bluuebunny/crossref_metadata_2025_split huggingface dataset:
Persistent Muscle Twitching With Phenobarbitone in a Preterm Neonate—Lack of Response or Manifestation of Toxicity?
Authors: Krishnamurthy Bhaskar , Pattanaik Smita , Dudeja Sankalp , Dutta Sourabh 
Published: February 2019

Background:
Phenobarbitone is frequently used for the treatment of seizures in neonates, but it has a narrow therapeutic index.

Case presentation:
A 28-week preterm infant born of vaginal delivery developed signs and symptoms suggestive of ventriculitis on day 9. After an episode of clonic seizures on day 11, phenobarbitone was administered intravenously at a loading dose of 20 mg/kg followed by maintenance doses of 6 mg/kg per day in 2 divided doses for 5 days. Due to suspected recurrence of seizures, a mini-loading dose of 10 mg/kg was administered on day 16; after which the child became unresponsive, hypotonic, and comatose with generalized slowing on electroencephalography. Pupils were dilated and fixed, and deep tendon reflexes were absent. Spontaneous respiration was depressed which resulted in ventilatory support. While awaiting the therapeutic drug monitoring results, 2 additional doses of 5 mg/kg of phenobarbitone were administered due to the persistence of muscle twitching. The phenobarbitone level (164 mcg/mL) was alarmingly above the normal range, warranting immediate discontinuation of the drug. This led to reduction in the plasma phenobarbitone levels into the therapeutic range (37 mcg/mL) over the next 10 days with subsequent improvement in the neurological status and respiration.

Conclusions:
Phenobarbitone levels are reported to be greater in preterm infants as compared to term infants. Persistence of seizures and muscle twitching on phenobarbitone could either be due to a lack of response or a manifestation of drug toxicity. This case underlies the importance of therapeutic drug monitoring, which can distinguish between the 2 causes, thus enabling the clinician to make an appropriate decision.
Associations between hospital structures, processes and patient experiences of preparation for discharge in breast cancer centers: A multilevel analysis
Authors: Nowak Marina , Swora Michael , Karbach Ute , Pfaff Holger , Ansmann Lena 
Published: February 2019

Background
Discharge management is a central task in hospital management. Mitchell's quality health outcomes model offers a contextual framework to derive expectations about the relationship between indicators of hospital structures and processes with patient experiences of preparation for discharge.

Purpose
The aim is to analyze the association between hospital structures and processes with patient experiences of preparation for discharge in breast cancer centers.

Methodology
The data were collected between February 1 and July 31, 2014–2016, with annual cross-sectional postal surveys on patient experiences of preparation for discharge in breast cancer center hospitals in Germany. These data were combined with secondary data on hospital structures, obtained from structured quality reports 2014 and the accreditation institution certifying breast cancer centers, constituting a hierarchical data structure. A total of 10,750 newly diagnosed breast cancer patients from 67 hospitals were analyzed. Following listwise deletion, 9,762 patients could be included in linear hierarchical regression analyses.

Results
Patients felt better prepared for discharge in hospitals that communicate the discharge date timely to patients, with good coordinative processes, and which cooperate with two other breast cancer center hospitals. Hospital structures, size, teaching status, and ownership were not associated with the patient experiences of preparation for discharge.

Conclusion
The results suggest that timely and informative communication, well-organized care processes, and the network structure of centers allow for an improvement of preparation for discharge. Current and future approaches for the improvement of hospital discharge should consider the identified hospital resources.

Practice Implications
Hospital management should increase the focus on structured communication and coordination processes to improve the discharge process. Cooperating networks should be expanded to increase expertise and resources. Results can be generalized to other care domains with caution. Patients' characteristics should further be assessed in order to use resources efficiently.
Surveying ADR Knowledge and Practices Among US Gastroenterologists
Authors: Peng Michael , Rex Douglas K. 
Published: February 2019

Background:
The adenoma detection rate (ADR) is of primary importance to the quality of screening colonoscopy. An online survey was conducted to assess knowledge and practices on ADR.

Methods:
Paid questionnaire distributed by email. Eligible respondents were board certified gastroenterologists who perform >80 colonoscopies per month with 3 to 35 years practice after fellowship.

