Recent Publications by CFE Educators

Poor blood pressure control results in tremendous morbidity and mortality in India where the leading cause of death among adults is from coronary heart disease. Despite having little formal education, community health workers (CHWs) are integral to successful public health interventions in India and other low- and middle-income countries that have a shortage of trained health professionals. Training CHWs to screen for and manage chronic hypertension, with support from trained clinicians, offers an excellent opportunity for effecting systemwide change in hypertension-related burden of disease. In this article, we describe the development of a program that trained CHWs between 2014 and 2015 in the tribal region of the Sittilingi Valley in southern India, to identify hypertensive patients in the community, refer them for diagnosis and initial management in a physician-staffed clinic, and provide them with sustained lifestyle interventions and medications over multiple visits. We found that after 2 years, the CHWs had screened 7,176 people over age 18 for hypertension, 1,184 (16.5%) of whom were screened as hypertensive. Of the 1,184 patients screened as hypertensive, 898 (75.8%) had achieved blood pressure control, defined as a systolic blood pressure less than 140 and a diastolic blood pressure less than 90 sustained over 3 consecutive visits. While all of the 24 trained CHWs reported confidence in checking blood pressure with a manual blood pressure cuff, 4 of the 24 CHWs reported occasional difficulty documenting blood pressure values because they were unable to write numbers properly. They compensated by asking other CHWs or members of their community to help with documentation. Our experience and findings suggest that a CHW blood pressure screening system linked to a central clinic can be a promising avenue for improving hypertension control rates in low- and middle-income countries.

Objective

The mechanism of hypoglycorrhachia-low CSF glucose-in meningitis remains unknown. We sought to evaluate the relative contribution of CSF inflammation vs microorganisms (bacteria and fungi) in lowering CSF glucose levels.

Methods

We retrospectively categorized CSF profiles into microbial and aseptic meningitis and analyzed CSF leukocyte count, glucose, and protein concentrations. We assessed the relationship between these markers using multivariate and stratified linear regression analysis for initial and repeated CSF sampling. We also calculated the receiver operating characteristics of CSF glucose and CSF-to-serum glucose ratios to presumptively diagnose microbial meningitis.

Results

We found that increasing levels of CSF inflammation were associated with decreased CSF glucose levels in the microbial but not aseptic category. Moreover, elevated CSF protein levels correlated more strongly than the leukocyte count with low CSF glucose levels on initial ( = 36%, 0.001) and repeated CSF sampling ( = 46%, 0.001). Hypoglycorrhachia (40 mg/dL) was observed in 50.1% of microbial cases, but only 9.6% of aseptic cases, most of which were neurosarcoidosis. Absolute CSF glucose and CSF-to-serum glucose ratios had similar low sensitivity and moderate-to-high specificity in diagnosing microbial meningitis at thresholds commonly used.

Conclusions

The main driver of hypoglycorrhachia appears to be a combination of microbial meningitis with moderate to high degrees of CSF inflammation and proteins, suggesting that the presence of microorganisms capable of catabolizing glucose is a determinant of hypoglycorrhachia in meningitis. A major notable exception is neurosarcoidosis. Low CSF glucose and CSF-to-serum glucose ratios are useful markers for the diagnosis of microbial meningitis.

Evidence supports vancomycin therapeutic-drug monitoring by area under the concentration-time curve (AUC), but data to establish an AUC upper limit are limited and published nephrotoxicity thresholds range widely. The objective of this analysis was to examine the association between initial vancomycin AUC and nephrotoxicity. This was a multicenter, retrospective cohort study of adult patients receiving intravenous vancomycin from 2014 to 2015. Nephrotoxicity was defined as a serum creatinine increase of 0.5 mg/liter and 50% from baseline on consecutive measurements. Vancomycin exposure profile during the initial 48 h of therapy was estimated using maximum probability Bayesian estimation. Vancomycin AUC and minimum-concentration () thresholds most strongly associated with nephrotoxicity were identified via classification and regression tree (CART) analysis. Predictive performances of CART-derived and other candidate AUC thresholds was assessed through positive and negative predictive value and receiver operating characteristic curves. Poisson regression was used to quantify the association between exposure thresholds and nephrotoxicity while adjusting for confounders. Among 323 patients included, nephrotoxicity was significantly higher in patients with AUCs from 0 to 48 h (AUC) of ≥1,218 mg · h/liter, AUC of ≥677 mg · h/liter, AUC of ≥683 mg · h/liter, and day 1 () of ≥18.8 mg/liter. Vancomycin exposure in excess of these thresholds was associated with a 3- to 4-fold-increased risk of nephrotoxicity in Poisson regression. The predictive performance of AUC for nephrotoxicity was maximized at daily AUC values between 600 and 800 mg · h/liter. Although these data support an AUC range for vancomycin-associated nephrotoxity rather than a single threshold, available evidence suggests that a daily AUC limit of 700 mg · h/liter is reasonable.

