Computers, Informatics, Nursing

Structure and Characteristics of Diabetes Self-management Applications: A Systematic Review of the Literature Diabetes is one of the most common chronic conditions, and a good self-management regimen is needed in order to control the disease and prevent complications. In the last few years, the number of health information technologies has increased, and while there are many smartphone applications for diabetic patients, their effectiveness is still unclear. This systematic review aims to outline structure and characteristics that can make an application for diabetes management effective and safe and improve usability and the chances of success for a mobile health service. Applications found in the literature have been analyzed to evaluate the different features. Findings of the review suggest that patients seem to be more attracted by tools that are helpful in everyday management of diabetes, and that allow them to save time and increase safety. The personalization of the application is essential to obtain success in promoting use, and applications should be based upon patients' predisposition to use technological tools that will ensure better outcomes. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding authors: Sara Angelini, MSN, RN, Department of Public Health and Infectious Diseases, Sapienza University of Rome, P.le Aldo Moro 5, 00185 Rome, Italy (sarangelini.s@icloud.com); Marco Di Muzio, PhD, RN, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Italy (marco.dimuzio.uniroma1.it). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Evaluation of Nursing Practice in Patients With HIV/AIDS With the Omaha System Electronic-Based Information Program: A Retrospective Study The Omaha System is a standardized health care terminology that has been used in many different settings for nursing care worldwide for more than 20 years. In Turkey, it has been used mainly in nursing education and research. In this context, the purpose of this study was to examine paper-based nursing care plans of inpatients with HIV/AIDS according to the Omaha System and to assess the clinical suitability of the Omaha System. The study has a descriptive-retrospective design and was carried out at the Department of Infectious Diseases and Clinical Microbiology in a hospital. The sample consisted of 30 patients with HIV/AIDS who were chosen randomly from patients hospitalized between January 2007 and April 2017. Nursing care plans were reevaluated and encoded according to the Omaha System. The five most frequently diagnosed problems were oral health (27.2%), neuromusculoskeletal function (20.2%), communicable/infectious condition (19.4%), skin condition (13.2%), and circulation (5.7%). A total of 4409 nursing interventions were applied to solve the problems, and almost 74% of the interventions were categorized in the surveillance. Among the targets, physical signs/symptoms were indicated for more than 68% (3.026). The results confirmed the clinical suitability of the Omaha System. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Ozlem Koseoglu Ornek, PhD, RN, Department of Nursing, Faculty of Health Sciences, Istanbul Bilgi University, Dolapdere Kampus, Haciahmet Mahallesi, Pir Hüsamettin Sokak, No. 20, 34440 Beyoğlu, Istanbul, Turkey (ozlem.koseoglu@bilgi.edu.tr; ozlem.koseoglu62@gmail.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

eHealth Services in the Near and Distant Future in Swedish Home Care Nursing Sweden and other developed countries are putting deliberate efforts into eHealth and digitalization of home care nursing. eHealth services have big potential in this area because they can provide mobile access to healthcare information. This study explores the eHealth services that home care nursing providers in Sweden currently use, plan to use, and have discarded. It also investigates their eHealth visions for the future. We sent a survey to the 264 Swedish municipalities responsible for home care nursing and received 144 responses (55%). The results show a large diversity of eHealth services in use. A few can be considered core services since they are broadly implemented or will be in the near future. Trials are also being carried out with more specialized services. The respondents envision more automation and remote monitoring services, while technical and usability issues are the main obstacles to implementation today. Much knowledge can be gained from proper evaluation of the ongoing work. More research is needed regarding (1) what eHealth can offer home care nursing, (2) the effects of using eHealth in home care nursing, and (3) if and how home care nursing organizations need to adapt to best make use of eHealth. The work presented in this study was funded by AFA Insurance. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Christofer Rydenfält, PhD, Department of Design Sciences, Faculty of Engineering, Lund University, PO Box 118, SE-221 00 Lund, Sweden. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Evaluating the Development Processes of Consumer mHealth Interventions for Chronic Condition Self-management: A Scoping Review Innovative, patient-centered mHealth interventions have the potential to help with the burden of chronic conditions. This review aims to describe the development of consumer mHealth interventions for chronic condition self-management. A scoping review methodology was used to search medical databases for eligible reports, published between January 1, 2010, and December 31, 2017, that provided information on consumer mHealth interventions for respiratory disease, cancer, diabetes, and cardiovascular disease. Twenty-one reports were included, representing the development of 14 mHealth interventions. Most were developed collaboratively, using user-centered and participatory design processes. Predesign work involved a thorough needs assessment, and redesign processes were described as iterative, engaging with usability testing and design improvements. Tensions from competing priorities between patients and healthcare professionals were uncovered, with the intention to develop a useful product for the patient while ensuring clinical relevance. This review provides clear evidence that consumer mHealth interventions are developed inconsistently even when engaging with participatory or user-centered design principles, sometimes without direct involvement of patients themselves. Further, the incomplete description of the development processes presents challenges to furthering the knowledge base as healthcare professionals need timely access to quality information on mHealth products in order to recommend safe, effective consumer mHealth interventions. Corresponding author: Leanna Woods, BN (Hons), Patient Care Level 6, St Vincent's Private Hospital Sydney, 406 Victoria St, Darlinghurst, New South Wales, Australia 2010 (Leanna.Woods@svha.org.au). L.W. is supported by a St Vincent's Clinic Foundation Grant and the University of Tasmania's Elite Research Scholarship funded by The District Nurses. The remaining authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Bedside Usability Surveys: Adding Authentic User Detail to the Assessment Errors in healthcare are a leading cause of death in the United States. Equipment usability and user interfaces remain an area not fully elucidated. Infusion pumps play a vital role in care delivery, often essential for critical therapies. While pump function is comparatively simple, their programming, configuration, and form provide opportunity for error. Our purpose was to assess qualities nurses identified as important to pump operation by electronic survey. A self-developed usability survey was distributed to a random sample of 500 nurses, stratified by unit type and employed at the large academic quaternary care hospital. The overall response rate was 48% (n = 240). Descriptive and inferential statistics describe the responses and represent more than 5500 weekly infusions. Nurses described confident use of the system with some differences by unit type. Ninety percent of respondents indicated they have omitted use of the dose error reduction system, which should raise safety concerns. Users reported issues with the user interface and error prevention systems. Qualitative items elicited suggestions for improving aspects of the pump. Employing a usability survey in a clinical area proved to be a simple, inexpensive way to gather more information on the use and potential improvements of infusion pumps. Corresponding author: Krisanne Graves, PhD, RN, CPHQ, Texas Children's Hospital, 6621 Fannin St, Suite A270, Houston TX 77030 (kxgraves@texaschildrens.org). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.cinjournal.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Current Trends in Robotics in Nursing Patents—A Glimpse Into Emerging Innovations The purpose of this study was to describe the current evidence found through a patent search about robotics used to assist nurses in providing care. The authors used a modified seven-step strategy of searching patents according to the US Patent and Trademark Office guidelines. The nursing robotic search was performed in four databases including the US Patent and Trademark Office issued patent database, the US Patent and Trademark Office published patent application database, the European Patent Office database, and Relecura. Keywords reflecting the scope of the term "robot" were defined for the purposes of this specific search. This broad search yielded large numbers of patents germane to nursing care. These results were narrowed using keywords and the Cooperative Patent Classification schemes to determine relevance, ensure rigor, and capture the most relevant results. This review of patents suggests robots for nursing care are proliferating. The opportunity for robotics in nursing is emerging in industry. Although nursing will likely benefit from robotics, we must determine the appropriate place to include robots in nursing care delivery. Partial support of the project was provided by The University of Alabama's Office for Research and Economic Development through NSF (IIP-1450293). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Rachel M. Frazier, PhD, Graphenics, LLC, Williamsburg, VA (rachel@graphenics.net). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Usability of a Disease Management Mobile Application as Perceived by Patients With Diabetes The use of mobile applications in chronic disease management has grown significantly over the past decade. When properly designed, these apps provide a convenient, safe, high-quality service to patients. In this study, a health management app was developed, and its usability among patients with diabetes mellitus was examined. A convenience sample of 136 patients, referred to two academic centers from December 2016 to July 2017, was enrolled. Upon completion of informed consent, the participants were asked to install the app on their smartphone. Two weeks later, they were required to complete a postapplication usability questionnaire, comprising 21 questions classified into six domains. The response rate was 89%. The highest scores were given for "ease of use and learnability"; the lowest-scored domains were "interaction quality" and "reliability." Urban residents, participants with lower educational qualifications, and retirees were significantly more satisfied with the app. Overall, patients with diabetes mellitus perceived the app as useful for disease management. However, the overall usability of health apps is expected to improve when a multidisciplinary team (health professionals, computer engineers, art designers) is involved in the development process. This work was a master's degree project approved at and founded by Guilan University of Medical Sciences, Iran (registration no. 951010). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Rasoul Tabari-Khomeiran, PhD, RN, Social Determinants of Health Research Center, Guilan University of Medical Sciences, Nursing & Midwifery Faculty, Danshjoo Rd, Rasht, Postal 41469-39841, Iran (rtabari@gums.ac.ir; rasooltabari@gmail.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Sequential Two-Stage Network and Thematic Analysis for Exploring an Interdisciplinary Care Approach in Nursing Homes Since various groups of older adults with different conditions and levels of function coexist in nursing homes, it is necessary to develop integrated care strategies through collaboration among experts across related fields. The purposes of this study are to identify the regularity of information sharing in managing daily function for older adults, with a special focus on interdisciplinary cooperation, and to explore a practical care strategy for nursing home residents. The collaborative methods of network and thematic analysis were done by conducting in-depth interviews with 33 interdisciplinary experts working at seven nursing homes. This study proposed three relationships and three themes as interrelated key factors for providing interdisciplinary care to the elderly at various levels of function based on the experiences accumulated by the practitioners. First, independent sharing is required to make professional judgments about how daily function in older adults changes from reported baselines. Second, practitioners accurately judge clinical situations and supplement experts' judgments through partial sharing. Finally, all interdisciplinary consensus through complete sharing achieves the ultimate goal of maintaining remaining function in older adults. These findings can be the first step in developing practical care guidelines for interdisciplinary use, and the results can be used to develop integrated assessment and intervention strategies. Corresponding author: Sung Ok Chang, PhD, RN, College of Nursing, Korea University, 145 Anam-ro, Seongbuk-Gu, Seoul, Republic of Korea 02841 (sungok@korea.ac.kr). This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (NRF-2015R1D1A1A01057258). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Quality Improvement in Online Course Development: Igniting the Online Teaching Team Online courses and programs in higher education, including nursing education, continue to multiply exponentially in the United States. In order to meet accreditation standards and build internal standards of quality in online course delivery, nursing administrators and faculty must keep abreast of evidence and best practice in online course design. Awareness and adoption of online standards of excellence may be a departure from standard operating procedure with faculty adept at creating face-to-face courses and mavericks self-taught in online course development. The Plan-Do-Study-Act process for improvement is a viable and scalable method to achieve national certification of online course quality, improving ability to compete in a dynamic online education environment. Considerations of infrastructure and multiple stakeholder groups are critical to successful implementation. The case of one nursing program that used faculty development, team building, and continuous quality improvement to successfully reach national online quality benchmarks is presented. The authors are certified as peer reviewers for Quality Matters, a scholarly activity for which they have received no personal remuneration. They have both presented at Quality Matters conferences. They have received no funding for this work. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Tara Spalla King, PhD, The Ohio State University College of Nursing, 1585 Neil Ave, Columbus, OH 43210 (king.2541@osu.edu). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Do Brief Educational Sessions Increase Electronic Health Literacy of Low-Income Persons Living With HIV/AIDS? This research explored whether participating in a brief educational intervention using the National Library of Medicine video, Evaluating Health Information: A Tutorial From the National Library of Medicine, would increase electronic health literacy. A quasi-experimental longitudinal design was used in two randomly selected settings of a treatment program for low-income persons living with HIV/acquired immune deficiency syndrome (N = 100). Individuals in both intervention groups watched the video and completed an at-home assignment brought to the second session 1 week later; one group received an additional 15 minutes with an HIV nurse clinician who reinforced video content. Generalized linear models were used in order to account for the longitudinal nature of the data; a full model was fitted first that included age, gender, race, ethnicity, education, acquired immune deficiency syndrome diagnosis, time, group, and the interaction of time by intervention group with electronic health literacy as the dependent variable. Group means were not significantly different, and the overall group pattern were the same; the only significant variable was older age, which is consistent with the findings of other literature. Electronic health literacy can be increased by viewing a free video; making this video available in a variety of settings and encouraging clients to use the Internet as a source of health information may improve self-management strategies of persons living with chronic illnesses. Corresponding author: Kathleen M. Nokes, PhD, RN, FAAN, Graduate Center, CUNY, 868 Buck Rd, Stone Ridge, NY 12484 (kathynokes@aol.com). Sources of funding: Jonas Center for Nursing and Veterans Healthcare and Alpha Phi Chapter of Sigma Theta Tau Research grant. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
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alsfakia@gmail.com

