggregates (grains) within the dermis. In contrast to mycetomas, they lack sinus tracts and are more common in the scalp. We describe a dermatophytic pseudomycetoma arising in the scalp of an 18-year-old African-American woman. Histopathologic examination showed a dense, mixed-cell infiltrate expanding the dermis. Accompanying this infiltrate were numerous grains scattered throughout the dermis. No sinus tracts were identified, but a number of grains were seen in the epidermal surface, admixed with serum crust. Recognition of a dermatophytic infection as a pseudomycetoma on a biopsy is important, as surgery may be required for a successful treatment.
Cost-effective Alternative for Negative-pressure Wound Therapy
Authors: Kim Jeff J. , Franczyk Mieczyslawa , Gottlieb Lawrence J. , Song David H.
Published: February 2017

Background:

Current predominantly used equipments for negative-pressure wound therapy (NPWT) are expensive. In current healthcare climate continually emphasizing cost containment, importance in developing more cost-effective alternatives cannot be understated. Previously, therapeutically equivalent methods of providing NPWT was demonstrated using just low-cost, universally available supplies, coined Gauze-SUCtion (GSUC). Here, we examine long-term potential financial savings of utilizing GSUC over commercialized products.

Methods:

A retrospective cost analysis was performed at the University of Chicago Medical Center between 1999 and 2014. All NPWT was provided via either GSUC or commercialized vacuum-assisted closure (VAC, KCI) device. Sum of all material component costs were reviewed to determine theoretical average daily cost. For the VAC group, recorded institutional spend to KCI was also reviewed to determine actual daily cost. In the GSUC group, this figure was extrapolated using similar ratios. Labor costs for each method were determined using analysis from prior study. Patient demographics, etiology, wound location, and treatment length were also reviewed.

Results:

Total of 35,871 days of NPWT was provided during the 15-year span. Theoretical average cost of VAC was $94.01/d versus $3.61/d for GSUC, whereas actual average was $111.18/d versus $4.26/d. Average labor cost was $20.11/dressing change versus $12.32. Combined, total cost of VAC therapy was estimated at $119,224 per every 1,000 days of therapy versus $9,188 for the GSUC.

Conclusions:

There is clear and significant cost savings from utilization of GSUC method of NPWT. Furthermore, the added advantage of being able to provide NPWT from universally accessible materials cannot be overstated.
Low Uptake of Meningococcal C Vaccination in France
Authors: Le Maréchal Marion , Agrinier Nelly , Fressard Lisa , Verger Pierre , Pulcini Céline
Published: February 2017

Background:

Meningococcal C glycoconjugate vaccine (MenCV) has been recommended in France since 2010, but its uptake remains low (64% coverage among 2-year-olds in 2014). Because general practitioners (GPs) are the cornerstone of the French vaccination program, we sought to assess their perceptions, attitudes, practices and recommendations to patients for this vaccine.

Methods:

A cross-sectional survey in 2014 asked a national sample of 1582 GPs if they would recommend MenCV for patients 12 months of age (routine vaccination) and 2–24 years of age (catch-up vaccination) and explored the barriers to vaccination.

Results:

Overall, 52% of GPs (800/1547) reported they always recommend routine MenCV vaccination and 33% (523/1572), catch-up vaccination. The most frequently reported barriers to vaccination were that parents have never heard of this vaccine (72%, 1094/1523), underestimate the risk of contracting meningococcal disease (69%, 1049/1514) and are unaware of its seriousness (55%, 838/1537). In multivariate analyses, GPs recommended routine and catch-up vaccination significantly more often when they had no doubt about the utility and safety of this vaccine, when they thought that the official MenCV recommendation was clear and when their own children were vaccinated. GPs who reported that their patients either were unaware of the severity of bacterial meningitis (P = 0.012) or had no doubts about the efficacy of MenCV recommended catch-up vaccination more often (P = 0.015).

Conclusions:

GPs did not appear to recommend MenCV often enough. Our results suggest that clearer recommendations and a better communications campaign directed at patients and healthcare workers could be useful.
Pseudomonas aeruginosa-associated Diarrheal Diseases in Children
Authors: Chuang Chih-Hsien , Janapatla Rajendra Prasad , Wang Yi-Hsin , Chang Hsin-Ju , Huang Yhu-Chering , Lin Tzou-Yien , Chiu Cheng-Hsun
Published: February 2017

Background:

The gastrointestinal tract is not the common infection site of Pseudomonas aeruginosa. The role of P. aeruginosa as a causative agent for diarrhea in children without preexisting disease is controversial.

Methods:

From 2003 to 2012, we reviewed the records of 259 diarrheal patients less than 5 years of age whose stool culture grew P. aeruginosa. Virulence phenotypes of bacterial isolates were determined in vitro, including cytotoxicity, penetration and adherence to epithelial cells.