Results:
There were 250 respondents. In total, 39% were unaware that ADR applies only to screening colonoscopies and 76% incorrectly answered that ADR includes sessile-serrated polyps/adenomas. A total of 51% of respondents incorrectly believe the threshold is set at 25% because 25% is a national ADR average. Many also believe the threshold depends on the patient population (current evidence suggests adjusting ADR for factors other than age and sex is unnecessary). 75% ranked ADR as highly important. 80% reported tracking ADR. A busy practice was the most common reason for not tracking ADR. Caps, chromoendoscopy, and good bowel preparation were viewed as valuable for improving ADR (this is true except for caps). High-definition colonoscopes and education were considered less valuable, despite evidence indicating that both are associated with improved ADR. In total, 57% reported not sharing ADR information with their patients, and 59% reported that no patients in the last 6 months asked for their ADR.

Conclusions:
The importance of ADR as a quality measure is well understood, but there are misconceptions among gastroenterologists regarding the definition and measurement of ADR, and which methods are proven to increase ADR. Patients are having very little impact on ADR measurement.
Gender Differences Among Patients Hospitalized With Cirrhosis in the United States
Authors: Rubin Jessica B. , Sundaram Vinay , Lai Jennifer C. 
Published: February 2019

Background and Aims:
Gender disparities exist in outcomes among patients with cirrhosis. We sought to evaluate the role of gender on hospital course and in-hospital outcomes in patients with cirrhosis to help better understand these disparities.

Study:
We analyzed data from the National Inpatient Sample (NIS), years 2009 to 2013, to identify patients with any diagnosis of cirrhosis. We calculated demographic and clinical characteristics by gender, as well as cirrhosis complications. Our primary outcome was inpatient mortality. We used logistic regression to associate baseline characteristics and cirrhosis complications with inpatient mortality.

Results:
Our cohort included 553,017 patients with cirrhosis admitted from 2009 to 2013. Women made up 39% of the cohort; median age was 57 with 66% non-Hispanic white. Women were more likely than men to have noncirrhosis comorbidities, including diabetes and hypertension but were less likely to have most cirrhosis complications, including ascites and variceal bleeding. Women were more likely than men to have acute bacterial infections (34.9% vs. 28.2%; P<0.001), and were less likely than men to die in the hospital on univariable (odds ratio, 0.88; 95% confidence interval, 0.86-0.90; P<0.001) and multivariable (odds ratio, 0.86; 95% confidence interval, 0.83-0.88; P<0.001) analysis.

Conclusions:
In patients hospitalized with cirrhosis, women have lower rates of hepatic decompensating events and higher rates of nonhepatic comorbidities and infections, resulting in lower in-hospital mortality. Understanding differences in indications for and disposition following hospitalization may help with the development of gender-specific cirrhosis management programs to improve long-term outcomes in women and men living with cirrhosis.
Liver stiffness measurement by acoustic radiation forced impulse and transient elastography in patients with intrahepatic cholestasis
Authors: Zayed Naglaa , Darweesh Samar K. , Mousa Shereef , Atef Mira , Ramzy Eman , Yosry Ayman 
Published: February 2019

Background
Transient elastography (TE) and acoustic radiation force impulse (ARFI) imaging enable a noninvasive assessment of liver stiffness measurement (LSM) and liver fibrosis/cirrhosis staging. However, their use in cholestatic diseases is still scarce.

Aim
The aim of this study was to evaluate the performance of TE and ARFI for the initial assessment of hepatic fibrosis in intrahepatic cholestatic (IHC) diseases and assess LSM changes after 3 months of specific therapy.

Patients and methods
This prospective study was carried out on 50 IHC patients. Assessment at baseline and after 3 months of LSM by TE and ARFI was performed.

Results
Overall, 60% of the patients were women (36.5±9.2 years). IHC etiologies were 23 (46%) autoimmune hepatitis, eight (16%) primary sclerosing cholangitis, eight (16%) drug induced, and five (10%) primary biliary cirrhosis. TE could diagnose ≥F2, ≥F3, and F4 stages at cutoffs of at least 6.7, 9.4, and 14.0 kPa, sensitivity/specificity were 100/50% for ≥F2, 88.2/83% for ≥F3, and 90/100% for F4. Moreover, the sensitivity and specificity of ARFI were 93/50% for ≥F2 (cutoff: 1.53 m/s); 71/67% for ≥F3 (cutoff 1.77 m/s); and 90/100% for F4 (cutoff: 2.43 m/s).
Follow-up showed a significant decrease in TE and ARFI values by 27 and 22.3% (P<0.001 and <0.001, respectively) and, accordingly, fibrosis stages decreased significantly by both TE and ARFI (P=0.002 and <0.001, respectively).

