bluuebunny/crossref_metadata_2025 huggingface dataset:
Lipoprotein(a) Testing and Emerging Therapies
Authors: Mayo-Malasky Perry , Frishman William H.
Published: November 2019

The study of lipoprotein(a) [Lp(a)] over the years has been a source of both enlightenment and frustration for the medical community. Accumulating evidence from large sample observational studies, Mendelian randomization studies, and genome-wide association studies has strengthened the association between Lp(a) and the development of atherosclerotic cardiovascular disease. This evidence supports the testing of Lp(a) in certain high-risk populations in order for clinicians to improve the risk profile of patients. Despite a variety of medical therapies that have been proven to reduce Lp(a) levels, the connection between the medical management of serum Lp(a) and improved cardiovascular outcomes remains elusive, due to the lack of specificity that current therapies have in targeting the Lp(a) production pathway. A new frontier in Lp(a) research has emerged with antisense-oligonucleotide therapy and RNA interference therapy, both of which target Lp(a) production at the level of mRNA translation. These therapies provide a pathway for investigating the effect of medical management of serum Lp(a) on cardiovascular outcomes.
The Prognostic Value of Podoplanin Expression in Nonmelanoma Skin Cancers: Correlation With Lymphatic Vessel Density
Authors: Neinaa Yomna Mazid El-Hamd , El-Ashmawy Amal Ahmad , Alshenawy Hanan Al-Saeid , Dorgham Wesam Lotfy
Published: November 2019

Background:

Podoplanin is one of the integral molecules controlling cellular motility and migration that is considered crucial in initiating tumor invasiveness and metastasis.

Objective:

This work aimed at studying the immunohistochemical expression of podoplanin in nonmelanoma skin cancers (NMSCs) and seborrheic keratosis (SK) in comparison to normal control skin and to evaluate its possible role in their pathogenesis.

Patients and Methods:

This study included 120 patients and paraffin blocks of epidermal tumors [30 SK, 30 basal cell carcinoma (BCC), 30 basosquamous carcinoma (BSC) and 30 squamous cell carcinoma (SCC)], in addition to 30 normal control skin specimens from age- and sex-matched healthy volunteers. All were examined for intratumoral and peritumoral immunohistochemical expression of podoplanin antibody (D2-40). In addition, morphometric measurement of lymphatic vessel density was evaluated in all studied specimens.

Results:

Podoplanin expression was significantly upregulated in all the studied epidermal tumor specimens in comparison to normal control skin specimens. The highest mean value of podoplanin expression (both intratumoral and peritumoral cells) was observed in SCC followed by BSC, then BCC, SK, and control skin in the same sequence. Positive correlations were detected between its expression in both BSC and SCC with the mean of lymphatic vessel density in the studied specimens and the presence of lymph node metastasis.

Conclusions:

Podoplanin plays an evident role in the development and progression of both benign and malignant skin neoplasms and may serve as a potential predictor of their clinical course and prognosis.
Caring for a Child with Phenylketonuria: Parental Experiences from a Eurasian Country
Authors: Zengin Akkus Pinar , Bilginer Gurbuz Berrak , Ciki Kismet , Ilter Bahadur Evin , Karahan Sevilay , Ozmert Elif Nursel , Coskun Turgay , Sivri Serap
Published: November 2019

Objectives:

Phenylketonuria (PKU) and mild hyperphenylalaninemia (HPA) are characterized by increased blood phenylalanine concentrations varying from mild to severe. Management of PKU was reported to be time consuming and burdensome for caregivers. This study intended to explore the experiences of families caring for a child with PKU/HPA in a country with a high PKU rate. The aim of this study was to compare parental well-being between parents of children with and without dietary restrictions and to explore the factors associated with parental psychological well-being.

Methods:

Participants were interviewed about their experiences, concerns, and challenges related to the disease by using a semistructured questionnaire. After the interview, parents filled out the Beck Depression Inventory and State-Trait Anxiety Inventory-Trait.

Results:

This study highlighted the adverse psychological, financial, and social effects of the diagnosis and management of the disease regarding the lives of the families of children with PKU/HPA. Although parental anxiety scores of children with and without dietary restrictions were similar, depressive symptom scores were higher in parents of children with dietary restrictions. However, in multiple regression analysis, lower household income and absence of perceived social support were found to be independent factors associated with higher depressive symptom scores. Having a daughter diagnosed with PKU/HPA and lower household income were found to be factors associated with higher anxiety scores.

Conclusion:

This study revealed that income level, perceived social support, and gender of the child were factors associated with psychological well-being of parents caring for children with PKU/HPA. Health care professionals should identify the challenges faced by families and should be aware of risk factors associated with lower parental well-being to achieve better family adjustment and better health outcomes.
Extramammary Paget's Disease: A Review of the Literature Part II: Treatment and Prognosis
Authors: Morris Caroline R. , Hurst Eva A.
Published: November 2019

BACKGROUND

Extramammary Paget's disease (EMPD) is a rare malignancy with unclear pathophysiology that occurs predominantly on apocrine-rich skin. Surgery is the treatment of choice; however, procedures tend to be extensive and associated with a high rate of recurrence.

OBJECTIVE

To review the current literature on EMPD regarding treatment and prognosis.

MATERIALS AND METHODS

Literature review using PubMed search for articles related to EMPD.

RESULTS

Extramammary Paget's disease classically presents as a slowly growing red plaque, which often mimics an inflammatory condition leading to significant delay in diagnosis. Diagnosis requires histopathologic examination and is often supported by immunohistochemical analysis. Once a diagnosis of EMPD is made, the patient must be risk-stratified and evaluated for an underlying malignancy.