Results:

The presence of P. aeruginosa in children with diarrhea less than 5 years old is 0.91%. P. aeruginosa-associated diarrheal diseases were classified into 4 groups: Shanghai fever (enteric infection and sepsis) (5%), P. aeruginosa enterocolitis (15%), P. aeruginosa-related diarrhea (19%) and antibiotic-associated diarrhea (43%). The remaining patients had coinfection with other pathogens (18%). Shanghai fever was the most severe enteric disease with invasive infection and complications. The clinical features of P. aeruginosa enterocolitis were prolonged fever with bloody or mucoid diarrhea mimicking bacterial enterocolitis. The clinical features of P. aeruginosa-related diarrhea and antibiotic-associated diarrhea were similar to viral or toxin-mediated diarrhea. Compared with other P. aeruginosa-associated diarrheal diseases, patients with Shanghai fever were younger, usually infants, and the characteristic laboratory findings included leukopenia, thrombocytopenia, high C-reactive protein, hyponatremia and hyperglycemia. Except for Shanghai fever, antibiotic treatment is not recommended. Isolates from Shanghai fever were more cytotoxic and adherent than isolates from uncomplicated diarrheal patients.

Conclusions:

P. aeruginosa could be an enteric pathogen even in healthy children. Young age and highly virulent bacterial strains were risk factors for Shanghai fever.
Posterior Medial Canthal Thermoplasty
Authors: Vahdani Kaveh , Thaller Vladimir Theodor
Published: February 2017

Purpose:

To describe a new, simple, quick, and minimally invasive surgical technique for managing medial canthal tendon laxity.

Methods:

The technique works by creating a directed posterior lamellar scar. Sutures are preplaced in firm medial canthal tissue, and a triangular diathermy burn is made between this fixation point and the medial tarsal plate (sparing the canaliculus). This area is then plicated horizontally by bringing the preplaced sutures through the medial tarsal plate. The authors report a retrospective case note review of a consecutive case series of 55 patients (59 procedures). All patients with moderate to severe medial canthal tendon laxity underwent a medial thermoplasty procedure in addition to standard surgery for correcting their eyelid malposition (entropion, ectropion, or symptomatic lax eyelids).

Results:

The study cohort included 30 men and 25 women, with a mean age of 77 years (range 51–93). Epiphora was the commonest presenting complaint (47%) followed by ocular irritation (44%), with the remainder heaving a combination of symptoms. Lower eyelid ectropion (n = 30, 51%) and entropion (n = 26, 44%), constituted the most common indications for surgery. The average postoperative follow-up period was 16 months (range 3–63 months). Fifty-three eyes (90%) had complete resolution of symptoms, while 2 (3.4%) had partial reduction of epiphora. With regard to the eyelid margin position, 57 eyelids (96.6%) were anatomically in a normal position, while 2 operations failed despite early satisfactory results. In terms of correction of medial canthal tendon laxity, 49 cases (83%) were deemed successful. There were no major complications, nor any significant long-term sequelae.

Conclusion:

Posterior medial canthal thermoplasty provides a simple, effective, and safe option for addressing medial canthal tendon laxity.
Dilated Superior Ophthalmic Vein: Clinical and Radiographic Features of 113 Cases
Authors: Adam Christopher R. , Shields Carol L. , Gutman Justin , Kim H. Joon , Hayek Brent , Shore John W. , Braunstein Alexandra , Levin Flora , Winn Bryan J. , Vrcek Ivan , Mancini Ronald , Linden Craig , Choe Christina , Gonzalez Mithra , Altschul David , Ortega-Gutierrez Santiago , Paramasivam Srinivasan , Fifi Johanna T. , Berenstein Alejandro , Durairaj Vikram , Shinder Roman
Published: February 2017

Purpose:

Dilated superior ophthalmic vein (SOV) is an uncommon radiographic finding. The authors review the presentation, etiology, radiography, and visual implications of 113 patients with dilated SOV.

Methods:

An observational case series and multicenter retrospective chart review were conducted. There were 113 patients with a dilated SOV. Outcome measures included patient demographics, clinical features, radiographic findings, diagnosis, and treatment, and treatment outcomes were assessed.

