The effect of perioperative benzodiazepine administration on postoperative nausea and vomiting: a systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Despite recent systematic reviews suggesting their benefit for postoperative nausea, vomiting, or both (PONV) prevention, benzodiazepines have not been incorporated into guidelines for PONV prophylaxis because of concerns about possible adverse effects. We conducted an updated meta-analysis to inform future practice guidelines. METHODS: We included randomised controlled trials (RCTs) of all languages comparing benzodiazepines with non-benzodiazepine comparators in adults undergoing inpatient surgery. Our outcomes were postoperative nausea, vomiting, or both. We assessed risk of bias for RCTs using the Cochrane Risk of Bias tool. We pooled data using a random-effects model and assessed the quality of evidence for each outcome using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS: We screened 31 413 abstracts and 950 full texts. We included 119 RCTs; 104 were included in quantitative synthesis. Based on moderate certainty evidence, we found that perioperative benzodiazepine administration reduced the incidence of PONV (52 studies, n=5086, relative risk [RR]: 0.77, 95% confidence interval [CI] 0.66-0.89; number needed to treat [NNT] 16; moderate certainty), postoperative nausea (55 studies, n=5916, RR: 0.72, 95% CI 0.62-0.83; NNT 21; moderate certainty), and postoperative vomiting (52 studies, n=5909, RR: 0.74, 95% CI 0.60-0.91; NNT 55; moderate certainty). CONCLUSIONS: Moderate quality evidence shows that perioperative benzodiazepine administration decreases the incidence of PONV. The results of this systematic review and meta-analysis will inform future clinical practice guidelines. SYSTEMATIC REVIEW PROTOCOL: The protocol for this systematic review was pre-registered with PROSPERO International Prospective Register of Systematic Reviews (CRD42022361088) and published in BMJ Open (PMID 31831540).

Quality of Life in Patients with Acquired Dermal Macular Hyperpigmentation: A Systematic Review.

Acquired dermal macular hypergpigmentation (ADMH) encompasses conditions including lichen planus pigmentosus, erythema dyschromicum perstans, ashy dermatosis, Riehl's melanosis and pigmented contact dermatitis. This group of cosmetically distressing pigmentary disorders pose a therapeutic challenge, yet there have been no systematic reviews published that describe their quality of life (QOL) impact. An electronic database search of PubMed, EMBASE, PsycINFO and Cochrane library was performed in December 2022, to search for articles published from inception until 15/12/2022. Articles were included if they fulfilled the following criteria: (1) primary clinical publication; (2) reports QOL in patients with ADMH; and (3) available in full-text. Overall, the review highlighted a considerable gap in the literature concerning the impact of ADMH on QOL. Seven studies fulfilling the inclusion criteria were included, with a total of 259 patients. All seven studies reported an impaired QOL in patients with ADMH. The currently available literature on this topic indicate that ADMH has a significant adverse impact on QOL, likely to a greater degree than melasma, and to a similar or lesser degree than vitiligo. Five of seven studies reported the QOL impairment for patients with ADMH based on the Dermatology Life Quality Index (DLQI); these studies consistently found a mean DLQI score reflective of a moderate effect on patient's QOL. Clinicians must be aware of, and should seek to address the significant, yet often overlooked, psychosocial burden associated with ADMH when taking a holistic approach to management.

Effect of perioperative benzodiazepine use on intraoperative awareness and postoperative delirium: a systematic review and meta-analysis of randomised controlled trials and observational studies.