Ear and Hearing

Test-Retest Variability in the Characteristics of Envelope Following Responses Evoked by Speech Stimuli Objectives: The objective of the present study was to evaluate the between-session test-retest variability in the characteristics of envelope following responses (EFRs) evoked by modified natural speech stimuli in young normal hearing adults. Design: EFRs from 22 adults were recorded in two sessions, 1 to 12 days apart. EFRs were evoked by the token /susa∫ i/ (2.05 sec) presented at 65 dB SPL and recorded from the vertex referenced to the neck. The token /susa∫ i/, spoken by a male with an average fundamental frequency [f0] of 98.53 Hz, was of interest because of its potential utility as an objective hearing aid outcome measure. Each vowel was modified to elicit two EFRs simultaneously by lowering the f0 in the first formant while maintaining the original f0 in the higher formants. Fricatives were amplitude-modulated at 93.02 Hz and elicited one EFR each. EFRs evoked by vowels and fricatives were estimated using Fourier analyzer and discrete Fourier transform, respectively. Detection of EFRs was determined by an F-test. Test-retest variability in EFR amplitude and phase coherence were quantified using correlation, repeated-measures analysis of variance, and the repeatability coefficient. The repeatability coefficient, computed as twice the standard deviation (SD) of test-retest differences, represents the ±95% limits of test-retest variation around the mean difference. Test-retest variability of EFR amplitude and phase coherence were compared using the coefficient of variation, a normalized metric, which represents the ratio of the SD of repeat measurements to its mean. Consistency in EFR detection outcomes was assessed using the test of proportions. Results: EFR amplitude and phase coherence did not vary significantly between sessions, and were significantly correlated across repeat measurements. The repeatability coefficient for EFR amplitude ranged from 38.5 nV to 45.6 nV for all stimuli, except for /∫/ (71.6 nV). For any given stimulus, the test-retest differences in EFR amplitude of individual participants were not correlated with their test-retest differences in noise amplitude. However, across stimuli, higher repeatability coefficients of EFR amplitude tended to occur when the group mean noise amplitude and the repeatability coefficient of noise amplitude were higher. The test-retest variability of phase coherence was comparable to that of EFR amplitude in terms of the coefficient of variation, and the repeatability coefficient varied from 0.1 to 0.2, with the highest value of 0.2 for /∫/. Mismatches in EFR detection outcomes occurred in 11 of 176 measurements. For each stimulus, the tests of proportions revealed a significantly higher proportion of matched detection outcomes compared to mismatches. Conclusions: Speech-evoked EFRs demonstrated reasonable repeatability across sessions. Of the eight stimuli, the shortest stimulus /∫/ demonstrated the largest variability in EFR amplitude and phase coherence. The test-retest variability in EFR amplitude could not be explained by test-retest differences in noise amplitude for any of the stimuli. This lack of explanation argues for other sources of variability, one possibility being the modulation of cortical contributions imposed on brainstem-generated EFRs. ACKNOWLEDGMENTS: This study was funded by a Collaborative Health Research Project grant from the Canadian Institutes of Health Research and the Natural Sciences and Engineering Research Council of Canada (grant no. 493836-2016). V.E. designed the study, performed the experiment, analyzed data, and wrote the article. D.P. discussed study design, helped with response analysis, and edited the article. S.S. and S.A. discussed results, and edited the article. The authors have no conflicts of interest to disclose. Received October 20, 2018; accepted March 8, 2019. Address for correspondence: Vijayalakshmi Easwar, 541 Waisman Centre, The University of Wisconsin-Madison, 1500 Highland Ave, Madison, WI 53705, USA. E-mail: veaswar@wisc.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Revised Hearing Handicap Inventory and Screening Tool Based on Psychometric Reevaluation of the Hearing Handicap Inventories for the Elderly and Adults Objectives: The present study evaluates the items of the Hearing Handicap Inventory for the Elderly and Hearing Handicap Inventory for Adults (HHIE/A) using Mokken scale analysis (MSA), a type of nonparametric item response theory, and develops updated tools with optimal psychometric properties. Design: In a longitudinal study of age-related hearing loss, 1447 adults completed the HHIE/A and audiometric testing at baseline. Discriminant validity of the emotional consequences and social/situational effects subscales of the HHIE/A was assessed, and nonparametric item response theory was used to explore dimensionality of the items of the HHIE/A and to refine the scales. Results: The HHIE/A items form strong unidimensional scales measuring self-perceived hearing handicap, but with a lack of discriminant validity of the two distinct subscales. Two revised scales, the 18-item Revised Hearing Handicap Inventory and the 10-item Revised Hearing Handicap Inventory—Screening, were developed from the common items of the original HHIE/A that met the assumptions of MSA. The items on both of the revised scales can be ordered in terms of increasing difficulty. Conclusions: The results of the present study suggest that the newly developed Revised Hearing Handicap Inventory and Revised Hearing Handicap Inventory—Screening are strong unidimensional, clinically informative measures of self-perceived hearing handicap that can be used for adults of all ages. The real-data example also demonstrates that MSA is a valuable alternative to classical psychometric analysis. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and text of this article on the journal's Web site (www.ear-hearing.com). ACKNOWLEDGMENTS: The authors thank Jayne Ahlstrom for editorial assistance. The authors thank the subjects who participated in this study. This work was supported (in part) by research grant P50 DC000422 from NIH/NIDCD and by the South Carolina Clinical and Translational Research (SCTR) Institute, with an academic home at the Medical University of South Carolina, NIH/NCATS Grant number UL1 TR001450. This investigation was conducted in a facility constructed with support from Research Facilities Improvement Program Grant Number C06 RR14516 from the NIH/NCRR. Portions of this article were presented at the Hearing Across the Lifespan 2018 conference, Cernobbio, Lake Como, Italy, June 7, 2018. The authors have no conflicts of interest to declare. Received December 31, 2018; accepted March 25, 2019. Address for correspondence: Christy Cassarly, Department of Public Health Sciences, Medical University of South Carolina, 135 Cannon St., Ste 303, MSC 835, Charleston, SC 29425, USA. E-mail: cassarly@musc.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Effects of GJB2 or SLC26A4 Gene Mutations on Neural Response of the Electrically Stimulated Auditory Nerve in Children Objectives: This study aimed to (1) investigate the effect of GJB2 and SLC26A4 gene mutations on auditory nerve function in pediatric cochlear implant users and (2) compare their results with those measured in implanted children with idiopathic hearing loss. Design: Participants included 20 children with biallelic GJB2 mutations, 16 children with biallelic SLC26A4 mutations, and 19 children with idiopathic hearing loss. All subjects except for two in the SLC26A4 group had concurrent Mondini malformation and enlarged vestibular aqueduct. All subjects used Cochlear Nucleus devices in their test ears. For each subject, electrophysiological measures of the electrically evoked compound action potential (eCAP) were recorded using both anodic- and cathodic-leading biphasic pulses. Dependent variables (DVs) of interest included slope of eCAP input/output (I/O) function, the eCAP threshold, and eCAP amplitude measured at the maximum comfortable level (C level) of the anodic-leading stimulus (i.e., the anodic C level). Slopes of eCAP I/O functions were estimated using statistical modeling with a linear regression function. These DVs were measured at three electrode locations across the electrode array. Generalized linear mixed effect models were used to evaluate the effects of study group, stimulus polarity, and electrode location on each DV. Results: Steeper slopes of eCAP I/O function, lower eCAP thresholds, and larger eCAP amplitude at the anodic C level were measured for the anodic-leading stimulus compared with the cathodic-leading stimulus in all subject groups. Children with GJB2 mutations showed steeper slopes of eCAP I/O function and larger eCAP amplitudes at the anodic C level than children with SLC26A4 mutations and children with idiopathic hearing loss for both the anodic- and cathodic-leading stimuli. In addition, children with GJB2 mutations showed a smaller increase in eCAP amplitude when the stimulus changed from the cathodic-leading pulse to the anodic-leading pulse (i.e., smaller polarity effect) than children with idiopathic hearing loss. There was no statistically significant difference in slope of eCAP I/O function, eCAP amplitude at the anodic C level, or the size of polarity effect on all three DVs between children with SLC26A4 mutations and children with idiopathic hearing loss. These results suggested that better auditory nerve function was associated with GJB2 but not with SLC26A4 mutations when compared with idiopathic hearing loss. In addition, significant effects of electrode location were observed for slope of eCAP I/O function and the eCAP threshold. Conclusions: GJB2 and SLC26A4 gene mutations did not alter polarity sensitivity of auditory nerve fibers to electrical stimulation. The anodic-leading stimulus was generally more effective in activating auditory nerve fibers than the cathodic-leading stimulus, despite the presence of GJB2 or SLC26A4 mutations. Patients with GJB2 mutations appeared to have better functional status of the auditory nerve than patients with SLC26A4 mutations who had concurrent Mondini malformation and enlarged vestibular aqueduct and patients with idiopathic hearing loss. ACKNOWLEDGMENTS: We gratefully thank all subjects and their parents for participating in this study. J.L. participated in data collection and patient testing, prepared the initial draft of this article, provided critical comments, and approved the final version of this article. L.X., X.C., and R.W. participated in the data collection and patient testing, provided critical comments, and approved the final version of this article. X.B. conducted genetic tests in all study participants, provided critical comments, and approved the final version of this article. A.P. and Z.F. provided critical comments and approved the final version of this article. H.W. participated in designing this study, provided critical comments, and approved the final version of this article. S.H. designed the study, participated in data collection and patient testing, and drafted and approved the final version of this article. The authors have no conflicts of interest to declare. Received September 18, 2018; accepted March 17, 2019. Address for correspondence: Haibo Wang, Department of Otolaryngology—Head and Neck Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Duanxing West Road, Huaiyin, Jinan 250022, Shandong, People's Republic of China. E-mail: Whboto11@163.Com or Shuman He, Eye and Ear Institute, Department of Otolaryngology – Head and Neck Surgery, The Ohio State University, 915 Olentangy River Road, Columbus, OH 43212, USA. E-mail: shuman.he@osumc.