Results:

Cases included 75 women (66%) and 38 men (34%) with a mean age of 49 ± 24 years (range, 0.4–90 years). Diagnoses fell under 6 categories: vascular malformation (n = 92, 81%), venous thrombosis (n = 11, 10%), inflammatory (n = 6, 5%), traumatic hemorrhage (n = 2, 2%), lymphoproliferative (n = 1, 1%), and infectious (n = 1, 1%). Imaging modalities utilized included MRI (n = 98, 87%), digital subtraction angiography (n = 77, 68%), CT (n = 29, 26%), and ultrasonography (n = 4, 4%). Disease status at last follow up included no evidence of disease (n = 57, 50%), alive with persistent disease (n = 53, 47%), and expired from disease (n = 3, 3%). Treatment and management was tailored to the underlying disease process with a mean follow up of 18 months (range, 1 day to 180 months). Visual impairment observed at presentation and last follow up across all cases was 26% and 22%, respectively.

Conclusion:

Dilated SOV is a rare radiographic finding resulting from a wide spectrum of etiologies with clinical implications ranging from benign to sight- and life-threatening. Dilated SOV is most often found with dural-cavernous fistula or carotid-cavernous fistula, orbital or facial arteriovenous malformation, and venous thrombosis. Recognition of this finding and management of the underlying condition is critical.
Imaging the Canaliculops With Ultrasound Biomicroscopy and Anterior Segment Ocular Coherence Tomography
Authors: Singh Swati , Ali Mohammad Javed , Peguda Hari Kumar , Naik Milind N.
Published: February 2017

Canaliculops is a noninflammatory and noninfectious ectasia of the canaliculus with serous fluid accumulation. Currently, the etiology is uncertain. To the best of the authors’ knowledge only 6 confirmed cases have been published earlier; however, the imaging features were not described. The authors report the ultrasound biomicroscopic and ocular coherence tomography features of a histopathologically proven canaliculops.
Photographs of Daily Activities–Youth English: validating a targeted assessment of worry and anticipated pain
Authors: Simons Laura E. , Pielech Melissa , McAvoy Shannon , Conroy Caitlin , Hogan Melinda , Verbunt Jeanine A. , Goossens Marielle E.
Published: February 2017

PHODA is an electronic measure that individualizes and guides treatment for individuals with chronic pain. Implicit in its design is recognition that pain-related fear is a driving force that impedes treatment progress. With this tool, patients visually rate their expectations about the harmful consequences of specific movements. This study aimed to (1) develop and validate PHODA-Youth English (PHODA-YE) and (2) evaluate the potential impact of PHODA-YE assessment on treatment outcomes. Participants were 195 youth, age 8 to 20 years, who presented to an outpatient pain clinic for evaluation (n = 99), or enrolled at the Pediatric Pain Rehabilitation Center (PPRC) intensive program (PPRC; n = 96). All patients completed the PHODA-YE along with measures of emotional functioning and disability. Patients in the PPRC completed the measure at both admission and discharge. After eliminating infrequently endorsed and poorly loading items, factor analytic procedures yielded a 4-subscale, 50-item measure with strong internal consistency (from 0.92 to 0.97 across subscales). Fear, avoidance, and functional disability were strongly associated with PHODA-YE scores, supporting construct validity. Within the PPRC sample, PHODA-YE was sensitive to changes over time in relation to functional improvements. Across the PPRC sample, patients found it helpful to complete the PHODA and target feared activities. Altogether, the PHODA-YE is a valid and concrete assessment tool that rapidly identifies specific activities and movements that elicit fearful responses from patients.
Burning pain: axonal dysfunction in erythromelalgia
Authors: Farrar Michelle A. , Lee Ming-Jen , Howells James , Andrews Peter I. , Lin Cindy S.-Y.
Published: February 2017

Erythromelalgia (EM) is a rare neurovascular disorder characterized by intermittent severe burning pain, erythema, and warmth in the extremities on heat stimuli. To investigate the underlying pathophysiology, peripheral axonal excitability studies were performed and changes with heating and therapy explored. Multiple excitability indices (stimulus–response curve, strength–duration time constant (SDTC), threshold electrotonus, and recovery cycle) were investigated in 23 (9 EMSCN9A+ and 14 EMSCN9A−) genetically characterized patients with EM stimulating median motor and sensory axons at the wrist. At rest, patients with EM showed a higher threshold and rheobase (P < 0.001) compared with controls. Threshold electrotonus and current–voltage relationships demonstrated greater changes of thresholds in both depolarizing and hyperpolarizing preconditioning electrotonus in both EM cohorts compared with controls in sensory axons (P < 0.005). When average temperature was raised from 31.5°C to 36.3°C in EMSCN9A+ patients, excitability changes showed depolarization, specifically SDTC significantly increased, in contrast to the effects of temperature previously established in healthy subjects (P < 0.05). With treatment, 4 EMSCN9A+ patients (4/9) reported improvement with mexiletine, associated with reduction in SDTC in motor and sensory axons. This is the first study of primary EM using threshold tracking techniques to demonstrate alterations in peripheral axonal membrane function. Taken together, these changes may be attributed to systemic neurovascular abnormalities in EM, with chronic postischaemic resting membrane potential hyperpolarization due to Na+/K+ pump overactivity. With heating, a trigger of acute symptoms, axonal depolarization developed, corresponding to acute axonal ischaemia. This study has provided novel insights into EM pathophysiology.
Psychophysical and psychological predictors of acute pain after breast surgery differ in patients with and without pre-existing chronic pain
Authors: Ruscheweyh Ruth , Viehoff Anika , Tio Joke , Pogatzki-Zahn Esther M.
Published: February 2017