BACKGROUND: Benzodiazepine use is associated with delirium, and guidelines recommend avoiding them in older and critically ill patients. Their perioperative use remains common because of perceived benefits. METHODS: We searched CENTRAL, MEDLINE, CINAHL, PsycInfo, and Web of Science from inception to June 2021. Pairs of reviewers identified randomised controlled trials and prospective observational studies comparing perioperative use of benzodiazepines with other agents or placebo in patients undergoing surgery. Two reviewers independently abstracted data, which we combined using a random-effects model. Our primary outcomes were delirium, intraoperative awareness, and mortality. RESULTS: We included 34 randomised controlled trials (n=4354) and nine observational studies (n=3309). Observational studies were considered separately. Perioperative benzodiazepines did not increase the risk of delirium (n=1352; risk ratio [RR] 1.43; 95% confidence interval [CI]: 0.9-2.27; I2=72%; P=0.13; very low-quality evidence). Use of benzodiazepines instead of dexmedetomidine did, however, increase the risk of delirium (five studies; n=429; RR 1.83; 95% CI: 1.24-2.72; I2=13%; P=0.002). Perioperative benzodiazepine use decreased the risk of intraoperative awareness (n=2245; RR 0.26; 95% CI: 0.12-0.58; I2=35%; P=0.001; very low-quality evidence). When considering non-events, perioperative benzodiazepine use increased the probability of not having intraoperative awareness (RR 1.07; 95% CI: 1.01-1.13; I2=98%; P=0.03; very low-quality evidence). Mortality was reported by one randomised controlled trial (n=800; RR 0.90; 95% CI: 0.20-3.1; P=0.80; very low quality). CONCLUSIONS: In this systematic review and meta-analysis, perioperative benzodiazepine use did not increase postoperative delirium and decreased intraoperative awareness. Previously observed relationships of benzodiazepine use with delirium could be explained by comparisons with dexmedetomidine. SYSTEMATIC REVIEW PROTOCOL: PROSPERO CRD42019128144.

Morbidity and mortality in patients managed with high compared with low blood pressure targets during on-pump cardiac surgery: a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: Many believe that blood pressure management during cardiac surgery is associated with postoperative outcomes. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the impact of high compared with low intraoperative blood pressure targets on postoperative morbidity and mortality in adults undergoing cardiac surgery on cardiopulmonary bypass (CPB). Our primary objective was to inform the design of a future large RCT. SOURCE: We searched MEDLINE, EMBASE, Web of Science, CINAHL, and CENTRAL for RCTs comparing high with low intraoperative blood pressure targets in adult patients undergoing any cardiac surgical procedure on CPB. We screened reference lists, grey literature, and conference proceedings. PRINCIPAL FINDINGS: We included eight RCTs (N =1,116 participants); all examined the effect of blood pressure management only during the CPB. Trial definitions of high compared with low blood pressure varied and, in some, there was a discrepancy between the target and achieved mean arterial pressure. We observed no difference in delirium, cognitive decline, stroke, acute kidney injury, or mortality between high and low blood pressure targets (very-low to low quality evidence). Higher blood pressure targets may have increased the risk of requiring a blood transfusion (three trials; n = 456 participants; relative risk, 1.4; 95% confidence interval, 1.1 to 1.9; P = 0.01; moderate quality evidence) but this finding was based on a small number of trials. CONCLUSION: Individual trial definitions of high and low blood pressure targets varied, limiting inferences. The effect of high (compared with low) blood pressure targets on other morbidity and mortality after cardiac surgery remains unclear because of limitations with the body of existing evidence. Research to determine the optimal management of blood pressure during cardiac surgery is required. STUDY REGISTRATION: PROSPERO (CRD42020177376); registered: 5 July 2020.