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Use of Commercial Virtual Reality Technology to Assess Verticality Perception in Static and Dynamic Visual Backgrounds Objectives: The Subjective Visual Vertical (SVV) test and the closely related Rod and Disk Test (RDT) are measures of perceived verticality measured in static and dynamic visual backgrounds. However, the equipment used for these tests is variable across clinics and is often too expensive or too primitive to be appropriate for widespread use. Commercial virtual reality technology, which is now widely available, may provide a more suitable alternative for collecting these measures in clinical populations. This study was designed to investigate verticality perception in symptomatic patients using a modified RDT paradigm administered through a head-mounted display (HMD). Design: A group of adult patients referred by a physician for vestibular testing based on the presence of dizziness symptoms and a group of healthy adults without dizziness symptoms were included. We investigated degree of visual dependence in both groups by measuring SVV as a function of kinematic changes to the visual background. Results: When a dynamic background was introduced into the HMD to simulate the RDT, significantly greater shifts in SVV were found for the patient population than for the control population. In patients referred for vestibular testing, the SVV measured with the HMD was significantly correlated with traditional measures of SVV collected in a rotary chair when accounting for head tilt. Conclusions: This study provides initial proof of concept evidence that reliable SVV measures in static and dynamic visual backgrounds can be obtained using a low-cost commercial HMD system. This initial evidence also suggests that this tool can distinguish individuals with dizziness symptomatology based on SVV performance in dynamic visual backgrounds. Acknowledgment: The work was supported by Defense Health Affairs in support of the Army Hearing Program. The views expressed in this article are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. The identification of specific products or scientific instrumentation does not constitute endorsement or implied endorsement on the part of the author, DoD, or any component agency. The views expressed in this presentation are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. The authors have no conflicts of interest to disclose. Received March 27, 2018; accepted March 2, 2019. Address for correspondence: Ashley Zaleski-King, Walter Reed National Military Medical Center (WRNMMC), 8901 Rockville Pike, Bethesda, MD 20889, USA. E-mail: ashley.c.king8.civ@mail.mil Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Predicting Speech-in-Noise Deficits from the Audiogram Objectives: In occupations that involve hearing critical tasks, individuals need to undergo periodic hearing screenings to ensure that they have not developed hearing losses that could impair their ability to safely and effectively perform their jobs. Most periodic hearing screenings are limited to pure-tone audiograms, but in many cases, the ability to understand speech in noisy environments may be more important to functional job performance than the ability to detect quiet sounds. The ability to use audiometric threshold data to identify individuals with poor speech-in-noise performance is of particular interest to the U.S. military, which has an ongoing responsibility to ensure that its service members (SMs) have the hearing abilities they require to accomplish their mission. This work investigates the development of optimal strategies for identifying individuals with poor speech-in-noise performance from the audiogram. Design: Data from 5487 individuals were used to evaluate a range of classifiers, based exclusively on the pure-tone audiogram, for identifying individuals who have deficits in understanding speech in noise. The classifiers evaluated were based on generalized linear models (GLMs), the speech intelligibility index (SII), binary threshold criteria, and current standards used by the U.S. military. The classifiers were evaluated in a detection theoretic framework where the sensitivity and specificity of the classifiers were quantified. In addition to the performance of these classifiers for identifying individuals with deficits understanding speech in noise, data from 500,733 U.S. Army SMs were used to understand how the classifiers would affect the number of SMs being referred for additional testing. Results: A classifier based on binary threshold criteria that was identified through an iterative search procedure outperformed a classifier based on the SII and ones based on GLMs with large numbers of fitted parameters. This suggests that the saturating nature of the SII is important, but that the weights of frequency channels are not optimal for identifying individuals with deficits understanding speech in noise. It is possible that a highly complicated model with many free parameters could outperform the classifiers considered here, but there was only a modest difference between the performance of a classifier based on a GLM with 26 fitted parameters and one based on a simple all-frequency pure-tone average. This suggests that the details of the audiogram are a relatively insensitive predictor of performance in speech-in-noise tasks. Conclusions: The best classifier identified in this study, which was a binary threshold classifier derived from an iterative search process, does appear to reliably outperform the current thresholds criteria used by the U.S. military to identify individuals with abnormally poor speech-in-noise performance, both in terms of fewer false alarms and a greater hit rate. Substantial improvements in the ability to detect SMs with impaired speech-in-noise performance can likely only be obtained by adding some form of speech-in-noise testing to the hearing monitoring program. While the improvements were modest, the overall benefit of adopting the proposed classifier is likely substantial given the number of SMs enrolled in U.S. military hearing conservation and readiness programs. ACKNOWLEDGMENTS: The authors thank Dr. Gary Kidd for sharing his TDT data and Dr. Ken Grant for sharing his SPRINT data. The authors also thank Kari Buchanan and the Hearing Center of Excellence for sharing the DOEHRS-HC data. All authors contributed equally to this work. All authors were involved in the data analysis and discussed the results and implications and commented on the manuscript at all stages. The views expressed in this article are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. The authors have no conflicts of interest to disclose. Received December 3, 2017; accepted March 14, 2019. Address for correspondence: Daniel E. Shub, National Military Audiology and Speech Center, Walter Reed National Military Medical Center, 4954 North Palmer Road, Bethesda, MD 20889, USA. E-mail: daniel.e.shub.civ@mail.mil Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Children With Normal Hearing Are Efficient Users of Fundamental Frequency and Vocal Tract Length Cues for Voice Discrimination Background: The ability to discriminate between talkers assists listeners in understanding speech in a multitalker environment. This ability has been shown to be influenced by sensory processing of vocal acoustic cues, such as fundamental frequency (F0) and formant frequencies that reflect the listener's vocal tract length (VTL), and by cognitive processes, such as attention and memory. It is, therefore, suggested that children who exhibit immature sensory and/or cognitive processing will demonstrate poor voice discrimination (VD) compared with young adults. Moreover, greater difficulties in VD may be associated with spectral degradation as in children with cochlear implants. Objectives: The aim of this study was as follows: (1) to assess the use of F0 cues, VTL cues, and the combination of both cues for VD in normal-hearing (NH) school-age children and to compare their performance with that of NH adults; (2) to assess the influence of spectral degradation by means of vocoded speech on the use of F0 and VTL cues for VD in NH children; and (3) to assess the contribution of attention, working memory, and nonverbal reasoning to performance. Design: Forty-one children, 8 to 11 years of age, were tested with nonvocoded stimuli. Twenty-one of them were also tested with eight-channel, noise-vocoded stimuli. Twenty-one young adults (18 to 35 years) were tested for comparison. A three-interval, three-alternative forced-choice paradigm with an adaptive tracking procedure was used to estimate the difference limens (DLs) for VD when F0, VTL, and F0 + VTL were manipulated separately. Auditory memory, visual attention, and nonverbal reasoning were assessed for all participants. Results: (a) Children' F0 and VTL discrimination abilities were comparable to those of adults, suggesting that most school-age children utilize both cues effectively for VD. (b) Children's VD was associated with trail making test scores that assessed visual attention abilities and speed of processing, possibly reflecting their need to recruit cognitive resources for the task. (c) Best DLs were achieved for the combined (F0 + VTL) manipulation for both children and adults, suggesting that children at this age are already capable of integrating spectral and temporal cues. (d) Both children and adults found the VTL manipulations more beneficial for VD compared with the F0 manipulations, suggesting that formant frequencies are more reliable for identifying a specific speaker than F0. (e) Poorer DLs were achieved with the vocoded stimuli, though the children maintained similar thresholds and pattern of performance among manipulations as the adults. Conclusions: The present study is the first to assess the contribution of F0, VTL, and the combined F0 + VTL to the discrimination of speakers in school-age children. The findings support the notion that many NH school-age children have effective spectral and temporal coding mechanisms that allow sufficient VD, even in the presence of spectrally degraded information. These results may challenge the notion that immature sensory processing underlies poor listening abilities in children, further implying that other processing mechanisms contribute to their difficulties to understand speech in a multitalker environment. These outcomes may also provide insight into VD processes of children under listening conditions that are similar to cochlear implant users. ACKNOWLEDGMENTS: The authors wish to acknowledge the contribution of the following undergraduate students from the Department of Communication Disorders at Tel Aviv University for assisting in data collection: Feigi Raiter, Feigi Grinvald, Shani Rabia, Adi Amsalem, Miri Rotem, Lea pantiat, Daniel Lex Rabinovitch, and Orpaz Shariki. The authors wish to thank Steyer grant (School of Health Professions, Tel-Aviv University) for their financial support. The authors specially thank all the adults and children who participated in the present study. All authors contributed to this work to a significant extent. All authors have read the article and agreed to submit it for publication after discussing the results and implications and commented on the article at all stages. All authors are, therefore, responsible for the reported research and have approved the final article as submitted. The authors have no conflicts of interest to declare. Received September 30, 2018; accepted March 17, 2019. Address for