The prediction of acute postoperative pain would be of great clinical advantage, but results of studies investigating possible predictors are inconsistent. Here, we studied the role of a wide variety of previously suggested predictors in 74 patients undergoing breast surgery. Preoperatively, patients filled out the Pain Sensitivity Questionnaire (PSQ) and a set of psychological questionnaires (the Beck Depression Inventory [BDI], State-Trait Anxiety Inventory [STAI], and Pain Catastrophizing Scale [PCS]) and participated in an experimental pain testing session, including assessment of conditioned pain modulation (CPM), temporal summation, and responses to heat, pinprick, and pressure pain. Postoperatively, patients reported pain intensity. Stepwise linear regression analysis was used to test for prediction of maximal pain on postoperative day 1 in the whole cohort and in the subgroups of patients with and without pre-existing chronic pain. In the total group, linear regression identified only the expectation of postoperative pain intensity as significant predictor (F[1,65] = 6.5,P< 0.05), explaining 9% of the variance. In patients without pre-existing chronic pain, a smaller CPM effect predicted more postoperative pain, explaining 17% of the variance (F[1,48] = 9.9,P< 0.01). In patients with pre-existing chronic pain, higher PSQ and PCS scores predicted more postoperative pain, together explaining 54% of the variance (F[2,19] = 11.1,P< 0.001). In conclusion, prediction of acute postoperative pain in the whole group was limited. This might be due to differing predictors in specific subgroups of patients. Although CPM predicted pain in patients without pre-existing chronic pain, PSQ and PCS predicted pain in patients with pre-existing chronic pain.
Clinical Outcomes of Concomitant Use of Warfarin and Selective Serotonin Reuptake Inhibitors
Authors: Dong Yaa-Hui , Bykov Katsiaryna , Choudhry Niteesh K. , Donneyong Macarius M. , Huybrechts Krista F. , Levin Raisa , Schneeweiss Sebastian , Gagne Joshua J.
Published: February 2017

Background

Patients treated with warfarin are often coprescribed selective serotonin reuptake inhibitors (SSRIs) for coexisting depression. Some SSRIs are potent CYP2C9 inhibitors that may increase warfarin plasma concentrations and the risk of bleeding. We aimed to examine the effect of the putative CYP2C9-mediated warfarin-SSRI interaction on clinical outcomes.

Methods

We conducted an observational cohort study among warfarin initiators who had a subsequent SSRI prescription in 5 US claims databases. Patients were followed for up to 180 days as long as they were exposed to both warfarin and their index SSRI groups. Cox regression models were used to estimate hazard ratios and 95% confidence intervals for bleeding events, ischemic or thromboembolic events, and mortality comparing patients treated with SSRIs that are potent CYP2C9 inhibitors (fluoxetine, fluvoxamine) with those treated with other SSRIs after propensity score matching.

Findings

The eligible cohort comprised 52,129 patients. Hazard ratios were 1.14 (95% confidence interval [CI], 0.94–1.38) for bleeding events, 1.03 (95% CI, 0.87–1.21) for ischemic or thromboembolic events, and 0.90 (95% CI, 0.72–1.14) for mortality. Results were consistent across individual component outcomes, different warfarin stabilization periods, and subgroup analyses.

Conclusions

Patients concomitantly treated with warfarin and SSRIs that are potent CYP2C9 inhibitors had comparable rates of bleeding events, ischemic or thromboembolic events, and mortality as did patients cotreated with warfarin and other SSRIs, although small but potentially meaningful effects on bleeding cannot be completely excluded. SSRI inhibition of CYP2C9 does not appear to affect major safety or effectiveness outcomes of warfarin treatment in clinical practice, where patients may be closely monitored.
Comparison of the Efficacy and Safety of Aripiprazole Versus Bupropion Augmentation in Patients With Major Depressive Disorder Unresponsive to Selective Serotonin Reuptake Inhibitors
Authors: Cheon Eun-Jin , Lee Kwang-Hun , Park Young-Woo , Lee Jong-hun , Koo Bon-Hoon , Lee Seung-Jae , Sung Hyung-Mo
Published: February 2017

Purpose

The purpose of this study was to compare the efficacy and safety of aripiprazole versus bupropion augmentation in patients with major depressive disorder (MDD) unresponsive to selective serotonin reuptake inhibitors (SSRIs).