Conclusion
TE and ARFI represent noninvasive methods with adequate diagnostic performance for the assessment of fibrosis, and monitoring disease progression and treatment response in intrahepatic cholestasis.
Early recurrence detected in hepatocellular carcinoma patients after transcatheter arterial chemoembolization treatment with plasma cell-free DNA
Authors: Li Zhen , Xiao Du , Li Xin , Zhan Pengchao , Wang Jiaxiang , Zhang Henghui 
Published: February 2019

Objective
Hepatocellular carcinoma (HCC) is one of the most lethal malignancies worldwide with poor prognosis due to the high incidence of recurrence. For patients with advanced HCC, transcatheter arterial chemoembolization (TACE) is the preferred treatment option owing to the minimal invasive clinical treatment with optimum therapeutic outcomes. But, there is a paucity of studies on early detection of residual cancer and relapse that result in the bottleneck of long-term effects after TACE therapy.

Patients and methods
Using next-generation sequencing platform targeting a panel of 622 cancer-associated genes, we prospectively evaluated the predictive significance of plasma cell-free DNA (cfDNA) to detect minimal residual disease in plasma cfDNA in comparison with DNA obtained from tumor tissue and blood cells of three eligible cases with HCC following TACE therapy.

Results
The results indicated that the mutational spectrum from plasma cfDNA was consistent with tumor-derived DNA and potentially suggested disease progression. Next, we determined if the dynamic variation of plasma cfDNA could indicate treatment response, the findings suggested that the mutation burden of plasma cfDNA could reveal relapse before alterations in conventional computed tomography imaging and serum α-fetoprotein values.

Conclusion
The mutation burden in plasma cfDNA may serve as a novel prognostic biomarker by providing early evidence of residual disease and identifying high risk of recurrence in patients with HCC following TACE therapy.
Attributes of analgesics for emergency pain relief: results of the Consensus on Management of Pain Caused by Trauma Delphi initiative
Authors: Porter Keith , Morlion Bart , Rolfe Mark , Dodt Christoph 
Published: February 2019

Objectives
Management of pain is suboptimal in many prehospital and emergency department settings, and European guidelines are lacking. We carried out the Consensus On Management of PAin Caused by Trauma (COMPACT) Delphi initiative to gain insights into the factors physicians consider important when selecting analgesics for trauma pain.

Patients and methods
A pan-European panel of experts in emergency medicine or pain (N = 31) was recruited to participate in the COMPACT Delphi initiative. In round 1, panelists supplied free-text responses to an open question about the attributes of analgesics for emergency pain relief favored by physicians. Common themes were consolidated into factors. In round 2, factors rated important by more than 75% of the panel were taken forward into round 3. In round 3, the point at which the consensus was achieved was defined a priori as at least 75% of panelists agreeing or strongly agreeing that a factor was important.

Results
Twenty-nine experts participated, representing 12 European countries and with a mean (SD) of 20 (8.6) years of clinical experience. Most worked in an emergency department (79.3%). The consensus was achieved for 10 factors that were important to consider when selecting analgesics for trauma pain relief. The highest level of consensus was achieved for ‘efficacy’ (100%), followed by ‘safety and tolerability’ (96.6%), and ‘ease of use’ (93.1%).

Conclusion
These findings may facilitate the development of evidence-based guidelines supporting the provision of pain management in prehospital, emergency department, and critical care settings.
Racial Differences in Insurance Stability After Health Insurance Reform
Authors: Freund Karen M. , LeClair Amy , Terrin Norma , Hanchate Amresh D. , Price Lori Lyn , Moreno-Koehler Alejandro , Suzukida Jill , Kher Sucharita , Byhoff Elena , Kressin Nancy R. 
Published: February 2019

Background:
One of the potential benefits of insurance reform is greater stability of insurance and reduced coverage disparities by race and ethnicity.

Objectives:
We examined the temporal trends in insurance coverage by racial/ethnic group before and after Massachusetts Insurance Reform by abstracting records across 2 urban safety net hospital systems.

Research Design:
We examined adjusted odds of being uninsured and incident rate ratios of gaining and losing insurance over time by race and ethnicity. We used billing records to capture the payer for each episode of care.

Subjects:
We included data from January 2005 through December 2013 on patients with hypertension between the ages of 21 and 64 years. We compared 4 racial and ethnic groups: non-Hispanic white, non-Hispanic Black, non-Hispanic Asian, and Hispanic.