correspondence: Yael Zaltz, Department of Communication Disorders, The Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. E-mail: yaelzaltz@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Switching Streams Across Ears to Evaluate Informational Masking of Speech-on-Speech Objectives: This study aimed to evaluate the informational component of speech-on-speech masking. Speech perception in the presence of a competing talker involves not only informational masking (IM) but also a number of masking processes involving interaction of masker and target energy in the auditory periphery. Such peripherally generated masking can be eliminated by presenting the target and masker in opposite ears (dichotically). However, this also reduces IM by providing listeners with lateralization cues that support spatial release from masking (SRM). In tonal sequences, IM can be isolated by rapidly switching the lateralization of dichotic target and masker streams across the ears, presumably producing ambiguous spatial percepts that interfere with SRM. However, it is not clear whether this technique works with speech materials. Design: Speech reception thresholds (SRTs) were measured in 17 young normal-hearing adults for sentences produced by a female talker in the presence of a competing male talker under three different conditions: diotic (target and masker in both ears), dichotic, and dichotic but switching the target and masker streams across the ears. Because switching rate and signal coherence were expected to influence the amount of IM observed, these two factors varied across conditions. When switches occurred, they were either at word boundaries or periodically (every 116 msec) and either with or without a brief gap (84 msec) at every switch point. In addition, SRTs were measured in a quiet condition to rule out audibility as a limiting factor. Results: SRTs were poorer for the four switching dichotic conditions than for the nonswitching dichotic condition, but better than for the diotic condition. Periodic switches without gaps resulted in the worst SRTs compared to the other switch conditions, thus maximizing IM. Conclusions: These findings suggest that periodically switching the target and masker streams across the ears (without gaps) was the most efficient in disrupting SRM. Thus, this approach can be used in experiments that seek a relatively pure measure of IM, and could be readily extended to translational research. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and text of this article on the journal's Web site (www.ear-hearing.com). ACKNOWLEDGMENTS: The authors thank Rachel Ellinger and Andrea Cunningham for their help with data collection. This work was supported by NIH R01 DC 60014 grant awarded to P. S., and an iCARE ITN (FP7-607139) European fellowship to A. C. The authors have no conflict of interest to disclose. Received June 4, 2018; accepted March 17, 2019. Address for correspondence: Axelle Calcus, Ecole Normale Supérieure, 29 rue d'Ulm, 75005 Paris, France. E-mail: axelle.calcus@ens.fr Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Genetic Inheritance of Late-Onset, Down-Sloping Hearing Loss and Its Implications for Auditory Rehabilitation Objectives: Late-onset, down-sloping sensorineural hearing loss has many genetic and nongenetic etiologies, but the proportion of this commonly encountered type of hearing loss attributable to genetic causes is not well known. In this study, the authors performed genetic analysis using next-generation sequencing techniques in patients showing late-onset, down-sloping sensorineural hearing loss with preserved low-frequency hearing, and investigated the clinical implications of the variants identified. Design: From a cohort of patients with hearing loss at a tertiary referral hospital, 18 unrelated probands with down-sloping sensorineural hearing loss of late onset were included in this study. Down-sloping hearing loss was defined as a mean low-frequency threshold at 250 Hz and 500 Hz less than or equal to 40 dB HL and a mean high-frequency threshold at 1, 2, and 4 kHz greater than 40 dB HL. The authors performed whole-exome sequencing and segregation analysis to identify the genetic causes and evaluated the outcomes of auditory rehabilitation in the patients. Results: There were nine simplex and nine multiplex families included, in which the causative variants were found in six of 18 probands, demonstrating a detection rate of 33.3%. Various types of variants, including five novel and three known variants, were detected in the MYH14, MYH9, USH2A, COL11A2, and TMPRSS3 genes. The outcome of cochlear and middle ear implants in patients identified with pathogenic variants was satisfactory. There was no statistically significant difference between pathogenic variant-positive and pathogenic variant-negative groups in terms of onset age, family history of hearing loss, pure-tone threshold, or speech discrimination scores. Conclusions: The proportion of patients with late-onset, down-sloping hearing loss identified with potentially causative variants was unexpectedly high. Identification of the causative variants will offer insights on hearing loss progression and prognosis regarding various modes of auditory rehabilitation, as well as possible concomitant syndromic features. ACKNOWLEDGMENTS: This study was provided with bioresources from the National Biobank of Korea, Centers for Disease Control and Prevention, Republic of Korea (4845-301, 4851-302 and -307). This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT & Future Planning (2015R1A1A1A05001472 to S.M.H., 2017M3A9E8029714 to J.J.S., 2014M3A9D5A01073865 to C.J.Y., 2018R1A5A2025079 to H.Y.G.) M.H.S., J.J., H.Y.G., and J.Y.C. designed the study conception. J.J, J.H.R., H.J.C., and J.S.L. performed the experiment. M.H.S., J.J., H.J.L., and B.N. analyzed and interpreted the data. M.H.S., J.J., H.J.L., B.N., H.Y.G., and J.H.R. wrote the article. The authors have no conflicts of interest to disclose. Received July 25, 2018; accepted March 2, 2019. Address for correspondence: Jae Young Choi, Department of Otorhino laryngology, Yonsei University College of Medicine, 50–1 Yonsei-ro, Seodaemun-gu, Seoul 120–752, Republic of Korea. E-mail: jychoi@yuhs.ac Address for correspondence: Heon Yung Gee, Department of Pharmacology and Brain Korea 21 Project for Medical Sciences, Yonsei University College of Medicine, 50–1 Yonsei-ro, Seodaemun-gu, Seoul 120–752, Republic of Korea. E-mail: hygee@yuhs.ac Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Improving Clinical Outcomes in Cochlear Implantation Using Glucocorticoid Therapy: A Review Cochlear implant surgery is a successful procedure for auditory rehabilitation of patients with severe to profound hearing loss. However, cochlear implantation may lead to damage to the inner ear, which decreases residual hearing and alters vestibular function. It is now of increasing interest to preserve residual hearing during this surgery because this is related to better speech, music perception, and hearing in complex listening environments. Thus, different efforts have been tried to reduce cochlear implantation-related injury, including periprocedural glucocorticoids because of their anti-inflammatory properties. Different routes of administration have been tried to deliver glucocorticoids. However, several drawbacks still remain, including their systemic side effects, unknown pharmacokinetic profiles, and complex delivery methods. In the present review, we discuss the role of periprocedural glucocorticoid therapy to decrease cochlear implantation-related injury, thus preserving inner ear function after surgery. Moreover, we highlight the pharmacokinetic evidence and clinical outcomes which would sustain further interventions. ACKNOWLEDGMENTS: The authors have no conflicts of interest to disclose. Received October 8, 2018; accepted March 14, 2019. Address for correspondence: Cecilia Engmér Berglin, Department of Otorhinolaryngology, B53, Karolinska University Hospital, 141 86 Stockholm, Sweden. E-mail: cecilia.engmer-berglin@sll.se Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Effect of Hearing-Protection Devices on Auditory Situational Awareness and Listening Effort Objectives: Hearing-protection devices (HPDs) are made available, and often are required, for industrial use as well as military training exercises and operational duties. However, these devices often are disliked, and consequently not worn, in part because they compromise situational awareness through reduced sound detection and localization performance as well as degraded speech intelligibility. In this study, we carried out a series of tests, involving normal-hearing subjects and multiple background-noise conditions, designed to evaluate the performance of four HPDs in terms of their modifications of auditory-detection thresholds, sound-localization accuracy, and speech intelligibility. In addition, we assessed their impact on listening effort to understand how the additional effort required to perceive and process auditory signals while wearing an HPD reduces available cognitive resources for other tasks. Design: Thirteen normal-hearing subjects participated in a protocol, which included auditory tasks designed to measure detection and localization performance, speech intelligibility, and cognitive load. Each participant repeated the battery of tests with unoccluded ears and four hearing protectors, two active (electronic) and two passive. The tasks were performed both in quiet and in background noise. Results: Our findings indicate that, in variable degrees, all of the tested HPDs induce performance degradation on most of the conducted tasks as compared to the open ear. Of particular note in this study is the finding of increased cognitive load or listening effort, as measured by visual reaction time, for some hearing protectors during a dual-task, which added working-memory demands to the speech-intelligibility task. Conclusions: These results indicate that situational awareness can vary greatly across the spectrum of HPDs, and that listening effort is another aspect of performance that should be considered in future studies. The increased listening effort induced by hearing protectors may lead to earlier cognitive fatigue in noisy environments. Further study is required to characterize how auditory performance is limited by the combination of hearing impairment and the use of HPDs, and how the effects of such limitations can be linked to safe and effective use of hearing protection to maximize job performance. ACKNOWLEDGMENTS: This work is sponsored by the US Army Natick Soldier Research, Development, and Engineering Center under Air Force Contract FA8721-05-C-0002 and/or FA8702-15-D-0001. Any opinions, findings, conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the Department of the Army. Distribution Statement A: Approved for public release. Distribution is unlimited. C.J.S. designed and performed experiments, analyzed data, provided statistical analysis and wrote the article; P.T.C provided data analysis and wrote the article; A.P.D, J.P.P., T.P., and J.B. collected and analyzed data; T.F.Q. and M.M. provided contributions to conception of the work and critical editing; P.P.C provided editing and final approval of the version to be published. The authors have no conflicts of interest to disclose. Received June 4, 2018; accepted February 21, 2019. Address for correspondence: Bioengineering Systems and Technologies Group, MIT Lincoln Laboratory, 244 Wood St. Lexington, MA 02421, USA. E-mail: christopher.smalt@ll.mit.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Global Infectious Diseases