Methods

This is the first randomized, prospective, open-label, direct comparison study between aripiprazole and bupropion augmentation. Participants had at least moderately severe depressive symptoms after 4 weeks or more of SSRI treatment. A total of 103 patients were randomized to either aripiprazole (n = 56) or bupropion (n = 47) augmentation for 6 weeks. Concomitant use of psychotropic agents was prohibited. Montgomery Asberg Depression Rating Scale, 17-item Hamilton Depression Rating scale, Iowa Fatigue Scale, Drug-Induced Extrapyramidal Symptoms Scale, Psychotropic-Related Sexual Dysfunction Questionnaire scores were obtained at baseline and after 1, 2, 4, and 6 weeks of treatment.

Results

Overall, both treatments significantly improved depressive symptoms without causing serious adverse events. There were no significant differences in the Montgomery Asberg Depression Rating Scale, 17-item Hamilton Depression Rating scale, and Iowa Fatigue Scale scores, and response rates. However, significant differences in remission rates between the 2 groups were evident at week 6 (55.4% vs 34.0%, respectively; P = 0.031), favoring aripiprazole over bupropion. There were no significant differences in adverse sexual events, extrapyramidal symptoms, or akathisia between the 2 groups.

Conclusions

The present study suggests that aripiprazole augmentation is at least comparable to bupropion augmentation in combination with SSRI in terms of efficacy and tolerability in patients with MDD. Both aripiprazole and bupropion could help reduce sexual dysfunction and fatigue in patients with MDD. Aripiprazole and bupropion may offer effective and safe augmentation strategies in patients with MDD who are unresponsive to SSRIs. Double-blinded trials are warranted to confirm the present findings.
Guarding the Gate
Authors: Freeman Marlene P. , Pooley James , Flynn Martina J. , Baer Lee , Mischoulon David , Mou David , Fava Maurizio
Published: February 2017

Background

Failed treatment trials are common in major depressive disorder and treatment-resistant depression, and remotely performed multifaceted, centralized structured interviews can potentially enhance signal detection by ensuring that enrolled patients meet eligibility criteria.

Methods

We assessed the use of a specific remote structured interview that validated the diagnosis, level of treatment resistance, and depression severity. The objectives were to (1) assess the rate at which patients who were deemed eligible for participation in trials by site investigators were ineligible, (2) assess the reasons for ineligibility, (3) compare rates of ineligibility between academic and nonacademic sites, (4) compare eligibility between US and non-US sites, and (5) report the placebo response rates in trials utilizing this quality assurance approach, comparing its placebo response rates with those reported in the literature. Methods included a pooled analysis of 9 studies that utilized this methodology (SAFER interviews).

Results

Overall, 15.33% of patients who had been deemed eligible at research sites were not eligible after the structured interviews. The most common reason was that patients did not meet the study requirements for level of treatment resistance. Pass rates were significantly higher at non-US compared with US sites (94.6% vs 83.3%, respectively; P < 0.001). There was not a significant difference between academic and nonacademic sites (87.8% vs 82.4%; P = 0.08). Placebo response rates were 13.0% to 27.3%, below the 30% to 40% average in antidepressant clinical trials, suggesting a benefit of the quality assurance provided by these interviews.

Conclusions

The use of a remotely structured interview by experienced clinical researchers was feasible and possibly contributed to lower-than-average placebo response rates. The difference between US and non-US sites should be the subject of further research.
Clinical Use of Mood Stabilizers With Antidepressants in Asia
Authors: Rajaratnam Kamini , Xiang Yu-Tao , Tripathi Adarsh , Chiu Helen F.K. , Si Tian-Mei , Chee Kok-Yoon , Avasthi Ajit , Grover Sandeep , Chong Mian-Yoon , Kuga Hironori , Kanba Shigenobu , He Yan-Ling , Lee Min-Soo , Yang Shu-Yu , Udomratn Pichet , Kallivayalil Roy A. , Tanra Andi J. , Maramis Margarita M. , Shen Winston W. , Sartorius Norman , Kua Ee-Heok , Tan Chay-Hoon , Mahendran Rathi , Shinfuku Naotaka , Sum Min Yi , Baldessarini Ross J. , Sim Kang
Published: February 2017

Objective

As most reports concerning treatment with combinations of mood stabilizer (MS) with antidepressant (AD) drugs are based in the West, we surveyed characteristics of such cotreatment in 42 sites caring for the mentally ill in 10 Asian countries.

Methods

This cross-sectional, pharmacoepidemiologic study used 2004 and 2013 data from the REAP-AD (Research Study on Asian Psychotropic Prescription Patterns for Antidepressants) to evaluate the rates and doses of MSs given with ADs and associated factors in 4164 psychiatric patients, using standard bivariate methods followed by multivariable logistic regression modeling.