CONCLUSION

Standard of treatment is surgery, with data suggesting that Mohs micrographic surgery may have superior clinical outcomes and lower recurrence rates. Alternatives such as photodynamic therapy and topicals have been explored and may be appropriate in certain situations. Patients with EMPD generally have a good prognosis with a 5-year overall survival rate of 75% to 95%.
The Force Required to Inject a Column of Filler Through Facial Arteries
Authors: Ramesh Sathyadeepak , Le Alan , Katsev Blake , Ugradar Shoaib
Published: November 2019

BACKGROUND

Injectable fillers have become an integral part of facial rejuvenation, but vascular occlusion is a dreaded complication of such injections.

OBJECTIVE

To determine the force required by the fingertip onto the plunger of the syringe to cause retrograde migration.

METHODS

In this cadaver study, twelve 2-cm arterial segments and 4 fillers were tested. Injection pressure required to force a column of filler for 1 cm was measured. Five oculoplastics specialists were subsequently recruited and asked to inject the filler at a typical injection pressure.

RESULTS

The nonhyaluronic acid filler required significantly more pressure to cause propagation of the material compared with all other fillers (p < .01). None of the other fillers differed significantly from each other. Typical injection pressures generated by experienced injectors were significantly lower than that required to cause propagation of filler at the desired velocity and significantly lower than mean arterial pressure. Measured pressure required to cause filler propagation was well within the normal range of the finger strength that can be generated by humans.

CONCLUSION

Typical injection pressures from fingertip to plunger are lower than required to cause propagation of filler intravascularly.
Trends in Tract-Level Prevalence of Obesity in Philadelphia by Race-Ethnicity, Space, and Time
Authors: Quick Harrison , Terloyeva Dina , Wu Yaxin , Moore Kari , Diez Roux Ana V.
Published: November 2019

The growing recognition of often substantial neighborhood variation in health within cities has motivated greater demand for reliable data on small-scale variations in health outcomes. The goal of this article is to explore temporal changes in geographic disparities in obesity prevalence in the City of Philadelphia by race and sex over the period 2000–2015. Our data consist of self-reported survey responses of non-Hispanic whites, non-Hispanic blacks, and Hispanics from the Southeastern Pennsylvania Household Health Survey. To analyze these data—and to obtain more reliable estimates of the prevalence of obesity—we apply a Bayesian model that simultaneously accounts for spatial-, temporal-, and between-race/ethnicity dependence structures. This approach yields estimates of the obesity prevalence by age, race/ethnicity, sex, and poverty status for each census tract at all time-points in our study period. While the data suggest that the prevalence of obesity has increased at the city-level for men and women of all three race/ethnicities, the magnitude and geographic distribution of these increases differ substantially by race/ethnicity and sex. The method can be flexibly used to describe and visualize spatial heterogeneities in levels, trends, and in disparities. This is useful for targeting, surveillance, and etiologic research.
Routine Therapeutic Drug Monitoring of Dabigatran: Experience at a Tertiary Center
Authors: Chin Paul Ken Leong , McNeill Richard , Lee Hyun Kyoung , Zhang Mei , Jensen Berit , Smith Mark , Doogue Matthew P.
Published: November 2019

Background:

A liquid chromatography-mass spectrometry assay to determine plasma dabigatran concentrations has been available for routine clinical use at our tertiary institutions since 2017. The aim of the study was to describe (1) the use of the assay over time; (2) the indications for testing; and (3) subsequent dabigatran prescribing decisions.

Methods:

Patients for whom dabigatran concentrations were measured were identified using the laboratory database, and clinical data were extracted from the associated electronic health records.

Results:

There were 233 samples in 24 months. The use of dabigatran increased over time, with a mean (95% confidence interval) increase of +0.5 (0.3–0.7) samples per month. Dabigatran concentrations ranged from <1 to 1060 mcg/L. The main reasons for testing were uncertainty about impact on renal function and drug interactions (39%), to inform prescribing decisions after thromboembolic or bleeding events (21%), and for investigation following dose-adjustment (16%). Dabigatran dose was changed after 30% (68/233) of assay results.

Conclusions:

The clinical use of the dabigatran assay has increased, with almost one-third of results associated with a subsequent change in dabigatran prescribing.
International Expert Panel Consensus on Fat Grafting of the Breast
Authors: Nava Maurizio B. , Blondeel Phillip , Botti Giovanni , Casabona Francesco , Catanuto Giuseppe , Clemens Mark W. , De Fazio Domenico , De Vita Roy , Grotting James , Hammond Dennis C. , Harris Paul , Montemurro Paolo , Mendonça Munhoz Alexandre , Nahabedian Maurice , Pompei Stefano , Rancati Alberto , Rigotti Gino , Salgarello Marzia , Scaperrotta Gianfranco , Spano Andrea , Stan Costantin , Rocco Nicola
Published: November 2019

Background:

Autologous fat grafting has broad applications in reconstructive and aesthetic breast surgery as a natural filler and for its regenerative purposes. Despite the widespread use of fat grafting, there remains no shared consensus on what constitutes the optimal fat grafting technique and its oncological safety. For this reason, the authors of this study have organized a Survey and an International Consensus Conference that was held at the Aesthetic Breast Meeting in Milan (December 15, 2018).

Methods:

All studies on fat grafting, both for breast aesthetic and reconstructive purposes, were electronically screened. The literature review led to 17 “key questions” that were used for the Survey. The authors prepared a set of 10 “key statements” that have been discussed in a dedicated face-to-face session during the meeting.