RéSUMé: OBJECTIF: Pour beaucoup, la prise en charge de la pression artérielle pendant la chirurgie cardiaque serait associée aux issues postopératoires. Nous avons réalisé une revue systématique et une méta-analyse d'études randomisées contrôlées (ERC) afin de déterminer l'impact de cibles peropératoires de pression artérielle élevées par rapport à des cibles basses sur la morbidité et la mortalité postopératoires d'adultes bénéficiant d'une chirurgie cardiaque sous circulation extracorporelle (CEC). Notre objectif principal était d'orienter la conception d'une future ERC d'envergure. SOURCES: Nous avons analysé les bases de données MEDLINE, EMBASE, Web of Science, CINAHL et CENTRAL afin d'en tirer les ERC comparant des cibles de pression artérielle peropératoire élevées à des cibles basses chez des patients adultes bénéficiant d'une intervention chirurgicale cardiaque sous CEC. Nous avons passé au crible les listes de références, la littérature grise et les travaux de congrès. CONSTATATIONS PRINCIPALES: Nous avons inclus huit ERC (N = 1116 participants); toutes les études ont examiné l'effet de la prise en charge de la pression artérielle uniquement pendant la CEC. Les définitions d'une pression artérielle élevée ou basse variaient d'une étude à l'autre et, dans certains cas, un écart a été noté entre la pression artérielle cible et la pression artérielle moyenne atteinte. Nous n'avons observé aucune différence dans les taux de delirium, de déclin cognitif, d'accident vasculaire cérébral, d'insuffisance rénale aiguë ou de mortalité entre les cibles de pression artérielle élevée et basse (données probantes de qualité très faible à faible). Des cibles de pression artérielle plus élevées pourraient avoir augmenté le risque de transfusion sanguine (trois études; n = 456 participants; risque relatif, 1,4; intervalle de confiance à 95 %, 1,1 à 1,9; P = 0,01; données probantes de qualité modérée), mais ce résultat se fondait sur un petit nombre d'études. CONCLUSION: Les définitions individuelles des cibles d'hypertension et d'hypotension artérielle variaient, ce qui a limité les inférences. L'effet de cibles de pression artérielle élevée (par rapport à une pression artérielle basse) sur d'autres mesures de la morbidité et de la mortalité après une chirurgie cardiaque demeure incertain en raison des limites de l'ensemble des données probantes existantes. Des recherches visant à déterminer la prise en charge optimale de la pression artérielle pendant la chirurgie cardiaque sont nécessaires. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42020177376); enregistrée le 5 juillet 2020.

The pro-death role of Cited2 in stroke is regulated by E2F1/4 transcription factors.

We previously reported that the cell cycle-related cyclin-dependent kinase 4-retinoblastoma (RB) transcriptional corepressor pathway is essential for stroke-induced cell death both in vitro and in vivo However, how this signaling pathway induces cell death is unclear. Previously, we found that the cyclin-dependent kinase 4 pathway activates the pro-apoptotic transcriptional co-regulator Cited2 in vitro after DNA damage. In the present study, we report that Cited2 protein expression is also dramatically increased following stroke/ischemic insult. Critically, utilizing conditional knockout mice, we show that Cited2 is required for neuronal cell death, both in culture and in mice after ischemic insult. Importantly, determining the mechanism by which Cited2 levels are regulated, we found that E2F transcription factor (E2F) family members participate in Cited2 regulation. First, E2F1 expression induced Cited2 transcription, and E2F1 deficiency reduced Cited2 expression. Moreover, determining the potential E2F-binding regions on the Cited2 gene regulatory sequence by ChIP analysis, we provide evidence that E2F1/4 proteins bind to this DNA region. A luciferase reporter assay to probe the functional outcomes of this interaction revealed that E2F1 activates and E2F4 inhibits Cited2 transcription. Moreover, we identified the functional binding motif for E2F1 in the Cited2 gene promoter by demonstrating that mutation of this site dramatically reduces E2F1-mediated Cited2 transcription. Finally, E2F1 and E2F4 regulated Cited2 expression in neurons after stroke-related insults. Taken together, these results indicate that the E2F-Cited2 regulatory pathway is critically involved in stroke injury.

Transfusion-Related Hypocalcemia After Trauma.