Results

Use of MS + AD increased by 104% (5.5% to 11.2%) between 2004 and 2013 and was much more associated with diagnosis of bipolar disorder than major depression or anxiety disorder, as well as with hospitalization > outpatient care, psychiatric > general-medical programs, and young age (all P < 0.001), but not with country, sex, or AD dose.

Conclusions

The findings provide a broad picture of contemporary use of MSs with ADs in Asia, support predictions that such treatment increased in recent years, and was associated with diagnosis of bipolar disorder, treatment in inpatient and psychiatric settings, and younger age.
Short-Term Effects of Methylphenidate on Math Productivity in Children With Attention-Deficit/Hyperactivity Disorder are Mediated by Symptom Improvements
Authors: Kortekaas-Rijlaarsdam Anne Fleur , Luman Marjolein , Sonuga-Barke Edmund , Bet Pierre M. , Oosterlaan Jaap
Published: February 2017

Background

Although numerous studies report positive effects of methylphenidate on academic performance, the mechanism behind these improvements remains unclear. This study investigates the effects of methylphenidate on academic performance in children with attention-deficit/hyperactivity disorder (ADHD) and the mediating and moderating influence of ADHD severity, academic performance, and ADHD symptom improvement.

Methods

Sixty-three children with ADHD participated in a double-blind placebo-controlled crossover study comparing the effects of long-acting methylphenidate and placebo. Dependent variables were math, reading, and spelling performance. The ADHD group performance was compared with a group of 67 typically developing children.

Results

Methylphenidate improved math productivity and accuracy in children with ADHD. The effect of methylphenidate on math productivity was partly explained by parent-rated symptom improvement, with greater efficacy for children showing more symptom improvement. Further, children showing below-average math performance while on placebo profited more from methylphenidate than children showing above-average math performance.

Conclusions

The results from this study indicate positive effects of methylphenidate on academic performance, although these were limited to math abilities. In light of these results, expectations of parents, teachers, and treating physicians about the immediate effects of methylphenidate on academic improvement should be tempered. Moreover, our results implicate that positive effects of methylphenidate on math performance are in part due directly to effects on math ability and in part due to reductions in ADHD symptoms.
Efficacy of Desvenlafaxine Compared With Placebo in Major Depressive Disorder Patients by Age Group and Severity of Depression at Baseline
Authors: Mosca Daniel , Zhang Min , Prieto Rita , Boucher Matthieu
Published: February 2017

Purpose

This post hoc meta-analysis evaluated the efficacy and safety of desvenlafaxine 50 and 100 mg versus placebo across age groups and severity of depression at baseline in patients with major depressive disorder.

Methods

Data from placebo and desvenlafaxine 50-mg and 100-mg dose arms were pooled from 9 short-term, placebo-controlled, major depressive disorder studies (N = 4279). Effects of age (18–40 years, >40 to <55 years, 55–<65 years, and ≥65 years) and baseline depression severity (mild, 17-item Hamilton Rating Scale for Depression total score [HAM-D17] ≤18; moderate, HAM-D17 >18 to <25; severe, HAM-D17 ≥25) on desvenlafaxine efficacy were assessed using analysis of covariance for continuous end points and logistic regression for categorical end points.

Findings

Desvenlafaxine-treated (50 or 100 mg/d) patients had significantly (P < 0.05, 2-sided) greater improvement in most measures of depression and function compared with placebo for patients 18 to 40 years, older than 40 to younger than 55 years, and 55 to younger than 65 years, with no significant evidence of an effect of age. Desvenlafaxine significantly improved most measures of depression and function in moderately and severely depressed patients. There was a significant baseline severity by treatment interaction for HAM-D17 total score only (P = 0.027), with a larger treatment effect for the severely depressed group.

Implications

Desvenlafaxine significantly improved depressive symptoms in patients younger than 65 years and in patients with moderate or severe baseline depression. Sample sizes were not adequate to assess desvenlafaxine efficacy in patients 65 years or older or with mild baseline depression.
Renal Transplant Recipients: The Factors Related to Immunosuppressive Medication Adherence Based on the Health Belief Model
Authors: Kung Pen-Chen , Yeh Mei Chang , Lai Ming-Kuen , Liu Hsueh–Erh
Published: February 2017

Background:

Kidney transplant failures are caused primarily by lack of adherence to immunosuppressive medication regimens by patients after transplantation. A number of studies have indicated that health-related beliefs are an effective predictor of health-related behavior.

Purpose:

The aim of this study is to understand the influence of the personal characteristics and health-related beliefs of patients on adherence to treatment with immunosuppressive medication based on the Health Belief Model.