Results:

The 10 key statements addressed all the most debated topics on fat grafting of the breast. Levels of evidence for the key statements ranged from III to IV with 2 statements (20%) supported by a level of evidence III and 6 statements (60%) by level of evidence IV. Overall consensus was reached for 2 statements (20%) with >75% agreement reached for 7 statements.

Conclusions:

The survey demonstrated a diversity of opinion and attitude among the panelists with regard to technique. Clear recommendations for evidence-based clinical practice for fat grafting use both in aesthetic and reconstructive breast surgery could not be defined due to the scarcity of level 1 or 2 studies.
Comparisons of Manual Tape Measurement and Morphomics Measurement of Patients with Upper Extremity Lymphedema
Authors: Horbal Steven R. , Chu Sung-Yu , Wang Nicholas C. , Chan Wen-Hui , Huang Yen-Ling , Brown Edward , Holcombe Sven A. , Cederna Paul S. , Wang Stewart C. , Cheng Ming-Huei
Published: November 2019

Background:

Lymphedema is a debilitating condition characterized by swelling from lymph fluid exceeding transport capacity. A gold standard for arm measurement is not established, and measurement methods vary. This study evaluates the comparability of the tape measure and Analytic Morphomics in deriving limb circumference measurements in patients with upper extremity lymphedema.

Methods:

Fifteen participants with diagnosed upper limb lymphedema were included between July 2013 and June 2017 at Chang Gung Memorial Hospital in Taipei, Taiwan. Affected and unaffected arm circumferences were measured using a flexible tape or morphomic measurement at 10 cm above and below the elbow. Computed tomography scans were standardized, processed, smoothed with a piecewise polynomial algorithm for Analytic Morphomics of arm circumference. Comparative plots, mean percent difference, and adjusted coefficient of determination (R
2) were utilized to compare the consistency of both measurement procedures.

Results:

The tape measure and Analytic Morphomics demonstrated consistent measures of arm circumference. On the affected arm, the mean (95% CI) difference in arm circumference between methods was 1.60 cm (0.99–2.20) above, and 0.57 cm (0.23–0.91) below the elbow. Mean percent differences in circumference was 6.65% (SD 3.52%) above and 1.38% (SD 2.11%) below the elbow. The adjusted R
2 for both methods was 94% above and 96% below the elbow.

Conclusions:

Analytic Morphomics showed strong consistency with the manual tape measure of arm circumference measurement in those with upper extremity lymphedema. Analytic Morphomics present an opportunity for a precise, granular measurement of limb composition for assessment of disease state and patient planning.
Use of Near-infrared Spectroscopy and Implantable Doppler for Postoperative Monitoring of Free Tissue Transfer for Breast Reconstruction: A Systematic Review and Meta-analysis
Authors: Berthelot Melissa , Ashcroft James , Boshier Piers , Hunter Judith , Henry Francis Patrick , Lo Benny , Yang Guang-Zhong , Leff Daniel
Published: November 2019

Background:

Failure to accurately assess the perfusion of free tissue transfer (FTT) in the early postoperative period may contribute to failure, which is a source of major patient morbidity and healthcare costs. This systematic review and meta-analysis aim to evaluate and appraise current evidence for the use of near-infrared spectroscopy (NIRS) and/or implantable Doppler (ID) devices compared with conventional clinical assessment (CCA) for postoperative monitoring of FTT in reconstructive breast surgery.

Methods:

A systematic literature search was performed in accordance with the preferred reporting items for systematic reviews guidelines. Studies in human subjects published within the last decade relevant to the review question were identified. Meta-analysis using random-effects models of FTT failure rate and STARD scoring was then performed on the retrieved publications.

Results:

Nineteen studies met the inclusions criteria. For NIRS and ID, the mean sensitivity for the detection of FTT failure is 99.36% and 100% respectively, with average specificity of 99.36% and 97.63%, respectively. From studies with sufficient reported data, meta-analysis results demonstrated that both NIRS [OR = 0.09 (0.02–0.36); P < 0.001] and ID [OR = 0.39 (0.27–0.95); P = 0.04] were associated with significant reduction of FTT failure rates compared with CCA.

Conclusions:

The use of ID and NIRS provided equivalent outcomes in detecting FTT failure and were superior to CCA. The ability to acquire continuous objective physiological data regarding tissue perfusion is a perceived advantage of these techniques. Reduced clinical staff workload and minimized hospital costs are also perceived as positive consequences of their use.
Terri Coutee: ASPS Patient of Courage, 2018
Authors: Chrysopoulo Minas T.
Published: November 2019

Mrs. Terri Coutee was selected as an American Society of Plastic Surgeons (ASPS) Patient of Courage in 2018. Following successful treatment of her second breast cancer, which included a double nipple-sparing mastectomy and delayed deep inferior epigastric perforator (DIEP) flap breast reconstruction, Terri changed her career path from teaching to patient advocacy. In 2016, she launched DiepCFoundation.org, a non-profit organization that provides education, support, resources, and a community for women and men seeking information about breast reconstruction after mastectomy. Today, DiepCFoundation connects patients and physicians on a global scale, fostering a shared decision-making approach to breast reconstruction.
Management of Locked Volar Radio-ulnar Joint Dislocation
Authors: Starnoni Marta , Colzani Giulia , De Santis Giorgio , Leti Acciaro Andrea
Published: November 2019