State of the globe: Antimicrobial resistance: Are we ready? Sunil Kumar Raina Journal of Global Infectious Diseases 2019 11(2):53-53

Fighting antimicrobial resistance: Status paper with action points by organized medicine academic guild Sunil Kumar Raina, Sagar Galwankar, Akshay C Dhariwal, Ramesh Bhatt, Raman Kumar, Ishwar Gilada, Praveen Aggarwal, S Vimal Krishnan, Santosh Soans, RP Srivastva, Udhay Bodhankar Journal of Global Infectious Diseases 2019 11(2):54-58

Antimicrobial resistance profile and Nim gene detection among Bacteroides fragilis group isolates in a university hospital in South India Shashidhar Vishwanath, Padmaja Ananth Shenoy, Kiran Chawla Journal of Global Infectious Diseases 2019 11(2):59-62 Introduction: Members of Bacteroides fragilis group are the most frequently isolated anaerobic pathogens in the clinical laboratory from diverse infection sites. The objective of this study was to characterize B. fragilis isolates from various clinical specimens, to analyze their susceptibility profile toward most common anti-anaerobic antimicrobials, and to study the frequency of nim gene determining resistance to nitroimidazoles. Methods: Specimens processed for anaerobic culture between January 2013 and December 2015 were analyzed. Isolates of B. fragilis group were identified and speciated by mass spectrometry. β-lactamase production was detected using nitrocefin disks. Agar dilution and antimicrobial gradient diffusion methods were performed to study their susceptibility profile. The isolates were screened for nim gene by conventional gel-based polymerase chain reaction. Results: A total of 57 isolates of B. fragilis group were studied. The commonly isolated species was B. fragilis (73.7%), followed by Bacteroides thetaiotaomicron (8.8%), Bacteroides vulgatus (8.8%), and others. Most of the isolates were recovered from deep-seated abscesses (47.4%). All isolates were found to be β-lactamase producers. Metronidazole (Mtz) resistance was observed in 4 (7%) isolates. Higher rate of resistance was observed toward clindamycin (31.6%). None of the isolates tested were found resistant to chloramphenicol, piperacillin-tazobactam, and meropenem. nim genes were present in 4 (11.4%) B. fragilis isolates (n = 35). Conclusions: Resistance to the most commonly used empirical anti-anaerobic drugs including Mtz was noted in the isolates of B. fragilis group. Routine anaerobic cultures when indicated and continual surveillance of antimicrobial resistance among the anaerobic bacterial pathogens is essential.

Effect of temperature and altitude difference on tuberculosis notification: A systematic review Yalemzewod Assefa Gelaw, Weiwei Yu, Ricardo J Soares Magalhães, Yibeltal Assefa, Gail Williams Journal of Global Infectious Diseases 2019 11(2):63-68 Background: Ecological factors are important indicators for tuberculosis (TB) notification. However, consolidation of evidence on the effect of altitude and temperature on TB notification rate has not yet been done. The aim of this review is to illustrate the effect of altitude and temperature on TB notification rate. Methods: Electronic searches were undertaken from PubMed, EMBASE, and Scopus databases. Hand searches of bibliographies of retrieved papers provided additional references. A review was performed using the Meta-analysis Of Observational Studies in Epidemiology guideline. Results: Nine articles from various geographic regions were included in the study. Five out of nine studies showed the effect of altitude and four articles identified temperature effects. Results showed that TB notification rates were lower at higher altitude and higher at a higher temperature. Conclusion: This review provides qualitative evidence that TB notification rates increase with temperature and decrease with altitude. The findings of this review will encourage policymakers and program managers to consider seasonality and altitude differences in the design and implementation of TB prevention and control strategies.

Empiric antibiotic therapy in the treatment of community-acquired pneumonia in a general hospital in Saudi Arabia Jaffar A Al-Tawfiq, Hisham Momattin, Kareem Hinedi Journal of Global Infectious Diseases 2019 11(2):69-72 Background: Guideline-based empiric antimicrobial therapy is recommended for the treatment of community-acquired pneumonia (CAP). In this study, we evaluate the pattern of empiric antibiotics of CAP patients. Materials and Methods: Patients with CAP were retrieved from the health information unit using the International Classification of Diseases, Ninth Revision. The electronic pharmacy database was used to retrieve prescribed antibiotics and the duration of therapy for each antibiotic. Results: A total of 1672 adult patients were included in the study and 868 (52%) were male. Of all the patients, 47 (2.8%) were admitted to the intensive care unit (ICU). The most frequently used antibiotics were levofloxacin (68.12%), ceftriaxone (37.7%), imipenem-cilastatin (32.5%), and azithromycin (20.6%). The mean days of therapy of each of these antibiotics were 3.2, 2.8, 4.4, and 2.9, respectively. A combination therapy of levofloxacin and imipenem-cilastatin was prescribed for 355 (21.8%) of non-ICU patients versus 20 (60.6%) of ICU patients (P = 0.0007). Imipenem-cilastatin was prescribed for 518 (31.8%) of non-ICU patients versus 25 (56.8%) of ICU patients (P = 0.0009). Levofloxacin was prescribed for 1106 (68%) of non-ICU patients versus 33 (75%) of ICU patients (P = 0.412). Ceftriaxone use decreased significantly from 40.9% in 2013 to 25.9% in 2016 (P = 0.034). In addition, levofloxacin use increased from 63.7% to 75% (P = 0.63). Conclusion: The most commonly used antibiotics were levofloxacin, ceftriaxone, imipenem-cilastatin, and azithromycin. The data call for further refinement and prospective audit of antibiotic use in CAP, especially in non-ICU settings.