BACKGROUND: Hypocalcemia is cited as a complication of massive transfusion. However, this is not well studied as a primary outcome in trauma patients. Our primary outcome was to determine if transfusion of packed red blood cells (pRBC) was an independent predictor of severe hypocalcemia (ionized calcium ≤ 3.6 mg/dL). METHODS: Retrospective, single-center study (01/2004-12/2014) including all trauma patients ≥ 18 yo presenting to the ED with an ionized calcium (iCa) level drawn. Variables extracted included demographics, interventions, outcomes, and iCa. Regression models identified independent risk factors for severe hypocalcemia (SH). RESULTS: Seven thousand four hundred and thirty-one included subjects, 716 (9.8%) developed SH within 48 h of admission. Median age: 39 (Range: 18-102), systolic blood pressure: 131 (IQR: 114-150), median Glasgow Coma Scale (GCS): 15 (IQR: 10-15), Injury Severity Score (ISS): 14 (IQR: 9-24). SH patients were more likely to have depressed GCS (13 vs 15, p < 0.0001), hypotension (23.2% vs 5.1%, p < 0.0001) and tachycardia (57.0% vs 41.9%, p < 0.0001) compared to non-SH patients. They also had higher emergency operative rate (71.8% vs 29%, p < 0.0001) and higher blood administration prior to minimum iCa [pRBC: (8 vs 0, p < 0.0001), FFP: (4 vs 0, p < 0.0001), platelet: (1 vs 0, p < 0.0001)]. Multivariable analysis revealed penetrating mechanism (AOR: 1.706), increased ISS (AOR: 1.029), and higher pRBC (AOR: 1.343) or FFP administered (AOR: 1.097) were independent predictors of SH. SH was an independent predictor of mortality (AOR: 2.658). Regression analysis identified a significantly higher risk of SH at pRBC + FFP administration of 4 units (AOR: 18.706, AUC:. 897 (0.884-0.909). CONCLUSION: Transfusion of pRBC is an independent predictor of SH and is associated with increased mortality. The predicted probability of SH increases as pRBC + FFP administration increases.

Hit by a Train: Injury Burden and Clinical Outcomes.

BACKGROUND: Few data exist regarding the train vs. pedestrian (TVP) injury burden and outcomes. OBJECTIVE: This study aimed to examine the epidemiology and outcomes associated with TVP injuries. METHODS: This is a retrospective National Trauma Databank study (January 2007 to July 2012) including trauma patients sustaining TVP injury. Demographics, injury data, interventions, and outcomes were abstracted. Patients injured by a train were compared to patients who sustained an automobile vs. pedestrian (AVP) injury. RESULTS: Of the 152,631 patients struck by ground transportation during the study time frame, 1863 (1.2%) were TVP. Median TVP age was 38 years (interquartile range [IQR] 24-50 years), 81.6% were male, median Injury Severity Score (ISS) was 13 (IQR 6-24). TVP patients were more severely injured (ISS 13 vs. 9; p < 0.001) and required more proximal amputations (13.4% vs. 0.2%; p < 0.001) and cavitary operations (18.2% vs. 2.8%; p < 0.001). TVP patients had higher rates of intensive care unit admission, mechanical ventilation and transfusion, longer length of stay, and higher in-hospital mortality. On multivariable logistical regression, TVP was an independent predictor for higher injury burden, ISS ≥25 (adjusted odds ratio [AOR] 1.650), immediate operative need (AOR 7.535), and complications (AOR 1.317). CONCLUSIONS: TVP is associated with a significant injury burden. These patients have a significantly higher need for immediate operation and more complicated hospital course.

VIII. THE PAST, PRESENT, AND FUTURE OF DEVELOPMENTAL METHODOLOGY.

This chapter selectively reviews the evolution of quantitative practices in the field of developmental methodology. The chapter begins with an overview of the past in developmental methodology, discussing the implementation and dissemination of latent variable modeling and, in particular, longitudinal structural equation modeling. It then turns to the present state of developmental methodology, highlighting current methodological advances in the field. Additionally, this section summarizes ample quantitative resources, ranging from key quantitative methods journal articles to the various quantitative methods training programs and institutes. The chapter concludes with the future of developmental methodology and puts forth seven future innovations in the field. The innovations discussed span the topics of measurement, modeling, temporal design, and planned missing data designs. Lastly, the chapter closes with a brief overview of advanced modeling techniques such as continuous time models, state space models, and the application of Bayesian estimation in the field of developmental methodology.

Treatment of Pulp Mill D-Stage Bleaching Effluent Using a Pilot-Scale Electrocoagulation System.