Isolated volar dislocation of the distal radio-ulnar joint is an extremely rare lesion. Diagnosis is commonly missed. The authors report their experience about a case of an acute locked volar distal radio-ulnar joint dislocation. A correct clinical and radiological diagnosis was done in the Emergency Department, and a closed reduction was achieved only after an axillary block, after a first failed attempt under slight sedation. A K-wire blocking the prono-supination and a short removable forearm cast protected the reduction for 25 days. Two weeks after the removal of the immobilization, the patient presented a complete functional recovery, with full range of motion. The authors highlight the importance of the clinical and radiological findings: a dorsal dimple at the ulnar side leads to a high index of suspicion, and represent the most relevant aid in diagnosis, associated to a proper imaging assessment. Prompt management allows a minimally invasive approach and a rapid functional recovery.
A Meta-analysis of Clinical, Patient-Reported Outcomes and Cost of DIEP versus Implant-based Breast Reconstruction
Authors: Khajuria Ankur , Prokopenko Max , Greenfield Max , Smith Oliver , Pusic Andrea L. , Mosahebi Afshin
Published: November 2019

Introduction:

Comparative data on clinical outcomes and cost of deep inferior epigastric perforator (DIEP) and implant-based reconstruction (IBR) are limited. We conducted a Preferred Reporting Items for Systematic Review and Meta-analysis-compliant systematic review and meta-analysis to compare clinical, patient-reported outcomes (PROs) and cost.

Methods:

The protocol was published a priori on PROSPERO (CRD42017072557). EMBASE, MEDLINE, Google Scholar, Cochrane Controlled Register of Trials, Science Citation Index, and ClinicalTrials.gov were searched from January 1994 to August 2018. Two independent reviewers evaluated the articles for inclusion. Study quality was assessed using Grading of Recommendations Assessment, Development, and Evaluation, and risk of bias (RoB) was assessed using Cochrane’s RoB in Nonrandomized Studies of Interventions tool.

Results:

Out of 6,381 articles screened, 16 were included [unilateral 782 DIEPs, 376 implants; mean age 49 years, follow-up (months): DIEP 29.9; IBR 35.5]. Mean flap loss and fat necrosis rates were 3.97% (SD 4.90) and 9.67% (SD 17.0), respectively. There was no difference in mean length of stay {standard mean difference 0.63 [confidence interval (CI) −9.17 to 10.43]; P =0.90}. The number of reoperations for complications was significantly lower in DIEP versus IBR [SMD −0.29 (CI −0.48 to −0.09); P < 0.01]. There were no randomized controlled trials. Study quality was low with high RoB. One study reported $11,941/Quality-adjusted Life Year incremental cost-effectiveness ratio for DIEP, with higher breast Quality-adjusted Life Year (DIEP 19.5; IBR 17.7) using Breast Questionnaire; 3 studies evaluated cost, favoring DIEP. Two comparative studies evaluating PROs favored DIEP.

Conclusions:

DIEP reconstruction maybe more cost-effective and yield superior PROs. However, poor-quality, bias-ridden studies limit the findings. Adequate reporting of core outcome measures is required to minimize reporting bias and facilitate evidence synthesis. Prospective, multicenter, cohort studies using robust patient-reported outcome measures (PROMs) tools, evaluating cost-effectiveness and contributing to national/international registries, will facilitate national-level policy and shared decision-making.
Intersection-splitting Deep Inferior Epigastric Perforator Flap
Authors: Andejani Doaa F. , AlThubaiti Ghazi A.
Published: November 2019

Preserving a dynamic abdominal wall is the premise behind the evolution of TRAM flaps into deep inferior epigastric perforators (DIEPs). Performing a true DIEP flap requires a highly refined surgical technique and often times involves a tedious intramuscular dissection which may account for the slow, albeit steady adaptation of DIEPs in breast reconstruction. This article intends to address a scenario in which an additional perforator from a different row is needed. Based on our current knowledge of the abdominal wall and its embryology, we propose splitting the rectus abdominis muscle through the intersections while recruiting a second perforator instead of converting the procedure into MS-TRAM or performing a second anastomosis through the perforator exchange technique, APEX. This potentially saves time and simplifies the procedure while maintaining the integrity of the abdominal wall.
“Get a Grip on Hypertension”
Authors: Gordon Benjamin D. H. , Whitmire Sarah , Zacherle Emily W. , Doyle Shelton , Gulati Sanjeev , Leamy Larry J. , Marino Joseph S. , Bennett Jeanette M. , Reitzel Adam M. , Swaine Ian L. , Howden Reuben
Published: November 2019

Purpose:

Isometric handgrip (IHG) training lowers systolic and diastolic blood pressure (SBP and DBP, respectively), but the efficacy of IHG training in cardiopulmonary rehabilitation patients is unknown. The purpose of this study was to determine if IHG decreases blood pressure in cardiopulmonary rehabilitation patients.

Methods:

Cardiopulmonary rehabilitation program participants (n = 11; 50-80 yr old) were randomized to IHG (n = 6) or control (CON; no treatment; n = 5) groups. IHG participants completed an IHG training program at 30% maximal voluntary contraction, 3 d/wk for 6 wk. Resting SBP, DBP, and heart rate were assessed weekly.

Results:

Mean regression for SBP following IHG was negative (−1.04 ± 0.80). Mean regression in the CON group was positive (0.50 ± 0.88), but there was no significant difference between groups. Separate analysis of weeks 1 to 7 yielded a negative mean regression (−1.12 ± 0.54) in the IHG group, but positive (1.2 ± 0.60) in the CON group. A Wilcoxon test of these differences yielded significance for SBP (P= .009). In 3 of 6 IHG participants, SBP was lower (mean ± SD: −16 ± 11 mm Hg;P= .12), and in 2 IHG participants, DBP was lower (−9 ± 1 mm Hg;P= .06) compared with baseline. In 2 of 5 CON participants, SBP was not significantly lower (−11 ± 7 mm Hg) and, in 3 of 5 CON participants, DBP was lower (−7 ± 4 mm Hg;P= .04).