Methods:

This cross-sectional study distributed questionnaires to patients who had been recruited via purposive sampling at one medical center in Taipei. All of the potential participants had undergone kidney transplantation at least 6 months previously. The self-developed questionnaire collected data in three areas: personal characteristics, health-related beliefs regarding transplant rejection, and adherence to the immunosuppressive medication regimen. One hundred twenty-two valid questionnaires were received. The collected data were analyzed using descriptive statistics, independent t test, one-way analysis of variance, Pearson’s correlation, and multiple regression.

Results:

Participants who had received dialysis treatment or had experienced rejection perceived susceptibility to rejection more strongly than those who had not. Participants who had undergone transplantation in Taiwan, had experienced more drug-related symptoms, or had contracted severe to extremely severe infections in the past showed lower rates of adherence to treatment with immunosuppressive medication. Adherence to medication regimens correlated negatively with length of time since transplantation. Length of time since transplantation, drug-related symptoms, perceived susceptibility to rejection, and perceived benefits of treatment were identified as major predictors of adherence to immunosuppressive medication regimens.

Conclusions:

The results partially conformed to the concepts of the Health Belief Model. Perceived susceptibility to rejection and perceived benefits of adherence to treatment were found to predict adherence rates. Patient education should be enhanced to reduce the risks of rejection and increase adherence rates to improve outcomes.
Procedural Learning Perspectives of Pulmonary Fellows and Practitioners
Authors: Lee Hans J. , Coleman Briana , Lerner Andrew D. , Feller-Kopman David , Semaan Roy , Frimpong Bernice , Yarmus Lonny
Published: February 2017

Background:

Procedural learning requires both didactic knowledge and motor skills. Optimal teaching styles and techniques remain to be defined for pulmonary procedural learning. We investigated the preferences of learners at 2 different points in a pulmonary career; as pulmonary fellows and as clinical practitioners.

Methods:

A perception survey was conducted among pulmonary fellows and practitioners from multiple institutions throughout the United States. Fellows and practitioners were immediately surveyed on procedural learning factors after completing a procedural learning course using low/high-fidelity and/or cadaver simulators. Survey questions consisting of biographical information and multiple choice, Likert style, and qualitative questions regarding learning preferences were collected.

Results:

Seventy-five physicians (44 pulmonary fellows, 31 practitioners) from 35 centers completed the survey. Pulmonary practitioners preferred an academic expert, whereas fellows preferred familiar faculty as lecturers for procedural learning (P=0.03). There were no statistical differences between fellows/practitioners value of the use of simulators, didactics, or handouts. Both groups preferred animal/cadaver and high-fidelity simulators to low-fidelity simulators. Both groups also preferred a traditional course structure to problem-based learning/flipped classroom. The most common answer to barriers for learning a new procedure was “time” for training followed by “opportunities” to learn.

Conclusions:

Pulmonary fellows and practitioners we surveyed preferred a traditional course structure with cadaver/animal models and high-fidelity simulation training as compared with a flipped classroom model and low-fidelity simulators, but whether this holds true for the wider population is unknown. Larger studies are needed to validate learning perception with outcomes.
Can the Video Head Impulse Test Define Severity of Bilateral Vestibular Hypofunction?
Authors: Judge Paul D. , Janky Kristen L. , Barin Kamran
Published: February 2017

Objective:

The objective of the study was to compare rotary chair and video head impulse test (vHIT) findings in patients with bilateral vestibular hypofunction (BVH) to determine whether vHIT can: 1) define severity of BVH and 2) accurately predict rotary chair findings in patients with BVH.

Study Design:

Retrospective chart review.

Setting:

Research hospital.

Patients:

Twenty subjects with bilateral vestibular hypofunction as assessed by rotary chair.

Intervention:

Rotary chair and vHIT.

Main Outcome Measures:

The main outcome measures were rotary chair phase, gain, and symmetry and vHIT vestibulo-ocular reflex (VOR) gain. Rotary chair and vHIT results were assessed and subjects were stratified into groups according to the severity of their vestibular hypofunction. For rotary chair, subjects were classified as mild, moderate, or severe BVH. For vHIT, subjects were classified as normal, unilateral, or bilateral.

Results:

Average lateral canal vHIT VOR gain: 1) significantly increased as severity of BVH decreased, and 2) demonstrated a significant and positive, linear relationship with rotary chair gains. vHIT was in disagreement with rotary chair in the classification of five subjects, which could be due to right-left asymmetry of BVH.