A pilot-scale study was conducted using electrocoagulation technology to treat chlorine dioxide bleaching-stage effluent of a local pulp mill, with the purpose of evaluating the treatment performance. The operating variables were the current density (0 ~ 133.3 A/m(2)) and hydraulic retention time (HRT, 6.5 ~ 16.25 minutes). Water quality indicators investigated were the conductivity, suspended solids (SS), chemical oxygen demand (COD), true color, and hardness. The results showed that electrocoagulation technology can be used to treat D-stage bleaching effluent for water reuse. Under the operating conditions studied, the removal of conductivity and COD always increased with increases in either the current density or HRT. The highest removals obtained at 133.3 A/m(2) and an HRT of 16.25 minutes for conductivity, SS, COD, true color, and hardness were respectively 44.2, 98.5, 75.0, 85.9, and 36.9% with aluminum electrodes. Iron electrodes were not applicable to the D-stage effluent due to formation of dark-colored ferric complexes.

Successful treatment of spontaneous intracranial hypotension due to prominent cervical cerebrospinal fluid leak with cervical epidural blood patch.

OBJECTIVE: To report a case of successful treatment of a patient with spontaneous intracranial hypotension correlated with MRI finding of cerebrospinal fluid (CSF) leak with extradural collection at the upper cervical spinal level. DESIGN: Case report. SETTING: An academic tertiary pain management center. METHODS: Fluoroscopically guided placement of an 18-gauge epidural needle into epidural space at the C7-T1 level was performed; an epidural catheter (Braun Perifix 20G) was advanced to C2 level (first patch) and C3 level (second patch). An epidurogram with Omnipaque injections confirmed contrast in the posterior and lateral epidural space. Autologous venous blood was then administered through the catheter. RESULTS: This patient received two lumbar epidural blood patches without lasting relief. Given the radiographic evidence of prominent CSF leak with extradural fluid collection at C1-2 level, the patient was then treated with a cervical epidural blood patch, which provided headache pain relief lasting 6 months. A second cervical epidural blood patch was performed, and the patient has been headache-free for nearly one year to date. CONCLUSION: Based on the successful treatment of this patient's spontaneous intracranial hypotension, we advocate that patients undergo epidural blood patches to target the site of any CSF leak identified by imaging studies to improve the efficacy of this intervention. This case demonstrates that cervical epidural blood patch, despite its inherent risks, may be more effective than lumbar epidural blood patch in treatment of cervical CSF leak.

Treatment of cervicogenic headache with cervical epidural steroid injection.

Cervicogenic headache (CGH) is defined as referred pain from various cervical structures innervated by the upper three cervical spinal nerves. Such structures are potential pain generators, and include the atlanto-occipital joint, atlantoaxial joint, C2-3 zygapophysial joint, C2-3 intervertebral disc, cervical myofascial trigger points, as well as the cervical spinal nerves. Various interventional techniques, including cervical epidural steroid injection (CESI), have been proposed to treat this disorder. And while steroids administered by cervical epidural injection have been used in clinical practice to provide anti-inflammatory and analgesic effects that may alleviate pain in patients with CGH, the use of CESI in the diagnosis and treatment of CGH remains controversial. This article describes the neuroanatomy, neurophysiology, and classification of CGH as well as a review of the available literature describing CESI as treatment for this debilitating condition.

Three-Dimension Sawbone Models and Shadow-Play: A Low-Cost Approach to Improve Orthopedic Plain Radiograph Reading in Medical Students.

BACKGROUND: The usage of 3D sawbone models and shadow-play is a novel teaching method in orthopedic education. The aim of this study was to evaluate the effectiveness of 3D sawbone models and shadow-play in improving medical student orthopedic knowledge and interpretation of plain radiographs. METHODS: Ninety-three medical students with no prior clinical orthopaedic experience were recruited into 2 groups: Group 1 underwent conventional education methods and Group 2 underwent a sawbone and shadow-play education. A pre and post-test designed to determine orthopedic knowledge and interpretation of plain radiographs was performed. Five participants were randomly selected for a semi-structured qualitative interview postintervention. RESULTS: There was an increase in mean test scores in both groups. The difference in the means of pre- and post-test average outcomes between the control group was 3.00 (SD = 2.08), as compared to 4.74 (SD = 2.69) for the sawbone group. Group 2 (sawbone) exhibited a significantly better improvement. (p < 0.001). Interviews revealed several themes: improved engagement, enhanced visualization, holistic learning, and challenges. CONCLUSIONS: The utilization of 3D sawbone models and shadow-play as teaching tools in orthopedics demonstrates significant efficacy and is more effective than conventional teaching methods in novice medical students. Students perceived the incorporation of sawbone models and shadow-play as highly engaging, providing them with enhanced visualization capabilities, consequently fostering a deeper comprehension of anatomical structures and X-ray interpretations.