Conclusions:

Our data suggest that standard IHG training may be inadequate for blood pressure management immediately following a major cardiac or pulmonary event. Future work with a larger cohort and more developed training protocol to determine the efficacy of IHG training in patients with cardiopulmonary disease is warranted.
A NOVEL FINDING OF HYPERREFLECTIVE MATERIAL IN THE SILICONE-RETINA INTERFACE
Authors: Trivizki Omer , Zur Dinah , Goldenberg Dafna , Rabina Gilad , Fleissig Efrat , Barak Adiel , Shulman Shiri , Loewenstein Anat , Schwartz Shulamit
Published: November 2019

Purpose:

To describe novel findings of hyperreflective material in the silicone-retina interphase on spectral domain optical coherence tomography (SD-OCT) imaging in eyes with silicone oil tamponade.

Methods:

Retrospective observational clinical study of consecutive patients who underwent primary pars plana vitrectomy with silicone oil tamponade for rhegmatogenous retinal detachment. Repeat clinical examination and spectral domain optical coherence tomography macular imaging performed 3 months after surgery were evaluated to identify any macular pathologies, including formation of epiretinal membranes, intraretinal changes, subretinal fluid, and edema before scheduled secondary vitrectomy for silicone oil removal.

Results:

Eighty-two patients (mean age 54 years, range 22–89) were included. Twelve eyes (14%) showed discrete preretinal hyperreflective organized coarse material in the silicone-retina interphase on spectral domain optical coherence tomography. The material was scattered in the posterior pole, with several foci showing additional hyperreflectivity of the inner retinal layers beneath. These findings did not resemble silicone oil emulsification in size, shape, or reflectivity.

Conclusion:

This is the first report on hyperreflective material detected by spectral domain optical coherence tomography in the silicone-retina interphase in eyes with silicone oil tamponade. These findings may represent an inflammatory response to silicone oil exposure that may be the initial manifestation of a future proliferative process, warranting a rigorous follow-up protocol for affected patients.
Autologous Descemet Stripping Automated Endothelial Keratoplasty to Eliminate Endothelial Rejection in Eyes at High Risk
Authors: Myerscough James , Friehmann Asaf , Bovone Cristina , Busin Massimo
Published: November 2019

Purpose:

To determine whether autologous Descemet stripping endothelial keratoplasty is technically feasible and whether it eliminates the risk of endothelial rejection in “only eyes” at high risk of immunological rejection.

Methods:

This is a prospective observational interventional study from 2016 to 2018 with a 24-month follow-up in a tertiary-level corneal referral center, Forlì, Italy. One 25-year-old woman with failed penetrating keratoplasty after endothelial rejection in the context of chronic panuveitis and a blind fellow eye due to retinal detachment underwent autologous Descemet stripping automated keratoplasty. An endothelial graft was harvested from the fellow eye by performing a hinged, microkeratome-assisted superficial stromal flap, with removal of the central posterior stromal bed. The posterior lamellar graft created was then transplanted into the other eye using a standardized Descemet stripping automated endothelial keratoplasty (DSAEK) technique. Main outcome measures were endothelial rejection, best spectacle-corrected visual acuity, and endothelial cell density.

Results:

No endothelial rejection was seen during the 2-year follow-up duration. Stable improvement in best spectacle-corrected visual acuity from 0.2 to 0.4 (decimal Snellen) was observed. Endothelial cell density of 1465 (cells/mm2) was recorded at the final follow-up.

Conclusions:

The use of this repeatable technique to harvest and transplant an autologous DSAEK graft eliminates endothelial rejection in high-risk eyes.
Quantitative and Qualitative Differences in Endothelial Cell Loss Between Endothelium-In Versus Endothelium-Out Loading in Descemet Membrane Endothelial Keratoplasty
Authors: Ho Joanne , Jung Hoon , Banitt Michael
Published: November 2019

Purpose:

This study compares endothelial cell loss (ECL) between donor grafts loaded in the Geuder Glass Cannula and the Coronet EndoGlide made specifically for Descemet membrane endothelial keratoplasty (DMEK).

Methods:

Prestripped tissues using the submerged cornea using backgrounds away (SCUBA) technique were obtained from an eye bank. Donor grafts were loaded with the Geuder Glass Cannula or Coronet DMEK EndoGlide. Grafts were then ejected directly onto a glass slide, stained, and imaged with confocal fluorescent microscopy. Trainable Fiji (ImageJ) segmentation software was used to quantify ECL.

Results:

Twenty-three total tissue samples were tested. Eleven grafts were loaded using the Geuder, and 12 were loaded with the Coronet. Preloading graft endothelial cell density was comparable between Geuder (2436 ± 581 cells/mm2) and Coronet (2577 ± 483 cells/mm2) groups with P = 0.56. Other baseline characteristics including donor age and time from death to loading were comparable (P = 0.73 and P = 0.66, respectively). Average ECL was 11.3% ± 3.0% in the Geuder group versus 7.2% ± 7.0% in the Coronet group and not significantly different (P = 0.07). When observing patterns of cell loss, grafts loaded in the Coronet DMEK EndoGlide resulted in more focal forceps grabs and trifold patterns. Grafts loaded with the Geuder Glass Cannula yielded more diffuse stippled stress lines.