A prospective study on impact of early initiation of antiretroviral therapy in human immunodeficiency virus-positive adults on immunological status and adverse events Vikas Kumar, Jatinder Singh Journal of Global Infectious Diseases 2019 11(2):73-79 Introduction: Antiretroviral therapy (ART) is a lifelong commitment for human immunodeficiency virus infection (HIV)-positive patients. The patients may develop early adverse drug reactions (ADRs) during the first 3 months of treatment, especially when they have advanced HIV disease with low CD4 counts. Materials and Methods: The present study was a prospective observational study that took place from January 2017 to July 2017 at ART center, Government Medical College, Amritsar, Punjab, India. The primary objective of the study was to evaluate ADRs to ART and immunological status in HIV-positive patients. The patients received ART regimens as per the National AIDS Control Organization guidelines. The sample included both ART-naïve and ART-experienced HIV-positive patients. The causality of reported ADRs assessed according to the World Health Organization guidelines. The study was conducted after taking approval from the Institutional Ethics Committee, Government Medical College, Amritsar, and informed consent from the patients. Data were analyzed statistically using Chi-square test, and P < 0.05 was considered statistically significant. Results: Out of total 350 patients screened during study period, 84 patients reported with confirmed ADRs. The most widely used treatment regimen was tenofovir + lamivudine + efavirenz (59.52%). Central nervous system (19.05%)-, renal (14.29%)-, and immune reconstitution inflammatory syndrome (14.29%)-related ADRs were mostly reported. The causality assessment revealed insignificant P value (Chi-square = 8.656 and P = 0.07), with 19.05% probable and 80.95% possible ADRs. Conclusions: The CD4 count <200/μl at the initiation of ART and treatment duration <1 year proved to be predictors for ADRs. Early initiation of ART in HIV-positive patients can improve immunological status and decrease in the incidence of ADRs.

The largest American study comparing transient elastography and the aminotransferase-to-platelet ratio index score, two noninvasive tests for liver fibrosis staging in HIV/HCV coinfected patients Jason Dazley, Elaine Szabela, A Adebara, Prerak Shukla, Raymund Sison, Jihad Slim Journal of Global Infectious Diseases 2019 11(2):80-82 Objective: Elastography has become the standard of care of diagnostic approaches for liver disease, particularly when dealing with hepatitis C. There areno studies in the inner-city populations of Newark, New Jersey, that describe the comparison of noninvasive markers, such as FibroScan andaminotransferase-to-platelet ratio index (APRI) scoring. Methods: Using a chart review method, we used a case-control study method of gathering and analyzing the data, using P < or = 0.05 as a significant variable. Results: The outcome of this study indicates that the FibroScan may be a better marker than the APRI score for the staging of liver disease when a patient has hepatitis B or C with or without HIV/AIDS. Conclusions: This may be a benchmark study to further enhance our understanging of the utility of the fibroscan.

A case of lipotourism-associated multidrug-resistant Mycobacterium abscessus infection Rose Anne Lee, Robin Wigmore Journal of Global Infectious Diseases 2019 11(2):83-85 Rapidly growing mycobacteria have become increasingly recognized as pathogens implicated in surgical site infections that can be both difficult to diagnose and treat with an evolving understanding of both intrinsic and acquired resistance patterns. As common environmental commensal organisms that can colonize water supplies, they are of particular concern in the setting of a growing medical tourism industry. We present a case of a 49-year-old woman who acquired a highly multidrug-resistant Mycobacterium abscessus skin and soft-tissue infection after cosmetic abdominoplasty that required radical surgical debridement and 6 months of intravenous therapy to eradicate. This case highlights the challenges in the management of M. abscessus infections including delay to diagnosis and resistance patterns that are likely to become more common despite antibiotic stewardship efforts.

Anemia in pregnant women with Hepatitis B viral DNA in Port Harcourt, Nigeria Theodora P Etu-Efeotor, Hannah E Omunakwe Journal of Global Infectious Diseases 2019 11(2):86-87

Anthrax-based epidemiological surveillance in Western Mexico Salvador Valle-Reyes, Tiburcio Lizama-Munguía, Jorge A Salazar-Barragán, José B Soto-Castellan, Erika J Verján-Carrillo, Francisco Espinoza-Gómez, Perla A Rios-Flores, Gabriel Ceja-Espíritu, Iván Delgado-Enciso, Uriel A López-Lemus Journal of Global Infectious Diseases 2019 11(2):87-88

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Trauma and Acute Care Surgery

Point-of-care Resuscitation Research: From Extreme to Mainstream: Trauma Association of Canada Fraser Gurd Lecture 2019 The Gurd Family surgical legacy was deeply intertwined with National service in both World Wars. My own personal research mission has attempted to emulate such service, by enhancing the tools and techniques available to facilitate point-of-care (POC) diagnosis and resuscitation in extreme and adverse environments. Our efforts involving POC diagnosis/resuscitation and the telementored guidance of those remotely responding to catastrophic injury have included collaborations with NASA, the Canadian Space Agency, the Canadian Forces, its democratic allies, and non-governmental surgical organizations. Research has been conducted in resuscitative suites and operating theatres, research laboratories, parabolic flight aircraft, on humanitarian surgical missions, and from ski-hills and firehalls. The initial phases of these efforts involved inaugural studies in resuscitative sonography including defining the EFAST examination. Although the original work was commissioned for Space Medicine, generalization to mainstream practice further justifies space medicine research. Iterative steps in advancing telementored resuscitation have subsequently involved the maturation of space mandated telementored ultrasound support (TMUS), exploration of TMUS in terrestrial clinical practice, and the creation of increasingly mobile (hand-held) TMUS solutions. Subsequently it was recognized that tele-ultrasound is simply one informatic dimension of remote telemedicine, and current efforts are focused in a Program known as TeleMentored Ultrasound Supported Medical Interactions (TMUSMI) of remote responders required to intervene with catastrophic trauma. While this research program has yielded many techniques and findings that have benefited mainstream terrestrial practice, these investigations are currently ongoing, and we hope to demonstrate that TMUSMI may benefit all Canadians especially those in remote areas, as well as potentially every global inhabitant without immediate access to care. Further, we propose that to abstract fully utilize these techniques, a new specialty, that of the remote medical mentor will be required, a new specialty that will require the creation and scientific validation of its principles and techniques. Address for Correspondence AW Kirkpatrick Regional Trauma Services EG 23 Foothills Medical Services 1403 29 ST NW Calgary, Alberta T2N 2T9 This manuscript was an invited Podium Presentation at the Annual Scientific Meeting of the Trauma Association of Canada, as the named Fraser Gurd Lecture 2019. Conflict of Interest No funding of any kind was provided to prepare this manuscript. AW Kirkpatrick continues to serve in the Canadian Forces Medical Services. AW Kirkpatrick has consulted for the Acelity and Innovative Trauma Care Corporations. © 2019 Lippincott Williams & Wilkins, Inc.

Ketamine Infusion for Pain Control in Adult Patients with Multiple Rib Fractures No abstract available

Promotility Agents For The Treatment Of Ileus In Adult Surgical Patients: A Practice Management Guideline From The Eastern Association For The Surgery Of Trauma Background Ileus is a common challenge in adult surgical patients with estimated incidence to be 17%-80%. The main mechanisms of the postoperative ileus pathophysiology are fluid overload, exogenous opioids, neurohormonal dysfunction, gastrointestinal stretch and inflammation. Management includes addressing the underlying cause and supportive care. Multiple medical interventions have been proposed, but effectiveness is uncertain. A working group of the Eastern Association for the Surgery of Trauma (EAST) aimed to evaluate the effectiveness of metoclopramide, erythromycin, and early enteral nutrition (EEN) on ileus in adult surgical patients and to develop recommendations applicable in a daily clinical practice. Methods Literature search identified 45 papers appropriate for inclusion. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was applied to evaluate the effect of metoclopramide, erythromycin, and EEN on the resolution of ileus in adult surgical patients based on selected outcomes: return of normal bowel function, attainment of enteral feeding goal, and hospital length of stay (LOS). The recommendations were made based on the results of a systematic review, a meta-analysis, and evaluation of levels of evidence. Results The level of evidence for all PICOs was assessed as low. Neither metoclopramide nor erythromycin were effective in expediting the resolution of ileus. Analyses of 32 randomized controlled trials showed that EEN facilitates return of normal bowel function, achieving enteral nutrition goals, and reducing hospital LOS. Conclusion In patients who have undergone abdominal surgery, we strongly recommend EEN to expedite resolution of Ileus, but we cannot recommend for or against the use of either metoclopramide or erythromycin to hasten the resolution of ileus in these patients. Level of Evidence Level II Type of Study Therapeutic Corresponding Author: Nikolay Bugaev, MD, Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, nbugaev@tuftsmedicalcenter.org, 800 Washington St, #4488, Boston, MA, 02111, Tel. 617-636-4488, Fax 617-636-8172 Conflict of Interests: no conflicts to disclose The manuscript was presented as a podium presentation at the 31st Eastern Association for the Surgery of Trauma (EAST) Annual Scientific Assembly. January 11, 2018: Lake Buena Vista, Florida. Disclosures of Funding: nothing to disclose. © 2019 Lippincott Williams & Wilkins, Inc.