Full-endoscopic versus microscopic spinal decompression for lumbar spinal stenosis: a systematic review & meta-analysis.

BACKGROUND CONTEXT: Symptomatic lumbar spinal stenosis is routinely treated with spinal decompression surgery, with an increasing trend towards minimally invasive techniques. Endoscopic decompression has emerged as a technique which minimizes approach-related morbidity while achieving similar clinical outcomes to conventional open or microscopic approaches. PURPOSE: To assess the safety and efficacy of endoscopic versus microscopic decompression for treatment of lumbar spinal stenosis. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A systematic review on randomized and nonrandomized studies comparing endoscopic versus microscopic decompression was conducted, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Treatment effects were computed using pairwise random-effects meta-analysis. Risk of bias was assessed using the Cochrane Risk-of-bias and ROBINS-I tools for randomized and nonrandomized trials respectively. Quality of the overall body of evidence was appraised using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS: A total of 19 primary references comprising 1,997 patients and 2,132 spinal levels were included. Endoscopic decompression was associated with significantly reduced intraoperative blood-loss (weighted mean differences [WMD]=-33.29 mL, 95% CI:-51.80 to -14.78, p=.0032), shorter duration of hospital stay (WMD=-1.79 days, 95% CI: -2.63 to 0.95, p=.001), rates of incidental durotomy (RR = 0.63, 95% CI: 0.43 to 0.91, p=.0184) and surgical site infections (RR=0.23, 95% CI: 0.10 to-0.51, p=.001), and a nonsignificant trend towards less back pain, leg pain, and better functional outcomes compared to its microscopic counterpart up to 2-year follow up. CONCLUSIONS: Endoscopic and microscopic decompression are safe and effective techniques for treatment of symptomatic lumbar spinal stenosis. Prospective studies of larger power considering medium to long-term outcomes and rates of iatrogenic instability are warranted to compare potential alignment changes and destabilization from either techniques.

Cognitive effects of quetiapine in a patient with dementia with Lewy bodies.

A recent large-scale randomized controlled clinical trial, the Clinical Antipsychotic Trials of Intervention Effectiveness-Alzheimer's Disease study, found a significant worsening of cognitive functioning in a sample of patients with Alzheimer's disease. To date there have been no equally powered studies examining the cognitive effects of atypical antipsychotics in patients with dementia with Lewy bodies, the second most prevalent neurodegenerative disorder. This case report describes a significant cognitive improvement observed through the use of an atypical antipsychotic in a patient with dementia with Lewy bodies. The observed divergence in cognitive responsiveness is discussed mechanistically on both the clinical and neuromolecular level. Limitations to this case study design are presented and discussed. The prudence of caution in importing the results of the Clinical Antipsychotic Trials of Intervention Effectiveness-Alzheimer's Disease study to the dementia with Lewy bodies population is summarized and presented for psychiatrists, neurologists and primary care providers, with an intent to stimulate discussion and further research.

A review of multi-factor authentication in the Internet of Healthcare Things.

Objective: This review paper aims to evaluate existing solutions in healthcare authentication and provides an insight into the technologies incorporated in Internet of Healthcare Things (IoHT) and multi-factor authentication (MFA) applications for next-generation authentication practices. Our review has two objectives: (a) Review MFA based on the challenges, impact and solutions discussed in the literature; and (b) define the security requirements of the IoHT as an approach to adapting MFA solutions in a healthcare context. Methods: To review the existing literature, we indexed articles from the IEEE Xplore, ACM Digital Library, ScienceDirect, and SpringerLink databases. The search was refined to combinations of 'authentication', 'multi-factor authentication', 'Internet of Things authentication', and 'medical authentication' to ensure that the retrieved journal articles and conference papers were relevant to healthcare and Internet of Things-oriented authentication research. Results: The concepts of MFA can be applied to healthcare where security can often be overlooked. The security requirements identified result in stronger methodologies of authentication such as hardware solutions in combination with biometric data to enhance MFA approaches. We identify the key vulnerabilities of weaker approaches to security such as password use against various cyber threats. Cyber threats and MFA solutions are categorised in this paper to facilitate readers' understanding of them in healthcare domains. Conclusions: We contribute to an understanding of up-to-date MFA approaches and how they can be improved for use in the IoHT. This is achieved by discussing the challenges, benefits, and limitations of current methodologies and recommendations to improve access to eHealth resources through additional layers of security.