Conclusions:

Our results suggest comparable ECL between Geuder (endothelium-out) and Coronet (endothelium-in) DMEK EndoGlide tissue injection techniques. Patterns of ECL in the Coronet group correlated with forceps grabs, but this study suggests that additional manipulation of tissue does not result in higher ECL.
Glaucoma After Iodine-125 Brachytherapy for Uveal Melanoma: Incidence and Risk Factors
Authors: Kim Eun-Ah , Salazar Diana , McCannel Colin A. , Kamrava Mitchell , Demanes David J. , Lamb James , Caprioli Joseph , McCannel Tara A.
Published: November 2019

Précis:

A single-center retrospective review over a 10-year period discovered an 8.6% risk of developing secondary open-angle glaucoma, and a 6.7% risk of neovascular glaucoma after brachytherapy for uveal melanoma. Additional risk factors were identified.

Purpose:

To report the incidence and identify risk factors for secondary open-angle glaucoma and neovascular glaucoma after iodine-125 brachytherapy for uveal melanoma in a tertiary ocular oncology and glaucoma practice.

Patients and Methods:

Eyes of patients who had been diagnosed and treated with iodine-12 brachytherapy for uveal melanoma over a 10-year period were included for review. Secondary open-angle glaucoma was defined as meeting the following criteria: at least 3 measurements of intraocular pressure (IOP) ≥21 mm Hg after the removal of the iodine-125 plaque and an open angle on gonioscopy. Neovascular glaucoma was defined as meeting the following criteria: at least 3 measurements of IOP ≥21 mm Hg and neovascularization of the iris or anterior chamber angle. Cumulative incidence was calculated and survival analysis was used to analyze risk factors for both secondary open-angle glaucoma and neovascular glaucoma.

Results:

A total of 374 eyes in patients diagnosed with uveal melanoma and treated with Iodine-125 brachytherapy were included in the study. Thirty-one eyes (8.6%) were diagnosed with secondary open-angle glaucoma and 25 eyes (6.7%) were diagnosed with neovascular glaucoma. Multivariate analysis identified the following risk factors for secondary open-angle glaucoma: older age, greater tumor size, iris location of uveal melanoma, higher baseline IOP, ciliary body involvement, and eyes having undergone combined brachytherapy with vitrectomy and silicone oil placement for radiation attenuation. The risk factors for neovascular glaucoma were as follows: greater tumor size, greater number of pack-years smoking history, pseudophakia, and higher grade of radiation retinopathy severity by fluorescein angiogram.

Conclusions:

We have identified additional risk factors for the development of both secondary open-angle glaucoma and neovascular glaucoma in patients with uveal melanoma who have undergone iodine-125 brachytherapy for local tumor control. The risk of secondary glaucoma is substantial. Close ophthalmic monitoring of patients is necessary for detection and timely treatment of glaucoma to maximize visual outcome.
Ceftolozane/Tazobactam for the Treatment of Osteomyelitis Due to Multidrug-Resistant Pseudomonas aeruginosa
Authors: Gerlach Anthony T. , Goff Debra A. , Bazan Jose A.
Published: November 2019

We conducted a retrospective study of 18 patients who were treated with ceftolozane/tazobactam (C/T) for greater than 48 hours for multidrug-resistant Pseudomonas aeruginosa (MDR-PA) osteomyelitis. Osteomyelitis was diagnosed by imaging, presence of systemic inflammatory signs and symptoms, elevated C-reactive protein, and positive culture for MDR-PA. Clinical cure was defined as complete or partial resolution of signs and symptoms of infection without need for escalation of antimicrobials during inpatient and outpatient therapy. The cohort was mostly male (81.2%) with a median age of 58.5 (53.5–68.5) years. The majority had polymicrobial osteomyelitis (77.8%) and a previous episode of osteomyelitis (83.3%). Clinical cure was achieved in 50% of patients, and C/T was well tolerated. These preliminary data suggest C/T maybe an option for treating patients with MDR-PA osteomyelitis, but more data are needed.
Impact of Vaccination on Morbidity and Mortality in Adults Hospitalized With Influenza A, 2014–2015
Authors: Kaselitz Timothy B. , Martin Emily T. , Power Laura E. , Cinti Sandro
Published: November 2019

Background

Influenza A is a significant cause of in-hospital morbidity and mortality in the United States. While vaccination has proven the most effective means of preventing infection, data examining its impact on patients hospitalized with influenza A are lacking. This is particularly true during seasons when there is poor vaccine matching, such as the 2014–2015 season. We hypothesize that vaccination is associated with less in-hospital morbidity and mortality among adults hospitalized with influenza A in a large tertiary hospital during the 2014–2015 season.

Methods

A retrospective chart review was conducted on all adults hospitalized with influenza A during the 2014–2015 season. Adjusting for confounders, multivariable logistic regression analyses were performed to examine the relationship between vaccination status and a variety of serious clinical outcomes.

Results

Of 217 adults hospitalized with influenza A, 118 were vaccinated (54%). Serious outcomes were frequent; 14 patients (7%) died, 31 (14%) required intensive care unit admission, and 27 (12%) required mechanical ventilation. Adjusting for sociodemographic and clinical confounders, we show that vaccinated patients were significantly less likely to die (odds ratio [OR], 0.29; 95% confidence interval [CI], 0.09–0.99), require mechanical ventilation (OR, 0.35; 95% CI, 0.14–0.83), and suffer a severe outcome (intensive care unit admission or death) (OR, 0.41; 95% CI, 0.19–0.87).