Conclusion:

vHIT can serve as an initial tool for identifying patients with BVH. Lower vHIT gains are consistent with having severe BVH. There was disagreement between vHIT and rotary chair, though not for any patients with severe BVH. Compared with rotary chair, the clinical gold standard for identifying BVH, vHIT possesses 100% sensitivity for excluding severe BVH when average vHIT gains are greater than 0.46.
Improvements in Gait With Hearing Aids and Cochlear Implants
Authors: Shayman Corey S. , Earhart Gammon M. , Hullar Timothy E.
Published: February 2017

Objective:

To evaluate whether wearing auditory assistive devices can improve gait and dynamic balance.

Patients:

Three adult users of bilateral hearing assistive devices: one with cytomegalovirus exposure wearing cochlear implants, one with Ménière's disease wearing hearing aids, and one with presbystasis wearing hearing aids.

Intervention:

Rehabilitative intervention involved participants performing gait and dynamic posture tasks with and without their hearing assistive devices.

Main Outcome Measures:

Gait velocity and Mini-BESTest score.

Results:

The participant with Ménière's disease showed a clinically significant improvement in gait in the aided versus the unaided condition (20.5 cm/s higher velocity and five point better Mini-BESTest score). The other two participants also improved with augmented audition, but to a lesser degree.

Conclusions:

Bilateral hearing augmentation may promote clinically significant improvements in gait, although the effects are not uniform among patients. Hearing aids or cochlear implants may be important interventions for improving stability during walking in some people with hearing loss.
Flow Rate Through Pigtail Catheter Used for Left Heart Decompression in an Artificial Model of Extracorporeal Membrane Oxygenation Circuit
Authors: Kim Won Ho , Hong Tae Hee , Byun Joung Hun , Kim Jong Woo , Kim Sung Hwan , Moon Sung Ho , Park Hyun Oh , Choi Jun Young , Yang Jun Ho , Jang In Seok , Lee Chung Eun , Yun Jeong Hee
Published: February 2017

In refractory cardiogenic shock, veno-arterial extracorporeal membrane oxygenation (ECMO) can be initiated. Although left heart decompression can be accomplished by insertion of a left atrial (LA) or left ventricular (LV) cannula using a percutaneous pigtail catheter, the venting flow rate according to catheter size and ECMO flow rate is unknown. We developed an artificial ECMO circuit. One liter saline bag with its pressure set to 20 mm Hg was connected to ECMO to mimic LV failure. A pigtail catheter was inserted into the 1 L saline bag to simulate LV unloading. For each pigtail catheter size (5–8 Fr) and ECMO flow rate (2.0–4.0 L/min), the moving distance of an air bubble that was injected through a three-way stopcock was measured in the arterial pressure line between the pigtail catheter and ECMO inflow limb. The flow rate was then calculated. We obtained the following equation to estimate the pigtail catheter flow rate.

Pigtail vent catheter flow rate (ml/min) = 8×ECMOflow rate(L /min)+9×pigtail catheter size(Fr)- 57

This equation would aid in designing of a further study to determine optimal venting flow rate. To achieve optimal venting flow, our equation would enable selection of an adequate catheter size.
Utility of CHA2DS2-VASc and HAS-BLED Scores as Predictor of Thromboembolism and Bleeding After Left Ventricular Assist Device Implantation
Authors: Kemal Hatice S. , Ertugay Serkan , Nalbantgil Sanem , Ozturk Pelin , Engin Cagatay , Yagdi Tahir , Ozbaran Mustafa
Published: February 2017

Ischemic and hemorrhagic events are the common causes of morbidity and mortality after continuous-flow left ventricular assist device (CF-LVAD) implantation. CHA2DS2-VASc score predicts thromboembolic (TE) event risk and HAS-BLED score predicts bleeding risk in patients on anticoagulant with atrial fibrillation (AF). We aimed to evaluate whether these scoring systems would be predictive of TE and bleeding complications after CF-LVAD implantation. From December 2010 to December 2014, 145 patients who underwent CF-LVAD implantation at a single center were included. Mean age was 50.7 ± 11.2 years, and 85.5% were male. Baseline CHA2DS2-VASc and HAS-BLED scores were retrospectively determined for patients with CF-LVADs. After device implantation, all patients were on warfarin (target international normalized ratio 2–3) as well as 300 mg of aspirin daily. Median length of support was 316 days (range 31–1,060), with 22 TE events (15.2%) and 32 bleeding (22.1%) events. The mean CHA2DS2-VASc score was 2.3 ± 1.4 and 2.5 ± 1.2 (p = 0.2) in patients with and without TE event, respectively. The mean HAS-BLED score was 1.8 ± 0.8 and 1.42 ± 0.6 (p = 0.004) in patients with and without bleeding, respectively. Baseline high HAS-BLED score was predictive of bleeding events after CF-LVAD implantation, whereas baseline CHA2DS2-VASc score was not predictive of TE events.