Measures:
We examined individual patients’ insurance coverage status in 6-month intervals. We compared odds of being uninsured in the transition and postinsurance reform period to the prereform period, adjusting for age, sex, comorbidities practice location and education, and income by Census tract.

Results:
Among 48,291 patients with hypertension, reduction in rates of uninsurance with insurance reform was greater for Hispanic (29.7%), non-Hispanic Black (24.8%), and non-Hispanic Asian (26.8%) than non-Hispanic white (14.9%) patients. The odds of becoming uninsured were reduced in all racial and ethnic groups (odds ratio, 0.27–0.41).

Conclusions:
Massachusetts Insurance Reform resulted in stable insurance coverage and a reduction in disparities in insurance instability by race and ethnicity.
A System-Wide Approach to Prevention of In-Hospital Newborn Falls
Authors: Carr Hester , Crotto Joshua , Demirel Shaban , Fisher Stephanie , Logue Leona , Marcott Meghan , Miller Lacey Rose , Mochnal Mary , Scheans Patricia 
Published: February 2019

Abstract

Background:
The Centers for Disease Control and Prevention lists accidents (unintentional injuries) as the fifth leading cause of infant mortality. Data analysis from a multihospital system of inpatient family birth centers revealed fluctuations in newborn birth admission falls rates at times above the benchmark reported in the literature.

Purpose:
We describe a multipronged approach to address an identified safety concern. The aim of the project was to decrease the rate of newborn falls during birth hospitalization. Despite applying multiple interventions described in the literature, newborn falls were not eliminated.

Study Design and Methods:
In this quality improvement project, a nursing leadership team was convened to review the literature, identify current and ideal states, obtain stakeholder input, identify contributing factors, and agree on standardized interventions to prevent newborn falls. The project received exempt status from the institutional review board.

Results:
Since we started the project in 2016, there was a downward trend in newborn birth admission falls in 2017; however, based on our variable data over the last 5 years and small numbers of falls, it is difficult to conclude that any one strategy or combination of strategies has been successful. Because falls from bed with the new mother were the most common types of newborn falls, interventions were focused; however, our falls rate for newborns never fell below comparable rates in the literature.

Clinical Implications:
More data are needed on effective interventions that can reduce the rate of newborn falls, especially those from bed while with the new mother. A comprehensive approach based on analysis of events and review of existing evidence are necessary first steps.
Cardiac Arrest Outcomes in Children With Preexisting Neurobehavioral Impairment*
Authors: Christensen James R. , Slomine Beth S. , Silverstein Faye S. , Page Kent , Holubkov Richard , Dean J. Michael , Moler Frank W. 
Published: February 2019

Objectives:
To describe survival and 3-month and 12-month neurobehavioral outcomes in children with preexisting neurobehavioral impairment enrolled in one of two parallel randomized clinical trials of targeted temperature management.

Design:
Secondary analysis of Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital and Out-of-Hospital trials data.

Setting:
Forty-one PICUs in the United States, Canada, and United Kingdom.

Patients:
Eighty-four participants (59 in-hospital cardiac arrest and 25 out-of-hospital cardiac arrest), 49 males, 35 females, mean age 4.6 years (sd, 5.36 yr), with precardiac arrest neurobehavioral impairment (Vineland Adaptive Behavior Scales, Second Edition composite score < 70). All required chest compressions for greater than or equal to 2 minutes, were comatose and required mechanical ventilation after return of circulation.

Interventions:
Neurobehavioral function was assessed using the Vineland Adaptive Behavior Scales, Second Edition at baseline (reflecting precardiac arrest status), and at 3 and 12 months postcardiac arrest, followed by on-site cognitive evaluation. Vineland Adaptive Behavior Scales, Second Edition norms are 100 (mean) ± 15 (sd); higher scores indicate better function. Analyses evaluated survival, changes in Vineland Adaptive Behavior Scales, Second Edition, and cognitive functioning.