Variability in international normalized ratio and activated partial thromboplastin time after injury are not explained by coagulation factor deficits Introduction Conventional coagulation assays (CCAs), PT/INR (prothrombin time/international normalized ratio) and aPTT (activated partial thromboplastin time), detect clotting factor (CF) deficiencies in hematologic disorders. However, there is controversy about how these CCAs should be used to diagnose, treat and monitor trauma-induced coagulopathy. Study objectives were to determine whether CCA abnormalities are reflective of deficiencies of coagulation factor activity in the setting of severe injury. Methods Patients without previous CF deficiency within a prospective database at an ACS verified Level 1 trauma center had CF activity levels, PT/INR, aPTT, and fibrinogen levels measured upon Emergency Department arrival from 2014-2017. Linear regression assessed how CF activity explained the aPTT and PT/INR variation. Prolonged CCA values were set as INR>1.3 and aPTT>34sec. CF deficiency was defined as <30% activity, except for fibrinogen, defined as <150mg/dL. Results Sixty patients with a mean age of 35.8 (std dev:13.6) years and median new injury severity score (NISS) of 32 (IQR:12-43) were included; 53.3% sustained blunt injuries, 23.3% required massive transfusion, and mortality was 11.67%. Overall, 44.6% of the PT/INR variance and 49.5% of the aPTT variance remained unexplained by CF activity. Deficiencies of CFs were: common pathway 25%; extrinsic pathway 1.7%, and intrinsic pathway 6.7%. The positive predictive value for CF deficiencies were: 1)PT/INR>1.3:4.4% for extrinsic pathway, 56.5% for the common pathway; 2) aPTT>34 sec:16.7% for the intrinsic pathway, 73.7% for the common pathway. Conclusion Almost half of the variances of PT/INR and aPTT were unexplained by CF activity. Prolonged PT/INR and aPTT were poor predictors of deficiencies in the intrinsic or extrinsic pathways, however, they were indicators of common pathway deficiencies. Corresponding Author: Ernest E Moore, MD, Email: ernest.moore@dhha.org Phone: 303-724-2685, Fax: 303-720-2682, Mailing Address: 655 Bannock Street Denver, CO 80203 Disclosure: Research reported in this publication was supported in part by the National Institute of General Medical Sciences grants: T32-GM008315 and P50-GM49222, the National Heart Lung and Blood Institute UM1-HL120877, in addition to the Department of Defense USAMRAA and W81XWH-12-2-0028. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the National Heart, Lung, and Blood institute, or the Department of Defense. Additional research support was provided by Haemonetics (Haemonetics, Niles, IL, USA) with shared intellectual property. © 2019 Lippincott Williams & Wilkins, Inc.

Blunt Rupture of Two Cardiac Chambers Following a Motor Vehicle Collision No abstract available

Reply to Letter: Observing Pneumothoraces: The 35 Millimeter Rule Is Safe for Both Blunt and Penetrating Chest Trauma No abstract available

A Preliminary Analysis of Level IV Trauma Centers within an Organized Trauma System Background The effect of Level IV trauma center (TC) accreditation within an existing trauma network remains understudied. This study compared pre- to post-accreditation data from Level IV TCs within a mature trauma system in Pennsylvania to determine whether TC designation affected time to and/or rate of transfer to definitive care. Level IV TCs were hypothesized to have a decreased time to transfer following accreditation and improved mortality. Methods The Pennsylvania Trauma Systems Foundation (PTSF) collects pre- and post-designation data from hospitals pursuing accreditation. Data from PTSF between 2012 and 2017 was analyzed. Variables of interest included patient demographics, injury severity, mortality and incidence of surgical interventions pre- to post-credentialing. A multilevel mixed-effects logistic regression model assessed the adjusted impact of Level IV TC accreditation on transfer rate. ArcGIS Desktop was used for geospatial mapping of lives and geographic area covered by the addition of Level IV TCs in Pennsylvania Results Five hospitals underwent Level IV credentialing from 2012-2017, providing data on 5,076 cases (Pre: 2,395 [47.2%]; Post: 2,681 [52.8%]). No significant difference in age, admission Glasgow Coma Scale score, or shock index was observed pre to post-accreditation. A difference in transfer rate was observed after credentialing in unadjusted (62.7% vs. 63.3%; p<0.014) and adjusted analyses (AOR: 1.13, p=0.389). There was a trend toward reduced odds of mortality post-credentialing (AOR: 0.59, p=0.261). Major surgical intervention decreased (Pre: 0.42%, Post: 0.04%; p=0.004). Conclusion Level IV TC accreditation has beneficial effects on increased transfer rates and may improve mortality. It is important to continue to observe the impact of Level IV TCs on patient outcomes within a mature trauma system. Level of Evidence III; prognostic and epidemiological Corresponding Author: Frederick B. Rogers, MD, MS, MA, FACS; Frederick.Rogers@pennmedicine.upenn.edu, 555 N. Duke St., Lancaster, PA 17602, 717-544-5945 (tel), 717-544-5944 (fax) All authors have neither conflict of interest nor disclosure of funding or proprietary interest to declare on the materials or subject matter discussed herein. This study was accepted for a Quick Shot presentation at the 32nd Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma held in Austin, Texas from January 15-19, 2019. © 2019 Lippincott Williams & Wilkins, Inc.

Cholecystitis Complicated by Intrathoracic Gallbladder No abstract available

Commentary: Blunt Rupture of Two Cardiac Chambers Following a Motor Vehicle Collision No abstract available

TITRATE TO EQUILIBRATE AND NOT EXSANGUINATE!: CHARACTERIZATION AND VALIDATION OF A NOVEL PARTIAL RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA CATHETER IN NORMAL AND HEMORRHAGIC SHOCK CONDITIONS Background Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a significant advancement in the control of non-compressible truncal hemorrhage. However, its ischemic burden and reperfusion injury following balloon deflation limits its utilization. Partial restoration of aortic flow during REBOA has the potential to balance hemorrhage control and ischemia. This study validates the mechanics, physiology, and optimal partial flow rates using a prototype partial REBOA (pREBOA) device. Methods 25 swine underwent placement of aortic flow probes and zone 1 pREBOA. Experiment 1(N=5) animals were not injured and assessed the tested the catheters ability to titrate and control flow. Experiment 2 (N=10) added 20% hemorrhage and either solid organ, or abdominal vascular injury to compare flow rate and re-bleeding from injuries. Experiment 3 (N=10) swine were similarly prepared, hemorrhaged, and underwent pREBOA at set partial flow rates for 2hr followed by complete deflation for 30min. Results Balloon volume at minimum flow (mean .09 L/min) was 3.5-6.0mL. Half maximal flow was achieved with 56.5% of maximum balloon inflation. pREBOA allowed very fine titration of flow rates. Rebleeding occurred at 0.45-0.83 L/min. Distal flow of 0.7 L/min had 50% survival, 0.5 had 100% survival, and 0.3L had 50% survival with mean end lactates of 9.6, 12.6, and 13.3 respectively. There was a trend towards hyperkalemia and hypocalcemia in non-survivors. Conclusions The pREBOA device demonstrated a high level of titratability for restoration of aortic flow. An optimal partial flow of 0.5L/min was effective at hemorrhage control while limiting the burden of ischemic injury, and extending the tolerable duration of zone 1 occlusion. Aggressive calcium supplementation prior to and during partial occlusion and reperfusion may be warranted to prevent hyperkalemic arrest. Level of Evidence III Study Type Therapeutic Presented at the 49th Annual Meeting of the Western Trauma Association, March 03-08, 2019 in Snowmass, CO This work was supported by a Department of Defense Medical Research and Development Program (DMRDP) research grant under the DHP 6.7 program: Proposal D6.7 16 C2 I 16 J9 1490, "Intermittent Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Severe Non-compressible Truncal Hemorrhage" Conflicts of Interest: The authors have no conflicts of interest to declare and have received no financial or material support related to this manuscript Disclaimer: The results and opinions expressed in this article are those of the authors, and do not reflect the opinions or official policy of the United States Army or the Department of Defense. Corresponding Author: Matthew J. Martin, MD, FACS, Trauma and Emergency Surgery Service, Scripps Mercy Hospital, 550 Washington Avenue, Suite 641, San Diego, CA 92127, (619) 299-2600, traumadoc22@gmail.com © 2019 Lippincott Williams & Wilkins, Inc.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

It is important for physician to be oriented with the following percentage of clinical symptoms and signs of suspected pulmonary embolism according to the literature reports: dyspnea (65%), pleuritic chest pain (47%), substernal chest pain (33%), pre-syncope or syncope (13%), haemoptysis (9%), fever with temperature higher than 38.5 °C (28%), cough (17%), signs of unilateral DVT (33%), totally asymptomatic (16%), sudden death (25%), sinus tachycardia with heart rate more than 100/min (26%), tachypnea with respiratory rate more than 20/min (75%), hypotension with shock (20%), hypoxaemia on arterial blood gases (75%), electrocardiographic right ventricular hypertrophy (50%) and radiological; atelectasis (49%), pleural effusion (51%), raised hemidiaphragm (36%), peripheral opacification with infarct (33%), and lung oligemia (36%)

ACUTE PULMONARY EMBOLISM

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Acute Disease

Preoperative embolization of skull–base tumors: Indications, utility, and concerns Luis Rafael Moscote-Salazar, Ali Adnan Dolachee, Alexis Narvaez–Rojas, Hayder Ali Al–Saadi, Arjan A Najim, Aysar Khudhair jassam, Alyaa Khadim Abdulreda, Ali Odai Mahmood, Haya Jasim Mohammed, Samer S Hoz Journal of Acute Disease 2019 8(3):89-94 Skull-base tumors are generally difficult to access compared with many other cranial lesions. Usually surgery remains the gold standard treatment for the majority of these tumors. However, in many cases, surgical resection is a challenge because the disease usually is already in the advanced stage by the time of diagnosis. Additionally, there are hypervascular lesions which cause excessive loss of blood, then results in multiple blood transfusions and prolonged operative time, increases the risk of neural injury and prevents complete excision. In order to reduce blood loss intraoperatively, many alternatives were available with the neurosurgical armamentarium, such as head elevation, intravenous use of tranexamic acid, total intravenous anesthesia and even preoperative embolization of tumors. However, preoperative embolization carries variable results, potentially aggravating edema and increasing tumor size. To ascertain the current status and the up-to-date indications, an evaluation of the therapeutic role of preoperative embolization was performed in the current study.