Discussion

Vaccination during the 2014–2015 season was associated with reduced morbidity and mortality among adults hospitalized with influenza A, despite the poor vaccine matching recognized during that season. Our findings suggest that during seasons with poor vaccine matching vaccination may afford protection against poor outcomes in patients hospitalized with influenza A.
Streamlining to Oral β-Lactam Versus Fluoroquinolone as Definitive Therapy for Enterobacteriaceae Bacteremia
Authors: Fong Karen , Dubrovskaya Yanina , Siegfried Justin , Papadopoulos John , Pham Vinh , (Polly) Jen Shin-Pung
Published: November 2019

Background

Oral treatment strategies for Enterobacteriaceae bacteremia (EB) are controversial. Fluoroquinolones (FQs) may be preferred for their high bioavailability, but β-lactams (BLs) should be explored as an additional option for EB treatment because of concerns of FQ resistance and adverse effects.

Methods

This retrospective study compared clinical characteristics and outcomes in patients with EB treated with oral BL versus FQ between January 2013 and July 2017. Adult patients with their first incidence of EB and transitioned from intravenous antibiotics to either study antibiotic class were included. The primary outcome assessed a composite of recurrence, superinfection, Clostridioides difficile colitis, emergence of multidrug-resistant organisms, infection-related readmission, and all-cause mortality within 90 days of EB treatment.

Results

A total of 173 patients were included (BL, n = 59; FQ, n = 114). The median age was 70 years, Pitt bacteremia score was 2 (range = 0–7), and Charlson Comorbidity Index was 5 (0–12). Urinary source of infection was most common (57%). Most oral BL courses used cefpodoxime (63%). Of note among baseline differences between groups, more patients receiving FQ versus BL had a presence of abscess (11% vs 0%, P = 0.01). The primary composite outcome occurred in 15 patients (25%) receiving BL and 28 patients (25%) on FQ (P = 0.901). Multivariate analysis identified urological complications, bacteremia onset in the intensive care unit, and the Charlson Comorbidity Index as independent predictors of the primary outcome.

Conclusions

Clinical outcomes were similar between those treated with oral BL compared with FQ. Oral BL may be considered for definitive treatment of EB.
Acute Parotitis Due to Candida glabrata
Authors: Shingde Rashmi V. , Kim Tae Jun , Givney Rodney C. , de Waal Patrick , Berry Catherine
Published: November 2019

This report describes the case of a 60-year-old man who developed acute parotitis with abscess formation. The causative agent of the parotid abscess wasCandida glabrata, which is an unusual cause of salivary gland pathology because it typically inhabits the oral cavity as a commensal microorganism. Acute parotitis occurs most often in elderly patients who are debilitated by systemic disease or as a postoperative complication. This case is interesting because the patient was immunocompetent and had no obvious risk factors for fungal parotitis other than poor dentition.
Recurrent Bacteremia Due to an Infected Inferior Vena Cava Graft in a Patient With Metastatic Renal Cell Carcinoma
Authors: Patel Raj H. , Denham James D. , Ramsakal Asha , Nanjappa Sowmya , Greene John N.
Published: November 2019

Bacteremia is a potentially life-threatening infection especially in cancer patients or immunocompromised individuals. Surgically implanted devices, such as inferior vena cava grafts, can often become compromised by bacterial biofilm production and serve as a nidus for recurrent, persistent infections such as bacteremia. Recurrent bacteremia suggests the presence of an undrained abscess or endovascular infection. We present a case wherein a 60-year-old man diagnosed as having renal cell carcinoma (status after pancreaticoduodenectomy) developed recurrent bacteremia with multiple enteric pathogens over a 2-year period because of an infected vascular graft.
The profile of the onco-hematology patient in the palliative care: 4 years of experience
Authors: Couto Maria Eduarda , Oliveira Isabel , Mariz Mário , Ferraz Gonçalves José
Published: November 2019

Objectives:

Most of the palliative care (PC) patients have oncologic diseases, being hematologic tumors a small part of them. According to the literature, onco-hematologic (OH) patients should be individualized from those with solid tumors for the specialized care required along their disease course. This study aims to review the casuistry of OH patients referred to PC in a specialized oncologic hospital and help to understand better how hematologists can improve the care of these patients.

Methods:

We analyzed all OH patients referred to the PC service in 1 oncologic hospital along 42 months, through consultation of their clinical files.

Results:

A total of 179 patients were reviewed (52.% males, median age of 71 years): 48.6% had non-Hodgkin lymphoma, 26.3% had multiple myeloma, 10.6% had acute leukemia, 14.5% had other OH diseases; 88.2% were treated for their OH disease (96.2% with chemotherapy, 28.5% radiotherapy, and 21.5% hematopoietic stem cell transplant). The referral was heterogeneous among physicians (27.4% by 1 physician). Most patients were firstly observed as inpatients (55.3%) and 17.9% in the outpatient consult. At the end of the study, 98.9% of the patients died (88.7% in the hospital, 10.2% at home). The median time between the end of treatment and referral do PC was 46 days and between referral and death was 16 days. We also reviewed medical prescription in the last month of life and we noticed that most invasive orders were requested by hematologists (as antibiotic prescription, imaging, and biopsy studies).

Significance of results:

This study demonstrated that OH patients should be referred earlier to PC and that a more intensive team work needs to be practiced between PC and hematologists. More educational programs for healthcare workers on this issue are needed in order to guarantee a more effective assistance in the appropriate time.
Prodopaminergic Drugs for Treating the Negative Symptoms of Schizophrenia
Authors: Sabe Michel , Kirschner Matthias , Kaiser Stefan
Published: November 2019

Background

The negative symptoms of schizophrenia pose a heavy burden on patients and relatives and represent an unmet therapeutic need. The observed association of negative symptoms with impaired reward system function has stimulated research on prodopaminergic agents as potential adjunctive treatments.