Measurements and Main Results:
Twenty-eight of 84 (33%) survived to 12 months (in-hospital cardiac arrest, 19/59 (32%); out-of-hospital cardiac arrest, 9/25 [36%]). In-hospital cardiac arrest (but not out-of-hospital cardiac arrest) survival rate was significantly lower compared with the Therapeutic Hypothermia after Pediatric Cardiac Arrest group without precardiac arrest neurobehavioral impairment. Twenty-five survived with decrease in Vineland Adaptive Behavior Scales, Second Edition less than or equal to 15 (in-hospital cardiac arrest, 18/59 (31%); out-of-hospital cardiac arrest, 7/25 [28%]). At 3-months postcardiac arrest, mean Vineland Adaptive Behavior Scales, Second Edition scores declined significantly (–5; sd, 14; p < 0.05). At 12 months, Vineland Adaptive Behavior Scales, Second Edition declined after out-of-hospital cardiac arrest (–10; sd, 12; p < 0.05), but not in-hospital cardiac arrest (0; sd, 15); 43% (12/28) had unchanged or improved scores.

Conclusions:
This study demonstrates the feasibility, utility, and challenge of including this population in clinical neuroprotection trials. In children with preexisting neurobehavioral impairment, one-third survived to 12 months and their neurobehavioral outcomes varied broadly.
Sensory pain characteristics of vulvodynia and their association with nociceptive and neuropathic pain: an online survey pilot study
Authors: Schlaeger Judith M. , Patil Crystal L. , Steffen Alana D. , Pauls Heather A. , Roach Keesha L. , Thornton Patrick D. , Hartmann Dee , Kobak William H. , Yao Yingwei , Suarez Marie L. , Hughes Tonda L. , Wilkie Diana J. 
Published: February 2019

Abstract

Objectives:
To evaluate self-reported sensory pain scores of women with generalized vulvodynia (GV) and provoked vestibulodynia (PVD), characterize pain phenotypes, and assess feasibility of using the Internet for recruitment and data collection among women with vulvodynia.

Methods:
Descriptive online survey. Data collected using an online survey accessed via a link on the National Vulvodynia Association web site. Convenience sample, 60 women aged 18 to 45 years (mean = 32.7 ± 5.5); 50 white, 2 black/African American, 4 Hispanic/Latino, and 4 Native American/Alaskan Native, diagnosed with vulvodynia, not in menopause. Pain assessment and medication modules from PAINReportlt.

Results:
Women with GV (n = 35) compared to PVD (n = 25). Estimated mean pain sites (2.5 ± 1.4 vs 2.2 ± 1.0, P = 0.31), mean current pain (8.7 ± 1.4 vs 5.5 ± 4.0, P = 0.0008), worst pain (8.1 ± 1.8 vs 6.1 ± 3.6, P = 0.02), and least pain in the past 24 hours (4.4 ± 1.8 vs 2.0 ± 2.0, P < 0.0001). Average pain intensity (7.1 ± 1.2 vs 4.6 ± 2.9, P = 0.0003) on a scale of 0 to 10, mean number of neuropathic words (8.3 ± 3.6 vs 7.7 ± 5.0), and mean number of nociceptive words (6.9 ± 4 vs 7.5 ± 4.4). Nineteen (54%) women with GV compared to 9 (38%) with PVD were not satisfied with pain levels.

Conclusion:
Women with GV reported severe pain, whereas those with PVD reported moderate to severe pain. Pain quality descriptors may aid a clinician's decisions about whether to prescribe adjuvant drugs vs opioids to women with vulvodynia.
Trigeminal Neuropathy After Mandibular Fractures: Epidemiology and Neurophysiologic Diagnosis
Authors: Joachim Michael , Tabib Rami , Laviv Amir , Pikovsky Anna , Zadik Yehuda , Zeltser Rephael 
Published: February 2019

Objectives:
To study the trigeminal nerve neuropathy prevalence after mandibular fractures and follow nerve recovery and to examine associations with clinical features.

Subjects:
The files of 304 patients treated for 424 mandibular fractures in Hadassah Medical Center between 2001 and 2008 were analyzed. Twenty-five patients with paresthesia were examined by electro-diagnostic conduction test (quantitative sensory testing).

Results:
The most common fracture sites were the symphysis (28.5%) and condyle (21.4%). A strong correlation between fracture severity and treatment modality was found. Nerve damage occurred in 13.4% of nondisplaced fractures and in 65.3% of >5 mm displaced fractures. Patients who were treated by open reduction internal fixation demonstrated the biggest difference in quantitative sensory testing values between the affected and nonaffected sides. C nerve fibers were the most damaged and least regenerated. There was correlation between damage perception and objective test results.

Conclusions:
There is a correlation between fracture type and displacement severity on neurologic deficit and prognosis. The objective neurosensory damage was manifested by higher nerve excitation threshold on the injured side. Patients should be informed on the prognosis of neurologic deficit according to fracture type.