Denervation as a Treatment for Arthritis of the Hands: A Systematic Review of the Current Literature.

Joint denervation has been proposed as a less invasive option for surgical management of hand arthritis that preserves joint anatomy while treating pain and decreasing postoperative recovery times. The purpose of this systematic review was to investigate the efficacy and safety of surgical joint denervation for osteoarthritis in the joints of the hand. EMBASE, MEDLINE, and PubMed databases were searched from January 2000 to March 2019. Studies of adult patients with rheumatoid arthritis or osteoarthritis of the hand who underwent joint denervation surgery were included. Two reviewers performed the screening process, data abstraction, and risk of bias assessment (Methodological Index for Non-Randomized Studies). This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with PROSPERO (#125811). Ten studies were included, 9 case series and 1 cohort study, with a total of 192 patients. In all studies, joint denervation improved pain and hand function at follow-up (M = 36.8 months, range = 3-90 months). Pooled analysis of 3 studies on the first carpometacarpal joint showed a statistically significant (P < .001) reduction in pain scores from baseline (M = 6.61 ± 2.03) to postoperatively (M = 1.69 ± 1.27). The combined complication rate was 18.8% (n = 36 of 192), with neuropathic pain or unintended sensory loss (8.8%, n = 17 of 192) being the most common. This review suggests that denervation may be an effective and low-morbidity procedure for treating arthritis of the hand. Prospective, comparative studies are required to further understand the outcomes of denervation compared with traditional surgical interventions.

Homonymous hemimacular thinning: a unique presentation of optic tract injury in neuromyelitis optica.

A 42-year-old African American woman with a 5-year history of neuromyelitis optica was found to have an incongruous homonymous hemianopia. Optical coherence tomography (OCT) showed corresponding left homonymous hemimacular thinning. Magnetic resonance imaging of the brain demonstrated a demyelinating lesion in the left optic tract (OT) just anterior to the lateral geniculate nucleus and diffusion tensor magnetic resonance tractography confirmed axonal fiber loss in the left OT. This case illustrates the complementary and confirmatory roles of visual field testing, macular OCT, and neuroimaging in an OT lesion, which caused selective hemimacular thinning through retrograde degeneration.

The clonal repopulation of HSPC gene modified with anti-HIV-1 RNAi is not affected by preexisting HIV-1 infection.

Despite advances in hematopoietic stem/progenitor cell (HSPC) transplant for HIV-1-infected patients, the impact of a preexisting HIV-1 infection on the engraftment and clonal repopulation of HSPCs remains poorly understood. We have developed a long terminal repeat indexing-mediated integration site sequencing (LTRi-Seq) method that provides a multiplexed clonal quantitation of both anti-HIV-1 RNAi (RNA interference) gene-modified and control vector-modified cell populations, together with HIV-1-infected cells-all within the same animal. In our HIV-1-preinfected humanized mice, both therapeutic and control HSPCs repopulated efficiently without abnormalities. Although the HIV-1-mediated selection of anti-HIV-1 RNAi-modified clones was evident in HIV-1-infected mice, the organ-to-organ and intra-organ clonal distributions in infected mice were indistinguishable from those in uninfected mice. HIV-1-infected cells showed clonal patterns distinct from those of HSPCs. Our data demonstrate that, despite the substantial impact of HIV-1 infection on CD4+ T cells, HSPC repopulation remains polyclonal, thus supporting the use of HSPC transplant for anti-HIV treatment.