Acute cholecystitis and helminthic infestation Pathum Sookaromdee, Viroj Wiwanitkit Journal of Acute Disease 2019 8(3):95-98 Acute cholecystitis is an important acute medical problem, so acute disorder of the gall bladder requires good clinical management. There are several etiologies of acute cholecystitis. Although it is not common, helminthic infection is one of the causes of acute cholecystitis. This condition is little mentioned in literature but it is an important issue in several tropical countries. Here, the authors performed a literature review to summarize published data available on an international database (PubMed). All available publications with complete information are summarized and extracted. In this article, the authors briefly summarized clinical features and management of acute cholecystitis and helminthic infestation. The relationship of nematode, trematode and cestode infestations with acute cholecystitis is also summarised.

Pneumococcal meningitis in Iran: a systematic review and meta–analysis Sedigheh Rafiei Tabatabaei, Ahmad Reza Shamshiri, Mohammad Javad Nasiri, Daniel M Weinberger, Masoud Dadashi, Abdollah Karimi Journal of Acute Disease 2019 8(3):99-105 Objective: To estimate the frequency of pneumococcal meningitis among patients with bacterial meningitis in Iran. Methods: PubMed, Embase, Web of Science and Scientific Information Database (www.sid.ir) were searched from 2000 to 2016 to identify studies on the frequency or prevalence of pneumococcal meningitis in Iran. Stata 14.0 (StataCorp, College Station, Texas, USA) was used to analyze the data. Results: Of the 131 records identified from the databases, 21 studies fulfilled the eligibility criteria. The analyses showed that 25.0% (95% CI: 19.0-32.0; I2=71%) of the confirmed bacterial meningitis (including children and adults) cases were caused by pneumococcus. Conclusions: The large fraction of meningitis cases caused by pneumococcus demonstrates that pneumococcal meningitis is a major public health problem in Iran, and the introduction of pneumococcal vaccines merits further attention from health authorities.

Utilization of accident and emergency department at a semi-urban Nigerian hospital: a preliminary prospective study Godpower Chinedu Michael, Ibrahim Aliyu, Ayuba Andesati, Bukar Alhaji Grema, Abubakar Mohammed Musa, Rafiyat Bolanle Abu, Hamisu Abubakar, Haliru Ibrahim, Emmanuel Edighotu Journal of Acute Disease 2019 8(3):106-112 Objective: To assess emergency department utilization at a semi-urban (resource-limited) Nigerian hospital. Methods: A systematic random sampling technique was adopted. A proforma was used to obtain general information such as age, gender, mode of transfer, time of presentation, symptom duration, diagnoses, treatment duration, treatment outcome (transfer to the ward, referral to another hospital, discharge or death) and date and time of discharge. Chi-square test and logistic regression analysis were used to determine the association of variables with mortality and predictors, respectively. Results: Patients were predominantly male (62.2%) with a mean age of (36.0±19.0) years. Most visits occurred in September (49.1%). The median symptom duration was 24 h (interquartile range: 4.0, 72.0 ). More incidences were caused by non-surgical (61.9%) than surgical reasons. Infectious diseases (predominantly malaria, 34.5%) and injuries from road traffic accidents (mostly head injuries, 9.4%) were the commonest non-surgical and surgical cause, respectively. The mortality rate was 9.2%. Typhoid-intestinal-perforation and sepsis contributed 45.2% of overall mortality. Age (χ2=16.44, P<0.001), symptom duration (χ2=22.57, P<0.001), and visiting month (Fishers exact, P=0.002) were associated with mortality. Moreover, age ( 37 years) (0R=4.60, 95%C/=1.96-10.82, P<0.001) and visiting in September/October (0R=4.01, 95%C/=1.47-10.93, P=0.007) were the predictors of mortality. Conclusions: Though most patients in emergency department survive, the mortality is still high. Appropriate hospital and community interventions should be implemented to reduce mortality.

Integron frequency of Escherichia coli strains from patients with urinary tract infection in Southwest of Iran Miaad K Alkhudhairy, Morteza Saki, Sakineh Seyed–Mohammadi, Nabi Jomehzadeh, Saeed Khoshnood, Mina Moradzadeh, Sajjad Yazdansetad Journal of Acute Disease 2019 8(3):113-117 Objective: To investigate the frequency of integrase genes intI1, intI2 and intI3 of Escherichia coli strains, and their association with resistance to routinely used antibiotics. Methods: A total of 120 Escherichia coli strains were collected from patients with urinary tract infection in Ahvaz, Southwest of Iran. Antibiotic susceptibility testing was performed. The presence of intI1, intI2, and intI3 genes was determined by polymerase chain reaction. Results: Antibiotic susceptibility testing disclosed the highest resistance rate to ampicillin (91.7%) followed by trimethoprim/sulfamethoxazole (65.8%), and ceftazidime (56.7%). The imipenem susceptibility rate was 91.7%. IntIl and intI2 were identified in 74 (61.6%) and 8 (6.6%) of Escherichia coli strains, respectively, but intI3 was not found in any isolates. The presence of integrons was significantly associated with resistance to ampicillin, trimethoprim/ sulfamethoxazole, ceftazidime, and ciprofloxacin antibiotics (P<0.05). Conclusions: The high resistant Escherichia coli isolates harboring class 1 integrons (intI1) were detected in patients with urinary tract infection in our region. Therefore, preventive strategies are necessary to restrict further dissemination of resistant strains.

Effects of shallomin and podophyllin solution 25% for genital HPV warts in women: a randomized controlled trial Shadab Shahali, Mansour Amin, Masoumeh Khajeh Hassani, Reza Yaghoobi, Morteza Saki Journal of Acute Disease 2019 8(3):118-122 Objective: To compare the effect of shallomin (pure fraction of Allium hirtifolium) with podophyllin 25% solution on external genital human papillomavirus warts in women. Methods: This study was a randomized controlled trial which was performed on two groups of 25 Iranian women with external genital warts at Imam Khomeini Hospital in Ahvaz, Iran. In the first group, shallomin was used once a day for six weeks at home. In the second group, 25% podophyllin solution, was applied on the lesion once weekly for six weeks. Results: Shallomin and podophyllin resulted in wart clearance in 13/23 (56.5%), and 12/24 (50%) of patients, respectively. The clearance rate for shallomin was not significantly different from that of podophyllin (P=0.082). Six weeks after the treatment, the sizes of the lesions in the shallomin group and the podophyllin group decreased by (1.43±0.53) mm and (1.64±0.70) mm, respectively. Conclusion: Shallomin is an effective treatment for genital warts, with similar efficacy to that of podophyllin.

Missed acute pulmonary embolism and sudden death: A case report Yasser Mohammed Hassanain Elsayed Journal of Acute Disease 2019 8(3):123-126 Rationale: Pulmonary embolism is a severe cardiovascular disease. Acute pulmonary embolism is an extremely common and potentially the serious pattern of venous thromboembolic disease. Unfortunately, missed diagnosis of pulmonary embolism is lethal and common because of its non-specific symptoms and signs. Patient concerns: A 42-year-old male patient presented with acute chest pain that was treated as gastroesophageal reflux disease. Diagnosis: Suspected acute pulmonary embolism. Interventions: O2 inhalation, urgent electrocardiography, and cardiopulmonary resuscitation. Outcomes: Deterioration and sudden cardiac death. Lessons: Physicians should pay much attention to the symptoms and signs of pulmonary embolism to reduce the rate of missed diagnosis.

Unusual form of strongyloidiasis with gastric involvements: A case report Soheil Ebrahimpour, Mahmoud Sadeghi–Haddad–Zavareh, Zeinab Darabi Ahangar, Zeinab Mohseni Afshar, Zeinab Sheidaie, Parisa sabbagh, Arefeh Babazadeh Journal of Acute Disease 2019 8(3):127-129 Rationale: Strongyloides stercoralis (S. stercoralis) is an intestinal nematode with a complicated life cycle that can involve the gastrointestinal system. Infected patients are generally asymptomatic; but if symptomatic, the symptoms will include skin rash, respiratory and gastrointestinal symptoms like abdominal pain, diarrhea, nausea and vomiting. Patient concerns: A 77-year old man presented with edema of the lower extremities and insignificant tenderness in the epigastric region. Diagnosis: The histopathology of gastric tissue showed severe inflammation and multiple ulcers in the cardia, antrum and proximal duodenum. A large number of rhabditiform larvae of S. stercoralis along with tissue hyperemia and infiltration of lymphoplasma cells, eosinophils, and neutrophils were found. Intervention: Treatment with albendazole. Outcome: Despite the albendazole treatment, the patient’s condition deteriorated and eventually died because of a sepsis-like syndrome. Lesson: Physicians should remain alert to the urgency due to threadworm, especially among the elderly people and immunosuppressed cases; and should ensure accurate diagnosis, suitable treatment and careful follow-up of these cases.

Necrotizing fasciitis of lower extremity due to diverticulitis perforation: a case report Halil Dogan, Bilginar Kovanci Journal of Acute Disease 2019 8(3):130-132 Rationale: Necrotizing fasciitis is an aggressive infection of subcutaneous tissues, which tends to spread rapidly through the fascial planes. Colonic diverticulosis is a common disease in advanced age, although it rarely causes a lethal necrotizing soft-tissue infection. Patient concerns: A 58-year-old woman complained of left leg pain for 15 d without abdominal pain. Diagnosis: Diverticulitis perforation presented as necrotizing fasciitis of the left thigh. Interventions: Extensive debridement. Outcomes: The patient died due to sepsis-induced multiple organ failure and severe metabolic acidosis. Lessons: Clinicians should be aware of presentations of diverticulitis in patients who have a soft-tissue infection in lower extremity even though patients may not have had a history of diverticulosis or abdominal pain.

 

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com