Methods

We conducted a systematic review and meta-analysis of published randomized controlled trials of amphetamine, methylphenidate, modafinil, armodafinil, lisdexamphetamine, L-dopa, levodopa, bromocriptine, cabergoline, quinagolide, lisuride, pergolide, apomorphine, ropinirole, pramipexole, piribedil, and rotigotine augmentation in schizophrenia and schizoaffective disorder.

Medline, EMBASE, and several other databases as well as trial registries were searched for placebo-controlled trials.

Results

Ten randomized controlled trials were included in the meta-analysis, 6 trials on modafinil, 2 on armodafinil, 1 on L-dopa, and 1 on pramipexole. Overall, prodopaminergic agents did not significantly reduce negative symptoms. Restricting the analysis to studies requiring a minimum threshold for negative symptom severity, modafinil/armodafinil showed a significant but small effect on negative symptoms. A subset of studies allowed for calculating specific effects for the negative symptom dimensions diminished expression and amotivation, but no significant effect was found. Prodopaminergic agents did not increase positive symptom scores.

Conclusions

The currently available evidence does not allow for formulating recommendations for the use of prodopaminergic agents for the treatment of negative symptoms. Nevertheless, the observed improvement in studies defining a minimum threshold for negative symptom severity in the absence of an increase in positive symptoms clearly supports further research on these agents.
Exploring the Prevalence of Clozapine Phenotypic Poor Metabolizers in 4 Asian Samples
Authors: Ruan Can-Jun , Wang Chuan-Yue , Tang Yi-Lang , Lin Shih-Ku , Lee Seung-Tae , Hong Kyung Sue , Rajkumar Anto P. , Jacob Kuruthukulangara S. , de Leon Jose
Published: November 2019

Purpose/Background

Clozapine clearance is influenced by sex, smoking status, ethnicity, coprescription of inducers or inhibitors, obesity, and inflammation. In 126 Beijing inpatients, we measured repeated trough steady-state serum concentrations and identified 4% (5/126) who were phenotypical poor metabolizers (PMs); none were ultrarapid metabolizers (UMs). They were defined as being 2 SDs beyond the means of total clozapine concentration/dose ratios stratified by sex and smoking. Using this definition, this study explores the prevalence of PMs and UMs using data from 4 already published Asian samples. Three samples were East Asian (Beijing 2, Taipei, and Seoul); one was from South India (Vellore).

Findings/Results

The prevalence of phenotypical PMs ranged from 2% to 13%, but inflammation was not excluded. The prevalence was 7% (14/191) for Beijing 2, 11% (8/70) for Taipei, 13% (9/67) for Seoul, and 2% (2/101) for the Vellore sample. Five phenotypic PMs appeared to be associated with extreme obesity. Phenotypic UM prevalence ranged from 0% to 1.6% but may be partly explained by lack of adherence. A Vellore phenotypic UM appeared to be associated with induction through high coffee intake.

Implications/Conclusions

Approximately 10% of Asians may be clozapine PMs and may need only 50 to 150 mg/d to get therapeutic concentrations. Future studies combining gene sequencing for new alleles with repeated concentrations and careful control of confounders including inhibitors, inflammation, and obesity should provide better estimations of the prevalence of phenotypic clozapine PMs across races. Clozapine UM studies require excluding potent inducers, careful supervision of compliance in inpatient settings, and multiple serum concentrations.
Updates on Preclinical and Translational Neuroscience of Mood Disorders
Authors: Mischel Nicholas A. , Kritzer Michael D. , Patkar Ashwin A. , Masand Prakash S. , Szabo Steven T.
Published: November 2019

Background

The development of new-generation antidepressants comes at a time of great clinical need when the global burden of depression, suicide, and other psychiatric conditions continues to increase. Our current treatment armamentarium is limited by the time delay needed for antidepressant effects and the significant number of patients who do not show an adequate response to antidepressants. The past 2 decades of psychiatric research has revealed that ketamine, known to be used only as an anesthetic and drug of abuse and to produce experimental models of psychosis, is effective at subanesthetic doses to ameliorate clinical depression.

Methods

We performed a systematic search of PubMed/MEDLINE indexed reports to identify clinical and translational research done with ketamine for purposes of treating depression.

Results

We will first present the rationale for investigating ketamine and otherN-methyl-d-aspartate receptor antagonists as a novel class of glutamate system targeting antidepressants. We will summarize putative molecular pathways underlying mood disorders and outline a brief history of investigation into ketamine as a treatment for depression. Recent clinical/translational evidence of ketamine's rapid-acting antidepressant mechanism will be critically reviewed in detail.

Conclusions

At the end of this review, we will opine on the role of ketamine and derivatives in clinical practice.
Using Simulation and Competency Assessment to Decrease Inappropriate Referrals to a Comprehensive Vascular Access Team
Authors: Nguyen Somali , Jones Allison , Polancich Shea , Poe Terri , Garrigan April , Talley Michele
Published: November 2019

This department column highlights translation of research into health care quality practice. Achieving the highest quality of health care requires attention to creating and sustaining process efficiencies through the development of bedside provider competencies that result in workflow improvements and positive patient outcomes. An improvement intervention aimed at decreasing unnecessary referrals to a comprehensive vascular access team (CVAT) resulted in a 21% reduction in inappropriate consults to the team in approximately 6 weeks. The purpose of this article is to describe a simulation and competency assessment intervention aimed at increasing staff nurse proficiency in the emergency department for placing ultrasound-guided intravascular catheters, thereby reducing the number of inappropriate referrals to a CVAT team.