BACKGROUND/OBJECTIVES

A variety of congenital developmental anomalies arise on the neck because of the many fusion planes and complex embryologic structures in this region. We describe a series of seven patients with a novel type of superficial midline congenital anomaly.

METHODS

Retrospective case series. Clinical and histopathologic features were compared and used to describe this entity.

RESULTS

Seven patients with nearly identical clinical findings were identified. In all cases, a small superficial cyst resembling a giant milium was observed at birth. There were no significant changes during infancy and no evidence of underlying abnormalities. The histopathologic findings were identical to those of an infundibular follicular cyst.

CONCLUSION

We have termed this entity midline anterior neck inclusion cyst. We believe it is a superficial developmental anomaly, probably a forme fruste of a midline fusion developmental defect, which has not to our knowledge, previously been described.

PURPOSE

Lung diseases are commonly associated with changes in lung tissue's biomechanical properties. Functional imaging techniques, such as elastography, have shown great promise in measuring tissue's biomechanical properties, which could expand the utility and effectiveness of radiotherapy treatment planning. We present a novel methodology for characterizing a key biomechanical property, parenchymal elasticity, derived solely from 4DCT datasets.

METHODS

Specifically, end-inhalation and end-exhalation breathing phases of the 4DCT datasets were deformably registered and the resulting displacement maps were considered to be ground-truth. A mid-exhalation image was also prepared for verification purposes. A GPU-based biomechanical model was then generated from the patient end-exhalation dataset and used as a forward model to iteratively solve for the elasticity distribution. Displacements at the surface of the lungs were applied as boundary constraints for the model-guided tissue elastography, while the inner voxels were allowed to deform according to the linear elastic forces within the biomechanical model. A convergence criteria of 10% maximum deformation was employed for the iterative process.

RESULTS

The lung tissue elasticity estimation was documented for a set of 15 4DCT patient datasets. Maximum lung deformations were observed to be between 6 and 31 mm. Our results showed that, on average, 89.91 ± 4.85% convergence was observed. A validation study consisting of mid-exhalation breathing phases illustrated an accuracy of 87.13 ± 10.62%. Structural similarity, normalized cross-correlation, and mutual information were used to quantify the degree of similarity between the following image pairs: (a) the model-generated end-exhalation and ground-truth end-exhalation, and (b) model-generated mid-exhalation images and ground-truth mid-exhalation.

CONCLUSIONS

Overall, the results suggest that the lung elasticity can be measured with approximately 90% convergence using routinely acquired clinical 4DCT scans, indicating the potential for a lung elastography implementation within the radiotherapy clinical workflow. The regional lung elasticity found here can lead to improved tissue sparing radiotherapy treatment plans, and more precise monitoring of treatment response.

BACKGROUND

Meningioma is the most common primary intracranial tumor and patients present with diverse neurologic symptoms related to meningioma location. This study aimed to systematically quantify the presenting symptoms of meningioma and identify prognostic factors for symptomatic outcome following resection.

METHODS

Two-hundred and eighty-three patients who underwent resection of a total of 313 meningiomas at a single institution were retrospectively identified, including 161 World Health Organization grade I (52.6%), 108 grade II (35.5%), and 37 grade III meningiomas (12.1%). Patient-reported symptoms were extracted from the medical record and dichotomized into acute (3 months) and long-term (3-12 months) categories. The χ test and multivariate regression were used to compare groups.

RESULTS

Patients presented primarily with headaches (48.2%) and either cerebral dysfunctions (48.5%) with convexity meningiomas or cranial nerve deficits (38.9%) with skull base meningiomas. Symptomatic improvement in the acute postoperative period was significantly correlated with long term symptomatic improvement (P ≤ 0.01). Headaches and seizures had the greatest rates of symptomatic improvement after surgery (78%), and the vast majority of patients with symptom improvement experienced complete resolution (86%). In contrast, symptoms persisted in >60% of patients with anosmia, sensory changes, or frontal, temporal, or cerebellar symptoms. Multivariate regression identified subtotal resection as a prognostic factor for persistent symptoms (odds ratio, 0.62; 95% confidence interval, 0.03-1.21; P = 0.041).

CONCLUSIONS

Symptoms improve in the majority of patients after resection of meningioma, with the rate of improvement varying according to symptom type and extent of resection. These data may be a useful when counseling patients about symptoms after resection of meningiomas.